"Do you at least take the oxygen off when you smoke?" I asked the patient, a man I'll call Mr. Smith.
I was seeing him for end-stage emphysema. He was dependent on oxygen 24/7 and still smoking two packs a day.
"Oh, no," he said, "I'm too short of breath to smoke without my oxygen."
As a pulmonologist, I'm only too familiar with the health effects of tobacco use. Even in Utah, the state with the lowest smoking rate (9.8 percent), most of the patients I see come to me because of tobacco-related lung disease.
I counsel all the active smokers to quit, and many tell me it was their own choice to smoke and they have no one but themselves to blame. But it's not so simple.
Many, most, have started smoking as children: Sometimes when they were lighting the cigarettes for their dads, sometimes emulating their parents, sometimes lured by the advertising designed to appeal to children.
And once you start, quitting smoking is incredibly difficult. The tobacco cessation rates are quite dismal. Only about 6 percent are able to quit, even with the majority of smokers having attempted tobacco cessation. Medications, counseling, nicotine supplements and incentives programs have had some success, but even in combination they are hardly a panacea.
I think of my patient who had lung cancer and was treated for it, but remained unable to quit smoking until he developed a second lung cancer. Finally, barely able to breathe, he was able to quit before he died.
And I think of Mr. Smith. These aren't bad people, or people without willpower. These are people who are physiologically susceptible to nicotine, just as the rest of the us are, but through bad luck, bad medical advice or bad initial choice, were exposed to cigarettes enough to become addicted.
And yes, smokers cost all of us more with their healthcare while they are alive. But arguments in favor of the existing practice in several institutions that discriminates against hiring smokers seem disingenuous. We don't have effective treatments to offer, and making them unemployable seems to do more for the company's bottom line than for the purported benefit of helping people quit.
Yes, medical care is astronomically expensive, and this increased expense has not come with increased health benefits. Yes, the major interventions that would help improve health and reduce healthcare costs have more to do with lifestyle than any physician prescription or test. If we don't smoke, if we eat better and exercise, we would all be healthier.
But I'm tired of hearing obese executives admonish the members of their healthcare plans to lose weight. The rates of meaningful, permanent weight loss are only slightly less dismal than the rates of successful tobacco cessation.
These problems are complex and arose over decades, with significant investment from corporations that profited from our use of their products. Similarly, obesity skyrocketed as high-calorie, high-salt and high-fat food became ubiquitous.
These are important public health problems that need to be fixed. But we must not pretend that when the 4-year-old subsisting on the typical modern toddler diet of chicken nuggets and french fries grows up to be the obese teenager drinking soda with diabetes, he did so by choice.
The 12-year-old living with parents who smoke is far more likely to start smoking herself.
Whenever my patients quit, I always ask how they were able to do it.
"I caught my little girl playing with a cigarette," one said, " and she told me 'Daddy, when I grow up I want to be just like you.' That was it. I never smoked another one."
Denitza P. Blagev is a pulmonologist in Salt Lake City, where she blogs at mybetterdoctor.com.