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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  • Very good read. Heavy, meaningful content that makes my daily ramblings of limited value other than keeping a limited circle of family and friends of our activities. Look forward to more.

  • I, like Pete, found it a very good read. Requires more than once to fully take all of it in. Look forward to more.

  • In addition to what I previously wrote, I have a friend that I have been trying to get to quit for YEARS. Her response is I will get fat like last time. This is even with a husband who has COPD bordering on emphysema. Her comment is he never stopped when I couldn’t smoke so why should I. At least now she does not smoke in the house proper. Pamphlets, etc., and nothing has worked.

  • Wow. Now I see how incredibly fortunate we were when our physician moved to another city and someone recommended Alex Lickerman! My husband and I have made enormous lifestyle changes since meeting Dr. Lickerman, and although I always knew how critical he was to the process, I now know how and why he was so determined to stick with us through our thicks & thins. Indeed, it is true: as we approach our 26th wedding anniversary, we have never been happier, healthier, or more in love with each other than we are right now. Thank you, Dr. Lickerman!!!!!

  • Alex, you have given me much to think about as I still smoke, even though I know the dangers, being a med tech for over 40 years. I am going to try concentrating each morning, to harden my resolve to quit permanently.

    Norah: Never ever give up! Most people who succeed in quitting long-term have a history of many, many failed attempts. You never know when it’s going to stick!


  • This is awesome. I’m so happy for you and proud of you. You’re a man of action (I stole that line from The Princess Bride). Keep it up, Alex! Good job!!!

  • Thanks Alex, this is great info!

  • This is wonderful! It helped inspire my acting class that I taught today. Very insightful. I focused on the power of motive. Thank you for being the buddha that you are, Alex.

  • Alex-

    Kudos on your new blog.

    Many thanks for the explanation of the Buddhist views on knowledge and widsom. I absolutely agree that the widsom necessary to effectuate the abandonment of harmful behaviors must lie in the acceptance of deeply held beliefs that such activities/lifestyle choices are in fact “too costly” to continue.

    Undoubtedly, Newton’s observation that “a body at rest tends to stay at rest,” evidences the natural principle that significant change requires the input of work (i.e. effort.) Too bad that the specific input necessary for such change is unique to the individual. Your job as physician would be so much easier and highly scalable if this were not the case!

  • Alex,

    First, congratulations on your first blog! Since my initial reading, I have been pondering Mr. Rodriguez and your message all week. While I am not a smoker, I do believe that there is a little bit of Mr. Rodriquez in each of us.

    Your message reminds me of one of my favorite quotes, “Do or do not. There is no try.” Notwithstanding embarrassment in quoting Yoda from Star Wars, this is a simple, yet deeply profound message. Whether you are trying to quit smoking or trying to hit revenue numbers, there is nearly an implied understanding that you will not succeed when “you try”—a hesitancy of some sort that stops you from achieving your goal.

    No matter the degree of challenge, I concur with you wholeheartedly that you must be intentional about your thoughts—only then will the appropriate behavior and actions will follow suit. Thanks for reminding me that mindfulness is a source of happiness and health. I look forward the the next blog.

  • Alex,

    Thank you. Thank you for all your time that you take with my wife and me. Thank you for helping my friends and colleagues in physical times of need. Thank you for calling me back the next day after an appointment and spending an hour talking with me as a fellow care giver about setting limits and not feeling guilty. You truly are a great physician and always know that your wisdom is never lost on me.

  • Absolutely true. I was a one to two pack-a-day smoker who had tried, unsuccessfully, a number of times to quit. When I finally was able to quit, it came, not through the use of a patch or the gum (both of which I’d tried before) or Zyban (for which I’d received a prescription, but had not yet started), but rather from two things: (1) reading a book* that, just as you described, worked by identifying the delusions under which smokers operate and deflating each of them one at a time, and (2) reading it at the right time in my life (I also practice Nichiren Buddhism—when I read the book, I had been practicing again for about five months, after having been away from it for a year and a half, and through the practice had gained the strength and quieted a lot of the anxiety, so that I could address those delusions head on). As a result, I successfully quit without the aid of any nicotine replacement or drugs, and have not had a cigarette (or any nicotine for that matter) for over three years now.

    *The book, for those who might be interested, was Allen Carr’s The Easy Way to Stop Smoking. I mention this not as a plug (I don’t have any financial stake in it), but merely because it might help others the same way it helped me.

  • I found your blog on Friday via Google while searching for easy way to quit smoking and your post regarding Happiness in this World » Cigarette Smoking Is Caused By A Delusion seemed interesting. I have a few websites of my own and I must say that your site is really top notch. Keep up the great work on a really high class resource.

  • I agree that cigarette smoking is caused by a delusion.

    In my case, it was a delusion that I was a smoker. Hence, every time I gave up (over the course of over two decades), I returned when the mind threw arguments like, “I’m going to start again anyway, so why not now?”

    Then I had an epiphany and realized that I was returning to smoking only because I believed that I was a smoker. If I were not a smoker, the issue would not arise.

    So, I tried an experiment. I recalled what smoking my first cigarette was like. It was a repulsive an experience. Then I approached the next cigarette I lit as if it were the very first I would ever smoke. It tasted awful and I stubbed it out after just one puff. When the urge hit later, I lit a fresh cigarette, again approaching it as if it were the first cigarette of my life that I was lighting.

    It tasted awful.

    I haven’t lit another since then. It’s early days yet, since I’ve just crossed the 6-month mark, but there has been no withdrawal symptom and I am as lean as I was in the smoking years.

  • Alex,

    I stumbled upon your website about a week ago and instantly felt that it was something special. In a short amount of time I have taken much of your advice to heart in my own life and have noticed wonderful changes. I recently stopped smoking cigarettes after about 10 years. I am 24 years old and to be smoking for that such a large percentage of my life is horrible. I woke up one day and had the wisdom that you speak of. I felt that all it took was determination and drive and that yes, it may be tough, but the benefits of quitting definitely outweigh the benefits of continuing. I now feel more vital than ever and reading this article today has re-affirmed the way I have been thinking and added some much needed insight. Thank you for sharing your wisdom with me and I look forward to reading all the articles on the site. From the other comments I can see that you are a good person who is doing a lot of wonderful things in the world and it seems a lot of people appreciate it, including myself.
    Thank you,

  • I’ve noticed that my addictive behaviors tend to recede after I’ve had a session with my shrink where I really wade into the muck of my contradictory feelings and self-judgments. Once those feelings have been examined, I don’t have the urge to run from myself with chemicals. Resolve has nothing to do with it—I just don’t want the stuff. Of course, while tomorrow is another day with its potential for regression, I can’t help but feel that the component of confronting feelings, rather than denying then, plays a huge part in why addictions start in the first place.

    Christian: Pleasure is above all distracting, and can enable you to escape unpleasant feelings quickly and easily, albeit temporarily.


  • I smoked on and off for 10 years, quitting when I found out I had conceived each of my two daughters, then resuming smoking sometime afterward (each time)…what finally did it for me was two things, that is to say, on two levels: 1) on the emotional/spiritual level I had a profound insight that I was an addict—realizing that I was indeed more like my family of origin (alcoholics & substance abusers) than I wanted to admit—and also that my daughters at that point were old enough & smart enough to recognize addictive behavior (and that I knew, in the deepest part of my being, that I DID NOT want to model addictive behavior them as they grew into their teens and young adult years!)—and then 2) on a biological level, when I started taking Zyban to help me quit smoking (after several crazy-making attempts to quit cold turkey)—this was on the advice of my then-physician—the effect was so immediate and powerful, and so disrupted the biochemistry of my nicotine addiction—that I was able to stop. Not perfectly—for about a week around 9-11-01 the emotional stress had me turning back to nicotine—but after more than five months of not smoking at that point, the physical act of smoking had become completely unpleasant, and I was able to put cigarettes down completely after that “slip.” I now know I will never smoke again. Yes, nine years later I weigh about 15 pounds more and am struggling to get rid of that excess weight but when it’s all said & done, I feel healthier in every way and I am proud of having looked my addiction in the eye, and said, Not me, Not anymore, this cycle of addiction stops with me.

  • I think sometimes people actually DO know the effects of smoking, but they mentally block it out. I did for several years until I quit. Sometimes you really are the only one that can help yourself.

  • Wow. I wish you were my doctor. The very idea of a doctor who cares about his patients well-being (and not just patching them up and getting them out of the office) is inspiring. Thanks for sharing your compassion and insight.

    On the subject of smoking, it’s unfortunate but information alone does not cause people to quit. The problem is that smokers enjoy smoking, more so than the knowledge of the risks to prevent them. It’s an addition of the soul as well as the body. Learn how to treat that and the world will beat a path to your door.

  • Hi Alex,

    Thank you for this wonderful site. I plan on exploring it in more detail after I post this comment. I’m 61 years old, an insulin-dependent diabetic since 1980 (some 31 years) and shamefully I smoke. There is definitely a “delusion” involved in as much as somewhere in the back of my mind I think “maybe I’m one of the ones it won’t kill” which is patently ridiculous. I have a lot of shame connected to my smoking. I hide when I smoke at work and when people see me sometimes they are surprised to find out I’m a smoker. A lot of shame and all the things that come with it involved here, the depth of insanity in rationalizing something that simply has no rational excuse, of knowing all the possible side effects beside lung cancer for diabetics, vascular disease and resulting amputations of legs…the whole litany of possibilities including blindness.

    Recently as a result of a severe bout of depression I began to reach out to find ways to make my life more interesting, to put motivation and purpose back in my days. I have been pursuing the path of changing how I look at things (my attitude) and really working on being in the moment and enriching my day-to-day life. I journal before the day begins and add something to it before the day ends. This has put a sense of interest and adventure back into my days and has made a huge difference in how I feel about myself.

    Of course, smoking is incredibly at odds with all of this. The sense of shame won’t go away. Maybe that’s a good thing. I know it affects my self-esteem to be working on loving myself, knowing my worth. Being good to myself so I can love others and leave some small good thing in each day has been important to me. Smoking is clearly NOT loving myself. It’s gotten to the point now where I can’t hide from having to deal with it. I’ve been smoking since I was 16 (I’ll be 62 on December 22nd) about a half-pack and day and only quit while I was pregnant with my two sons, only to start again when they each were about 2 years old.

    I’m a medical transcriptionist at the VA Medical Center in Milwaukee and I transcribe all sorts of hematology/oncology notes, some of which are about lung cancer. So intellectually I know the possible horrors of base of tongue, head and neck, esophageal, and vocal cord cancers and the disfigurement and pain of radiation treatment and chemotherapy as a direct result of smoking. I’m also afraid that I’ll eat everything in site if I quit, and another example of sneaky rationale is me thinking that even if I quit that’s no guarantee I won’t get lung cancer so why bother.

    I’ve gotten to a place in my life where I have to make a decision because of the shame I experience with my smoking and how it is at total odds with trying to move forward toward enlightenment in my life. I don’t think I’m a nicotine addict. I think that I escape my life by smoking. When I’m smoking I’m clearly not living my life or present in that moment, feeling my feelings, or doing any of the things that help us grow.

    I think I have to come to grips with the fact that during that time when I want to smoke and have the urge to light up, I won’t drop dead from my various neuroses if I choose not to. If I can only learn to just be there with that time and let it pass I’ll be on my way. I also have to let go of the notion that it’s the only “naughty enjoyment” I have left (fear of loss of something pleasurable). I don’t drink. I don’t smoke dope or take illicit drugs, and I do go out of my way to eat healthy foods. I don’t need that one vice I have left and hopefully I will be able to summon up the strength a cigarette at a time to put them down.

    There’s so much more living I could be doing while I’m in the nicotine fog, and simply cutting down is not an option as it only feeds into the belief that I’ve done something about the real problem. Thank you so much for your wonderful site and all the wisdom that’s here to explore!


  • I just turned 42 last week. Decided that it was time to quit smoking after more than half of my life. Most people are shocked when they find out that I smoke. I work out 2-4x a week, I have been a vegetarian for 24 years, (actually switched out the meat for the cigs). I am a massage therapist by trade and go out of my way to eat extremely healthy.

    I also love to smoke and alcohol is also something I like to abuse often. Anyway, I have been seriously trying to figure out why I smoke and drink so much. I have always had anxiety. That could be it, but cigarettes really just cause me anxiety in the long run. Alcohol seems to help during consumption anyway. Unless I act foolish and remember the next day, even worse not remember the next day. That does not help anxiety.

    So I am on day 5 of a total body cleanse (something I do every year) except this time I am quitting smoking as well as all animal products, processed sugars, caffeine, alcohol, etc. I am planning to do this for 2 weeks. I am not having a problem not smoking. At least not much of one. I just won’t have a cigarette. My worry is that after my cleanse I may easily go back to smoking. I hate smelling of smoke, my clothes, my car, my hair. Although most people say they do not smell smoke on me I know that it is there. I know all the health risks about smoking. So why does it not bother me that much?

    I just don’t really have a problem with death. I think it is life that scares me more.

    I guess I am trying to figure out why that is.

    Thanks all

  • Your words have moved me.

    I will search for and find all the wisdom within, in order to address my addictive smoking, and let go of my need.

    I wish all doctors approached their patients problems from a perspective at similar to yours. Thank you.


  • Do you wish to deny any physical/neurobiological basis of long term addiction or habit formation? Do you wish to imply that psychology alone (be it knowledge, resolve, motivation, or wisdom) can win over all bad habits and addictions? Doesn’t it sound a bit like popular “positive psychology” where you can simply “change your thought to change your life”? Only if it were that easy as the zillions of self-help books would have us believe? Why would so many people suffer so much in their lives despite having the knowledge, if only translating that knowledge into wisdom was the solution—and a feasible and practical one at that?