Cigarette Smoking Is Caused By A Delusion

I leaned back in my chair and breathed a heavy sigh. My patient noticed my discomfort. “I know I should quit,” he told me with a guilty shrug of his shoulders.

“Have you ever tried?” I asked.

“Once,” he replied, “but it didn’t stick.”

My patient had been a pack-a-day smoker for the past 20 years, something he’d only begrudgingly confessed in response to a standard inquiry I make of all my first time patients. He didn’t see it as a problem himself. Or at least he hadn’t mentioned it when I’d asked him at the beginning of the visit why he’d come to see me.

“Are you aware of all the ways cigarette smoking is bad for you?” I asked.

An alarmingly high proportion of patients know surprisingly little about all the potential consequences of tobacco smoking. My patient, however, was able to come up with two of the major ones: heart attacks and lung cancer. “Why do you keep smoking when you know it causes heart attacks and lung cancer?” I asked him. He shrugged, obviously embarrassed to be caught in a contradiction. But even as I tried to shame him into wanting to quit by preying on his need to appear consistent, I knew no contradiction actually existed.


The key ingredient to achieving happiness is wisdom. And wisdom, rather than knowledge, is what my patient seemed so desperately lacking. He knew intellectually he shouldn’t smoke, but that knowledge hadn’t yet penetrated to become wisdom—to become, in essence, action. Despite his embarrassment, my patient presented no contradiction because action never arises from knowledge alone. It arises from knowledge that is believed. How often do we understand with our intellects how we ought to behave but find ourselves unable to do so? Why, for example, do some people know how to set appropriate boundaries with others, but other people can’t bring themselves to say no to anyone? Why do some alcoholics figure out they need to stop drinking and stop, while others state they know they should, but never do? Why do some people hear advice to quit smoking and quit that very day, while others smoke on even after heart attacks and strokes?

The answer lies not just in what we believe but also in the degree to which we believe it. Deeply held belief introduces a critical ingredient necessary for change: motivation. One of my patients tried and failed to quit smoking for several years until his wife casually mentioned one day how much she hated coming home to a smoke-filled house, and he stopped for good the next day. He’d finally discovered the motivation to quit: a sudden, burgeoning awareness (that is, a deeply felt belief) of the harm his smoking was doing not to himself but to his wife. He was ultimately more capable of believing that his wife’s life was at risk than he was his own. Not surprising when you consider most of us tend to deny the possibility of our own death far more vigorously than we deny the possibility of everyone else’s.


“How many of your patients actually quit because you tell them they should?” my patient wanted to know after I told him my other patient’s story. In fact, one meta-analysis tells us on average only 2 out of every 100 smokers told by their physicians to quit will succeed in establishing long-term abstinence. It’s less clear how many alcoholics or drug addicts who recognize they’re addicted and need to quit actually do. But the principle remains the same: some people can digest intellectual knowledge and translate it into deep and motivating belief, belief they must change their behavior despite all the obstacles—and some simply can’t. Specifically, with regard to smokers, 98 out of every 100 can’t.

What’s the difference between those two smokers who hear their physicians’ warnings about the dangers of smoking and for the first time truly understand it’s time for them to quit and the other 98 who agree they should quit, who may even want to quit, but repeatedly fail in their attempts? Why did the possibility of losing his wife motivate one of my patients but not another? Why do some find the wisdom and others do not?

One could argue that my patient did in fact believe in the dangers of nicotine, both to himself and his wife, but that he was simply too addicted to succeed in quitting. I would argue, however, the problem lay less with the strength of his addiction and more with the weakness of his belief. If those dangers, which he only weakly believed applied to himself, could have in some way been brought home to him—as Ebenezer Scrooge’s impending death was brought home to him by the Ghost of Christmas Yet To Come showing him his own tombstone—I’m convinced my patient would have been able to resist the pleasure smoking provided and managed the pain of withdrawal abstention would have produced. Just when new and powerfully motivating belief will erupt is unpredictable, which is why I teach residents and students to ignore the odds and counsel all of their smoking patients to quit each and every time they see them. Despite our preconceived expectations that most of our patients won’t be able to listen, clearly we have no way of predicting which 2 out of every 100 will.


I would argue there are two possible approaches to the practice of medicine and that the second of the two is better. The first involves diligently providing appropriate advice about smoking cessation, abstention from alcohol for those who abuse it, or pharmacological management of depression and anxiety (to name only a few of the common ailments that affect my patient population).

The second approach, though, involves becoming interested in the beliefs patients hold that keep them trapped in harmful behavior patterns. It involves embracing a view of the human mind that recognizes all behavior is reinforced by belief and that if we could only help patients find their way to wisdom, their lives might then become governed by actions that lead to happiness and joy rather than pain and suffering. This is how I view the proper role of a physician: not just as an advocate for patients’ health but for their happiness as well. While I certainly don’t believe I have all the wisdom my patients would ever need to solve every problem they face, I am equally certain they do themselves.

My ultimate aim and, it turns out, the most enjoyable part of my day, involves encouraging patients to challenge their deeply held beliefs that, in my view, obstruct their ability to change maladaptive behaviors. Though I often fail, I am never able to predict with whom I will succeed, so I approach every patient as a mystery to be solved, always full of hope. And as my patient left my office that morning no more determined to become a non-smoker than when he’d first entered, I wondered: what do you need to hear? What experience will cause some critical piece of wisdom to penetrate into your heart and somehow motivate you to save your own life?

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