Illness and health
SMOKING AND HEALTH
It seems that smoking tobacco is declining in the developed world, but increasing in developing countries1.
However, in the United States, where smoking has declined, there is a reported increase in the use of smokeless or chewing tobacco. In Croatia, smoking remains widespread. Laws restricting smoking in public places were introduced, only to be watered down within a few months. Croatia signed the World Health Organization’s ‘Framework Convention on Tobacco Control’ on June 2nd 2004, and was fully accepted as a participant on October 12th 20082. Croatia’s first report on the prevalence of smoking in the country, submitted on January 11th 20113, but using figures from 2001, shows shockingly high figures for all age groups4.
Anti-social delusions
It can be difficult for smokers to realize that cigarette, cigar and pipe smoke can be both offensive and damaging to non-smokers. Some smokers simply close their minds to the fact that their habit is polluting the air for all around them. Some delude themselves into thinking that it doesn’t matter.
Self-delusion always plays a big part in addictions. Many smokers think that the ill effects of smoking are exaggerated by the anti-smoking brigade. One chain smoker told me recently that smoking wasn’t nearly as harmful to the health as stress, although his reasoning was vague. Some smokers think the harm is limited to the risk of lung cancer, and point with misplaced triumph to the cases where non-smokers die of the disease. Tobacco use is a major risk factor in heart attacks, strokes, emphysema and most if not all cancers, especially of the lungs, pancreas, bladder, mouth and larynx.
In fact, nicotine is so poisonous that tobacco has been used as a pesticide from the 15th century up to modern times.
Negative effects
A major problem regarding smoking and its ill-effects is the cost of healthcare for smoking-related diseases. One bizarre, not to mention inaccurate counter-argument is that smokers tend to die earlier than others with healthier habits, so they do not incur the costs of long-term care in old age. For healthcare workers, it is frustrating when smokers seek treatment for smoking-related problems, without being prepared to give up the cause of the problem, or at least to try. There’s probably nothing more futile than applying chest physiotherapy to a patient with chronic obstructive lung disease who prepares for the session by smoking (‘helps me cough up better, dear’); and nothing sadder than a patient puffing away on cigarettes while travelling to a chemotherapy session for lung cancer (‘helps me relax’).
Passive smoking
It’s one thing to risk damaging one’s own health. The biggest problem with smoking is its unavoidable effect on others. Parents smoke over their babies and small children without a thought for the dangers of passive smoking. Yet it is well established that passive smoking can contribute to various major and minor illnesses, especially affecting the lungs, but also including an increased risk of osteoporosis and bone fractures5,6, diabetes7 and hip development problems (Legg-Calvé-Perthes condition)8 in the young. In 2010 the Lancet published online an analysis of the effects of passive smoking, which concluded that in 2004 it caused some 603,000 deaths, with children accounting for 28%9.
Social effects
Attitudes to smoking have changed. In the early 20th century, smoking was widespread, especially among men. Restrictions reflected social attitudes: in ‘polite society’, especially in the UK, ladies were expected to smoke less, if at all, and certainly not in public. Cigarette advertising was rampant, awash with images of health, happiness, sophistication, manliness, femininity, physical fitness and limitless freedom... In the 1960s cigarette sponsorship of sport became commonplace. At tennis tournaments in the UK, cigarettes were freely available, a tactic that seems like a cynical investment, as every person who got hooked would be paying dearly for the freebies over many years.
In Hvar Town there is an old tradition that on the feast of Candlemas (2nd February) young people can smoke their first cigarette by the little chapel of Gospa Kruvenice (Our Lady of the Flag), after a due number of prayers. Very gradually the custom is evolving, so smoking now takes second place to lighting a symbolic fire of purification.
Manners have changed over the years, and politeness is arguably less common than it used to be. Smokers used to ask if those nearby minded them lighting up. Now they assume that if smoking is permitted (and sometimes even if it isn’t) they don’t need to ask, non-smokers must just put up with it. The modern scourge of littering is made up of a high proportion of cigarette packets and butts. The Croatian shipping line Jadrolinija has notices asking people not to throw litter into the sea, and particularly not fag-ends, as the discarded filters are known to be harmful to fish10,11 .
Changes, Government restrictions
The WHO Framework Convention on Tobacco Control, which came into force in 2005, aims to limit the spread of tobacco use worldwide, by encouraging countries to promote the health message, and to take steps to curb tobacco use, while still allowing each country freedom to choose if or how it implements the terms of the Convention: ‘Signature of a convention indicates that a country is not legally bound by the treaty but is committed to not undermine its provisions’.
Events can force change. The major fire at Kings Cross Underground station in London in 1987, which killed 31 people, was started by a cigarette butt setting fire to rubbish under an escalator. This led to a ban on smoking throughout the Underground network, which, surprisingly, was largely respected. Later UK legislation banning smoking in restaurants, pubs and the workplace also seems to have succeeded, despite fierce opposition in some cases.
Croatia’s measures to restrict smoking reflect the ambivalence governments show towards unpopular legislation which might undermine a source of national revenue. The 2011 Report states: ‘...smoking is prohibited in all closed public areas in Croatia. Smoking is only permitted in special areas reserved for smokers, designated for accommodation of guests, marked as areas where the smoking is permitted, but the serving of food and drinks is not permitted. The smoking areas must cover less than 20% of the overall public places, they are reserved for smokers only, with special ventilation system, automatically closing door etc.
According to the Act on Amendments to the Act on Restriction of the Use of Tobacco Products (OG 119/09) the exception are the facilities serving only drinks, which are not able to to fulfil the conditions for smoking areas and are designated as smoking area by the owner or the facility user, but with special ventilation system and obligation of having promotional material on the harmful effects of tobacco products.’
In practice, the law is flouted in government offices, hotels, restaurants and cafés alike, to the discomfort and frustration of non-smokers. Cigarettes are relatively cheap in Croatia, but not that cheap in comparison to the average wage, income or pension.
Freedom for all
We all have the right to live as we choose, within reason. By minimizing the negative impact we have on people around us, we create a happier and healthier society. Smoking is a negative contributor with no positive factors going for it.
Discouraging and restricting smoking is not about removing smokers’ freedom to choose what they do. The aim is to prevent their unhealthy habit from affecting others, particularly children.
Advice to smokers
* Remember that your cigarette smoke has a harmful effect on those around you.
* Your cigarette smoke travels a long way: try not to smoke anywhere in your home, especially if you have children.
* Choose smokeless or chewing tobacco rather than cigarettes.
* When in company, always ask if those around you object to you smoking.
* Be prepared to refrain or go elsewhere if they do.
* Respect no-smoking areas.
* Respect the environment: dispose of cigarette butts and packets in a responsible way.
* Do not encourage others, especially children, to smoke.
* If you do sport, avoid smoking for about 2 hours before exercising: that can increase your lung capacity by about a third.
Quitting
If you ever feel like quitting smoking, persevere. It is a difficult addiction to overcome, but not impossible. Even if you fail a few times, try to regain the motivation. Look up all the possible tactics for giving up the habit, and experiment until you find the one that works for you. It helps if you are supported by people close to you, but only you can solve the problem. Weigh up all the cons and any pros you can think of, then make the resolution.
References:
1 WHO Report on the Global Tobacco Epidemic 2008
http://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf
2 http://www.who.int/fctc/signatories_parties/en/
3 http://www.who.int/fctc/reporting/party_reports/cro/en/index.html
4 http://www.who.int/fctc/reporting/party_reports/croatia_annex1_prevalence_figures.pdf
7 Houston T K, Kiefe C I, Person S D, Pletcher M J, Liu K, Iribarren C, 2006. Active and passive smoking and development of glucose intolerance among young adults in a prospective cohort: CARDIA study. BMJ 332 (7549) 1064-1069. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/16603565
8 Garcia Mata s, Ardanaz Aicua E, Hidalgo Ovejero A, Martinez Grande M, 2000. Legg-Calvé-Perthes disease and passive smoking. J.Pediatr.Orthop. 20 (3) 326. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/10823599
9 Online: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61388-8/abstract. Published in the journal (8th January 2011): Oberg M, Jaakkola M S, Woodward A, Peruga A, Pruss-Ustun A, 2011. Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. Lancet, vol.377, issue 9760, pp 139-148
10 http://universe.sdsu.edu/sdsu_newscenter/news.aspx?s=71209.
11 Slaughter, Elli 2010. Toxicity of cigarette butts and their chemical components to the marine and freshwater fishes, atherinops affinis and pimephales promelas. Master’s degree thesis, Faculty of San Diego State University.
http://sdsu-dspace.calstate.edu/xmlui/bitstream/handle/10211.10/599/Slaughter_Elli.pdf?sequence=1
Note: to see picture captions, hover your mouse over the image
ANTIBIOTICS AND SELF-CARE
Use with care
Swallowing a pill is all too often seen as the quick solution to problems of ill-health. This is not so. Using antibiotics incorrectly can lead to recurrence of illnesses or infections. Prescription of antibiotics is becoming less widespread, as patients and doctors alike are becoming aware that they are not a cure-all, and that they have to be used with discretion. But a lot of people still rely on them without understanding their overall effects, or how to use them to best advantage for recovering good health.
Antibiotics create an artificial feeling of wellness. But they take their toll of the body’s systems, at the same time as they destroy harmful organisms. The natural immune system defences are undermined, so resistance to further infections is reduced. You are also more prone to soft-tissue injuries and strains while your immune system is low.
Antibiotics can make the body more vulnerable to food intolerance reactions, including skin effects and joint or muscle pains. Certain antibiotics cause side-effects such as skin rashes, flaky skin or thrush. Overuse of a particular antibiotic can lead to allergy to it. Body energies are lowered, which can be tiring and depressing. Some antibiotics can in themselves cause a level of depression and occasionally hallucinations. It has also been suggested that, taken long-term, antibiotics may have an adverse effect on the memory.
Over the years, the link between the overuse of antibiotics and the rise of so-called 'superbugs' such as MRSA (Methicillin-resistant staphylococcus aureaus) and CDiff (Clostridium difficile) has become clear. Doctors and other practitioners who prescribe pharmaceutical medicines have been strongly advised to limit prescription of antibiotics to specific cases where they are definitely needed. The practice of taking antibiotics preventively, or in cases of viral infection is discouraged, as is self-medication. Concern has also been expressed about the routine administration of antibiotics to animals, poultry and fish reared in cramped conditions and destined for human consumption.
Let the immune system recover
If you are taking antibiotics, there are two priorities: firstly, to recover from the illness or infection which made you take them in the first place, secondly to recover from the weakening effects of the antibiotics themselves. This applies equally, whether you are feeling ill, or whether you are suffering from an apparently superficial infection such as a gum abscess or skin wound and feel well in yourself.
Antibiotics may bring quick relief from the symptoms, but don’t be tempted to continue with normal daily activities, including exercise and sports, on the assumption that the medicine has cured the illness or infection.
If you take antibiotics for an illness or infection, remember that rest, preferably in bed, is essential. If you really cannot spend a day or two in bed, try to organize yourself so that you can lie down and sleep or doze at regular intervals during the day, or whenever you feel the need. Leave out all activities which are not absolutely essential. Do not force yourself to stay awake reading, watching television or talking to people. However undemanding such activities might seem, they are mentally tiring when your energies are drained. You may find it difficult to sleep through the night if you sleep a lot during the day, but do not worry, your sleeping patterns will regulate themselves as your energies return to normal.
If you take antibiotics for an infection such as an abscess rather than an illness, and you do not have symptoms of being unwell, complete bedrest is probably not necessary, but you should have rest breaks at frequent intervals during each day, and you must avoid over-tiring yourself.
Recover fully
After a course of antibiotics, it is common to feel tired and run-down, sometimes even depressed, and therefore very low on energy. If you have had more than one course of antibiotic treatment in quick succession, the immune system can remain undermined for a long time.
Do not try to get back to normal immediately after you have finished the course. You need at least five days, sometimes even longer, to recover from the effects of the antibiotics alone, and you need that time clear of the antibiotics in order to judge whether you are fully over your illness or infection. On no account should you do strenuous labour, exercise, sports or journeys (especially by plane) before all the effects of illness, infection and the antibiotics have had a chance to clear completely. You risk causing a recurrence of your problems, or even longer term effects such as chronic fatigue syndrome.
To recover fully, you have to conserve energy. Try to pace yourself carefully each day. Include rest and relaxation periods within your daily schedule. Use deep breathing exercises to help your lungs work properly and to calm the system. Check your pulse rate first thing in the morning, and during the day if it seems to vary a lot. Eat a healthy diet with regular meals, plenty of fruit and vegetables, and foods like natural yoghurt to restore the beneficial bacteria in the gut which are part of your natural immune defences. Make sure your digestive system and sleeping patterns get back to normal.
Once your body is functioning properly, your energy levels are good, and you feel in balance, you can return safely to your normal activities, providing you do so in easy stages.
MISTAKES THAT MAKE US ILL
It’s very common for people to ignore the early warning signs of illness, and continue with physical activities, only to find that they make themselves quite ill. On the Dalmatian coast people usually swim in the sea from about April until October or November. Even in high summer, swimming with a sore throat, however slight, can lead to a bad chest infection. In the autumn, the risk is even higher, because the weather can be sunny and hot, yet very chilly in the shade or when it is windy. I’ve also heard doctors advise patients to continue going swimming while taking antibiotics for illness. One friend who took that advice when suffering from severe tonsillitis was ill for most of the next year with recurrent infections and ever-stronger antibiotics.
Occasionally in the run-up to an illness there is a deceptive feeling of unlimited energy and a need for strenuous physical activity. For example, a young man remembered feeling unusually active the day before he fell seriously ill with poliomyelitis as a child. He had spent several hours playing frenetically on a scooter. Afterwards the right leg with which he had been propelling the scooter was worst affected by the partial paralysis which weakened his torso and limbs. This false energy is a common effect in the onset of polio, and has been found to cause more severe degrees of paralysis.
I can remember feeling strangely energetic the day before I was taken seriously ill with pleurisy at the age of twelve. I went for a run on that wet, dark evening, something I had never done before, only to spend the next few weeks in bed, too weak to do anything except take medicines and read for short periods at a time. Twenty years later I repeated the mistake. While at the Winter Olympics as a physiotherapist to the British team, I spent a rare day off cross-country skiing enthusiastically for several hours, an unusual activity for me. I had been aware of a slight pain across my upper back that day, and had previously had a slight cold. After the skiing I realized I was seriously ill. Our consultant chest physician quickly diagnosed double pneumonia and pleurisy, and expertly guided me back to health over many months. In the many years which have passed since then, I have managed to avoid making that mistake for a third time, so far.
Exercising when ill can damage the heart. Certain sports, such as squash, are high risk for people who have high blood pressure or heart problems. Pericarditis is inflammation in the tissues covering the heart. It is a condition which can happen to very fit sports competitors who train or compete while they have an illness or infection, and it must be diagnosed and treated correctly to prevent further consequences. Exercising with infections can damage the heart muscle itself. Sudden death in sport is well-documented, but often fit young athletes think it will never happen to them, or they don’t know how to recognise the symptoms of illness which should be danger signs. I have known apparently fit sports players die while doing their sports: a 16-year-old junior international oarsman, a 21-year-old recreational squash player, and a County squash player of around 30. The oarsman had passed a stringent fitness test, including heart checks, just weeks before he died. The two squash players were known to have suffered from apparently minor infections immediately before their deaths.
Overuse of antibiotics can contribute to chronic illness and so-called 'superbugs'. Doctors’ mistakes can play their part in sport-related deaths. Doctors dealing with sports participants have to have a lot of experience to be aware of all the possible problems which might affect a fit and healthy-looking individual. In the UK canoeists have for some years been issued with a fact-sheet giving guidelines for inexperienced doctors about Weil’s disease. The canoeists are advised to show them to any doctor they consult if they fall into potentially polluted waters. However, if the doctor ignores the guidelines, the canoeist is helpless unless a second opinion can be obtained quickly: I heard of a case a few years ago in which a canoeist died because the doctor refused to consider the possibility of Weil’s disease.
Fortunately, tragic outcomes from sport and energetic activities are rare. The better informed people are about how to deal with illness effectively, the better they can care for themselves, and the less they risk long-term or fatal complications.
