Smoking can Trigger Blindness

Researchers from Japan and the U.S. have shown that Japanese smokers face a macular degeneration risk four times higher than nonsmokers.

In this disorder, over time, light-sensitive cells in the retina die, causing vision loss. The disease is most common among men than among Japanese women, but this sex-based distinction reflects the fact that Japanese women smoke less.

“The bottom line for people worried about age-related macular degeneration is that there is a modifiable risk factor that is very, very strong, and that’s smoking,” says Dr. Peter Gehlbach, an ophthalmologist at Johns Hopkins University in Baltimore, and a co-author of the study.

According to the National Institute of Health, more than a third of Americans who are aged over 75 suffer from macular degeneration. This condition can occur in two forms: a “wet” one marked by permeable blood vessels in the retina and a “dry” one, more common, progressing slowly.


The disease is not curable, but various treatments, including drugs and surgery, are able to delay its progress.

The “wet” form of the disease responds to drugs like Lucentis, which prevents the formation of abnormal blood vessels in the eye.

In a recent study, another drug from Roche, Avastin, seems to have the same effect as Lucentis, but it is believed to have greater side effects.

Avastin, the drug which is not approved to treat macular degeneration, but is more often used, costs $ 50 a dose, compared to $ 2,000, the price for the drug Lucentis.

The Japanese study published in the journal Ophthalmology was conducted on 279 men and women who suffer from macular degeneration and 143 people who are not suffering from this disease.

Tests have shown that tobacco is associated with blindness, 75% of smokers have shown symptoms of the disease, compared to only 40% of people who don’t smoke.

Taking other differences into account, smokers have a four times greater risk of developing the disease. Also, smokers had a nearly fivefold increase in risk of developing a vision disorder called polypoidal choroidal vasculopathy, which also leads to bleeding in the retina.

High blood pressure and excess weight is associated with increased risk of macular degeneration.

Simon Kelly, an eye surgeon at the Royal Bolton Hospital in England, suggests that the study supports the connections.

“The public health need is now, in my opinion, to highlight this link of smoking and to patients and the public all over the world. In Europe we are calling on governments to put the message ‘smoking causes blindness’ on tobacco products,” “he said.

Kelly, who didn’t participate in the new study, argues that in his experience, smokers appear willing to give up their habit when they become aware of the risk of blindness.

“We have found that such a message has traction amongst teenagers,” he added

Smoking while pregnant ‘triggers asthma through DNA changes’

They have discovered this could be partially because smoking while pregnant can change the structure of the child’s DNA, weakening the immune system.

While it is commonly thought that genes are immutably, except if exposed to radiation, more and more evidence is showing that DNA can be changed by more
everyday environmental influences. This happens through a normal biological process known as DNA methylation.

Now American medical researchers have found a potential genetic “root cause” of the link between smoking while pregnant and childhood asthma.

They found that the children of women who smoked while pregnant were more likely to have experienced more DNA methylation of the AXL gene, which is crucial
to development of the immune system.

Carrie Breton, assistant professor of preventive medicine at the Keck School of Medicine of the University of Southern California USC in Los Angeles, said: “We
found that children exposed to maternal smoking in utero had a 2.3 percent increase in DNA methylation in AXL.”

She explained this was “compelling evidence that environmental exposure to tobacco smoke during pregnancy may alter DNA methylation levels.”

There was no significant association with grandmaternal smoking, however.

Exactly what effect these genetic changes have in such children is difficult to determine. They could also suffer from asthma more than others because the
smoke affected their physical development in the womb, or simply because they breath in more smoke as children.

The research was presented on Wednesday to the American Thoracic Society in Denver.

Leanne Metcalf, director of research at Asthma UK, said: “This research reinforces why smoking during pregnancy should be avoided.

“Causing fundamental changes to a child’s DNA which is not easily reversed and exposing that child to an increased chance of developing asthma and a weaker
immune system will have extremely serious long term implications for any child. This is bad news for children, communities and our health service.”

“Children whose parents smoke are 1.5 times more likely to develop asthma and Asthma UK needs all parents and expectant parents to avoid exposing children
to cigarette smoke to help protect them from developing asthma – once the damage is done, it’s very hard to undo.”


© Copyright of Telegraph Media Group Limited 2011, Stephen Adams (

Study find smokers risk surgery complications

Results from a clinical study presented at ANESTHESIOLOGY 2010 found that smokers have significantly more complications post-surgery than non-smokers, including a higher death rate.

“Previous research told us that comprehensive warnings about the dangers of tobacco can change attitudes towards smoking, especially among patients coming in for surgery,” said Alparslan Turan, M.D., lead study investigator, Associate Professor, Department of Outcomes Research, Cleveland Clinic. “The preoperative period is an excellent time to address the health risks associated with smoking, using it as a teachable moment.”

Some of the increased incidence of adverse outcomes among smokers the study found included:

  • Smokers were 40% more likely to develop major complications and die within 30 days of surgery.
  • Smokers had an increased risk for respiratory complications.
  • Pneumonia risk was doubled among smokers.
  • Smokers were 87% more likely to experience unplanned intubation (a tube inserted in the patient’s throat to help him/her breathe).
  • Smokers were 53% more likely to require artificial mechanical ventilation that lasted more than 48 hours after surgery.
  • Smokers also saw a significant increase in cardiovascular complications and were:

57% more likely to experience cardiac arrest
80% more likely to have a heart attack
73% more likely to have a stroke

  • Surgical site complications were also higher among smokers. They were:

30-42% more likely to have a surgical site infection
There was a 30% increase in the risk for serious systemic infections such as sepsis.

“Another key finding of the study is that the more a patient smoked, the more complications he/she was likely to experience,” said Dr. Turan.


About the Study

The Cleveland Clinic researchers evaluated 635,265 patients from the American College of Surgeons National Surgical Quality Improvement Program database.

There were over 200 participating centers prospectively collecting data with standardized methods that provided researchers a vast amount of data to overcome many of the limitations of previous studies, and results represent the current situation in the United States. The study compared 82,304 smokers with 82,304 non-smoking patients who had similar surgical procedures and similar preoperative risk factors using sophisticated statistical techniques.

For more information on ASA’s smoking cessation program and resources, please visit


The American Society of Anesthesiologists

Anesthesiologists: Physicians providing the lifeline of modern medicine. Founded in 1905, the American Society of Anesthesiologists is an educational, research and scientific association with 45,000 members organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.

For more information on the field of anesthesiology, visit the American Society of Anesthesiologists website at For patient information, visit

This news release is protected by copyright. American Society of Anesthesiologists attribution is required. Copyright © 2010. American Society of Anesthesiologists. All Rights Reserved.

Cigarettes which have lower levels of nicotine than conventional ones, may be even more harmful

In recent years, tobacco companies have been marketing “safer” cigarettes made from complex fibers or genetically altered tobacco plants to reduce nicotine concentration.

But stem cell scientists at the University of California-Riverside in the US have found the smoke coming off the end of a smoldering harm reduction cigarette, known as sidestream smoke, is even more toxic than sidestream smoke from conventional brands.

Researchers say because it isn’t possibly to determine chemical toxicity on actual human embryos, they developed tests with human embryonic stem cells, which model young embryos, to measure the toxicity of smoke. Tests measured both mainstream smoke, when a smoker actively inhales, and sidestream smoke, which contributes to secondhand smoke, from both conventional and harm reduction cigarette brands.

“Harm reduction products are not necessarily safer than their conventional counterparts,” said the study’s lead scientist Prue Talbot in a new release October 20. “Our analyses show there is significant toxicity in harm reduction products, and our data show that reduction of carcinogens in harm reduction mainstream smoke does not necessarily reduce the toxicity of unfiltered sidestream smoke.” Results of the study will appear in the November issue of Toxicological Sciences.

“This information should be valuable to potential users of harm reduction cigarettes and should be taken into account when establishing policies regarding the sale, advertising, and use of harm reduction products,” Talbot said.

Harm reduction brands the team tested were Marlboro Lights, Advance Premium Lights, and Quest, while  Marlboro Red cigarettes represented conventional brands.

Heavy smoking during middle age can double the risk of Alzheimer’s disease and dementia

Smoking already causes millions of deaths each year from cancer and heart disease.

“Our study suggests that heavy smoking in middle age increases the risk of both Alzheimer’s disease and vascular dementia for men and women across different race groups,” Rachel Whitmer, a research scientist with Kaiser Permanente in Oakland, California and colleagues wrote in the Archives of Internal Medicine.

They said smoking also causes cancer and heart disease. The new findings show it threatens public health in late life, when people are already more likely to develop dementia.

Whitmer’s team analyzed data from 21,123 members of a health plan who took part in a survey when they were in their 50s and 60s.

About 25 percent of the group, 5,367 volunteers, were diagnosed with some form of dementia in the more than 20 years of follow up, including 1,136 people who were diagnosed with Alzheimer’s disease.

Alzheimer’s, the most common form of dementia, is a fatal brain disease in which people gradually lose their memories and their abilities to reason and care for themselves. It affects more than 26 million people globally

People who smoked more than two packs of cigarettes a day had a higher risk of both Alzheimer’s disease and vascular dementia.

“The increase in risk is not just for heavy smokers,” Whitmer said in a telephone interview. “It’s not if you smoke less you are in the clear, that is for sure.”

She said compared with nonsmokers, those who smoked more than two packs a day had a 114 percent increased risk of dementia, a 157 percent increased risk of Alzheimer’s disease and a 172 percent greater risk of vascular dementia.

Whitmer said it has been difficult to study the effects of smoking on brain health because heavy smokers often die from other conditions first.

“This is the first time someone has been able to look really over the long term,” Whitmer said.

“We’ve known for some time that smoking is bad for your respective health,” she said. “This really adds to our understanding that the brain is also susceptible.

The World Health Organization says 5 million people die every year from tobacco-related heart attacks, strokes and cancers. Another 430,000 adults die annually from breathing second-hand smoke.

A report last month said the worldwide costs of coping with dementia will reach $604 billion in 2010, more than one percent of global GDP output, and those costs will soar further as the number of sufferers triples by 2050.

CHICAGO | Mon Oct 25, 2010 4:53pm EDT

Houston (TX) Votes 13-2 for Clean Indoor Air

Nation’s 4th largest city joins growing smoke-free trend

Houston (TX), 10/18/06–  Today, the Houston City Council voted 13-2 for comprehensive smoke-free workplace legislation.  Beginning September 2007, virtually all Houston workplaces, including restaurants and bars, will be smokefree.  Houston joins New York, Los Angeles, San Francisco, and Boston as big cities with strong clean indoor air laws.

Unlikely allies, such as Houston’s Chamber of Commerce, AFL-CIO, and Restaurant Association, joined with health groups to push for today’s legislation.

“It’s a great day for Houston’s workers,” says Joe Cherner, founder of BREATHE (Bar and Restaurant Employees Advocating Together for a Healthy Environment).  “No one should have to breathe a cancer-causing substance to hold a job.”

Houston is the nation’s 4th largest city.

Garden City (KS) and Zionsville (IN) Go Smokefree

States, cities, and towns all over the U.S. are passing legislation to protect workers and customers from the harmful effects of tobacco smoke, such as cancer, heart disease, and breathing disorders.

Yesterday, Garden City (KS) Commissioners voted for clean indoor air in virtually all workplaces, including restaurants and bars.  The law also forbids smoking within 50 feet of the primary entrances to fraternal organizations, sports arenas, educational facilities, and public governmental assemblies.

Zionsville (IN) Councilmembers voted 4-1 in favor of a similar law.  Council member David Brown said, “I voted for this law because it is an idea whose time as come, not only in Indiana but nationwide.  Smoking in airplanes was eliminated 20 years ago and we look back on that now as pretty archaic. Someday, we’ll look back at this the same way,” he said.

France to Make Restaurants Smokefree

Nightclub and casino workers still forced to breathe smoke

France is preparing to clear the air in smoky restaurants and other public areas starting next year, the newspaper Le Figaro has reported.  The measure, which could be applied nationally from January 1, 2007, would bring France closer in line with Britain, Ireland, Italy, Spain and Sweden.

“It’s going to happen” for France, too, the country’s health minister, Xavier Bertrand, told Wednesday’s edition of Le Figaro.

The newspaper said the government was planning a decree announcing the new law, but would exempt casinos, nightclubs, and tobacco shops.

“Congratulations to France,” says Joe Cherner, President of SmokeFree Educational Services, Inc.  “We are thrilled for restaurant workers.  We only wish the same respect for health was shown to nightclub and casino workers.”

Prime Minister Dominique de Villepin’s office stressed, though, that “nothing is yet definitively decided.”  But it said “the timetable is known”, pointing to a parliamentary report on the issue due to be submitted next month (September).  “The government will announce its plan in the following month (October). The decree’s application could take effect from January 1, 2007,” the newspaper said.

News of the possible smoking ban came after a study published Saturday by Britain’s scientific review the Lancet which said that smoking triples the risk of heart attacks and all sorts of smoking — including passive smoking — was bad for the heart.

France has long shed its image of a country overrun with smoky bars and cafes, though tobacco addiction is still a big problem despite successive government price rises that have made packets of cigarettes among the most expensive in Europe.

Smoking kills 61,000 people a year in the country and another 5,000 die of second-hand smoke, according to the health minister.

French cigarette consumption unexpectedly rose this year after four years of decline.  About 30 percent of the French population smokes, more than in any European countries except Greece.

Parts excerpted from Agence France Press, 8/23/06

France Announces Plan to Go Smokefree

France will begin implementing a smokefree workplace law beginning next February, prime minister Dominique de Villepin announced in a television interview. Cafes, nightclubs, and restaurants will be given until January 2008 to comply, said Villepin.

“We started on the basis of a simple observation – two figures: 60,000 deaths a year in our country linked directly to tobacco consumption and 5,000 deaths linked to passive smoking.  “That makes more than 13 deaths a day. It is an unacceptable reality in our country in terms of public health,” he said.

Mr. de Villepin added the state would take charge of one-third of the costs of anti-smoking treatments, such as a patch.  “That would represent the first month of treatment,” he said.

Opinion polls in France show 70% of people support smoke-free legislation, says the BBC’s Valerie Jones in Paris.

Worldwide, the entire countries of Ireland, Italy, Scotland, England, Norway, Sweden, New Zealand, Uganda, Malta, Uruguay, and Bhutan have enacted comprehensive smoke-free workplace legislation, including smoke-free restaurants and bars.

Parts excepted from the BBC, 10/8/06

Fired Up to Quit – Seeing a Way Through that Nasty Smoking Habit

When Jim Franzen quit smoking in 1993, after 43 years as a smoker, it was his thirty-fifth attempt. Like many smokers who want to quit, Franzen, a Ventura resident and artist for the Disney Studios, had tried everything – nicotine chewing gum, the nicotine patch, even going it alone “cold turkey.”

“I’m an alcoholic and I had given up alcohol,” Franzen said, “but that was nothing compared to cigarettes. Booze is addictive, but it’s not as portable as cigarettes. And even a drunk doesn’t reinforce the habit as much as a smoker. The pack-a-day smoker gets four-hundred hits daily; no drug gets reinforced as much as that.”

According to the Cancer Prevention Center at the University of California, San Diego, 46 million Americans–26 percent of the adult population–still smoke. Of those, current estimates show that over 80 percent would like to quit. And of the 2,500,000 smokers who attempted stopping in California in 1993, less than 10% succeeded.

It comes as no surprise to smokers who have tried to quit that the smoking “habit” is now widely recognized in medical and scientific literature as full-blown drug addiction. A common scenario of nicotine withdrawal symptoms includes irritability, anxiety, headaches, difficulty concentrating and memory loss, insomnia or an excessive need for sleep, inertia, increased appetite, weight gain, digestive changes, constipation, even depression.

If it sounds as bad as a Biblical plague or the tests of Job, it is – ask anyone who has tried. And that’s just the beginning. Once through the initial 3-7 days of acute withdrawal, ex-smokers face a life-long struggle to stay quit. They must combat a complex mix of habitual behaviors, social rituals, and psychological and emotional dependence that require constant vigilance – all this while resisting the lure of a drug that remains legal, easily available, and – compared to other potent drugs – socially acceptable.

Now for some good news: More than three million Americans quit smoking every year, according to the National Cancer Institute, and the success rate of quitters is steadily climbing. Society’s increasingly negative view of smoking, scientific discoveries concerning nicotine addiction and brain chemistry, and the growing sophistication of structured smoking cessation programs create a climate in which there has never been more help for quitters.

If you’ve decided that you can no longer ignore the nagging of your family and the unarguable ill effects on your health (is that you wheezing at the top of the stairs?), you may wish there were a magic formula. Should you join a program, or go it on your own? What can you expect on the road from “Smoking” to “Non,” and who has the map?

Franzen says that for him, the biggest boon to finally breaking the habit was the support and inspiration he received from the American Lung Association’s Freedom from Smoking clinic, which he used in conjunction with the nicotine patch. “When I got cravings during the program and after, I would call my fellow addictees and we’d compare notes. I needed people I could talk to who were having the same problems, who wouldn’t judge me, and I needed to meet people who have quit, because I figured if they could do it, I could do it. I know it’s not for everyone, but for me it’s a miracle. I feel like I’m really done with cigarettes now.”

The Freedom from Smoking program is one of many options for the Ventura County resident that offer support and teach a variety of coping strategies and skills to help the smoker quit. Most incorporate techniques from behavior modification and cognitive therapies, as well as health education, group counseling and support.

“A large part of breaking the habit is creating new ones,” says Jerry Leavitt, assistant director of the American Lung Association and facilitator of the Freedom from Smoking clinic. “Physically, the nicotine leaves the system in 72 hours, but as hard as that stage is, it’s short- lived. Most people find the on-going psychological addiction much harder to deal with.

“We’re conditioned to want that cigarette at certain times, and it serves a lot of purposes for us: We use it to deal with stress. It’s a break from routine, it’s a social thing, it’s how we cope with loneliness, with boredom, and for some, the cigarette becomes a substitute for friends, and a source of comfort.”

A standard approach is to give the smoker two to four weeks before quitting to observe and record their smoking habits, tracking when and why they smoke and noting the behaviors and emotions that trigger the desire for a cigarette.

Lynne Rowe, program director for the Smoking Cessation Research Institute in Palo Alto, says that a period of preparation for quitting is essential. “The smoker has all these rituals. You get in the car and you light a cigarette. You finish a meal and you have a cigarette. It’s helpful to give them time before they quit to think about these trigger points, and to create positive replacements.”

Once trigger points are identified, the group and facilitator help the smoker devise coping strategies. Some suggestions: change your routine; distract yourself by doing a crossword puzzle or taking up needlepoint; avoid places and people that might tempt you to smoke; soak in a hot bath; chew on stick cinnamon, toothpicks, sugarless gum. According to Rowe, it’s important to think of smoking cessation in positive terms, to replace the pleasure you get from smoking with other pleasurable activities. “You want to take away the feeling of it being a burden,” she says. “If it’s a burden, it’s doomed to fail.”

But habits are more than a collection of behaviors; the rituals around smoking and the effect of nicotine itself, which acts as both stimulant and relaxant, become the smoker’s way of dealing with emotional stress. “Most people start smoking when they’re young because they think it’s cool,” Leavitt says. “But then it becomes a way of managing stress, and it becomes so ingrained as a way of dealing with emotions that, oddly enough, we use it to cope with pleasurable feelings as well as with negative feelings–like the cigarette after the meal, the cigarette after sex. The earlier you started smoking the less apt you are to have developed alternative coping strategies.”

Of course, Leavitt points out, living a life that is free of stress and emotion is not possible. “But non-smokers manage, so there are other ways of dealing with it, and the smoker needs to learn them.” Stress management and relaxation techniques form the backbone of a number of smoking cessation programs. One widely-taught method involves learning to breathe.

“It’s essential to breathe deeply to control stress,” says Leavitt. “The smoker typically takes shallow breaths, except when smoking. People who have gone through this program and quit successfully tell me that the single most helpful thing they learned was deep breathing.”

Along with stress management, most programs encourage the quitter to begin a physical conditioning program, which helps combat stress and control weight. “It’s good if you can do something aerobic, but it doesn’t have to be a lot,” Georgette Davis, facilitator of the American Cancer Society’s Fresh Start program says. “I teach people stretching and relaxation and tell them that if a craving is strong, take a 5 minute break and stretch, or get up from the desk and go for a fast walk. The more you exercise the faster you’ll work the nicotine out of your system and feel better. It helps if people see the whole process in a positive way – as part of the creation of a healthy life-style.”

As well as helping smokers through the difficult initial period of withdrawal, stress management offers smokers new ways of coping with feelings that cigarettes may have helped them to ignore. Dr. Nina Schneider, a smoking cessation researcher for the UCLA School of Medicine and the VA Hospital in Brentwood, has studied tobacco dependence and run smoking cessation clinics for over twenty years. “It’s as if we each carry a tool kit, and we reach in there and pull out a tool for dealing with whatever comes up–a tool for anger, for socializing, for aggression, for being tired. But smokers, the first tool they reach for is a cigarette. That’s why it’s important to visualize ahead, to anticipate situations and strategize solutions in advance. In clinics I’ll say to people, Okay, you don’t smoke. Now here comes something that’s difficult for you to cope with – what will you actually do instead of smoke?”

Davis encourages smokers to learn to deal with emotions directly, and to become more assertive about needs and wants. “Go in your bedroom and beat a pillow and scream, if you have to. Allow yourself to cry. Ask yourself if the situation is one that can be changed by communicating with another person directly, then do that if possible. I’ve seen a number of smokers who are leading packed lives – they’re working and then coming home and taking care of the kids, they never have a moment to themselves – and part of the process for them is learning to put themselves first.

“I always tell my classes, `Okay, you’ve been good to your family, good to your friends – now it’s time to be good to yourself.'”

Most programs allow the smoker to use nicotine replacement therapy in addition to the program, and leave this to the discretion of the individual in consultation with a physician. Both the gum and the patch work by delivering a steady dose of nicotine that is gradually decreased over time. The patch is self-applied once a day, while the gum is self-administered in prescribed doses as needed throughout the day. Both require a prescription.

While not a magic potion that will automatically turn a smoker into a non-smoker, nicotine replacement can be a powerful ally. “The patch is not a panacea,” Rowe says. “People think that it will completely take their cravings away. It doesn’t. But it will mitigate them and ease the withdrawal process.”

Rowe recommends that if nicotine replacement is used, it should be combined with a counseling or support program. “It is essential, while on the patch, to focus on the behavioral and psychological aspects of your smoking – changing your habits, learning to deal with emotions and stress without smoking. Ideally, by the time you come off nicotine altogether, you think of yourself as a non-smoker.”

According to the National Cancer Institute, nearly half of adults who once smoked have quit; of those, ninety percent say they did it on their own, without the aid of a formal cessation program.

That doesn’t mean that you should discount the help you might receive from a program: like-minded buddies to share ups and downs with, somewhere to vent when times get rough, and a wealth of health information and coping strategies. But experts agree that whether you choose to participate in a structured program or go it alone, the key to success is if the smoker really wants to quit.

“You want to get people when they’re motivated,” Rowe says. “Not because their spouse wants them to quit, not because their doctor says they have to, but because they want to – then you give them a structure to enact that commitment. Of course some things will work better than others, but across the board the key to success is to identify and develop strong personal reasons for quitting.”

In most programs, the smoker is asked to write out a list of reasons for quitting, then to whittle the list down to a primary motivation. When tempted to smoke, repeat your primary motivation to yourself: “I want to live to see my grandchildren grow up,” or “I want to wake up in the morning with clear lungs and be able to breathe freely.” For many smokers, reminding themselves of their goal gives them the impetus to withstand the temptation to return to smoking.

Strong motivation also creates a willingness in the wanna-be ex-smoker to set priorities and to make allowances for the process of withdrawal. In order to stop smoking, you may find it necessary to take time off work, for example, to allow yourself a period of time that is as stress-free as possible; you may want to tell friends and family that you are giving up smoking and ask their forbearance during your inevitable mood swings; and you’ll need to forgive yourself if your behavior and performance do not always match the level that you have come to expect.

“The problem is we’re all looking for quick fixes, and there are none,” Franzen says. “If you’re going through withdrawal, you will suffer. You will have bouts of anxiety, there’s just no way around it, and it won’t be over until it’s over. Stopping any addictive practice requires being ready and motivated to do whatever it takes.”

Ask anybody who has successfully quit and they will tell you that leading a smoke-free life is worth it in the end. Dulanie Ellis-LaBarre, a script supervisor and mother who lives in Ojai, quit smoking 3 years ago. “The illusion I lived under as a smoker was that smoking made me more calm, but it turns out to be the opposite,” she says. “I’m much more calm, patient and tolerant, and my moods are more even now that I’m off the roller- coaster of smoking and craving. As hellacious as quitting smoking is – and it is, it’s the worst and nothing else compares–once you get through it, the view from the other side is glorious.”

Rachel Altman