Smoke being the ultimate pollutant, the total negation of a healthy and productive life. Or maybe just exhaled steam, coming from someone's mouth in a cold room

Marla continually breathes smoke. Her mouth is shaded by a continual stream of Bad Health. This is part of the let-it-slide life the Narrator secretly wants, but is too scared to go for.

When he first visits his spirit cave, it appears that he too is breathing smoke, as wisps of vapour come from his face. The second time, he comes face-to-face with the queen of french inhaling herself.
The third time he enters the cave, it is a far more urgent affair, as he is trying to avoid the stinging pain of the real world. In fact, he could be said to be avoiding breathing the smoke coming from his own hand.
As he bends over her, he chokes on this smoke, mingled in his dream as being either from her or from his hand
The quote above comes from the final fight, as part of his litany of self-disgust and will to destroy. He has linked the destructive urges to his own damaged psyche.

Finally, when he sucks on a bullet and chews pure gunpowder, he is breathing all the smoke he needs. He has reached a level of physical disregard and sick courage that even his darker half can admire.
He ends up puffing wisps of explosives out of a hole in his face that isn't even natural. His other half breathes a wisp from his mouth before disappearing.
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