Reaching Through the Smoke Screen

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Joe Monroe has a life-changing conversation with a dermatology patient who presented for one set of complaints but found hope for addressing another problem.


A 41-year-old woman came in for evaluation of two lesions: one on the dorsum of the left hand, the other on the lateral aspect of the right calf. Both had been present about a year, growing slowly. Neither caused any discomfort, but they were of concern nonetheless. A friend who had seen them insisted that the patient seek evaluation.

On examination, I strongly suspected both lesions were basal cell carcinomas, even though these are unusual on 41-year-old patients. (They are much more common on those 60 or older who usually have had far more time to accumulate the requisite sun exposure). But this patient’s skin, while dark, was extraordinarily sun-damaged, explained by the patient as due to her “love of the great outdoors.”

But there was more going on. For one thing, she had a mask of irregular brownish hyperpigmentation covering her forehead, cheeks, and maxilla. On questioning, this turned out to have been present for at least 10 years, darkening over time. Melasma, also known as the “mask of pregnancy,” was what we were dealing with, even though the patient had never been pregnant or taken birth control (the usual sources of the requisite estrogen); excessive UV exposure and darker skin predispose individuals to this common condition. We talked about her melasma for a few minutes, and I referred her to our cosmetic dermatology section for treatment.

But beyond the sun damage and melasma, there was still a sallow look to her skin. “How’s your health, in general?” I asked, as I often do. Patients tend to assume we know all about their history of hepatitis or liver transplant. But, no, she hadn’t had any of those issues and was otherwise healthy, she said.

Suddenly inspired, I finally asked the right question: “Are you a smoker?”

Tears welled in her eyes. “Yes, I’ve smoked for more than 20 years. How did you know? Do I smell like cigarettes?”

“No,” I responded. “And no offense, but I can see changes in your skin—yellowing—caused by smoking. There’s a way to make that better. Do you have any interest in quitting?”

Though stunned by this information, fortunately she was very much interested in becoming an ex-smoker—arguably, the most significant issue uncovered on this visit. Basal cell carcinomas, serious as they can be, can be removed and hopefully prevented in the future. Melasma is treatable and “merely” a cosmetic issue. But the effects of smoking are protean.

Even though it’s not our primary task to counsel smokers, when I identify one who seems willing to learn about smoking cessation strategies, I take the time to do it. Fortunately, she was the last patient of the morning, so we had an extra five minutes at our disposal.

I could tell my message was well received by the way she listened intently. I think she knew this was potentially the most important day in her life. We’ll see. But studies show that this kind of brief counseling session is amazingly effective in getting patients to stop smoking.

To many providers, such interventions seem like a waste of time, maybe even rude. But I would assert that patients like this one interpret our silence as tacit approval for continuing to smoke. I hear this a lot: “My doctors all tell me I’m healthy. They’ve never even asked me about smoking.”

Is there a more fit topic to discuss with patients than that of smoking, which kills more Americans than murder, suicide, the effects of drug or alcohol abuse, HIV, motor vehicle accidents, drowning, and gunshot wounds combined? And that doesn’t begin to address the millions who don’t die an early death but who have sharply reduced quality of life from the effects of smoking (chronic lung diseases, stroke, heart attack, and bladder cancer, just to name a few).

It is, far and away, the biggest preventable health care problem in this country, the impact of which is almost impossible to overstate. And all this for the only product sold in the US that is not only utterly devoid of an upside, but also certain to create health problems when it is used as intended.

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