“Mr. A,” a 56-year-old, gay-identified Caucasian man, was hospitalized on our adult psychiatry unit 15 times over a 10-year span and hospitalized multiple times at other hospitals in the area. Several hospitalizations were protracted, lasting several weeks. Mr. A had a distant history of at least one suicide attempt, an overdose of clonazepam. Often, he presented with severe depressive symptoms, suicidal ideation, and auditory hallucinations criticizing him and/or commanding him to commit suicide. He did not exhibit grossly psychotic behavior. He at times tested positive for stimulants, but made inconsistent statements about his history of stimulant use and attempts at drug abuse treatment. He was variously diagnosed with schizoaffective disorder, major depression with or without psychotic features, posttraumatic stress disorder, and polysubstance or stimulant dependence. Usually he self-presented through the emergency department; on the last admission, he came in complaining of a broken tooth. During his last hospitalization, he reported severe depression, anxiety, insomnia, and irritability. He described his health as fair and ascribed several limitations due to multiple physical and mental health problems. He struggled with extreme pain despite daily prescribed opiate and sedative use. He held a college degree but was fully disabled and received a pension for psychiatric disability.

Mr. A's medical record at our hospital was notably absent of detected pulmonary or cardiovascular disease. Over the 10 years of admissions, sporadic reference was made to hypercholesterolemia, use of a beta-blocker, and a heart murmur. His oxygen saturation was checked in the emergency department and was normal at the time (97% on room air). There also was one visit recorded in which the patient presented with chest pain and ultimately was admitted to the medical center. The evaluation was notable for negative cardiac enzymes, a normal ECG, and an echocardiogram demonstrating good cardiac function. Mr. A had a portable chest X-ray that was read by the radiologist as low lung volumes. Examination of the films by one of the authors (R.S.), a pulmonary/critical care physician, indicated that the study was poor in quality because Mr. A did not give a good inspiratory effort, which makes confirmation of any lung pathology difficult. Mr. A's chronic use of tobacco, however, was noted in the chart.

In our interviews with Mr. A during his last hospitalization, he reported smoking two packs of cigarettes per day for 25 years. It was estimated that he spent $289 per month on cigarettes, 10% of his income. He described 10 attempts to quit using tobacco in his lifetime, including two trials in the previous year. Each quit attempt was unassisted, that is, without clinical support or use of any of the cessation medications approved by the Food and Drug Administration. The longest period he reported being tobacco-free in any single attempt was 7 days. He stated he had not received any advice to quit smoking in the past year by a mental health or general medical provider. While hospitalized on our smoke-free unit, Mr. A expressed a craving for cigarettes but a desire to quit smoking with the eventual goal of complete abstinence. We spoke with Mr. A about his use of tobacco and thoughts about quitting and provided him with a self-help guide on smoking cessation. Despite these efforts, we learned that soon after hospital discharge, he resumed smoking two packs of cigarettes per day. It is this addiction to nicotine which ultimately killed him—not his depression, suicidal thoughts, or use of opiates, which traditionally are perceived as more acute and pressing psychiatric issues.