A half-century after the first ships carried leaves of tobacco from the New World to the Old, a handful of English Catholics went on trial for plotting to blow up King James I and Parliament with gunpowder. As the conspirators awaited the verdict and sentence for their act of treason -- to be hanged, drawn and quartered -- they did what many facing imminent death have done ever since: They smoked. For the last 16 years, as people with HIV have stared down the barrel of their mortality, those who smoke have had to reconcile a habit that almost guarantees long-term health problems with the immediate desire for a drag.
Until recently the here and now prevailed. But in these days of potent antiviral cocktails, the HIV positive may face a life sentence approaching that of the uninfected. Many people with HIV are now setting their alarms to go back to work, confronting credit-card debts amassed during spending sprees or scrounging to buy back life-insurance policies. How to grow old with good health, if not with good grace, means making a number of novel lifestyle decisions to maximize well-being over the long haul. For smokers, that means choosing between emptying the ashtray or chucking it altogether. This decision, easy to make but agonizing to execute, is only aggravated by the improbable news that cigarette smoking doesn't make HIV a faster killer, and that nicotine -- that most addictive of compounds -- may have genuine medical benefits.
The knowledge that smoking is harmful is centuries old, of course. It wasn't long after tobacco smoke first wafted skyward in England -- and only a year before the explosive attempt on his life in 1605 -- that King James, in his "Counterblaste to Tobacco," fulminated against "a custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs." Other rulers went further: Smokers were excommunicated by Pope Innocent X and condemned to death by Ottoman Sultan Amurat IV; they had their noses slit by a czar and were impaled by a shah. In our own country, public health messages have long drilled it into us that smoking is the major cause of lung cancer and chronic pulmonary and cardiovascular diseases, causing millions of deaths every year and costing billions of tax dollars. "Smoking is the number-one cause of preventable death in this country," says Gloria B. Soliz, a facilitator at the Last Drag, a gay San Francisco smoking-cessation group. Her colleague Jim Smith says, "One out of every three people who smoke develop a tobacco-related illness. Those ire awful odds."
Still, millions puff away, and those with HIV consume cancer sticks with the best of them. Results in 1994 from the long-term San Francisco Men's Health Study of 1,000 single gay and straight men ages 18 to 55 showed that significantly more HIV positive gay men smoked than HIV negative gay or straight men (48 percent, 38 percent and 28 percent, respectively). They also lit up more often -- about 10 percent smoked two or more packs a day. At Quest, a 1,000-patient San Francisco medical group focusing on HIV care, Dr. Margaret Poscher sees a sizable number of smokers: "I would say 25 percent or more," she says. "Of those, probably 60 percent are die-hards who will never quit no matter what. The rest are open to quitting."
I aspire to die of lung cancer," says Christopher Murray, a 29-year-old New Yorker, chanting the die-hard's credo. "I quit for five years when I found out I was HIV positive. Smoking is about stress reduction, but it's also about rage." He adds, "I'm in one of those times when I'm indulging." For Scott Williams, 28, however, 1997 is the year to kick the habit. "I hope to quit before summer comes," says the writer in his Haight-Ashbury kitchen, cigarette in hand. "I've tried to quit about 20 times. I've done everything: I've relied on willpower and tried to go cold turkey. I've chewed the gum, worn the patch, gotten poked with needles. I've done workshops, support groups. I don't want to smoke down the road." In her smoke-ending groups, Soliz hears these laments every day. "Most smokers want to be nonsmokers," she says with a sigh. "People are concerned about getting dates. They want to be attractive to others."
But trying to appear alluring, mysterious or just plain cool is what got many hooked in the first place. "In college, I always sat in the student union with all the cool smokers dressed in black, and we'd puff cigarettes and talk for hours," recalls Scott Williams, who lit up ("a More menthol") for the first time when he was 17. Michael Achille, a 33-year-old public relations professional, also began with a More, at 18. "I immediately abandoned More because they looked so gay, and I started smoking Marlboro -- in the box."
Whether it's More menthol or Marlboro box, by today's standards of both beauty and acceptable behavior, smoking is neither. Those who indulge are pariahs, banned from most indoor spaces and scorned as they huddle outside doorways trying to satisfy an irritating but implacable addiction. Among the hardcore, even love may sometimes take a backseat to nicotine. "I had people not date me because the cigarettes were too much for them," Achille says. "That was embarrassing, because I was like, 'See ya later.'" Trying to balance his tobacco habit with a relationship with a virulent antismoker, Williams went to inconvenient extremes. "Every time I had a smoke -- on the sidewalk in front of his apartment -- I had to go back inside, brush my teeth, wash my face and hands. And he would still sniff me and say, 'I can smell it!'" Scott Croft, a San Francisco webmaster, goes out of his way to gratify his pack-a-day habit politely. "I'm very conscientious," says the soft-spoken 34-year-old. "I don't smoke in other people's houses or cars. Or if I'm in a group of people, I'll stand downwind from them. I try not to infringe on anyone else's rights." Such politeness is to be commended: Although a U.S. Surgeon General's report first linked secondhand smoke to cancer in 1964, it took almost 30 years for the Environmental Protection Agency to officially classify it as a Class A carcinogen, believed to kill some 3,000 people each year.
Marlene Dietrich, wreathed in the haze of her cigarette smoke, might represent the zenith of style, but for mere mortals, smoking is linked to a litany of less-than-glamorous medical outcomes, the most indecorous being cancers of the anus and genital tract. Not surprisingly, HIV positive smokers are much more likely to develop both oral candidiasis (thrush) and hairy leukoplakia -- leathery patches on the tongue and mouth lining (luridly known as "smoker's tongue") -- than their nonsmoking sero-peers. The oft-noted sensation of "kissing an ashtray" is rooted in physical changes that occur in the mouths of smokers. Even scarier, the bacteria that cause the nasty condition Mycobacterium avium complex have been found in the tobacco, cigarette paper and filters of four major brands -- and the MAC bug even survives the smoking process.
Ever since AIDS began, as smokers with HIV reached for their Merits, Kools, Winstons or Camels, they have asked the big question: Will cigarettes make me get sicker faster? Common sense says the obvious answer is yes, but results of two large studies find quite the reverse. "In our research, we did not find increased disease progression or death in smokers," says Dr. Richard Burns, who led a National Institutes of Health study of 3,221 men and women with HIV enrolled at 17 sites in 13 U.S. cities. The other study, led by Lois J. Conley, MPH, of the Centers for Disease Control and Prevention, included 512 HIV-infected men from cohorts in San Francisco, Denver and Chicago who were repeatedly interviewed between 1988 and 1992. Like Burns, Conley and colleagues concluded that smoking "was not associated with an increased likelihood or rate of developing Kaposi's sarcoma [KS], PCP or AIDS" -- findings published in the journal AIDS last October.
That cigarette smoking seems not to hasten AIDS is remarkable enough, but these two studies made some discoveries that are breathtaking, if not downright shocking. Conley was stunned to note that her smokers got PCP less frequently than her nonsmokers (11 percent and 19 percent, respectively). "PCP is a tricky one," she says guardedly. "There are conflicting findings. I couldn't say anything conclusive." More conclusive, though, is the fact that she saw no increased risk of KS among those who smoked, while Burns even saw a decrease among the smokers in his study. "Curiously -- but not so surprising, perhaps -- there were decreases in certain outcomes that might be an effect of smoking," he explains. Among those curious but beneficial outcomes: Reduced rates of cytomegalovirus retinitis and colitis; the HIV-related skin disorder Molluscum contagiosum; cryptococcal infections outside the lung; and aphthous ulcerations.
Where there's smoke, there's fire. Burns did see a connection between smoking and the likelihood of developing AIDS dementia, "which was most disturbing," he says, quickly adding: "That was among the weakest associations that we found." However, both Conley's and Burns' studies found that HIV positive smokers developed bacterial pneumonia much more often than nonsmokers (21 percent and 8 percent, respectively). "With pneumonia, there does seem to be an association with smoking," Conley says. "That's one of our important findings."
Is it possible that so vile a habit may protect against these most fearful of opportunistic infections? One explanation for this bordering-on-bizarre observation, at least regarding PCP, lies in cigarette smoke's malignant qualities. Conley believes cigarettes may break down a protein that PCP attaches to in the lungs. Burns says smoking turns off some immune functions while switching on others. "An immune response to cigarette smoke seems to cause a decrease in certain clinical outcomes," he explains. "If there is one component of cigarette smoke that is beneficial, it is important to know what it is."
Many researchers, of course, have unequivocally proclaimed cigarettes as disease-progression catalysts. Dr. Richard Nieman at St. Mary's Hospital, London, studied 84 outpatients from 1986 to 1991 and concluded that smokers develop AIDS twice as fast as nonsmokers, most with a PCP diagnosis (nine months and 16 months). "If you have HIV and smoke, you are more likely to get full-blown AIDS," he bluntly told Reuters in 1993. "We think it's because of the effects smoking has on the immune system." It should be noted that in the same year, two epidemiologists at Oslo's National Institute of Public Health published exactly the opposite findings. After following 80 HIV positive asymptomatic gay men for more than five years, the Norwegian team concluded that cigarette smoking is not associated with a rapid progression to AIDS. (Interestingly, when they added booze to the mix, the researchers also found no association between smoking and drinking and rapid progression to AIDS; the spirit the participants imbibed is not reported.)
Ever since cigarette ads were banned from television some three decades ago, the ferocity of antismoking campaigns has been intensifying. Alternately humorous (stark roadside billboards, say, painted with yellowed Cheshire Cat -- like grins bearing the sarcastic slogan "Smokers Have Such Nice Smiles") and grisly (cross sections of char-grilled lungs enshrined in lucite reliquaries for display in elementary schools and public libraries across the land), these efforts have raged in the name of public health. But during the past 20 years, some heretical scientists have silently and stealthily been gathering evidence that nicotine, tobacco's most active ingredient, might be medically useful. The publication of Conley's and Burns' tantalizing findings coincides with the case now being made by researchers that nicotine may have a role in treating such serious illnesses as Alzheimer's and Parkinson's diseases, Tourette's syndrome, even schizophrenia. "The problem with nicotine is that it's tied to cigarettes, and that's seen as 'bad,'" Dr. Paul Newhouse of the University of Vermont's College of Medicine told The New York Times in January. "People have difficulty being convinced that nicotine is potentially valuable." Newhouse has found notable increases in short-term recall, spatial memory and reaction times among Alzheimer's patients treated with a nicotine analog called ABT-418. In the same article, Dr. John A. Baron, a Dartmouth Medical School professor who has spent the past 10 years studying nicotine and Parkinson's disease, said, "The link between smoking, nicotine and possible benefits is uncomfortable for many people. It's hard to accept, in an emotional sense, that an exposure so harmful can have benefit."
Emotional or not -- and people on both ends of the butt get pretty fired up about the issue -- the Last Drag's Gloria Soliz is unimpressed by reports of the possible health benefits of tobacco. "Cigarettes contain 2,000 to 4,000 harmful chemicals. And the cigarette is a very good delivery system for them." When isolated in the test tube, more than 40 of those chemicals have in fact been identified as carcinogens. "No matter what the research shows as far as immediate benefits," she adds, "in the long run it's definitely not contributing to people's health."
And it's the long run that people with HIV are now training their sights on. "I don't want to be sitting in the wrinkle room smoking a cigarette when I'm 65," Scott Croft says. "I expect to get that old with all the new therapies and treatments. I plan on it." Croft, who has smoked since he was 13 (his first pack shot out of a hospital vending machine), was diagnosed with HIV in 1989 and, except for thrush and "that smoker's cough in the morning," is in good health. A week before Michael Achille is due to get his first post-Crixivan lab results back, he says, "I'm quitting smoking because it's really, really time. I'm not getting younger. And I'm trying to be healthier in every way."
"People with HIV are living longer, and as people enter their 40s, that's prime time for heart disease," says Quest's Dr. Poscher. "We're going to see a lot of complications that we weren't even worried about because people were dying. I had a patient with an oral cancer who had quit smoking and then started again. I asked, 'How many cancers do you want to have removed from your lips?'"
Do smokers with HIV hope to enjoy a longer life smoke-free, or will they face the future with fag in hand? When Scott Williams learned he was HIV positive in July 1995 -- news he greeted by lighting up more than ever -- he immediately took steps to maximize his health advantages over the virus. Today, with 560 CD4 cells, an undetectable viral load and one of San Francisco's top HIV doctors, he is very optimistic. "I feel like I can live a relatively longer life span. I mean, I don't think that I'm going to die in 10 years," he says. "Quitting smoking is something I want to do this year because I have respiratory problems. I cough and feel phlegmy, I have a hack -- it's nasty. I cough up lung butter, you know?" He laughs. "I don't want to be put in the position of being an old person who's a smoker," he says with a grimace. "I see them, and they look gross, and I don't want to be there."
The Catholic conspirators who hatched the gunpowder plot almost four centuries ago, mostly young men, didn't ripen into wizened old smokers either. Not long after they had their last drags, they went, one by one, to the scaffold. "Behold the heart of a traitor!" cried the executioner as he held aloft that still-beating organ, freshly hacked from the chest of Guy Fawkes, the band's most famous member, to a cheering crowd. In 1997, as people with HIV ponder pension plans and IRAs, those who smoke must examine their own hearts to determine whether the love of tobacco is worth the betrayal of future well-being. While doing so, they ought to consider this: Even King James I would condone regicide in realms where tobacco is king.