At least one of every 10 patients arrive at Jeffrey D. Forman's medical office with an oxygen tank.
They lug them like carry-on bags. They wheel them on devices that resemble golf caddies, careful not to tangle the plastic tubing that fills their nostrils with life-giving oxygen.
Once, it was cigarettes they carried. Now, battling lung cancer, emphysema or a wasting disease called chronic pulmonary obstructive disorder, they bear the costs of a lifetime of smoking. They illustrate the price that all Americans pay for tobacco and the reason why Virginia Gov. Timothy M. Kaine (D) has brought his tobacco-producing state closer than ever to a ban on smoking in bars and restaurants.
After five decades of smoking, Pattie Tatem, 67, sits in a wheelchair with an oxygen tank at her feet, a victim of severe chronic obstructive pulmonary disease. The disease takes her breath away and makes her feel as if she's drowning. It wiped out her retirement savings. Now it's slowly killing her.
"It catches up with you, and when it hits you, it hits you hard," said Tatem, whose treatment costs are footed mostly by taxpayers through Medicare.
To recover some of Virginia's health-care costs caused by tobacco, Kaine proposed doubling the state tax on cigarettes to 60 cents a pack. The governor and the General Assembly took aim at tobacco in other ways, too, by moving to ban smoking in restaurants and bars and prohibiting people from lighting up in a vehicle when a child is present.
Last week, Kaine announced a compromise with House Speaker William J. Howell (R-Stafford) on a smoking ban that some anti-smoking advocates criticized as too timid. But in years past, even that would have been dead on arrival in the House. The governor's tobacco tax, in contrast, never made it to the floor of the Republican-controlled House or the Democratic-controlled Senate.
In a state whose fortunes have been interwoven with tobacco since Colonial times, opponents warned against damaging an industry that contributes healthy paychecks and tax revenue to the commonwealth.
"These are jobs in my community you're talking about," said Sen. John C. Watkins (R-Chesterfield), whose district is near Philip Morris USA.
But doctors, health advocates and patients tally the costs differently: More than 9,000 Virginians die every year because of tobacco use, and more than 9,000 Virginia youths get hooked every year. More than 1,000 people die from secondhand smoke.
Laurens Sartoris, president of the Virginia Hospital & Healthcare Association, said Virginians pay financially, too, because they pay for smokers' medical bills.
Consider Medicaid, the government-run health insurance for the poor. The program, whose costs are split by states and the federal government, reimburses doctors, hospitals and other providers at a rate substantially below the cost of medical care.
When a smoker goes into the hospital for cancer treatment -- smokers are statistically more likely to need medical care earlier and longer than nonsmokers -- Medicaid covers 75 cents of every dollar in expenses. Taxpayers and patients with private insurance make up the difference.
"That is a hidden, extraordinary, regressive tax on everybody's insurance premiums," Sartoris said.
That's why anti-smoking advocates had pushed for a bigger tobacco tax: to narrow a $148 million gap in Virginia's Medicaid funds that is expected to grow. Along with the smoking ban, the tax would pay further dividends by inhibiting people from starting to smoke and forcing others to cut down, advocates said.
Research shows that for every 10 percent increase in the price of cigarettes, tobacco use drops 7 percent among youths and 2 percent among adults.
Forman, who grew up in Howard County, sees the human consequences of smoking every day. At least half of his patients are smokers or former smokers.
Forman can easily spot the signs of blocked airways: Patients purse their lips, puffing and hyper-inflating their chests in an effort to empty their damaged lungs. After a few minutes with a CT scan, he finds a spidery white speck that means a cluster of cancer cells has taken root in a person's lung.
Then he must break the news to people such as Don Eason.
"I said, 'What you're telling me is, I'm going to die,' " recalled Eason, who underwent surgery about three years ago to remove his right lung and a chunk of his left.
Like many smokers, Eason, 70, an easygoing man with white hair, a Southern accent and a persistent cough, knows what led to this. He was 15 years old and stocking shelves at the A&P in Franklin, Va., when he first smoked. It was a Pall Mall then, and later Salem menthols.
Eason enlisted in the Air Force, became a traveling salesman, ran a barbershop, married, had children and divorced. But cigarettes were a constant. He smoked a pack, maybe a pack and a half, every day.
"Back then, a cigarette and a radio were your buddies," Eason said, remembering the days on the road peddling farm equipment.
After doctors told Eason that he had a year to live, he put his affairs in order. He did not want to leave debts for his daughters to pay. He gave away belongings. He picked out a coffin.
Tatem, a wisecracking former dental hygienist, also started smoking young. As a teenager in Norfolk, she and some girlfriends pilfered Lucky Strikes from her mother's purse. Soon, she became a pack-a-day smoker. Her favorite ritual centered on a morning cigarette, a freshly brewed pot of coffee and a chocolate cookie.
These days, Tatem must be connected to the oxygen supply at all times, a nuisance when the tubes irritate her nostrils or get tangled underfoot in her living room. Her skin, gray and fragile, rips as easily as wet paper, one of the effects of a medication that helps her breathe. Another makes her bones brittle, causing painful fractures.
Two years ago, Tatem was rushed to the hospital. Doctors put her in the hospice unit.
"They said there wasn't anything they could do for me," Tatem said. She rallied, but she said she knows that her prognosis is grim. And she, too, wishes she had never smoked.
"I feel angry at myself for doing it, because no one made me do it," she said.