‘Can it really be that hard?’
The three of us exchange glances. It’s after-hours and we’re sitting in a small room with one too many chairs and precisely one too few windows. Overhead, an ancient strip light hums away like tinnitus, bathing us in sterile, anodising, brightness. Odd, I think to myself, that the last time this room saw any sunlight was the day it was built.
‘No idea, Prof. I’ve never smoked.’ Ameer looks back at the Professor.
‘Well, nor have I,’ says Prof. They both turn to me.
The layers of hermetically sealed asbestos between us and the outside world have trapped the summer and will not let it go. Each of us has our collar undone and our sleeves rolled up. Our chairs are so close that we sit ramrod straight so as not to encroach on each other’s personal space. This forced physical proximity makes me feel more candid, like we’re just three mates tucked in the corner of an old pub.
‘It’s hell.’ They both look a little surprised. I carry on. ‘Do you know Bill Hicks?’
Across the corridor from our confessional lies the reason for our discussion. In a room that has a window, but lacks a view, baby Theo is tethered to two small plastic tubes that run over his chubby cheeks, loop his ears and plug into the wall. The tubes deliver a steady trickle of oxygen.
Theo was born almost four months too early. When he left his mother’s womb the surface inside his lungs, a sprouting network of tubes branching outward from his windpipe and bubbling off into tiny alveoli, where he can absorb the oxygen he needs and lose the carbon dioxide he doesn’t, should have resembled an inverted forest. Without the time his lungs needed to grow, when Theo was born that forest was more akin to a shrubbery. Surfactant, a soap-like substance, should have been spread throughout his lungs, like a thin layer of WD-40, providing just enough surface tension to stop those gas-exchanging alveoli from collapsing down like deflated balloons. But Theo was delivered two weeks before his lungs developed type II pneumocytes – the cells that produce that surfactant – and three months before they would have produced anywhere near enough. Importantly, Theo’s five-hundred gram body just wasn’t ready to breathe. His brain and his muscles hadn’t had time to fully rehearse even that most simple and automatic of processes.
Theo did have one stroke of luck: he was born in a rich Western nation in the early part of the twenty-first century. Shortly after he was born, a doctor passed a tiny plastic tube into Theo’s trachea and doused his lungs in man-made surfactant, so that Theo’s alveoli wouldn’t collapse. The tube was connected to a breathing machine, supplying the right amount of oxygen, and gradually teaching Theo’s body to take over his own work of breathing. It was a long and rocky course. Theo had had infections, a common problem for preterm babies. His immature gut had been at risk of breaking down and he had very nearly needed an operation. But after everything, he had come through. And he had grown. However, Theo wasn’t out of the woods yet. The respiratory support he had needed to keep him alive had left him with bronchopulmonary dysplasia: the inside of his lungs were scarred. In time he’d overcome it but, right now, Theo had a persistent need for help with his breathing. When Theo came upstairs to us, on the paediatric intensive care unit, he had outgrown the nursery masks that supplied his lungs with just enough pressure to stent them open. Upstairs he’d progressed well, rapidly overcoming his need for that pressure. But Theo still needed a small amount of oxygen and he would do so for a while. That was the problem. Theo was going to need oxygen in his home, and that would mean that Theo’s father would have to give up smoking. Or risk his house exploding.
‘American comedian. He died of pancreatic cancer.’ I pause. Doctors always seem to remember how celebrities die. ‘Anyway, he had given up smoking. His act included this great sketch about how, years afterwards, every time he saw someone smoking, that cigarette looked like it was made by God, rolled by Jesus, and licked shut by Claudia Schiffer.’
I decide it’s best not to tell Prof exactly what Bill Hicks said about Claudia Schiffer.
‘I smoked for a while, during uni. I haven’t smoke in years now, but it’s still a surprising act of will. I know, in the abstract sense, that I don’t want a cigarette. But that doesn’t remove the desire. The ritual, the five minutes of head space, the caffeine-like hit.’ I stop before I start harping on like a jilted lover.
Prof smiles; ‘Well, let’s make sure he gets some help.’
I thought of Theo and this conversation recently, when I read with a heavy heart that last year cigarette consumption rose in Australia, ending ten years of gradual decline. This, despite some of the most stringent anti-tobacco measures in the world. In Australia, cigarettes are sold in ugly, uniform packets and carry graphic health warnings. Furthermore, taxation means that a pack of smokes seems to cost only slightly less than a small estate car. By contrast, the UK, erstwhile the poor relation in terms of meaningful anti-tobacco policy, continues to see cigarette consumption fall.
They say that half the things you learn in medical school will be out of date within five years and they’re right. What they don’t tell you is that some of the things you learn in medical school might not be the whole story. Most doctors will have heard of the British Doctors study by Richard Doll and Austin Bradford Hill. In a world where it’s rare for a paper to be talked about more than a few years after it’s published, the British Doctors study is still analysed more than sixty years since it appeared in the British Medical Journal. The reason medical students still learn about it is that it is an elegantly simple example of a particular kind of study, called a cohort study. And it provided unassailable proof that smoking causes lung cancer. The British Doctors study is as close as medicine gets to gospel truth. I seem to recall my public health lecturer being giddy with excitement to explain it to us. What he didn’t mention though, is just how long fears regarding an association between cancer and smoking had existed. If he had, we might have noticed something interesting.
In nineteen-thirties Germany the Nazi party had been aware of the link between smoking and cancer. Leading German scientists were utterly convinced of the relationship. The state machinery had thus gone to considerable lengths to attempt to deter the population from lighting up, including bans on smoking in various public locations and preventing children under eighteen buying tobacco. The Reich didn’t hesitate to use the full force of its dismayingly effective propaganda machine in discouraging smokers, with all sorts of purity slurs and disingenuous associations. History has taught us, all too well, just how effective that propaganda machine was. Only, here’s the thing – it didn’t work. Prior to the war, tobacco consumption in Germany continued to rise. Not even one of the most perversely controlling regimes in modern history could effectively tackle smoking.
I’m not comparing Western anti-tobacco measurements to pre-war Germany. But I am noting the tendency of punitive measures to reach a stalling point in their effectiveness.
So why do I think cigarette smoking continues to fall in the UK, despite having long lagged behind Australia? I wonder whether it’s because, in Australia, vaping of nicotine-based products is banned, whilst in the UK it isn’t. I see the sense of a ban. Given that the longterm effects of vaping are unknown, that nicotine is one of the most addictive substances on earth and that prevention is better than cure, early restrictions on nicotine vaping seem to make complete sense. Only, do they? There are an increasingly vocal number of adult physicians arguing that vaping is a useful tool in the battle against cigarette consumption. In the UK, many people are turning to the far-cheaper practice of vaping as an alternative to cigarettes. Some patients even report trying to utilise it in their efforts at smoking-cessation.
It all just got me wondering whether Theo’s dad vapes these days.