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An Excerpt from Why People Smoke in Honor of Lung Cancer Awareness Month

November is Lung Cancer Awareness Month, and to mark the occasion, we are sharing an excerpt from the introduction of the new book Why People Smoke: An Innovative Approach to Treating Tobacco Dependence. Why People Smoke is by Frank T. Leone and Sarah Evers-Casey, who are, respectively, Director and Associate Director of the Comprehensive Smoking Treatment Program at the Perelman School of Medicine at the University of Pennsylvania. The book is a first-of-its-kind clinical guide to treating tobacco dependence, and it helps readers make meaningful connections between tobacco’s effects at the cellular level, the predictable behavioral manifestations of the disorder, and the social science and systems requirements required to make a fundamental impact on this disorder.

A friend of mine once asked me, “Do you have to really want to quit smoking before you stop?” I knew the traditional answer to that question would have been yes, but the look in her eye was telling me she needed to hear something different. She had just been struck by tragedy—diagnosed with lung cancer at an early age and feeling all of the weight of her reluctance to stop smoking. I just blurted out “Of course not!” With a look of tremendous relief on her face, she explained that she desperately wanted to want to quit smoking… but something was telling her she didn’t want to quit smoking.

We’ve known people who have struggled with this conflict for decades, always interested in addressing their tobacco use but never quite ready to take the bull by the horns. It’s easy to imagine the guilt and shame my friend felt while facing down a horrible disease—knowing all of her friends and family would be blaming her for her problem. People who don’t understand tobacco dependence sometimes unfairly write off the reluctance to quit as fear or weakness, but the person who is stuck smoking knows how persuasive the soft power of nicotine addiction can be.

Although the addictive potential of nicotine has been well established, it is not yet treated the same as other addictions. By asking her question, my friend had turned the tables. She was saying that “un-smoking” is not simple. Quitting is not just the absence of smoking. She was saying that un-smoking is a new skill, one that needs to be learned, and one that she needed help learning. She was saying it was our responsibility to help her.

For 20 years now, we have been caring for patients with tobacco dependence. We’ve learned so much from our patients over the years, and every day they teach us new ways of seeing the problem and making a difference. A decade ago, we started an effort we called Project 430K. The U.S. Surgeon General had just published a report estimating that 430,000 people died each year in the United States from smoking-related illness and disability. The catastrophic price paid for failing to recognize the true nature of nicotine’s effect motivated us to begin sharing what we had learned about treating tobacco dependence in a more meaningful way. So we wrote a book.

Why People Smoke: An Innovative Approach to Treating Tobacco Dependence is not another self-help book. It’s not a book that reiterates all the bad things smoking can do to a person. It’s a book that’s designed to help people understand the true nature of tobacco dependence—and the path out of nicotine’s trap—from the perspective of the people who suffer the problem.

Smoking is not just as the antecedent to disease; it is the cardinal sign of a distortion in the brain’s wiring. Despite its enormous death toll, this problem is the product of a predictable exposure so it’s also a problem where a single responsible, informed individual can really make a major difference in someone’s life. Over the past 10 years, we have taught hundreds of people to think about tobacco differently—people just like you who have gone on to help thousands of patients stop smoking. In the process, we keep learning. This book is a product of that effort, and we hope you find the insights into tobacco dependence as awesome, and as empowering, as we do.

There are lots of answers out there, but we all need to keep asking the correct questions to find them. The one universal message within these pages is that none of us are finished figuring out the answers to the problem of tobacco dependence. What makes perfect sense today might not make sense tomorrow. What has yet to be imagined might someday become a fundamental truth. But the first step in achieving your goal is taking a moment to respect your goal: by reading this book, it is clear that you are trying to re-think everything you have ever heard about helping people control their nicotine addiction. Sometimes, that will be hard. You will be asked to reassess all your prior assumptions and evaluate them against the science. Sometimes, those two things won’t square up on the first pass. Richard Dawkins, an esteemed evolutionary biologist and author, was famously quoted as saying, “Science does violence to common sense.” What you think you know, you might not; what you assume is true might just be orthodoxy. And orthodoxy prevents progress. Just because an idea has spent a long time considered not wrong, does not necessarily mean that it is right. In this book, we do our best to present what we have found to be correct over the years of doing this work. Some of it will be familiar, some of it will seem to contradict established common sense. In either case, our hope is that the information we present will spark a clinical curiosity within you. The drive to learn beyond these pages will help us all do a better job in the future.

Our hope is that, in the future, no one’s friend will need to feel the enormous weight of guilt and blame complicating the darkest moments of their lives.