What should smokers be scared of?

This comes up every day. Everyone’s afraid of the big “C”, and they should be. Smoking increases a person’s risk of dying of lung cancer by about 12-20 times (whatever that means, but it’s significant).

And while cancer may be scary, other diseases are just as bad. Lung cancers attributable to smoking cause about 125K deaths per year (all numbers US). Add in head and neck cancers, and the number goes up to about 133K. Add in cancers with less clear causative associations and we’re up to 160K.

In contrast, there are about 130K cardiovascular deaths yearly attributable to smoking, and about 100K deaths due to lung disease such as emphysema.

So let’s explore the various ways of dying of tobacco poisoning.

Lung cancer sucks—it really sucks. I’ve had two close relatives die of it. I’ve lost friends to it. I’ve lost patients to it. Since it it responsible for about a third of smoking-related deaths, it’s important. It’s the one all my patients are scared of. But there’s still two-thirds left.

For example, COPD—chronic obstructive pulmonary disease. This is a spectrum of diseases that includes emphysema and chronic bronchitis. It good and truly sucks. My father told me that when he was in his medical training, emphysema was the disease that he’d least want to die of (or more properly, live with). The chronic breathlessness, fatigue, and weakness is horrible. Patients often feel they are hungry for air—and there’s very little I can do about it. Emphysema involves irreversible destruction of lung tissue. The lung’s primary duty is gas exchange, and gas exchange is dependent on surface area. Lungs aren’t all that big. If they were simple sacs, their effective surface area would be in the range of a few square feet. The lungs create surface area by having millions of small sacs called “alveoli”, which provide about 100 m2 of active surface area (about a tennis court’s-worth).


The scary thing about this picture of a lung isn’t the black carbon deposits, it’s the large holes containing the black carbon deposits. The alveoli that used to occupy those spaces have broken down, creating large, rather than small sacs, reducing effective surface area significantly. Less surface area = less gas exchange = feeling like you can’t breath—because you can’t. About a third of smoking related deaths are caused by lung diseases such as emphysema. Yuck.


  1. Does kicking the habit carry with it some reversal of the damage done to the lungs?

  2. Reversal, no, not generally. It slows ongoing damage significantly.

    Cardiovascular dangers of smoking reduce quickly after quitting (completely quitting—even a little smoking is bigbad).

    On going lung damage slows or stops, but the damage done is done.

  3. MartinC

    The lung damage aspect was one of the things I used to get myself off cigarettes about ten years ago. I think it should be emphasized a lot more. Lung cancer is like russian roulette to most smokers. There’s a chance you’ll get it and thats the end – but at the same time there is a greater chance that you won’t.
    Lung damage on the other hand is noticeable every morning you wake up with a coughing fit or get pains in your chest. Its something that most smokers can directly relate to and can understand the direct benefit that stopping smoking can entail. By the way it took about a year of nicotine chewing gum to get me through the craving for a cigarette. And then another year of ordinary chewing gum to get off the nicotine chewing gum addiction!

  4. Dianne

    Cardiovascular dangers of smoking reduce quickly after quitting (completely quitting—even a little smoking is bigbad).

    There is a dose-response curve for smoking and the risk of lung cancer. Is there one for cardiac disease as well or is it an all or nothing effect? And does smoking of other substances have the same effect (i.e. is the risk due to some property of tobacco or some property of putting smoke into your lungs. Or both. My guess, if I encountered the question on a multiple choice test would be both.)

  5. Dianne

    Smoking also reduces bone density so increases the risk of osteoporosis, hip fractures, and death or disability due to complications thereof. And stroke and multi-infarct dementia. I’d rather have cancer, COPD, or cardiac disease than stroke or MID, personally. And it seems to increase the risk of Crohn’s disease (although decrease ulcerative colitis…possibly change UC to CD somehow?) Althogether a nasty thing to do to yourself and PalMD is actually underplaying the risks, not exaggerating to scare anyone.

  6. I’m showing this picture to my brother. I’ve been trying to get him to quit for ages, but he keeps smoking under the illusion that he “can quit whenever he wants to.”

    I can’t even get him to look at literature because he doesn’t read (he can read he just elects not to and sometimes doesn’t even read things right in front of him)

    Short of tossing him in a cell and keeping away all forms of nicotine for a year, I don’t know what to do sometimes.

  7. NoAstronomer

    My father smoked heavily from his teen’s until age 59. He lived through morning coughing fits, persistent bronchitis and gradually deteriorating lung capacity. But it was the big ‘C’ that forced him to quit.

    He was lucky and is still with us. If you can call having a lung removed ‘lucky’.

  8. Peggy H

    One of my two sisters worked as a nurse for years until she messed up her back with heavy lifting, and she always said that the diagnoses of emphysema was one of the only things that would make her seriously contemplate suicide. She has never smoked.
    Our older sister has smoked most of her adult life. At 62 she looks like she’s in her 80s; she has COPD and emphysema and is intermittently dependent on oxygen — only intermittently dependent because she still turns the oxygen off while she smokes.
    Being 12 years younger, I grew up with a great negative example to look at, and am very glad I never started smoking.

  9. Something to add…the number I gave are deaths. Just because you die of, say, cancer, doesn’t mean you might not have also suffered from emphysema and heart disease before the cancer got you.

    These diseases frequently travel together, with a patient feeling lousy from their COPD, having had multiple cardiac procedures, and haveing chemo for their cancer.

  10. phisrow

    COPD really freaks me out. I was a fairly classic sickly/asthmatic when I was a kid and I remember a number of occasions, really hot, humid nights, of being unable to sleep for hours because I was too busy gasping. The idea of doing that on a gradually increasing and terminal basis doesn’t bear thinking about.

  11. How much damage is done by light “social smoking?” Is there measurably increased risk for people who have maybe one cigarette a month when they’re at a bar?

  12. baryogenesis

    I used to have the occasional smoke, esp at a bar ( you can no longer legally hurt the wait staff in a bar anymore), but found that my smoking increased over the years until I was a pack a day smoker. One day I felt that I couldn’t breathe, butted out, gave away the pack, and have never gone back. A good scare can do it. Cold turkey can work. Trying to gradually quit is bogus–you’re kidding yourself. I just kept remembering the fright of not being able to take a deep breath and it worked better than any picture, no matter how gross.

  13. WIll K.

    I was a teenage smoker, but I quit in college. I wish I could say I did it out of health concerns, but really it was the price that did it.

    I’ve never read much about the damage caused by smoking, but am I safe to assume that smoking during the teenage years (say from fourteen years old) is more damaging to the lungs than it is as an adult? Or would the damage be fairly equal?

  14. a’ight…these are great questions…i’m gonna need a whole new post to work on answers.

  15. Mary Kelly

    I remember walking just three short blocks to the corner store for a pack of cigarettes (this is twenty years ago) and coughing the whole trip there. My husband quit. When he would come home from work and we would go to kiss he’d say, “oooh, you stink”; from the smoke. That did it for me. Seems it has to be more than the fact we all knew which is that it’s unhealthy. It takes something as important as your own sweet husband not being able to stand kissing you, or something similarly disturbing. I did it in stages. First I didn’t smoke in the car, then I didn’t smoke at work either, then I finally got some Nicorette gum from a co-worker and that did the trick. It actually took me a year. I would backslide and buy a pack every time I drank. They are a dual addiction. But I remember the last one because it made me feel sick. And I haven’t smoked another one.

  16. This stuff all needs fact-checking (it all sounds reasonable, though I prefer to see the references), but it’s a nice way of communicating the benefits of stopping smoking:


  17. I finally managed to quit last year after 20+ years. For me, it was the cardiovascular probs that were the most pressing (and getting a new cornea). Not out of the woods yet on cardiovascular issues, but at least moving the right direction. Chantix was an enormous help.

  18. Kagehi

    Interestingly, was just reading an article on an experiment on smokers. They are not yet sure if people have a cognitive problem that “lends itself” to addiction, or of addiction causes the cognitive dysfunction, but here is the jist of it:

    Normal people, when they invest in something like stocks, will, upon noticing a gain on a stock, place more into it, on the presumption that the future result will be greater than their current one. Smokers, in the study, simply don’t. It doesn’t matter if they gain big, it has ***no*** effect at all on whether or not they invest more or less money in the same stock the next time.

    Basically, knowing that you will live longer, that you will save money by not buying cigarettes, or that you drastically reduce your chances of cancer or heart disease, all the things we think *should* have an impact on these people, doesn’t. They see only the short term gains from the immediate behavior, and even if they recognize that greater gains may be possible via a change in that behavior, its not *sufficient* to stimulate them to make the choice to do something else. They know the gains are there, they know they could get more from doing it, but somehow that knowledge isn’t sufficient to make them “want” to do so.

    So, its possible that, for many of these people, the cognitive systems needed to kick the addiction are either so badly damaged, or simply not working to start with, that trying to convince them of all the bad things they can avoid, or all the benefits that might be gained, will have “no effect”. If they do stop, then they might continue “that” new behavior, since now they have immediate, and tangible, gains they can deal with. But, future predictions of benefit… may simply be short circuited so badly that they are meaningless to them.

  19. I smoked once in a while but never habitually. I eventually gave it up entirely. I knew a girl in high school who was asthmatic and smoked. That never made any sense to me. The irony is that I was on the volunteer ambulance crew who picked up her dad for (if I remember correctly, it’s been 30 years) for a heart problem. I haven’t seen her since and I hope she finally quit. I dealt with COPD, heart and cancer patients as a volunteer EMT. If that doesn’t get you to quit, I don’t know what will.

  20. jorge666

    I smoked for over 35 years. One of my jobs was a paraprofessional supervisor of Medical Center Clinics with the Oncology Clinic (w/outpatient chemo treaments) being one. Needless to say my boss and I didn’t smoke before going on our daily rounds to visit the clinic, but had one as soon as we got out of there. Even that didn’t make me quit. I finally quit when my mother had a heart attack followed by a stroke. She was a very nice healthy woman before all this, and now she is somewhat of a wreck who has a hard time recognizing her grandchildren.
    I finally decided I didnt’ want to go out that way. It took a 2 weeks of medium strength patches (smoked “ultra light” coffin nails – the full dose nicotine patches gave me some of the weirdest dreams I have had since the early 70’s) and then 4 weeks of the light (5mg) patches. It has been 9 years and I still want a smoke every once in a while like when you have a lasagna dinner. It feels like my lungs want to go to the 7-11 and get a pack of Camels.

  21. “This comes up every day.”

    nuff said.

  22. Joseph Brenner

    I was born with Epilepsy, to two normal parents who smoked. Years later I was informed that my mother didn’t smoke while carrying my three older siblings, who were all born healthy. I had Cancer, at age two, which resulted in the removal of a kidney, and later, scoliosis, which left me with one compressed and one hyperextended lung. Then there’s the diabetes.
    In spite of all this, I took up smoking in my teens, then gave it up when I realized it was triggering my grand mal episodes. A week of seizures is an excellent motivator.
    To answer the question posed by this blog, smokers should be afraid, not just for themselves, but everyone they come in contact with, and especially their children.

  23. dragonet2

    I didn’t care one way or another except that I always thought smoking was a nasty and expensive habit.

    All three of my uncles died of a weird and rare cancer, oat cell cancer involving their lung lining. My mom quit smoking in the 60s and is still alive at 84.

    On the other hand, my grandma (the mother) smoked until about a year before she died, mom took them away when she realized grandma was lighting them up, taking a drag, then setting them on a counter. And forgetting them. she lived in an old-folks high rise, a fire was totally out.

  24. I teach biology at the local community college, and nearly every time I talk about the dangers of smoking, someone asks me if this applies to “other smoke”, generally meaning marijuana. I understand that it’s the microscopic particulates in smoke that are responsible for the damage that leads to emphysema, but I’d be curious to hear if there’s been any studies on the impact of marijuana in particular.

  25. At 62 she looks like she’s in her 80s; she has COPD and emphysema and is intermittently dependent on oxygen — only intermittently dependent because she still turns the oxygen off while she smokes.

    Any statistics on how many people die every year because they smoke while on oxygen (explosions and fires)?

  26. Great post. Smoking is such an ugly habit, and there are ways to quit it. Willpower is the chief force for that – I just don’t understand why people would voluntarily pay someone to kill them.

    The key is you have to want to stop. Only you can determine the outcome of your challenge.

    All the best,

  27. Natalie

    HHN, have you ever actually been a smoker? It’s a lot harder than just chanting “willpower” over and over.

    I quit cold turkey a year and a half ago, and about 4 months ago fell completely off the wagon (drastic life change, a regular problem for addcits). Now, I’ve quit again as of 4 days ago. I have no illusions that I’ll never backslide again, but every day I spend not smoking is better than the alternative.

  28. Natalie

    “I just don’t understand why people would voluntarily pay someone to kill them.”

    Forgot I had something to say about this as well. You actually might be on to more than you realize, HNN – I’ve read that smoking and depression are highly correlated, and treating depression can make it easier for smokers to quit. In my own case, depression and stress caused me to start smoking again, and I was only able to quit a second time after I got health insurance (allowing me to treat my depression if it becomes problematic again).

  29. There are big connections between smoking and mental illness…a big literature on it too. Perhaps more later.

  30. Joseph Brenner

    I can’t speak for Nathan, but I smoked for several years, and like many smokers, wished I could quit. I got the usual crap from nonsmokers,”if you wanted to quit you would have”, etc., despite a very real desire to stop.
    Well, that finally happened right after a week of poverty forced cold-turkey, when I discovered that they were triggering my grand mal seizures. One smoke, and one week of total disorientation, seizures, chewing up my own tongue, blacked eyes, and other bruises later, I emerged from the fog and decided my life was worth more than this. On that day in 1984 I put them down forever. I have never gone back, except during nightmares, from which I awoke fearing for my life.
    Mine is an extreme case, I know, but if you just stop and think about how powerful these things are to cause such problems you might think twice before you light another, ever.
    I think Nathan is right to say YOU HAVE TO WANT IT. But even more, YOU HAVE TO FEAR IT.
    I pray you are successful.

  31. Natalie


    I don’t disagree at all that a smoker has to want to quit to be successful. I am offended by the incredulous question “why would you pay someone to kill you” and the suggestion that willpower alone will beat an addiction. To me, that shows a deep misunderstanding of how addiction works.

    For some reason, people treat tobacco smoking differently than they treat other addictions. It seems unlikely to me that, if this conversation were about heroin or crack or methamphetamines, someone would pop up and say “I just don’t understand why crackheads pay someone to kill themself” and “Willpower is the chief force for” getting sober.

  32. HHN, another thing you “don’t understand” apparently is addiction (or sophistry).

  33. He did get it right in that you do have to want to stop before you can kick an addiction…it’s just that it’s only the first step…

  34. llDayo

    12 hours into day 1 and counting. The link in your article got me thinking about quitting (something I’ve tried a few times in the past). After reading how the body heals over time I realized how much I missed having a large lung capacity (how many smokers do you know can hold their breath under water for over a minute?) and a decent singing voice. So, last night was pool league night. I finished off the pack and woke up quitting cold turkey! So far, so good.

  35. Natalie

    Good for you, IlDayo!

    Starting to bike commute to work was a huge motivation for me to quit again. Being lapped by 60 year old men on the bike path (I’m 24) was quite embarrassing.

  36. Tikaysha

    I definitely think there’s a link between depression (or at least overwhelming stress) and smoking. I grew up hearing all about the evils of cigarettes, I watched them kill my grandmother, and then I started smoking. And at the time I called myself a coward, because I was depressed enough to idealize death, too poor for the therapy a part of me knew I needed, and needed a clear, obvious way to rebel from a very unhealthy romantic relationship. So I channeled all that hate into smoking, and called it “my slow death” with a smile on my face.

    I had to fix all those other problems before I could tackle the smoking, and then I had to get my (new! better!) s/o to convince all our friends to just let me be about smoking so I wouldn’t dig my heels in and continue to spite them. Only then was I able to say for myself “I don’t like doing this, lets stop.” And then it took about a year of false starts of various lengths, but I’m in my longest not-smoking stretch so far at a month and counting. But I know that success is tied to my mental health, and I worry about what might happen should I have another really bad depressive episode. Because while even the scent bothers me now, I know that they taste different when I’m depressed.

    That was meant to be something about the way depression and addiction tend to follow one another, and turned into a little personal anecdote. But I wonder if anyone’s studied to see how many depressive smokers do it because of the negative health effects?

  37. Joseph Brenner

    While I agree that tobacco is treated differently than other addictions(probably because of it’s legality), I know firsthand that willpower is all it took to beat it.

    To most smokers, cancer or some other disease is just an abstract thought, far removed from them. But when I awoke from a week of seizures knowing that they were triggered by a smoke, that’s all it took. Falling off the wagon was no longer an option.

  38. I have just had this argument with my sister. My mom, who has been a smoker for 50 years, has already had a heart attack and has a fairly serious case of COPD. She recently quit smoking. My sister says she isn’t sure that quitting smoking is all that good for mom and at this point it really doesn’t make any difference as far as her health. I argue that it might not make any difference on whether she will ever get lung cancer at this point, but that quitting smoking has an immediate benefit of reducing the risk of heart attack and that it could help her COPD (Otherwise, if she keeps smoking, the COPD will get worse.)

  39. Natalie

    Joseph Brenner,

    It sounds like you had more than just willpower – you had a motivation (seizures). Perhaps we are defining willpower differently, but saying all it takes is willpower is akin, to me, as saying that any smoker can quit at any point if they just have enough willpower. I have not personally found that to be true – a motivation to quit and a desire to quit are needed as well.

  40. I agree with Natalie. My dad smoked for almost 30 years and wanted to quit for a long time. It wasn’t until he had a stroke related to smoking that he finally did quit. That wasn’t even enough to get me to stop though! When a lot of friends and family members smoke temptation is always within arms reach. Once you get that first puff, you’re back off the wagon.

  41. Joseph Brenner

    Let me just define willpower, from my perspective. It is the choice I made to not let tobacco control me.
    The part I didn’t tell you before is that I had seizures before I smoked, and still do today. A lot of smokers(including myself, at one time) would rationalize and say, “You may as well smoke, anyway.” But I chose to stop believing that there is any good reason to smoke. There is no wagon to fall off of. I am the driver.
    That motivation is available to everyone.

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