Why are opioids a national crisis, but smoking a personal choice?

OxyContin, in 80 mg pills, is shown in a file image. President Donald Trump says he will declare the opioid crisis a national emergency.
OxyContin, in 80 mg pills, is shown in a file image. President Donald Trump says he will declare the opioid crisis a national emergency. Los Angeles Times/TNS

President Donald Trump says he will declare that the opioid crisis is a national emergency, though it’s unclear how he will address it and whether he will beef up medical intervention such as free rehab or overdose kits for first responders.


About 33,000 Americans died of opioid overdoses in 2015, nearly triple the number who died in 2002, according to the National Institute on Drug Abuse.

But opioids are far from the most lethal addiction in America. Smoking results in the deaths of 480,000 Americans a year, making it the top cause of premature death, according to the U.S. Centers for Disease Control and Prevention.

The strong, bipartisan response to opioid addiction naturally leads to this question: Why does popular opinion so heavily favor the strongest possible measures to reduce the toll taken by opioids, but people start yelling about “nanny states” and “personal choice” when the government tries to do more about cigarettes?

Both start as personal choices and grow to be hard-to-kick physical addictions. Most fatal opioid overdoses involve prescribed pain relievers that people started by taking legally. Most who become addicted to nicotine do so before they’re even old enough to make a legal personal choice for themselves; according to the National Survey on Drug Use and Health, 80 percent of adult smokers started before they were 18.

Yet opioids, unless they are provided through a legal prescription, are illegal, and smoking is legal. Not only that; opioids physically harm only the people who take them; second-hand smoke harms the people who are near smokers.

Why, then, these divergent views about the two addictive drugs? One is viewed as a national crisis demanding immediate attention; the other is a personal choice.

Probably it’s because opioid deaths occur more quickly and dramatically and, for the most part, among younger people. Unless a person dies in a fire caused by a smoldering cigarette, smoking deaths occur over decades and are defined as illnesses: lung cancer, emphysema, stroke, heart attack.

But they are not really natural deaths; on average, smoking reduces life expectancy by 10 years. Maybe if we defined the fatal diseases brought on by smoking as long-term cigarette overdoses, we’d view them differently.

The U.S. Food and Drug Administration is now proposing a drastic reduction in the nicotine content of cigarettes, to levels where they would be far less addictive. It’s unclear whether the agency can do this; the law prohibits it from requiring that all nicotine be removed, and if it aims for miniscule levels, tobacco companies might argue in court that this is virtually the same as eliminating it.

But if the levels aren’t dropped to miniscule amounts, it could do more damage. If nicotine levels are at, say, 10 to 20 percent of normal, might people smoke five to 10 times as much to get their fix? It’s the smoke that causes most of the disease, not the nicotine.

The FDA is still working out the details, but with the tobacco industry ready to fight – and to buy allies in Congress – the key is public support. Are we ready to beat down, once and for all, the biggest addictive killer in our nation?

Karin Klein is a freelance journalist in Orange County who has covered education, science and food policy. She can be contacted at Follow her on Twitter @kklein100.