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B’OR HA’TORAH 8 (1993)

Should Jewish Law Forbid Smoking?Eli Schussheim was born in Argentina , where he studied at a number of yeshiva acade

mies and completed medical school. Since 1965, he has been a member of the general surgery staff of Shaare Zedek Medical Center in Jerusalem. From 1967-71, he was a sur gery lecturer at the Shaare Zedek Nursing School, and from 1967-71, the Knesset doctor.. .A member of the inspection committee on mohalim (ritual circumcisers), Schussheim is also a medical consultant for the State Comptroller of Israel. He is also one of the founders and former director of the Neveh Simcha gerontological hospital in Jerusalem.

The chairman of Efrat, an organization encouraging childbirth, Schussheim also pub lished two booklets on childbirth and on marital happiness, subjects he frequently lectureson . Since 1977, he has written a weekly column for the local religious newspaper Yom Shishi.. One of Schuss heim's special interests is the prayer and cantorial music of the Days of Awe. He lives in Jerusalem with his wife and five children .

* * *The following responsum between Dr. Eli Schussheim, MD and Rabbi Eliezer Waldenberg on the hazards of

smoking appeared in the Hebrew-language publication of the Dr. Falk Schlesinger Institute for Medical Halachic Research of the Shaare Zedek Medical Center in Jerusalem - Assia, vol. 34, October 1982. Dr. Schussheim provided B'Or Ha'Torah with the article that had accompanied his letter and brought it up to date. " Unfortunate ly," he comments, "the basic facts have not changed in the past ten years , and the subject is all too relevant to day.”

Other leading adjudicators of our generation who have ruled or warned against smoking include the lateRabbi Moshe Feinstein (Responsa lggrot Moshe, Yoreh De'ah, part 2, no. 49) ; Rabbi S. Z. Orbach (Avraham S. Avraham , Lev Avraham , part 2, p. 17); and Rabbi C.D. Ha'Levi (Aseh L 'cha Rav, part 2, no. 1; part 3, no. 18).

Information on the Jewish sources cited below can be found in the "Alphabetical List of Sources" at the endof this volume .

His HonorRabbi E/iezer Waldenberg

Jerusalem, 5 Shvat 5742 (1982)

As your excellency knows, I have been practicing medicine in Jerusalem for many years, treating mainly rabbis and Torah-observant Jews.

It breaks my heart that this is such a heavily smoking population while cigarette smoking has been proven conclusively detrimental to health and liable to shorten life, G-d forbid.

I have taken upon myself to prevent smoking, especially among young people, and to influence chain smokers to stop. As part of this effort, I wrote an article detailing the serious damage caused by smoking. The article draws upon major research projects, statistics, and my 18 years of experience.

I am convinced that success in preventing and stopping smoking among the Torahobservant community depends first and foremost upon the attitude of the poskay halacha [the leading rabbis of our generation who make new rulings in Jewish law] on this subject.

Therefore, I ask with all my heart, should not Jewish law forbid smoking?I am enclosing my article, "Health Dangers of Smoking" and thank you for your response .

With respect and esteem, Dr. Eli Joseph Schussheim

58 Should Jewish Law Forbid Smoking? B'Or Ha'Torah

HEALTH DANGERS OF SMOKING

by Dr. Eli J. Schussheim

PART ONE

After the exodus from Egypt, G-d prom ised the Jewish people,

If you obey G-d your L-rd and do what is upright in His eyes, carefully heeding all His Commandments and keeping all His decrees , then I will not strike you with any of the sick nesses that I brought on Egypt. I am the G-d Who heals you (Exodus 15:26).

The difficulty of the commentators in explaining this apparent contradiction is well known. If G-d will not smite us with "any of the sicknesses" to begin with, then why should we need Him to heal us? Why, furthermore, should the practice of medi cine be necessary? Here is the source of preventive medicine. G-d heals us by pre ventive measures, and through the medi um of doctors.

The doctor is an agent of G-d. He is entitled and obligated to engage not only in treating and curing disease, but also in preventing disease through guidance and education. Thus, I took up an anti-smoking campaign as a top priority issue in pre venting disease and other health danger.

What happens to a person when he smokes?

Burning tobacco releases gas-containing smoke and various chemical com pounds, mainly nicotine, carbon monoxide, tar, and dozens of other poisonous materi-

als. With every inhalation of smoke, these poisons are easily absorbed through the breathing passages and in the end reach the tissues and organs of the body through the blood circulation. The toxins cause damage on various levels in various tis sues and organs.

Which systems in the body are vulnerable and sensitive to these poisons?

As smoking is a process of inhaling poison into the breathing passages down into the lungs, it is clear that the respiratory system is the first to suffer. Next is the car diac system - the heart and blood vessels; then the digestive system, the nervous system, and so on. Most of the organs and systems of the body are vulnerable and sensitive to smoke-poison on various lev els.

What harm does smoking cause the respiratory system?

The purpose of the respiratory system is to bring oxygen from the air into the lungs, and from there into the blood. Travelling from the lungs, the blood supplies oxygen to all body tissues. On its return to the lungs, the blood releases carbon diox ide, which the lungs exhale into the air . This is the process of breathing, a function which is normally carried out 16-18 times a minute. In order to perform this task, the respiratory system contains a system of tubes which start at the mouth and nose and continue through the throat, the trachea (windpipe), the bronchial tubes, and divide up inside the lungs into secondary vessels of small diameters that decrease to microscopic size. These vessels end in microscopic sacs called alveoli. These sacs are wrapped in a net of very fine, thin

B'Or Ha'Torah Should Jewish Law Forbid Smoking? 59

blood vessels called capillaries. The oxy gen from the air enters through the respir atory system until it reaches the alveoli. From there the oxygen passes into the blood through the capillaries. In the blood, oxygen is absorbed into red blood cells, which oxygenate all the organs, tissues, and cells in the body.

We all know that there are dust particles, germs , viruses , carbon , and so on

in the air we breathe which are likely to reach the alveoli through the respiratory system and cause damage . To prevent

this , G-d created a wondrously sophisticated filter system in the

respiratory tract, starting at the nose and its cavities, and continuing along the length of the bronchial tubes . These

filters keep harmful particles from passing through and entering the lungs and the alveoli. To do this , the interior wall of the respiratory tract is coated with a layer of small-haired cells called cilia,

which brush off foreign particles entering the respiratory tubes. There are also mu cus-secreting cells found in the interior walls of the respiratory tract, as well as special cells which aid the filtering system by swallowing foreign bodies.

The filtering system of the respiratory tract is too delicate to control the onslaught of inhaled smoke. Even worse, the toxins damage the filter system and easily enter into the lungs and the blood system . Cigar ette smoke paralyzes the respiratory f ilter cilia and makes them disappear , while stim ulating the mucus-producing cells to over secrete. In this way, the mucus cells in crease. As a result , membranes are created which contain foreign particles. These con gested membranes cling to the interior wall of the respiratory tract. In this state, the only way for the body to free itself of the parti cles and mucus clinging to the respiratory tract walls is to cough and expectorate.

HOW WE BREATHEAir is w armed and moi stened as it is dr awn

- in to the body b y the nose.

......._ "---- -To keep food from entering the ai r passage,th e glottis acts as a sa fety d oor . It closes

when food is swallowed.

The passage along which a i r is d r awnin to the b od y is known as the tr achea.

From the trachea, the air is t aken to the lungs by way of the bronchial tubes.

muscles lift the r i bs. Air is squeezed out again when the diaphram lifts and the ribs d r op.

d iaphragm

Figure 1 The respiratory system and its location.

The air from the bronchial tubes flows intomillions of a ir sacs, call ed alveoli, whichmake up the s pongelike mass of each lung. -

Each air sac is covered with a network of tiny blood vessels called capillaries. These blood vessels take the oxygen from the air into the blood st r eam.


Figure 2 Terminal respiratory units of the bronchial tree.

Thus , repeated coughing and expecto ration are the first signs of damage to the respiratory system caused by smoking . The smoke toxins , together with the viruses and particles in the air, affect the bronchial mucus of the lungs and cause a chronic in fection of the bronchial tubes called chronic bronchitis. The infectious mucus thickening and the accumulation of secretions clog up the respiratory tract. As air is no longer able to reach all the alveoli , the total area of oxygen-contact in the blood vessels is reduced. As this condition continues, the thinner walled alveoli burst from imprisoned air that they were not able to release. In consequence , large holes are formed in the lungs and the contact area of oxygen with blood is further decreased . This phenome non is called emphysema , the decreasing of lung space. Unfortunately, there is no

known cure for emphysema because de stroyed alveoli cannot be repaired. This disease results in a decreased supply of oxygen to the vital organs, causing the body to prematurely age.

PART TWO

Is there a connection between smok ing and lung cancer?

Definitely! Lung cancer is almost the onlyone of the malignant growth diseases in which a direct connection can be drawn between the cause of the disease and the disease itself . The connection between smo king and lung cancer is so clear that 90% of all cases of lung cancer are related to smok ing. The disease is manifested by an in crease of mucus cells in the bronchial tubes (caused by irritation of the tobacco smoke poisons) , and at a certain stage, these cells change nature and start dividing uncontrolla bly. This causes the formation of a malig nant growth which congests the bronchial tubes. In this blocked area , the lung collaps es and ceases to function.The malignant cells have an additional property of trailing into organs far away from the lungs.

The chances of a smoker getting lung cancer are 60 times greater than those of a non-smoker. Thus, not smoking is a salient way of preventing malignant growths in the lungs. Means to prevent malignant growths in other organs are almost unknown.

How does smoking damage the heart and blood vessels?

As in the case of the respiratory sys tem, today there is no dispute over the detrimental influence of smoking on the cardiac system. Many facts decisively indicate this deleterious influence.


1) Smokers suffer from heart at tacks caused by blockages in the heart muscle 8 times more than non-smokers.

2) There is a high occurrence of sudden death, G-d forbid , caused by sudden disturbances in the heart rhythm of smokers.

3) There is a high occurrence ofhigh blood pressure among smokers.

4) There is a high occurrence of calcification of the arteries among smokers.

5) Death caused by calcificationof the blood vessels is five times greater among smokers than among non-smokers.

6) The rate of cholesterol-causingcalcification of the arteries and danger of heart disease is high among smokers.

7) There is a tendency towardblood clotting in smokers.

Based on what we know today , the ex planation of the above facts is that the nic otine and other harmful components of to bacco smoke, when inhaled, irritate the nervous system, which regulates the activity of the heart and blood vessels. This increases the heartbeat, disturbs the heart rhythm, increases the working of the heart and its consumption of oxygen, and caus es other detrimental influences on the del icate, complex cardiac system. In addition to the nicotine poison, the carbon monoxide found in cigarette smoke increases calcification of the arteries and decreases the supply of oxygen to the cardiac mus cIe. Sudden disturbance in the heart rhythm explains the high occurrence of sudden death, G-d forbid , among smokers .

The blood vessels most vulnerable tocigarette smoke are those supplying blood

to the heart (as said above) and also to the lower limbs. Smoking can cause an infec tious process in the lower limbs that clogs up their blood vessels. Known as Berger's Disease, this process appears only among smokers , especially amongst the young. In Berger's Disease, putrefaction (tissue de ath) in the extremities of the limbs some times leads to amputation.

How does smoking damage the di gestive system?

The nicotine poison in tobacco smokeirritates the mucus of the stomach and in testines. This increases both acidic secre tions in the stomach and natural contractions of the digestive tract. These irritations make smokers very prone to suffer "heartburn," contractions in the stomach and in testines, and diarrhea. As this process continues, ulcers are likely to develop in the stomach or the duodenum. Studies conducted in the USA show:

1) Ulcer occurrence is two times greater among smokers than among non-smokers.

2) Ulcers occur in direct relation ship to the number of cigarettes smoked.

3) Smoking delays the cure of stomach and duodenal ulcers.

4) Ulcer complications amongsmokers are more difficult and dan gerous than in non-smoking related cases.

What harm does smoking cause the nervous system?

Tobacco smoke poison enters the body through the respiratory system and reach es the brain through the blood. First the


toxins irritate the central nervous system, then repress it. The most common symp toms caused by this are headaches, sleep disturbances, forgetfulness, and trembling hands. The optic nerve is especially sensi tive to nicotine. Nicotine is liable to reduce the sharpness of sight until the point of blindness, G-d forbid.

Is there any other serious damage that smoking can cause?

Statistics show that a large number ofmalignant growths, such as cancers of the mouth mucus, throat , esophagus, and the urinary tract are found more significantly among smokers than among non-smo kers.

Can cigarette smoke harm the health of non-smokers exposed to it?

Most people believe that smokingharms only the smoker himself . Recent studies have made it clear, however, that people who are situated near a smoker in a closed area - such as an office, a wed ding hall, a vehicle - become passive smokers, inhaling smoke and tobacco poison saturated air. There are those who claim now that "second-hand smoke" is more dangerous than smoke inhaled by the "first-hand smoker," especially when he is smoking a filter cigarette.

Are children of parents who smoke liable to suffer?

There are a number of facts which clearly indicate that children of smokers are li able to suffer , especially from irritations in the respiratory passages. Breathing the smoke-filled air of their environment, they become passive smokers . The facts are:

1) There is a higher frequency of respiratory congestion among chil dren of parents who smoke.

2) Coughing is six times more common among children of smokers than among children of non-smo kers.

3) Children of smokers have a greater occurrence of infections in the bronchial tubes and lungs.

4) Among children operated on to have tonsils and polyps removed, 58% were children of smokers and 28% children of non-smokers.

Is there a consensus of opinion in the medical world regarding the haz ards of smoking?

Until 30 years ago, no serious research had been conducted on the subject. In the past 30 years, tens of thousands of re search studies have been published. These studies clearly show that smoking results in many diseases and shortens life, G-d forbid , as described in Part One here. Similar studies have been conducted in different ways throughout the world, and they all report the findings described above. There is no difference of opinion among researchers about the harm done by smoking. There are differences of opin ions as to which mechanisms in the body are affected , but not as to the harm itself.

If smoking is so harmful, why don't people stop smoking?

The reasons for smoking are a subject for a study of its own. Smoking is a habit formed by various factors: psychological, emotional, social, asthetic, and so on. It is a habit that people generally start at a young age. Young people smoke mainly to


imitate adults, to stand out , to make an im pression. There is also peer-group pres sure where smokers try to convince non smokers to be like them. It is very easy to start smoking in order to feel accepted into a group , into society.

A short period of "amateur" smokingquickly turns into a habit, an addiction al most as hard to shake off as a drug addic tion , if not harder. No matter how clearly aware smokers are of the dangers of smoking, it is still extremely difficult for them to stop.

Nevertheless, what is the great temptation of the pleasure of smoking?

Studies show that people are drawnmore to the very act of smoking rather than to the chemical influence of tobacco. Apparently, it is pleasant and relaxing to light a cigarette or pipe, feel it in the hands, hold it in the mouth, suck in the smoke, flick the ashes , and so forth. Stud ies also show that in many cases the cig arette has the same effect on the adult that the pacifier has on the baby.

Do all smokers suffer equally from the health hazards?

Definitely not! A number of factors work ing together determine the degree of dam age caused by smoking. These factors are:

1) The amount of smoke. As in all forms of poisoning, the risk is linked to the amount of toxins absorbed into the body. The most serious harm occurs to people who smoke more than 20 cigarettes a day.

2) The quality of tobacco. Themost hazardous component, nico tine , is found in varying percentag-

es, according to the type and culti vation of the tobacco. Today there is refined, low-nicotine tobacco avail able. This type of tobacco contains smaller amounts of poison, but it is by no means nicotine-free. In other words, there is no tobacco which does not harm health.

3) The form of smoking. It is more harmful to smoke cigarettes than cigars , pipes, or water pipes. The smoke of the cigarette paper it self is an additional hazard. Also , cigarette smoke is inhaled deeper into the respiratory system and absorbed very easily.

4) Some people are more sensi tive than others to nicotine. This ex plains why two people smoking the same amount are not affected equally. This fact both supports and contradicts the smoker's standard defense that "I know heavy smokers who lived many years in excellent health."

Is it possible to be cured of smok ing?

Definitely yes. Although smoking is adifficult habit to stop, it is definitely pos sible. It is easier actually than rehabilitation from other addictions. Drug, alcohol, sleeping pill, and tranquilizer addictions create a physical dependency which is very difficult to stop, whereas smoking is a "psychological" addiction. The body does not become addicted to demand nicotine and other tobacco toxins. In the USA today , nicotine dependency is considered a physical addiction. Chain smokers there are given nicotine patches to put on their skin over blood arteries, so that small amounts of nicotine can continue entering


the body while the person reduces actual smoking. I do not agree with this. My proof that nicotine dependency is psychological is the fact that Torah-observant smokers very easily go 26 hours without smoking during Shabbat because of their psycholo gical-cognitive awareness that they are forbidden to smoke then. However , these same people find it hard to go for a few hours without a cigarette on weekdays .

ing danger even more than trans gressing a mitsva.

3) Belief that it is possible to stop. More than 30 million people in the USA, several millions in Europe, and hundreds of thousands in Israel are former smokers .

The manner of quitting has to suit your own personality. You can gradually de-

"In the USA today, nicotine dependency is considered a physical addic tion... I do not agree with this. My proof that nicotine dependency is psy chological is the fact that Torah-observant smokers very easily go 26 hours without smoking during Shabbat because of their psychological-cognitive awareness that they are forbidden to smoke then. However, these same people find it hard to go for a few hours without a cigarette on weekdays."

Many people stop smoking after unfortunately suffer ing from smoke-caused dis eases . Certainly it is preferable to quit out of desire to preserve one's health rather than because of disease, G-d forbid. It is possible and worthwhile to stop smoking at any age. The following three principles can help smokers achieve this difficult goal.

1) Clear knowledge of the hazards of smoking. This is vital for an enduring decision to stop.

2) A strong desire to preserve the health of the body in a strict, non compromising way , as commanded by the Torah. "Watch yourselves very carefully" (Deuteronomy 4:15). Health is the most precious posses sion we have in this world. Thus, preserving one's health is one of the most important mitsvot (Command ments). The Torah allows us to break almost all of its Command ments in order to save life. The Tal mud says that one should avoid risk-

crease cigarette intake, or you can make a single decisive stop. Either way, there will be a certain unpleasantness and uncom fortable side effects. These phenomena disappear most easily among those who stop smoking in a single decisive act. It is within the authority of the individual to stop smoking , and no special methods or magic cures can make it easier or faster.

How can the side effects caused by stopping smoking be prevented?

The discomfort is psychological and notphysical, despite its physical expression . Thus, one should not worry about these reactions. There are some small measures that can reduce this phenomenon.

1) Increase physical activity - walking , exercising , and so on.

2) Avoid overeating. After stopping smoking there is a tendency for increased appetite and weight gain. This is because of the reawakening


of the taste buds in the mouth, which were less sensitive during the smok ing period.

3) Use substitutes for smokingsuch as chewing gum, sucking can dies, holding a cigarette mouthpiece or a dummy cigarette .

4) Drink more, especially fruitjuice.

What do you recommend to smokers who absolutely cannot quit smoking?

There are isolated cases of people whosuffer emotional disturbances when they try to stop smoking. For these few isolated cases it is recommended to.

1) Switch to smoking cigars or pipes, or

2) Don't smoke more than tencigarettes a day .

3) Use refined tobacco low in nicotine.

4) Smoke only in fresh air, so asnot to breathe in smoke-saturated air.

If smoking is so terrible, why isn't it prohibited by halacha (Jewish law)?

This question should be addressed not to me but to the great rabbinic adjudicators of our generation, may they be granted long lives. However, in my humble opinion, there are important sources which answer the question. From the Torah verses, "Only take heed and watch yourselves very carefully" (Deuteronomy 4:9) and "Watch yourselves very carefully" (Deute ronomy 4:15), the Talmud Sages deduced the obligation to care for and preserve life (Brachot 328).

Maimonides ruled that "It is a Positive

Commandment to remove every impedi ment that endangers life and to protect oneself from it , as it is said, 'Watch your selves very carefully.' The Sages forbade all things which endanger life, and anyone who transgresses them, saying 'I am en dangering myself, what does it matter to others?' or 'I am not strict in this' should be strapped".

Maimonides also ruled that "G-d created the body healthy and whole. It is impossible for a sick person to understand or have knowledge of G-d. Therefore , one must stay away from things that harm the body , and one must do only things that are healthy and healing" (Hilchot De'ot 4:1).

Since the danger in smoking has onlybeen known for the last 30 years, most of the leading halachic adjudicators have not yet dealt with the problem. I hope that indeed smoking will be forbidden by strength of the halacha.

Bibliography

J. Gopin , J. Kark, M. Mainemer et al., “Prevalence of Selected Health Characteristics of Women and Com parison with Men,” Israel Journal of Medical Science 17:145 (1981).

J. Gopin, J. Kark, S. Halton, et al., “Cigarette Smoking and its Relation to Anthropometric Characteristics and Biochemical Variables in Jerusalem - 17-Year Olds and Adults,” lsra.el Journal of Medical Science 18:1233 (1982; 8).

C. Macarthur and E. Konx , “Smoking in Pregnancy : Effect of Stopping at Different Stages,” British Journal of Obstetric Gynaecology 95:551 (1988; 25).

D. Hole, C. Gillis, C. Chopra et al., “Passive Smoking and Cardiorespiratory Health in Scotland,” British Medical Joumal 229 :1100 (1989).

N. Dalages, L. Pickle, J. Mason, et al., “The Relation of Passive Smoking to Lung Cancer,“ Cancer Research 46 :4808 (1986).

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