Kurt Vonnegut once said, “The public health authorities never mention the main reason many Americans have for smoking heavily, which is that smoking is a fairly sure, fairly honorable form of suicide”.
The flick of a lighter ignites the end of a cigarette into a cherry-red ember, you inhale deeply, as the tobacco smoke fills tiny sacs in your lungs called alveoli, where the smoke is absorbed into your bloodstream. From there, nicotine, the active ingredient in tobacco smoke, travels rapidly throughout your system within 10 seconds of inspiration, reaching its target in the brain where it triggers the release of dopamine, which is a chemical responsible for the brain’s reward and pleasure centers. Through the actions of several neurotransmitters including dopamine, heart rate increases, the vascular system constricts, and the user feels a sense of alertness and mild euphoria, referred to as the nicotine buzz – notably enjoyable in combination with coffee, with a few drinks in your system, or after sex.
Because it sparks brain synapses, nicotine has been proven to be an effective cognitive enhancer, as well as having demonstrated effects on preventing Alzheimer’s disease. Plus, what compliments the perfectly fitting suit like a vodka soda and a heater? What better feeling is there than being beer-drunk with your buddies on a sunny day and sharing a lung dart? The act of smoking is social and ritualistic in many communities.
However, as I climb higher and higher up the mountain of med school, my perspective changes. A quick glance of the leading causes of death includes heart disease, cancer, and chronic respiratory disease as the top three. Cancer is the most notable for its correlation with smoking, as one in every twenty smokers will likely develop lung cancer. Seems small enough to roll the dice. However, because of its effects on the cardiovascular system, smoking also highly increases your chance of heart disease and atherosclerosis. And if you’re have a 20 pack year history (the equivalent of one pack per day for 20 years), you are literally guaranteed to develop emphysema if something else doesn’t kill you – and I promise you don’t want to be breathing like a guppy with an oxygen tank by your side for the miserable final years of your life.
In short, smoking is good for your brain, and fucking awful for the rest of your body. But this is nothing new. I don’t say this to act like some moral authority health-gestappo, because I certainly indulge in many vices myself. And I believe, with proper knowledge, that everyone should have the constitutional freedom to live their life how they wish.
Around twice a month, we have patient interactions in which we practice our clinical skills – sometimes we take a history, sometimes we give a physical exam, and sometimes we’re simply assigned to talk to the patient and try to understand them, in order to boost our skills in the art of being an empathetic, socially adept physician. All of these interactions are recorded on video, watched by our instructors, scrutinized and graded.
Recently, my medical school gave us the task of talking to a patient who smokes. We were instructed to ask the patient about their personal life, their smoking habit, how it plays a role in their daily lives, as well as providing counsel and encouragement to quit.
I scoffed at the assignment, but understood its purpose. I stepped into the patient room with my white coat, pretending that I was some sort of medical expert, in hopes of convincing a patient to quit their deadly habit.
I greeted the patient with, “Hello, I’m Student Doctor Soze” as I extended my hand to shake the tattered, leathery mitt of John Doe, 68 years old, roughly six feet tall and 180 pounds, dark greying unkempt hair with a beard. He smelled like smoke. The patient appeared calm, relaxed, and very uninterested. I also noticed a boot on his right ankle with crutches to his side.
Through his sad eyes, I could see that Mr. Doe did not want to be in the room just as much as me. Nevertheless, I began asking him about his life. He spoke slowly – unemployed, disabled, and lives alone. We talked for a bit as I tried to put together a mental framework of the man in front of me.
Eventually, I bridged into the topic of the day – smoking. John Doe began smoking mildly in his teens, served our country in Vietnam, and married his sweetheart upon his safe return. He smoked approximately two packs per day for roughly forty years after the war. For a guy who likely saw atrocities such as dismembered limbs flying in the air, bullets ripping through his friends’ brains, and bayonets thrust into a man’s chest, I suppose a heavy smoking habit isn’t the worst way to cope.
We are taught that before we tell a lifetime smoker to quit cold turkey, they should first be asked to make moderate changes, such as shifting from two packs per day to one, or something of that sort. “Have you ever tried to quit, or reduce your smoking habit?” He replied, “yes, I tried to cut down to only one cigarette per hour. But then I just kept watching the clock waiting for the hour to strike so I could smoke again”. Small change is better than nothing, “how long did this last?” … “Two days”.
I asked Mr. Doe what he does on a day-to-day basis and how smoking is correlated with his activities. “I wake up and eat some toast… have a cup of coffee and a cigarette.. I lie on the couch and smoke and watch crime shows. Usually I eat lunch. Then I watch a movie or more crime shows”. I felt a deep pit in my stomach. Playing devil’s advocate and going off script a bit, I said, “Yeah, I’m sure smoking helps you keep your mind sharp to figure out who the killer is before the detectives do”. He laughed, “Exactly. I like to read sometimes too… I like Hemingway”. I took that and asked him about his favorites, and we talked about Hemingway and literature briefly.
“Do you get any physical activity? Ever go for a walk in the neighborhood or anything like that?” The man pointed down to his booted ankle and said, “I can’t really walk anymore. I can’t work. I can’t do nothing”. We were told that we were supposed to encourage physical activity. Scratch that idea.
Can’t work. Can’t move. Poor. Old. Disabled. I was running out of encouraging words. I finally shifted to the final and most important factor in quitting – support. “Tell me about your friends and family”. He took a long pause. “I don’t really have any friends. Once a month or so I get coffee with a guy I know”… “Any family?” He paused again. I looked into his 68 year-old, watery eyes and felt his despair like it was my own. “I have a niece that lives in Arizona. I talk to her once a year”. There again was a long pause. I didn’t interject because I knew more was coming. “My… my wife died ten years ago. She was the love of my life. I have no reason to quit smoking. I have no reason to live. I don’t drink. I don’t do anything. Smoking is the only thing I enjoy in life anymore”.
I sat in silence for a moment processing what the man had just told me. It took every bit of willpower for me not to defy my instructors. I wanted to say, fuck it man. Keep smoking. You shouldn’t have to waste the last years of your life alone and disabled, craving the only thing you enjoy. Who the hell am I, at twenty-three in my first year of medical school, to tell you to quit something that may give you an extra year of life if you’re lucky. Shit, you’ve been smoking for so long that the damage is done. Quitting won’t do shit for you aside from marginally please your doctor, who also knows your outcome is inevitable. And fuck anyone who tells you otherwise.
But I was being recorded on video, so I begrudgingly mustered, “You know… I can’t tell you that smoking is wrong. Your life, and what you personally value, is all that matters”. Knowing that I was being watched, I continued… “But even so, the mere fact that you are alive on this earth is a blessing, and one that you should be thankful for. The quality of your life for the remainder of your days here is something to keep in mind. You will feel better if you cut down on the smoking, and you will thank yourself if you do. Because you deserve to enjoy the rest of your healthy years on earth as much as you possibly can”.
I half-heartedly meant this, but it sounded nice. Before I left, he asked me what my name was again – he raised his hand to show me a ring on his finger. His ring was the ring symbol for the saint who shares the same name as me. “See this, this saint is my protector. Maybe you are my patron saint”. I stood there half confused, but smiled – “maybe I am”.
I shook his hand, and said I enjoyed talking to him, as he placed his left hand on top of mine, looked me in the eye, and said, “You’re a fine young man. Thank you”, with piercing sincerity.
I left the room shaken. All previous patient encounters felt so fake, so forced. But this time, for the very first time, I felt something. I felt that I connected to this worn-down old man in such a strange way. I was transported into the life of someone less fortunate than me, and not through some bullshit fake-victim card that society loves to play. This man, a disheartened war veteran, stricken with disability, heartbroken with loss, completely alone, wasting away the end of his life lying on his couch watching television while enjoying a cigarette, is someone I felt sorrow for. I don’t think I’ll ever forget him.
Part of it was because I know he felt something. He began quiet, disinterested and hardly speaking. Midway through he laughed, and it was the type of laugh that probably doesn’t come often for a man like him. Who knows when the last time was that someone actually asked or gave a shit about him. Towards the end he battled back tears and spilled his life’s tragic story to me, a young idiot who he had met ten minutes prior. And when I left, I sensed his genuine appreciation, as well as a sense of hope.
If he did quit or cut down or even attempt to reduce his smoking, great. If not, he has every right to smoke every cigarette down to the filter before he departs from this earth, and I salute him.