My own relationship with cigarettes began before I ever took a puff.  Both of my parents smoked.  It was an era where smoking was the fashion and before the Surgeon General declared smoking dangerous to your health.  The day after the report came out my father stopped his three-pack a day habit.  His Viceroys were replaced by an astonishing amount of Wrigley’s Spearmint gum which led to a twenty pound weight gain, and an even more precarious handle on his already volatile temper.  Though she switched from Viceroys to Kents to some famously low tar/low nicotine brand, my mother had less fight in her.  Her smoking continued unabated until she died.

Smoking was ubiquitous in my extended family and neighborhood, but it was clearly not approved of for children.  My first direct experience with cigarettes was being accused of smoking by a busybody neighbor whose identity I never learned.  She (it had to be a woman since the incident happened during the day and there were never any men around during the day in the late 1950s) claimed to have seen me smoking with some older boy in the basement of the apartment house across the street from where I lived.  This scene allegedly took place near the incinerator.

I was perhaps 11 years old and the fact that the smoking supposedly took place in the basement of the apartment house gave credence to my denials, since I was notoriously afraid to go through the basement as a shortcut to a “secret” place where the kids on my block used to play.  Nobody knew this, but my fear was fueled by a nightmare of a boy being hung upside down and roasted above the incinerator’s flames for having committed one of the many sins I knew I was capable of.  My mother believed me but made a show of disciplining me in some way in order to save face with the neighbor.

For sometime after this event, I remember suspiciously eyeing the women on my block wondering who was the spy.  I did not realize it at the time but spying on your neighbors was something that America was deeply conflicted about in those days.  It was the end of the McCarthy era, but we were still in the throes of the “Red” scare.

In any case, I did not start smoking until my mid-teens.  It was actually my mother who helped me get started.  In one of the more classic examples of enabling behavior, I used to sit in the front seat of the car and light her cigarettes for her, so she would not have to take her hands off the wheel.

My mother was terribly anxious behind the wheel and I was already being groomed as the man of the family.  To keep her from becoming completely flummoxed, I had things set up so all she had to do was extend her right hand long enough for me to put a cigarette between her index and middle fingers.  I would push in the cigarette lighter, fish a Kent out of the soft pack and light her cigarette once the lighter popped out.  When the ash got long enough I would gently remove it from her hand and flick the cigarette ash into the ashtray, and return the cigarette to her hand.  All the while I can remember watching her foot repeatedly depress and let up on the accelerator keeping time with the rhythm of her dread.  When the cigarette got close to the filter I would remove it from her hand and stub it out.  After a few minutes we would resume our little Oedipal minuet.

Pretty soon I was smoking a pack a day.  I’m actually not sure how heavy my smoking became because I honestly stopped thinking about it shortly after I began. At the time, I inhabited two distinctly different worlds and my memory of that time is clouded by the fact that these two worlds rarely intersected.

Where I grew up in the Bay Bridge section of Brooklyn, New York, the neighborhood was divided by Ridge Boulevard.  It was named for the ridge that overlooked the bay called the Narrows which separated Brooklyn from Staten Island.  The ridge faces west and the world to the west of the ridge was middle class families.  The further west you went from Ridge Boulevard toward the bay, the more affluent the neighborhood became.  The homes went from apartments and twin houses to single family homes with nice yards.  To the east of the ridge was progressively more working class.  The streets no longer had names like Colonial Road and Narrows Avenue but numbers beginning with 3^rd Avenue.  Here there were a smattering of row houses, apartments and beginning at 3^rd Avenue, storefronts with walk-up apartments over the stores.  In the movie Saturday Night Fever, John Travolta’s character came from the part of Bay Ridge that was east of Ridge Boulevard.

One of my worlds was that of the oldest son in a good Catholic family who lived west of Ridge Boulevard.  Smart and well behaved, I enjoyed carrying the aspirations of an immigrant family.  I could pass for a “collegiate” type who wore blazers, madras ties and white bucks.  I could do the Eddie Haskell thing from Leave it to Beaver, but do it so convincingly, even I believed it.  I knew how to say the right things to grownups so they would nod approvingly.  Smoking was hidden and shameful in this world.

At the same time, my family was busy imploding under the weight of my parent’s failed marriage, my father’s failing business and my parent’s uncanny ability to punctuate their fits of passion by producing another sibling.  I was bitter and resentful and drawn to the more sinister aspects of my second world.  The world east of Ridge Boulevard was where boys wore stove- pipe black pants, greased their hair, shoplifted and flipped the storekeepers the bird as they ran down the street.  In this world smoking was not only cool, it was expected.

By the time I arrived at college I was smoking extra long Pall Mall non-filtered cigarettes.  As I said earlier, I do not remember how much I smoked but it had to be at least a pack a day.  I had never kept track and never tried to control it.  It was simply not a problem until the first week of school when a kid I met asked me if I wanted to try out for the crew team.  I must have looked at him cross-eyed because he said, “You know, rowing.”  I guess he must have been from the kind of place that was west of Ridge Boulevard but I thought, “What the hell, I’m in college.”  He told me tryouts were the next morning at 7:00 A.M.  We were to meet at the track behind the gym.

I showed up the next day and a grand total of nine freshmen showed up to try out for freshman crew.  You might know as little as I did about crew, so let me explain that a full boat in crew consists of eight oarsmen and a coxswain.  This meant that everybody made the team, but more importantly, no one could quit without depriving the others of a chance to participate.

Our “tryout” consisted of running four laps around the track.  I was okay at sprinting, having run toward or away from shoplifting or fights in my adventures east of Ridge Boulevard, but this marathon of perhaps a half mile was a revelation.  I could barely finish and at the end was coughing up alarmingly thick black phlegm.  After this auspicious tryout, I was “chosen” for the team and since I was not the smallest of the nine, I was going to have to row.

That day I went back to my off-campus rooming house and used my half-empty pack of Pall Malls to build a monument to my resolve to stop smoking.  For the next 20 years I persisted in my efforts to demonstrate control over nicotine.  But the first thing I did was to stop altogether.  I placed that half-empty pack on the dresser and left it there to remind myself of how bad I felt after the half- mile run I had endured earlier in the day.

For more than a year I did not smoke, and did not miss it.  Rowing is an extraordinarily demanding sport and I endured the pain of getting into shape to test myself and prove my strength.  The camaraderie of crew is intense and the sense of shared purpose and competition among the oarsmen helps motivate each member of the crew.  Not smoking was just another test of strength and resolve.

In the fall of my sophomore year, I developed a bone spur in the palm of my left hand.  Eventually it prevented me from rowing and required surgery.  During my convalescence I tried to work out on my own but without the camaraderie of the other oarsmen, it seemed to be all pain and no gain.

At this point I had moved to an off-campus apartment with two old high school friends, one who smoked.  Every now and then the non-smoking roommate would bum a Lucky Strike from the smoker.  Pretty soon I was bumming them as well.  I was reassured by the fact that nothing seemed to happen – no intense craving, no immediate escalation back to a pack a day.  In short, there was no problem.

One scene from this period is especially revealing.  We were all pretty hard up for money.  Rent was twenty-five dollars per month for each of us and we each put in five dollars a week for food.  Even in 1968 this was not a lot of money.  We were also a pretty lazy bunch.  I’ll spare you the details, but suffice to say it took a long time for a cigarette butt to get from the inverted old television tube we used for an ashtray to the trash.  It’s March of 1969 and we are watching a basketball game on TV.  We are out of money and out of cigarettes so we dig around in the “ashtray” and the trash for butts.  It only took three or four old Lucky Strike butts laid end to end and some cigarette rolling paper, and we were in business.

I guess we thought it was funny.  I know these makeshift cigarettes were pretty rank.  But it did not take long to get past the bitter taste.  For some reason it did not strike us as a sign of desperation to pick through the trash for nicotine. Once again, it was no problem

Very gradually my smoking increased.  By the time I graduated college and moved to the Boston area, I was smoking a half pack a day.  Most of my friends smoked and all of my colleagues in the small drug counseling center where I worked smoked a lot more.  It was not something I liked about myself but in keeping with the psychology of addiction I rationalized that I did not have a problem and could stop at any time.

In the summer of 1976 I once again stopped smoking.  I had started going out with the woman who would eventually become my wife.  We were leaving to go camping in New Hampshire and I pulled up to a gas station.  I told her we needed gas and I wanted to get a pack of cigarettes since I was down to my last two.  She looked at me and said, “You know I really don’t like you smoking.”  I replied, “Well if that’s the case, then I’ll stop.”  And I did.

What I did not know at the time was that this was one of a number of things she did not like.  A few months later she told me during a Christmas trip to see her family in Pennsylvania that she thought I could stand to lose a little weight.  So I lost 17 pounds.  I was actually pretty pleased with myself.  I did not like the fact that I smoked and was relieved that she confronted me and that I could demonstrate self-control by stopping.  I always struggled with my weight through adolescence and early adulthood.  Her desire for me to lose weight stung me a little but gave me the motivation to take the weight off.

A few weeks later, when she started in on me about biting my nails, I got nervous.   I didn’t want to be smoking and I knew I needed to lose some weight.  I also thought my nail biting was a pretty unappealing habit.  But, honestly, I could not think of anything else I really wanted to change and I was afraid of whatever else she might come up with.  So we got into a nice protracted power struggle over this habit of mine.

But I did not go back to smoking, and four years later we were married and living in Philadelphia when my next encounter with nicotine took place.  She was a resident in Obstetrics/Gynecology and I was pursuing doctoral studies.  It was New Year’s Day of 1980.  She had to work but I was on winter break.  I was in the habit of getting up with her at 5:00 A.M. to make her breakfast so we could have a little time together to start the day.  During school I would have the uninterrupted time between 6:00 A.M. when she left and my first class to get a lot of work done.  But since it was a holiday I found myself hanging out with our German shepherd at 6:00 A.M. with no plans.

In those days I did a lot of fly-fishing and I was thumbing through some old fishing magazines.  The radio was on and I heard a weather forecast predicting unseasonably pleasant weather with a high temperature of 60 degrees.  My fishing buddies and I have often observed the parallel between fishing magazines and pornography.  Pretty soon I was fantasizing (about fishing, not naked ladies) when I came across an article about a trout stream near Harrisburg that is open to fishing all year round.  I looked at the dog and informed her that Harrisburg is only a two-hour drive.  She looked back at me with a somewhat non-committal look on her face.  When I explained that we could go fishing her ears pricked up and she started wagging her tail.

By 10:00 A.M., I had located the stream.  It was a beautiful day and the stream was crystal clear.  I could see fish against the backdrop of the freestone bottom.  I was a reasonably accomplished fisherman, but after an hour and a half I had not gotten a strike.

It typically takes a fair amount of trial and error to figure out how to catch a fish in a new area.  A real short cut is to find someone who is familiar with the stream and pick their brain.  I was working my way upstream, hoping to run into another fisherman when I spotted someone through the trees.  As I approached, I could tell he was an experienced angler.  He was laying out some beautiful casts and I had a hunch he could be helpful if I could draw him into a conversation.  When I saw him raise his fly rod and set the hook to a nice trout, I knew I had to find a way to talk to him.

He worked his way over to the right bank to release the fish.  I was on the same side of the stream and walked slowly toward him when I saw my opportunity.  He sat on the bank and took out a pack of Marlboros.  I walked up to him and bummed a smoke.  Shortly, a lively conversation was underway.  As luck would have it, he had intimate knowledge of the stream and during the regular season worked as a guide on some of the more renowned trout streams in Pennsylvania and New York.  I took his name, phone number and advice.  I fished for another couple of hours and caught and released three nice trout.  But what stayed with me was the taste of that Marlboro.

I was able to put it out of my mind, but for some reason every now and then for the next few months I would find myself thinking about that smoke.  It made no sense to me.  I had not had a cigarette in three and a half years and, generally, tried to avoid situations where there was a lot of smoking since I found it distasteful.

At some point, and I don’t remember when, I had another cigarette.  That first cigarette on the stream after three and a half years is so vivid in my memory and yet I have absolutely no recollection of the subsequent cigarettes until the last six years later.

During that six-year interim I resumed smoking.  I never smoked more than eight to ten cigarettes per week.  People used to express envy at my apparent control.  Former smokers would say if they could smoke in the way that I did, they would resume smoking.

During this period I smoked in a highly ritualized fashion. I never kept a pack of cigarettes.  I would allow myself a cigarette on the first and tenth tee when I played golf, which was perhaps three times a week.  I would bum cigarettes from the guys I played golf with and, then, every couple of weeks, buy them a pack.  The other time I would smoke was when my wife and I would go out to dinner.  Before sitting down, I would pull the waiter or waitress aside and explain to them that at the end of the meal I was going to want a cigarette and that I would make it worth their while if they could produce one.  Invariably they did.

My wife was not happy with this arrangement.  At some point she stopped protesting and I am sure I took that as a sign that she no longer had a problem with it.  I have come to believe that I had just worn her down and with a three year-old daughter and another on the way, there were some battles she was not going to fight.

I remember feeling mildly smug about having won what seemed to me to have been a power struggle over something pretty important.  After all, it should have been obvious that my smoking was under control.  Furthermore, I could not imagine that there was significant health risks associated with approximately one cigarette per day.  She had finally realized there was nothing to fight about and had relented in letting me enjoy my innocent pleasure.  I had no idea that I was about to “hit bottom” with respect to my addiction to nicotine.

Among the many adjustments my wife and I made after our first child was born was that if I were to play golf on the weekend, it would be very early in the morning.  I got together with a group of men who were in a similar circumstance and we would tee off at the local public golf course as soon as you could see well enough to follow the ball.  We worked out an arrangement with the pro shop that we would pay after we played on the occasions during the summer when first light came before the shop opened.

I can remember in the summer when our first child was born playing 18 holes of golf, getting my hair cut, doing the weekly food shopping and getting home all before 11:00 A.M.  By the time our second child arrived, there was a routine where I played golf very early on Saturday and relieved my wife when I got home.  Since I had gotten up at 4:00 A.M. on some summer days, the fact that they often needed to be napped on my watch was more than welcome.

The day I “hit bottom” was one of those Saturdays.  My second child had been born in April of 1986 and this was mid-June.  I had gotten up early and raced to the golf course.  When I arrived, I was the first guy there.  A couple of minutes later, people started showing up but none were the guys I usually bummed cigarettes from.  I had already gotten all my golf gear together and was becoming agitated as guys headed down to the first tee in the predawn darkness.  I headed down with them and pretty soon one of my suppliers showed up and I bummed a cigarette.

Someone asked me how the new baby was, and I as puffed I expressed some pleasantry about how wonderful she was.  An eerie quiet began to come over me as I thought about my daughters, smoked my cigarette and reflected on the previous 45 minutes of my life.

What struck me was how insanely I had raced to the golf course.  I realized I had driven 85 miles per hour down a residential thorofare just before first light.  I thought about the risks I had taken.  Deer were plentiful in the area and are known to be on the move in the earliest part of the day.  At the speed I was driving I would have had no chance to stop.  Drunk drivers are more prevalent in the wee hours.  Indeed it occurred to me that I was a kind of drunk driver because the truth was I was driving like that to get to my next cigarette.  When I thought about what could have happened, that my children could have been left fatherless, I was shaken.  I had already seen a lot of harm done because of addiction.  I quietly accepted the truth that I had failed in my efforts at control and surrendered to the reality that I needed to accept that abstinence from nicotine was my only option.  That was 17 years ago.

In relating this story I am in no way trying to trivialize the calamitous objective harm that often accompanies addiction.  What I am trying to illustrate is that addiction sometimes transcends the amount of the substance and that “hitting bottom” does not necessarily involve objectively destructive consequences.  Perhaps an example from my clinical practice involving a less socially acceptable drug will help illustrate these ideas.

Hitting Bottom: You Can’t Orchestrate an Epiphany

Hitting bottom is a very private matter.  It is an experience that may or may not be related to the actual consequences of addictive behavior.  I am often asked about drug testing.  This subject will be discussed more thoroughly in a later section but its primary function is control and the discovery of use.  For active addicts, it does not necessarily increase the likelihood of someone hitting bottom.  Hitting bottom involves an internal shift for the addicted person.

Harold was referred by a colleague who had seen him as part of a program for impaired clergy.  My colleague was moving out of the area and asked if I could take on another client.  Though my practice was overfilled, this man’s story intrigued me.

Harold was a crack-addicted black Episcopal priest.  He was living in a community of impaired clergy, having successfully completed an inpatient rehabilitation program four months earlier.  Weekly psychotherapy sessions were part of his aftercare plan.  He was also required to receive regular drug testing.

On the face of it Harold appeared to be a well-motivated person who was deeply committed to doing whatever was necessary to return to his full pastoral duties.  As I got to know him it became clear that there was a far more complex story unfolding in our sessions.

Harold had been abused by a priest in his early adolescence and his most recent rehabilitation was the third in a matter of three years.  His diocese had already extended itself beyond its own limits and the threat of expulsion was clear and credible were he to use again.

Harold was an extraordinarily charming man.  He was warm, engaging, smart and self-deprecating.  Yet there was a decided edge to him that expressed itself in sarcasm and manipulativeness.  I came to appreciate that he was deeply conflicted and traumatized by the sexual abuse.  There was an emotional turbulence that simmered just below the surface.

When I inquired about his abuse history, he told me he had confronted his abuser during his most recent rehabilitation.  The priest had been defrocked and he felt that he was moving toward something like forgiveness.  But the agitation these discussions evoked bespoke a far more unsettled state of affairs.  He had never brought legal action against the Archdiocese.

Since he was being regularly monitored through urine testing, I assumed any drug use would be discovered.  As a consequence, our conversations gravitated toward other issues.  His sense of isolation within the Episcopal community was a big concern, and he felt stigmatized by living in a community of impaired clergy, most of whom were more apparently disabled than he.  He wanted to get back to a regular parish where he could resume his pastoral duties even though he was deeply conflicted about his beliefs and how they often clashed with church doctrine.

Over a period of perhaps six months he was gradually granted more privileges and was functioning as an assistant at a parish within driving distance of his residence.  During this same time we started meeting once per week instead of twice.  His work was taking up more of his time and my office was a good distance from where he lived.  The diocese made it a point of referring impaired clergy to resources outside their geographic domain for security reasons.  In short, things seemed to be progressing well for Harold.

Shortly after beginning our once per week schedule, I greeted Harold in my customary fashion by shaking his hand and felt an odd sensation.  I am sure it did not fully register at the time but what I felt was a roughness in the middle and index fingers and thumb of his right hand.

For whatever reason, I put this out of my mind and can only reconstruct it based on the events that ensued.  Certainly, denial was at work, as well as my own ego and professional need to succeed.  As I have tried to repeatedly emphasize, collusion and enabling are in many ways the natural behavior of people who care about an addict.

In any case, it was two weeks before our next session because Harold called to cancel the appointment during the intervening week.  Once again I greeted Harold with our customary handshake.  I found myself startled by what felt like calluses on his right hand.

I do not remember what was said during this session.  I was preoccupied by what I had felt and confused about how to address it.  I somehow allowed the entire session to go by while we talked about other things.  A metaphor that makes the rounds in addiction circles comes to mind in reflecting on this event.  The idea is that addiction is the elephant in the living room that no one talks about.

By the time of our next session, I was better prepared.  I did not know where the conversation would lead, but I was determined to confront the situation on the theory that saying anything is better than saying nothing.

As the session began in the usual way, I was momentarily unnerved by the realization that there would be no good time to bring this up.  I sensed after a few minutes how easy it would be to avoid a difficult conversation.  Thankfully my sense of professional duty and genuine regard for my client won out.  I said rather abruptly, “Harold, tell me about your hand.”  He reflexively pulled his hand into his lap and with a stunned look on his face said, “What?”  I said, “Tell me about your hand.”

To my surprise and alarm he began to smile.  I pressed him about his hand and he started to giggle and it dawned on me that he was both amused and nervous.

Harold: It’s no big deal.

Dr. Mallouk: Tell me about your hand.

Harold: What about it?

Dr. Mallouk: Harold, your fingers and thumb are just about charred.

Harold: So?

Dr. Mallouk: Isn’t that where you hold a crack pipe?

Harold: Your point?

Dr. Mallouk: You’ve figured out a way to beat the drug testing.

Harold (smiling): It wasn’t that hard.

Dr. Mallouk: Tell me.

Harold: They always have me come on either Thursday or Friday.  They call me a couple of days in advance.  As long as I am clean for three days, the test comes back negative.

Dr. Mallouk: What if they only give you two days?

Harold (still smiling): Since I’ve been back to work, I just ask them to push it back.  They’ve been cool with that.

Dr. Mallouk: So you’ve been getting over on them, beating the system.  I guess you think you’re pretty hot shit.

Harold: Wow, Doc!  Take it easy.

Dr. Mallouk: Sorry, Harold, I guess I got carried away.

Harold: No problem.

Dr. Mallouk: But tell me something.

Harold: What’s that?

Dr. Mallouk: Who cares about you?

Harold: What do you mean?

Dr. Mallouk: Come on, Harold.  I’m not talking Greek here.  You’re having what you seem to think is fun.  Getting over on “the man”.  But has it occurred to you that nobody really cares about you or at least not about what you do?

Harold: What are you driving at?

Dr. Mallouk: I’m not sure but it just seems a little odd to me.

Harold: What seems odd?

Dr. Mallouk: I mean, haven’t you recently been given more pastoral privileges?

Harold: Yes.

Dr. Mallouk: And you and I both know you’re more likely to relapse when things are going well.  So this is no surprise though you seem to be seeing it as a success at beating the system and not a failure.  But what does not make sense is that no one seems to have noticed.

Harold: Who would notice?

Dr. Mallouk: Haven’t you been saying Mass?

Harold: Yes.

Dr. Mallouk: And giving communion?

Harold (not smiling and not laughing): Yes.

Dr. Mallouk: And your right index, middle finger and thumb are the ones you use to pick up the Eucharist and place it in the hand or on the tongue of the communicants.  Am I right?

Harold: (silence)

Dr. Mallouk: It’s hard to imagine that someone hasn’t noticed and what occurs to me is that nobody cares.

Harold: (silence)

Dr. Mallouk: Harold?

Harold: What?

Harold: You’ve already cost the Archdiocese an enormous amount of money and because of the past their liability exposure is considerable.  Hasn’t it occurred to you that you would cost them a lot less dead than alive?

Harold’s session ended on a somber note. He subsequently recommitted himself to abstinence, but there was yet another level of failure for him to experience.

Harold had regarded drug testing as an indignity that constantly reminded him of his second-class status within the clergy. Beating the system was his conscious way of claiming legitimacy but also seduced him back into his addiction.

Once he became abstinent and looked back on his relapses, he developed a profound respect for how powerfully addiction had distorted his thinking.

A recovering doctor taught me some years ago that drug testing can actually be a source of protection and comfort for the addict. As Harold began to see the screening in this light, he became angry at the ineffectual nature of the drug testing system.

I encouraged him to approach the church administration. He did, and shared his knowledge of how easy it was to beat the system. He helped retool the church’s system so that the testing became truly random. He persuaded them to adopt a maximum notice of 24 hours.

Two months later, Harold faced his next crisis. He arrived for a session in a state of high panic. He had smoked pot the night before and was notified that morning that he would have to give a urine specimen later in the day. He had helped engineer his own failure and was shaken in a way I had never seen. He was convinced he would be expelled from the priesthood when his urine came back dirty.

We reviewed how he had put himself in harm’s way and prepared him to accept the inevitable consequences. He was chagrined that after all the outrageous things he had gotten away with, he was going to be defrocked for smoking a little pot. Clearly, he still had lessons to learn.

When I next saw him, there was a distinct calmness in his demeanor. He told me that he had spent the weekend after our previous session in silent prayer, asking God to direct his life. The only honorable definition he had of himself was as a priest, and he was asking God how to bear losing that identity. He was learning how to suffer and it was proving to be a spiritual experience.

The results of the drug screen had come back on Monday. He was astonished to find that the test was clean. Harold believed God had intervened.

My work with Harold ended six months later as he became more and more integrated into the pastoral community. As far as I know, he has continued his recovery to this day.