Smoke Signals

Let me begin by telling you how much I used to love to smoke cigarettes.  As a child, my friends and I rode around on our bicycles and picked up cigarette butts from the ground, letting them dangle from our mouths while we rode wildly down the streets. I once stole a cigarette from my aunt’s purse and kept it stashed in a wallet for months afterward, during which time I would periodically open the clasp and inhale the sweet smell of tobacco. As a teenager, I began to smoke ‘for real’ – roll-your-owns, cloves, menthols, and so on and so forth.  I did this despite the fact that my grandmother was a smoker who developed COPD. Over the years I watched her become increasingly fearful as the disease progressed, leaving her homebound and dependent on supplemental oxygen, until she later died from complications arising from her condition. Even the haunting memories of my grandmother’s suffering failed to subdue my fascination with – and later, my addiction to – cigarettes.

But this isn’t really an essay about smoking and my personal struggles with nicotine addiction.  I’m actually writing this with the intention of addressing global health priorities. I’m hoping my own experience with what’s generally considered to be a bad health habit will generate a discussion on how to hinder behaviors, such as smoking, that contribute to the onset of non-communicable diseases which are killing human beings off at alarmingly high rates. In a recent article published in the New England Journal of Medicine, it’s reported that there are “four common behavioral risk factors (tobacco use, excessive alcohol consumption, poor diet, and lack of physical activity) [that] are associated with four disease clusters (cardiovascular diseases, cancers, chronic pulmonary diseases, and diabetes).”[2] There are studies and statistics out there to support that statement, but the question is, how are we going to get people to care about this issue, and further, to make major adjustments to their lifestyles in order to prevent the onset of these non-communicable disease patterns?

I’ll be honest. I don’t have the answer. I finally stopped smoking in my early twenties, with only a few lapses here and there, and thankfully I didn’t develop other addictive behaviors. Further, I’m employed and I can afford to purchase fresh, healthy food and to pay for a gym membership. I work as a registered nurse in the Bronx, and the same can’t be said for the majority of our patients who are representative of the working poor, the unemployed, and/or the underserved in New York City. Most of the patients who arrive at the Emergency Department where I work have diabetes, hypertension, high cholesterol and asthma. They fit the non-communicable disease model…hell, they ARE the model. And I’m not exaggerating when I state that the majority of those we treat engage in at least two of the risk factors mentioned earlier that are directly associated with the onset of their present disease processes.

Part of my role as a nurse is to educate my patients about the repercussions associated with smoking, obesity, and poor dietary habits, but there’s a consensus among the staff where I work that our patients aren’t very receptive to health education overall. Perhaps this is because the patients arrive at our door in a truly emergent state or, at the very least, they arrive in personal crises related to their abdominal pain, fever or tooth ache.  Under such circumstances, I suppose anyone would be averse to an educational session with a health care provider they never anticipate seeing again, since their time spent with the staff in the ER is relatively short-lived. However, it’s worth noting that many of our patients utilize the ER repeatedly for the same complaints because they aren’t following up on an outpatient basis with appointments made to manage their chronic conditions, and/or because they aren’t “compliant” (as we say in the health care business) with their medication regimens. Therefore, the patients are flung into health crises time and time again.

Also, there is the issue of access. Do the individuals we treat live in proximity to a pharmacy where they can obtain their medications? Do they live near a grocery store that sells produce and other healthier food choices at affordable prices? Do they have health insurance to assist with their medical expenses? Do they have money to purchase a subway/bus pass to get to their medical appointments? These are arguably concerns on a global level, not just in the Bronx.

Non-communicable disease processes and the behavioral and dietary risk factors that trigger their onset are considered a “global disease burden.”[1]  Recommendations to minimize their impact on world-wide morbidity and mortality rates include anti-smoking/drinking campaigns, with taxation and restrictions on those same industries. There are also endorsements on imposing “targeted pricing and regulatory interventions” [1] on certain foods that are attributed to the rise of obesity. And, as many of us know, engaging in regular exercise is recommended over leading a sedentary lifestyle.

Now we need to figure out how to inspire people world-wide to care about all of this. Again, the people who I treat in the Bronx generally don’t heed recommendations to modify the habits that spur their repeated health crises. I make that point not to sound flippant, but to demonstrate that within a contained region it’s proving to be a challenge for the population to induce lifestyle changes, so I’m left wondering what is the global smoke signal that will provoke masses of people on the planet to do such a thing?

[1]Ezzati, M., & Riboli, E. (2013). Behavioral and Dietary Risk Factors for Noncommunicable Diseases. New England Journal of Medicine, 369, 954-64. Retrieved October 14, 2013, from

[2]Hunter, D. J., & Reddy, K. S. (2013). Noncommunicable Diseases. New England Journal of Medicine, 369, 1336-43. Retrieved October 14, 2013, from


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