John is a 43-year-old gay-identified man who arrives coughing at my office for his weekly therapy appointment. “I’ve now been living with HIV for 15 years and undetectable for as long as they could measure viral loads. Now my doctor is telling me I have to quit smoking my pack a day.”
I clarify, “So, you’ve been taking medications every day to enhance the quantity and quality of your life, yet you’re still smoking a pack of cigarettes a day. How does this make sense?”
“Everyone has to die from something,” he replied.
On the surface, what John is describing might seem a complete contradiction. How could someone who is so attentive to his body’s very survival and well-being be so actively destructive at the same time? Yet, this is exactly the predicament that many living with HIV are now facing, as they are two-thirds more likely to smoke than their HIV-negative counterparts. They may be adherent and steadfast in using medications to stay healthy, but equally dedicated to smoking tobacco cigarettes on a daily basis. It is the oral equivalent of writing with one hand and erasing with the other, which usually results in feelings of shame, embarrassment and guilt.
There are many reasons why someone might continue to smoke despite the well-established risks and why in 2010 the Centers for Disease Control and Prevention found that the overall prevalence of recent smoking cessation was only 6.2%. One has to do with the fact that nicotine itself is a powerfully addictive drug. The National Institute on Drug Abuse has described the attraction:
Cigarette smoking produces a rapid distribution of nicotine to the brain, with drug levels peaking within 10 seconds of inhalation. However, the acute effects of nicotine dissipate quickly, as do the associated feelings of reward, which causes the smoker to continue dosing to maintain the drug’s pleasurable effects and prevent withdrawal.
Months after quitting, there are often palpable withdrawal symptoms of irritability, anxiety, sleep deprivation and reduced attention span.
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