Dr. Qaadri

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COPD-Chronic Obstructive Pulmonary Disease to be found with the creative excuses of die-hard smokers

By Dr. Shafiq Qaadri, MD

Family physicians often find themselves trying to coax their patients to quit smoking. Though we have successes, I seem to have many unre­pentant smokers. Their excuses are all striking exam­ples of the psychology of self-justification. With this sampling, I celebrate their wit and wisdom.

Safety in numbers: At a University of Toronto teaching hospital, of all places, I saw the memora­ble spectacle of a group smokefest.

The city was awash in freezing rain that day. Yet at the hospital entrance I came upon two die‑hard smokers--both attached to intravenous medica­tion poles--braving the cold. They seemed content to be receiving chemicals from two routes: healing through the arm, damaging via the lungs. I found myself thinking, "Why not put the nicotine in the intravenous bag directly? That would be more effi­cient drug delivery. Or perhaps we should create medicated cigarettes."

As I watched, another smoker arrived, a man with a below-knee amputation driving a motorized cart. Despite severe circulatory disease, this fellow had not shaken his habit. Cigarette cartons were plainly visible in his cart basket.

The final irony: Two doctors and a nurse, certi­fied healthcare providers, joined the smoking lineup. The three patients seemed reassured to have physicians in their midst. Smoking was the great equalizer.

Quitting time: Most smokers are accomplished quitters, having done so many times, Any excuse is a good excuse: a newly smoke-free workplace, a New Year's resolution, a life-insurance exam. Re­cently, however, I heard a patient with a new spin. He deserves the award for the best target quit date.

I had told the award winning quitter's father that he had lung cancer. George Sr. smoked a pack of heavy tar cigarettes a day. Showing him the large spot on his chest X-ray did not cause him to slow down. When I discovered the cancer had spread to his spine, he began to smoke three packs a day. He is deteriorating rapidly.

George Sr. explains his continued smoking thus: "Dr. Qaadri, when you gotta go, you gotta go.”

Soon after, his son came to my office for counsel­ling. George Jr., a man in his early 30’s, also smokes a pack a day of the same heavy‑tar cigarettes.

"George," I said to the son, "can't you read the signs? Your dad smokes a pack a day and gets can­cer. You're smoking a pack a day of the same brand. "

"Yes," George Jr. said, "I'm stressed right now, looking after dad. I'll quit later."

"Later?" I asked.

"I'll quit when my dad dies," he told me. At first I could not follow the morbid logic of his statement. I had never heard such a bizarre quit date, but such it was. We'll see if he keeps his word.

Smoking in utero: Carol, a 25-year-old mother of two, is an enigma. Haggard, she weighs less than 45 kilograms and has lost her hair, a consequence of chemotherapy for lymphoma. Yet she persists in smoking a package of cigarettes a day.

"Dr. Qaadri, smoking's my thing," she tells me dismissively. "I'm a mess without cigarettes."

"But your cancer?" I say earnestly.

"I asked my specialist if there was a cure," she responded. He said no. I said, 'Well, there's no cure for my smoking either.'

"But, Carol, you've just had chemotherapy.”

"I asked my doctor if he could guarantee the can­cer would go away if I stopped smoking. He said no. So I smoke."

When she managed to get pregnant--remarka­ble for someone who has recently had chemothe­rapy--there was still no change.

I said, "Carol, what about the baby?"

"Listen," she replied, “I smoked with both my pregnancies and nothing came of it. Don't worry." Her determination and addiction are remarkable. We await her delivery with concern.

Record-keeping: A patient new to my practice was already taking several medications. When I asked him what pills he was taking, he said he had writ­ten them all down. He then took out a cigarette package and calmly started reading the list of med­ications he had written on it.

We both managed to smile at this irony. Reciting medicines for angina, hypertension and diabetes from a cigarette package was almost poetic.

Accounting: Then there are the patients who use verbal gymnastics to downplay the amount they smoke. Here is a prime example of self-vindication.

Listening to a patient who was wheezing terribly, I commented, "It seems you're smoking a lot."

"I don't smoke that much," the man replied, "only three packs a day."

“Only three packs a day?" I said indignantly.

He just smiled.

"What do you call too much?”

"Well, doc," he said, "I have friends who smoke four to five packs a day. That's too much."

Getting patients to quit smoking is demanding. All the counselling, nicotine patches, videos and fear tactics can end in naught. However, the glimpses into human nature it offers are sustain­ing. The dedicated smoker can surmount all: preg­nancy, death of a loved one, even cancer.

It is the triumph of defiant minds over inhaled matter. Virtuoso smokers remain immune to lec­turing, and their eminent excuses can be at once amusing and frustrating.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education (CME) lecturer. www.doctorQ.ca

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