Half jokingly and half seriously, physicians who are experts in caring for people with HD have referred to HD as "one of the smoking diseases." Certainly a very large portion of people with HD smoke cigarettes. People with HD often view it as "one of the last pleasures I have left." Smoking becomes symbolic of independence.

Smokers and their caregivers are faced with a number of problems. Some folks with HD have an altered sense of hot and cold. Their fingers are often burned lighting cigarettes or smoking them down to the butt. Impaired judgement can make them unaware of the danger of burns to clothing, ashtray fires, or lighting

the cigarettes of friends who are themselves unsafe smokers. The movement disorder makes it unsafe to use and dispose of matches and lighters. Impulse control problems may drive them to take another person's lit cigarette right out of his mouth.

Caregiver Tips Take seriously the smoker's emotional need to smoke. Discuss the use of nicotine patches Build a reward system to encourage him to quit. Use large ashtrays that are solid, sturdy, and untippable. Limit smoking to a well-protected area. Purchase nonflammable clothing, furniture, and floor covering. If necessary, have the smoker wear asbestos vest. Install extra smoke detectors. Use a "smoker's robot". It holds a cigarette to prevent ashes and embers from being dropped.

There are a number of clever devices that allow people to continue to smoke safely. "Smoking robots" eliminate the need to light and handle the cigarette. Asbestos vests protect clothing. However, supporting smoking with assistive devices only delays dealing with the inevitable issue of unsafe smoking. The unsafe smoker doesn't want to hear your suggestion to quit or your offer of more supervision. Caregivers are often caught in a power struggle. You may try to responsibly manage his smoking but he can't see the risk of burning himself or even worse!

If you anticipate this months ahead of time, or if you have the opportunity to begin a discussion about limiting or quitting smoking, take advantage of it. If the unsafe smoker has a lengthy spell of illness or hospitalization that precludes his smoking, use it as an opportunity to encourage him to cut down or quit smoking. Although this may put the caregiver in a patronizing position to the unsafe smoker, it may reduce or eliminate unnecessary risk of burns and fire for years to come.