Smoking bothers me. Bigots bother me. Liars bother me. Pop music bothers me (yes, pretty much all of it). Trolls bother me. But what bothers me more than most anything else is hypocrisy.
hy·poc·ri·sy \hi-ˈpä-krə-sē\ (noun): the behaviour of people who do things that they tell other people not to doI will not claim to be completely innocent of hypocrisy, since I eat doughnuts and drink coffee despite knowing it isn't the best breakfast/lunch/dinner/snack for me, and despite telling my patients not to do exactly what I just did 20 minutes prior. And 60 minutes prior. And 4 hours prior. And seven times the previous day.
However, there are some flavours of hypocrisy which I find just completely intolerable:
- A member of Indonesian parliament who was an anti-porn crusader but was caught watching porn in parliament
- A guy who worked at the International Monetary Fund and was later the Secretary of the Treasury of the United States who didn't pay all his taxes
- A judge who ran a successful anti-drunk driving campaign who then drove drunk into a city bus
Meet Dr. Carter (not his real name™).
There were several-dozen surgeons ultimately responsible for my training, Dr. Carter prominently included (for reasons which will become obvious shortly). These men and women were tasked with teaching me how to diagnose surgical diseases, how to operate, when to operate, and when not to operate. In addition to the surgical aspects of medicine, they also taught me the more abstract points of actually being a physician - how to talk to patients, how to break bad news, and (possibly most importantly) how to behave in general. This portion of my education was not done in a classroom, it was only learned by carefully observing their behaviour and emulating the conduct I considered best and most appropriate.
More important than anything else Dr. Carter ever taught me was one very valuable lesson - how not to act.
As a cardiothoracic and vascular surgeon, Dr. Carter was responsible for curing some of the worst diseases in some of the sickest patients - he performed coronary artery bypass grafts, lung resections and pneumonectomies for lung cancer, and lower extremity bypasses for peripheral arterial disease. Some of his patients were actively dying, while most of the rest were passively dying.
My first procedure with Dr. Carter was a short one, an arterio-venous fistula procedure for a patient with kidney failure who needed to start on dialysis. For the entire hour-long procedure I kept smelling the rancid reek of cigarette smoke wafting off the patient, and I distinctly remember thinking that this patient wasn't doing himself any favours by smoking, despite his already-failed kidneys. That may be a slight under-representation of my actual thought, which was much closer to "This fucking moron is actively killing himself! Why bother going through dialysis if he's trying to commit suicide by tobacco?"
That experience shook me and affected me deeply. I worked with Dr. Carter twice more over the next month, and because smoking is a major risk factor for heart disease, and peripheral arterial disease, I was completely unsurprised that both patients had that same familiar odour of cigarette smoke. Of course I had previously seen numerous other smokers in my then-brief medical career, but for some reason these particular events stuck with me and began to colour my future interaction with smokers. Over the ensuing days and weeks I began to ask patients not only if they smoked and how much, but why. Why had they started? Why had they continued? Why hadn't they quit? Weren't they aware of the damage they were doing to literally every single cell in their bodies? I confess I never really got any answers that satisfied my morbid curiosity, so eventually I capitulated and stopped.
About a month later as I was about to rotate off Dr. Carter's service, I was assigned to assist him on a coronary artery bypass graft (in other words I was going to watch carefully and try to stay the hell out of his way). This was an operation I had been looking forward to for the entire rotation, one of the most fascinating operations in existence, and I was giddy at the opportunity. I eagerly scrubbed in and waited for Dr. Carter to arrive. I was somewhat surprised when his patient did not smell of tobacco.
If you can already see the punch line coming, then you're several steps ahead of where I was at that point. M. Night Shyamalan ("Sixth Sense" MNS, not "The Village" MNS) I am not.
When Dr. Carter finally entered, that familiar scent of cigarette smoke entered with him and smacked me across the face. It dawned on me (as it no doubt did on all of you several paragraphs ago) that it hadn't been the patients who had smelled of tobacco smoke, it was Dr. Carter. My mind started racing. How was this possible? This man was responsible for treating lung cancer, coronary artery disease, and peripheral arterial disease - the very diseases directly caused by cigarettes. How could he possibly be a smoker himself? How could he look a patient in the face and tell him he had lung cancer, and yet still smoke?
As if he hadn't surprised me enough at that point, Dr. Carter floored about an hour later. In the middle of the procedure, Dr. Carter paused, looked up, and said (I swear I am not making this up), "I'm going to go get a breath of fresh air". He then broke scrub and walked out of the room.
I looked in bewilderment at the scrub tech, who obviously worked frequently with Dr. Carter, because she simply sighed and rolled her eyes. She clearly saw the look of utter confusion in my eyes, so she explained to me quite simply, "He's going outside for a cigarette". Under my mask she couldn't see my jaw open wide in disbelief. I stood there completely baffled, wondering if that could possibly be true. And about eight minutes later he strolled back in (reeking even worse of cigarette smoke, of course) and completed the operation without mentioning his little break any further.
This event took place very early in my training, so I did not have the guts to confront him about his smoking. By the time I finished my surgical training several years later, he was still smoking, and still taking his "fresh air" breaks.
I happened to run into Dr. Carter at a surgical meeting a few years after this, and I was hopeful that he had broken his habit. As I shook his hand, however, those same acrid fumes greeted me. I saw him get up to leave in the middle of a presentation and return a few minutes later, his air no doubt somewhat fresher.
Maybe I'm wrong. Maybe I'm making a mountain out of a molehill here. Maybe I'm being overly judgmental and a big asshole. Maybe he simply started smoking long ago and has been unable to quit despite numerous attempts.
But maybe not. Maybe he needs to quit no matter what it takes and set a better goddamned example for his patients. Which means I probably shouldn't have a doughnut or three tomorrow for breakfast.
Fortunately for me, doughnuts don't stink. Or cause cancer.
After the hospital where I worked in the 90s introduced a no-smoking policy, I would often see the consultants driving round and round the hospital grounds, each on their own individual "fresh air" break...ReplyDelete
I live in a neighborhood that is anchored by the campus of a major teaching and research hospital and university. Until the whole "hospital campus area" was declared smoke-free just a few years ago, it was not uncommon to see hospital *patients,* most clad only in their hospital gowns, and many toting along their IV bags on a pole, going outside for a smoke break...even during the subzero-wind-chill days of winter!Delete
Never figured *that* one out...you're in a hospital because you have some health issue that needs attention, but have no problem risking hypothermia and frostbite just to have a cigarette...
People who are capable of great good are also capable of great evil; the two co-exist. I don't expect my doctors to be perfect, but I wish they wouldn't expect me to be either. If I felt that I could tell an ER doctor that I suffer from major depression and was sure that that wouldn't negate every other thing that came out of my mouth, I wouldn't neglect to tell them that. If I was sure that I could honestly say that I know that I drink more than I should and not be judged, I would more easily say that too. I don't wish to lie to my doctors, but I don't wish to be judged for being human more so.ReplyDelete
As an ER doctor, I can promise you two things. First, withholding information about health conditions or habits from someone you expect to evaluate and treat you is foolish and potentially dangerous. You are asking us appropriately generate a diagnosis and treatment plan without all the relevant facts. In some cases, that could be harmful to you. In many cases, it will lead to an incorrect diagnosis. Will you be counseled against drinking too much? Hopefully. But unless it is the source of the problem that brought you to the ER in the first place, most of us just want to move on and get to the issue at hand. Thinking that your history of depression will affect anything, other than a visit specifically for a psych evaluation, is completely untrue. Depression is not that special. A huge proportion of the patients I see have depression, it is just not relevant to most visits. Second, if you withhold or try to hold back information, and we find out, your credibility is gone. And believe me, we usually find out. One of the skills ER Docs use frequently is bullshit detection. When I discover that a patient has willfully deceived myself or the staff, our therapeutic relationship is severely damaged. And while I will continue to evaluate and treat them, I will be questioning everything they tell me that cannot be verified.Delete
As in the rest of life, honesty is the best policy.
Anonymous ER doctor,Delete
OT - you are correct and in a perfect world that is the way it should work. However, I don't know what an individual patient experiences if they let a doctor know they are a mental health patient or on psych meds but there is a lot of stories on the Internet. Also, I read somewhere that the greatest stigma against them is in the medical profession.
I am not a mental health patient but struggle with fatigue. I take doxepin for sleep occasionally. When I was taking Silenor it was cool as no one really bothered to look into what it is. But when I switched to doxepin liquid b/c it's cheaper, there is no end of strange looks from healthcare workers and they attempt to fob me off as depressed. However, they weren't ER docs though. I haven't been to an ER in over 10 years.
There's an easy fix for getting rid of doctors who smoke: Stop treating doctors like gods and start treating them the way other employees get treated. A hospital is a business and most surgeons can't practice without having hospital privileges. I know of at least 2 local hospitals that stopped hiring smokers several years ago. None of their employees are allowed to smoke at work, at lunch, on breaks or at home. They even tested for nicotine as part of their drug screening. Considering that smoking is still perfectly legal, I was surprised they were able to get away with that. But the HR rep said that smokers cost the hospital more in terms of health care expenses, blah-de blah-blah. (My thought was "So does obesity, but you wouldn't dare have a written policy stating you refuse to hire fat people." But I refrained from expressing that opinion.) If hospitals simply stop hiring physicians who smoke, in another dozen years or so, they would disappear from the hospital setting.ReplyDelete
NIH is now smoke-free. It came at a price though. There was at least one employee fired (not a surgeon or a researcher - just one of the people who keeps the place going [in this case, literally]) for smoking a cigarette while walking from one end of the campus to the other. Evidently it was the second time that a Particular Person who already disliked this individual had spotted him smoking a cigarette since the campus had gone smoke-free, and it was now the second time she called his supervisor.ReplyDelete
So one of the institutes is stuck with her and we lost someone who was employed to FIX THE HEATING/COOLING systems in one of the many buildings scattered across the main campus.
Despite his smoking, he was a far more valuable resource to the NIH community at large than an individual employee to a single institute.
Particularly as NIH isn't pursuing hiring people who FIX THINGS and that portion of the workforce is aging rapidly. When the old guys go, we're screwed. You don't want to know how many mysterious leaks are found in the buildings and the tunnel system!
Donuts have artificial sweeteners to taste so delicious. Artificial sweeteners cause cancer (and diabetes).ReplyDelete
Might as well eat them though. If the donuts don't eventually kill you, the erratic sleep schedule and stress will. ;)
I think that you are unfairly slandering coffee in this post. Last I remember the scientific cesspool that is dietary research now held that coffee was either harmless or even good for you.ReplyDelete
I think the point was that a doughnut and a cup of coffee is not a nutritionally complete breakfast.Delete
The hospital I trained at had a very prominent cardiothoracic surgeon who had a CABG (cardiac bypass) performed at said hospital. That did not, however, deter him from his frequent, if not daily breakfast of eggs, bacon, biscuits and gravey, etc. in the hospital cafeteria.ReplyDelete
There were many great doctors in past generations who smoked (athletes too).ReplyDelete
It's a bad habit- not evil. Why this compulsion to ostracize those people?
Primarily because it makes those who do feel better about themselves. Firing smokers because "they cost the company money"? Please. That's bull. Overmoralizing rationale.
The most appropriate response to Dr. Carter is to feel sorry for him - almost certainly he knows the situation and doesn't know how to, or want to, stop. As long as he does his job well, that is your professional concern.
If you are personally concerned, tell him what he already knows- he should stop, or let him know a good way.
If you are not personally concerned, as long as he doesn't do it in your presence, let him be.
You apparently missed the entire point of the piece. Read the title again, and then think about what you just said.Delete
Smoking IS an evil habit, because it not only is terrible for the smoker and causes numerous life-threatening illnesses, it affects everyone else around as well. But then you knew that, didn't you.
Do you smoke?
No I don't smoke. Never have. Would never consider it.
But I have taken care of many smokers, far more than you, I bet.
We have a different view of the concept of evil. What you say about the health effects are true. But does that make it evil or just harmful?
is Dr. Carter a hypocrite or just a talented professional caught in a trap, he can't escape?
I think it's just possible that if you had grown up before say 1970, in a neighborhood where all your friends smoked, where your parents smoked, where the movies told you it was cool to smoke, you might have smoked too. And it might not have been easy for you to quit either. i'll bet Dr. Carter's story is something like that.
And no, it doesn't effect everyone around us, as long as it is confined. Of course, you will bring up the health care costs - look that's a good reason to get people to stop. The health care costs of bad habits are all around us. Try to reform without being judgmental. Let's just try and confine the harm.
I have taken care of heroin addicts. Heroin is a terrible drug. But the people who use it are trapped. They are a more complex subject because they often do commit crimes against others -and are manipulative, but they are intrinsically no more evil than anyone else.
Dr. B, i know this won't change your mind. If you want to call their habit evil, that's your prerogative. Let's try and get them to stop. But there are far more things worthy of being judgmental about - and in fact it makes people worse physicians when they do that because they don't use their best efforts whatever they are to help people like Dr. Carter.
You assume poorly. I grew up in the era where it was ok to smoke on planes, in restaurants, etc. It is impossible to confine smoke as you suggest. Even when walking outside with my wife, if there is a smoker nearby the smoke will trigger her asthma. Why should someone else's disgusting habit with no redeeming qualities whatsoever be allowed to cause my wife (and countless others) respiratory distress?Delete
Smokers aren't "trapped". That's a load of horseshit. My uncle smoked for 30 years, and when he finally realized the toll it was taking, he quit. My mother too. This was also before the medications and nicotine supplements that are available now. I know quitting is difficult, but it is by no means impossible.
I see countless young people today who smoke. I guarantee you that all of them are aware of smoking's dangers, yet they do it anyway. They did not start smoking in a time before the risks were known. So calling them "trapped" is ridiculous.
Heroin is a different story, a red herring, and irrelevant to this discussion.
There is nothing legal that come to mind that a doctor could do that I would consider worse than smoking. Nothing.
Anonymous, smoking IS a nasty habit because unlike most habits, it hurts those who don't indulge in it but have to be in the vicinity of a smoker. Dr. Carter's patients and co-workers shouldn't have to put up with him stinking like an ashtray when he's around them.Delete
Smoking is esp. damaging to small children, yet parents who claim to adore their little ones still light up in the same house or car with their infant, knowing that they're basically smothering their baby on the installment plan. Even back when when I smoked, I always went outside if I was at a house with children and I told their parents to do the same.
Dr. Carter's smoking doesn't deserve sympathy on anyone else's part. If he were forced to chose between his livelihood & his cigarettes, he'd quit. I quit smoking cold turkey on Jan. 1, 2010 after my dentist told me cigarettes were wrecking my gums and I'd lose my teeth if I didn't stop. I could have chosen to be a stubborn idiot like Dr. Carter, but I decided it was better to keep my teeth rather than my bad habit.
Quitting cigarettes isn't much more annoying than quitting caffeine. Annoying, yes. But if someone wanted to (key word: wanted) they could easily do it with minimal side effects. No one is trapped smoking anymore than they are trapped drinking too much coffee. It's a conscious choice.Delete
Also, if Dr. Carter is walking out in the middle of a surgery, he's NOT doing his job well. If he reasons it's ok to walk out when someone's life is on the line to go smoke, he's no doubt making other poor judgement and taking short cuts to get out quicker. That's hardly indicative of a competent doctor.
the secret to quitting cigarettes is to stop lighting them on fire and sticking them in your mouth.Delete
yes it is a very addictive substance. yet people get through the detox period, then light another one on fire and stick it in their mouth.
A doctor who smokes is dangerous to the patients in a psychological manner. If he told one of his patients to stop smoking yet smelled strongly of the stuff himself, the patient is less likely to listen to him/believe what hes saying, as to them its a sign that he doesnt believe whatever he is saying, so why should they. Thus, some, not all, end up back at the hospital again for the same damn reasons.Delete
(same poster as anonymous 25 jan 20:40) Also, in the case of a doctor who eats junk/sleeps irregularly, its not readily evident to the patient during, say, a consultation, thus a doctor who eats unhealthy foods telling a patient to eat better won't have the same effect as a doctor smelling of cigarette smoke telling their patient to stop smoking, as it is not readily apparent that the doctor doesnt listen to his own advice. Unless the doctor is for some reason eating a big mac while telling a patient to stop eating junkfood, it is simply not the same thing. There is also the saying "Do as I say, not as I do" but people who are adamant against stopping or at least unwilling to stop their smoking will readily cling to the fact that the doctor is a hypocrite and thus will find only further resolve to continue smoking.Delete
My dad comes from a long line of beer alcoholics and was one for most of his life, and he has smoked since he was 17 years old.Delete
Sometime in my late teens he was on the drunk side of buzzed and sat at a table with me. With a beer in his hand and a cigarette in his mouth he told me simply "Don't drink and don't smoke".
My dad has done much to f-up my life and I could have easily played the hypocrisy rage card then. But I didn't see hypocrisy there; I saw love.
Not that this will change your mind but it is a different perspective that I hope you will consider.
I believe it's well established that people are much less likely to trust and comply with a medical plan if it was compiled by a obese doctor then a healthy-weight doctor. I would be very surprised if that was not also the case for a doctor who reeked of smoke. Not entirely relevant for a surgeon perhaps but consciously or otherwise, people don't trust health advice handed to them by people who obviously don't know how to look after themselves.Delete
Do remember Ugi though that after a surgery there is still the consultation afterwards, to make sure everything is fine/give closure and time for the doctor to give some perhaps much needed advice. Doc even wrote a post about it a while ago. Its during this time, just like Doc does, that the surgeon might bring up the smoking eating problems etc.Delete
this reminds me of an incident that happened several years back - but not before it started becoming commonly known that smoking was not a good idea.ReplyDelete
I was taking a class which involved restoring furniture, and most of us were manually sanding to get ready for the new varnish. one particular student began berating us all for "wrecking our lungs breathing the sanding dust" - and flounced downstairs to grab a dust mask to protect her lungs.
about 5 minutes later she jumped up again, whipped off the mask and declared "I'm going out for a smoke"
If you don't mind answering, I'm currently training to be a surgical assistant and have a question for you, Doc. Is it ethical for a surgeon to leave during surgery like that? Especially when the patient is being left with (what sounds like, at least) an inexperienced resident who may be incapable of handling any complications that may happen during the 8 minutes they're gone? It seems like it would be negligent and extremely irresponsible for a surgeon to leave during the middle of surgery just to go smoke a cigarette, but like I said, I'm only a student and still have so much to learn.ReplyDelete
Though I'm not in the medical field, I have the same question. While I know that some surgeries are more involved than others, and may take many hours to complete, I always thought that everyone in the operating room (surgeons, assistants and nurses, anesthesiologists) shared the goal of completing the process as expeditiously as possible. Not that we want anyone to rush or take shortcuts that could cause mistakes. But we realize that there are always risks associated with having a person's body cut open, and maintaining anesthesia and other medical support during that process. So we hope that time frame will be minimalized to whatever extent possible.Delete
If a team member needs to step away to answer the call of nature, fine. I want my surgeon to be focused and comfortable, not distracted by a distended bladder :) But "taking a break" from surgery to smoke a cigarette is, IMHO, no more considerate than stepping away from the operating room to check e-mail or post to social media.
Good post as always, Doc. This reminds me a lot of a person my dad is friends with. He was a respiratory therapist who frequently smoked. He'd gotten really sick multiple times BECAUSE of his smoking too. He's retired now, but I'm pretty sure he still smokes.ReplyDelete
My husband told me about a colleague of his that had tried to quit smoking many times over the years. He heard of a drastic measure that supposedly had awesome success rates, and decided to give it a go.ReplyDelete
1. Empty an entire carton of cigarettes into a glass of water.
2. Soak overnight.
3. Drink the water. All of it.
Apparently it worked so well that he can't even smell cigarette smoke without gagging now.
I'd ask a doctor before attempting that. depending on how much nicotine leaches from the tobacco into the water, he may, indeed, never smoke another cigarette as long as he lives... and you can use the other half of the glass as an insecticide.Delete
This method could kill you.Delete
that's another way of saying it, yes.Delete
Not to mention getting an entire carton of cigarettes in to one glass. That would be more like a quarter keg.Delete
You're right, RB. A carton is 10 packs, or 200 cigarettes - a large volume, as well as 3x more cigs than even most heavy smokers would consume in one day.Delete
Again, this method could kill you. The liquid "concentrate" of even one pack could do so, since smokers normally spread out their intake and don't ingest the full chem content of a cigarette (much of which, literally, goes up in smoke).
RB, I had the same thought...it would have to be a *pack," not a "carton" of cigarettes, to fit into even a large drinking glass. And, I can't imagine anyone could even drink *that* much without vomiting. That's why spittoons were standard fixtures in homes and public gathering places when lots of folks chewed tobacco instead of smoked...can't swallow the stuff without getting really sick.Delete
The actions of a smoker are incomprehensible to those who've never inhaled deeply. It's a nasty addiction. Unlike heroin and other things you can withdraw from you don't actually ever quit smoking. You just stop for various lengths of time. Sometimes the rest of your life.ReplyDelete
The hypocrite concept is a big grey area here as well. From what I read in your story, the only person not a hypocrite is Dr Carter (nhrl-tm). Where was he telling people to not smoke? Most doctors in the real world will tell you to sleep properly, eat well, exercise, limit alcohol, caffeine and trans-fat intake, etc., yet when was the last time you've met a real-life doctor that adhered to *any* of those prescriptions?
In my experience, this is what the contents of the hypocratic oath should read: "First do no harm, and second, tell your patients not to do any of the things you did all day every day in med school.."
When something's evil, it's simply evil. Those souls indulging in some particular evil themselves have, perhaps, the strongest authority to pontificate, however hypocritically. They deserve our empathy and gratitude as much as our wrath. Unless they throw the butt out the window of course, at which point I'd gladly nudge them into cross traffic. Cheers.
Sorry, but the whole "You can't understand until you've walked a mile in their shoes" line doesn't hold water here.Delete
Yes Dr. Carter advised all his smoking patients to quit smoking, every day, while reeking of a dirty ashtray. That defines "hypocrisy". Admittedly doctors are not bastions of good health and/or habits, but that does not make what Carter did any less hypocritical. Try working for a day as a trauma surgeon, gulping down whatever I can find to eat whenever I find a spare minute to eat it, feeling lucky to get 20 minutes of sleep on a busy night. That isn't controllable or changeable, but does it make me a hypocrite when I tell my patients and their families to go home and get some sleep?
I've known too many former smokers who would flatly refute what you say about there being no ex-smokers. My mother smoked for years, quit cold turkey, and has never had another craving. My uncle too.
I (somewhat) disagree with your "isn't controllable or changeable" contention. Why aren't other professions stretched so thin time and break wise? I know patients don't wait for convenient hours to get sick but really, couldn't part of the problem be solved by simply having more doctors on staff? Rotating on-calls? Most capable professionals are often caught between customer deadlines, leaky pipes, screaming hungry children and managing the health care of their own loved ones. Plenty of times we justify grabbing McDonalds as expedient while telling our kids they shouldn't eat that crap. Yeah. It makes you a hypocrit. A bit at least.Delete
My mother also quit cold-turkey with no cravings. My dad quit many times without success until the cigarettes quit him. I'm sure there're differences in our addiction abilities and depths, and I imagine Dr Carter (now a bonafide hypocrite, thanks for the details) is in that special unfortunate level I seem to have inherited from my dad.
On the bright side though, you do have a number of patients to look forward to that might just perk up when given a teminal prognosis, allowing them to finally light up again.
Thanks for the in-depth reply, I appreciate it.
Hiring more doctors would be a fine solution, IF it were that simple. This isn't McDonald's where you can place a "Hiring" sign in the window and get a couple of kids on board whenever you need to. There just aren't that many of us willing and able to do the job.Delete
"Able to do the job" is a major factor in this equation too. Sure, most large hospitals have plenty of residents on staff. But everyone has different specialties. So it's not as if any particular doctor can automatically "fill in" for somebody else. Every "job" that comes into the emergency room requires a very specific level of expertise.Delete
There are ways to increase the pool of physicians and you know better than I what they are. What is lacking is a will.Delete
Smoking is one of many possible MD hypocrisies. Unfortunately, I've known more than a few physicians with alarming health-related habits (against which they warned their patients). Those habits involved a lot more than undersleeping or hastily gulping fakefood due to a horrid schedule.ReplyDelete
So what you're saying is that doctors are human?Delete
Now I have to ask, what do you mean by "fake food"? Unless you're talking about eating plastic apples, you sound an awful lot like a Food Babe fan (emphasis on "awful").
I don't know who/what Food Babe is. To me fakefood is the instant-packeted or nonthreatening-shaped stuff that falls out of vending machines or fast fooderies. Its major virtue is that it plugs a stomach hole.
I doubt that your coffee or pastry poisons the very air that people breathe, so yeah, you're a hypocrite but smoking is so stupid and annoying and affects people around them that I won't smack you for it.ReplyDelete
I have one friend who (still) smokes. She does her best to set them aside when I visit her home, or we go out for a cup of coffee or something. It's still a constant presence, but I do appreciate her efforts to space them out. I haven't seen her in a while as she now works evening shift, so I hope she's quit. If not, I hope she will quit soon before it really smacks her around.