This piece, reprinted from The Lancet, raises all sorts of controversial questions. The answers to the questions vary greatly across a broad spectrum of expert opinion.
Copyright The Lancet.

Last month, I looked one of my patients squarely in the face and said: "My advice to you is to go home, have a cigarette, and forget all this nonsense about giving up." This suggestion may fly in the face of all orthodox health education but, perversely, in her case it may actually prolong her life.

She is, you see, 92 years old and has been a smoker since she was 14.Luckily for her, she remains fit and active and was a very rare visitor to the surgery until 6 months ago when she presented with a minor gynaecological condition. I referred her to hospital where the zealous doctor taking her history discovered she was a smoker and reprimanded her severely.

She is of the generation to obey injunctions from doctors without question. She was also brought up not to waste anything, so after 78 years she finished the last few cigarettes in the packet and then stopped smoking. How is she now? Well, of course she is miserable, and has started coming to the surgery with various minor ailments. Eventually one of my colleagues started her on antidepressants but she could not tolerate them and when I next saw her, her positive and active disposition had given way to a crumpled, complaining misery.

A few questions revealed the source of the problem, and I think she expected me to congratulate her on her efforts, but I could not. At 92, the "will to live" has as much to do with whether life is worth living, as it has to do with physical health. Depriving her of cigarettes after nearly 8 decades of smoking would not make any significant difference to her health, but the resulting misery will almost certainly shorten her life and certainly make her remaining months less pleasurable.

So I told her to go and light up, and furthermore promised to call in a few days and smoke a cigar with her, just to check that she was following doctor's orders. When I did so, she was a different person--bustling about, talking, and smiling broadly--and she has not been to the surgery since. Cigars may be damaging my health, but I am sure they have given her a new lease of life.

I thought of her last week, when an alcoholic patient came to the surgery and I decided to offer him a drink. This was a very different situation involving a middle aged man, who finally faced up to his heavy drinking and came to the surgery to ask for help. He was shaking and sweating and clearly in need of urgent help. Luckily, I had recently received a glossy brochure advertising mental- health services, with particular focus on problems of addiction, which contained all the phrases you want to hear: "responsive and speedy service", "crisis team available 24 hours", and so on. I referred my patient and told him that he could expect swift and effective help from this new revamped service.

6 weeks later he was back in a very bad state having heard nothing, and tried to stop drinking without help. The only way to get him to function sufficiently to go home was to give him a drink and luckily I found a stray bottle from last Christmas at the back of the cupboard. When I rang the number on the glossy brochure (I wonder how much that cost?) and asked what the crisis team was doing, I was told that they were short of resources and the patient had to wait his turn, unless of course he was suicidal. When I pressed them for action, I was told "what do you expect? This is the NHS, you know".

Should I have given my patient a drink? In the opinion of a colleague in the detox unit, if an alcoholic tries to stop drinking without help and gets into that sort of state, then giving him a drink is the right thing to do. The only thing that worries me is that I might get a reputation for advising smokers to light up, and giving drinks to alcoholics, but if you take the time to look at the "whole person" sometimes you just have to break the rules.