Tuesday, 31 May 2022 | Dr Gaurav Sanjay | DEHRADUN
GUEST COLUMN
Dr Gaurav Sanjay
Each year World No Tobacco Day is observed on May 31. This day serves as a reminder to raise awareness about the dangers of smoking and to encourage smokers around the world to quit the habit of smoking.
According to 2021data, there are almost 267 million tobacco users in India. Among adults (age 15+), 28.6 per cent of the population currently uses tobacco products (men 42.4 per cent; women 14.2 per cent). Tobacco use is a major risk factor for development of many chronic diseases including cancer, lung disease, cardiovascular disease and stroke. It is one of the major causes of death and disease in India and accounts for nearly 1.35 million deaths every year.Smoking also increases risk for developing tuberculosis and problems of the immune system including rheumatoid arthritis.
The negative impacts of tobacco smoking on the general health of humans are well established and known to the society. There is a statutory warning on each pack of cigarette or tobacco pouch, reminding the consumer about the negative effect of smoking but despite this tonnes of tobacco are being consumed every day in our country. In fact, India is second in the world in terms of consumption of tobacco.
Tobacco smoking is known to increase the heart rate, blood pressure and increase of carbon monoxide level in the blood stream. The elevated heart rate and blood pressure drops within three months of quitting smoking, blood circulation improves and lung function becomes better after three to nine months with decreased symptoms of coughing and shortness of breath. Quitting will not only save the patients but also their loved ones especially the children from exposure to passive smoking.
Smoking itself decreases the tolerance of pain and nicotine blunts the effect of painkillers. This becomes a challenge in surgical patients especially during the post operative period. The management of pain in these patients become difficult because the operative pain is compounded with the usual ischemic pain these patients have. For elective surgeries these patients are usually advised to stop smoking. Smoking is an addiction and because of that a smoker suffers from the physiological and psychological impacts nicotine has on the body and brain. This problem should be understood not only by the patient and the treating medical team but by the family as well.
The habit of smoking and chewing tobacco usually starts in teenage. Hence, there should be strict ban on tobacco sale around schools and others educational institutions. All forms of advertisement glorifying tobacco should be prohibited in the mass media.Merely a statuary warning that smoking is injurious to the health is not enough especially in the case of children and people those who are ignorant and illiterate.
In addition to chronic respiratory disorder and lung cancer, tobacco also causes hypertension and arteriosclerosis. Smokers arrive in the orthopaedic OPD mainly due to ischemic pain and in delayed cases with gangrene in the lower limbs. The author has an experience of treating many patients of peripheral vascular disease and gangrene. In these patients whenever there is a need of painkillers, they do not give them as much relief as to the general population.
Because of the narrowing of the blood vessels, there is decreased perfusion in the distal tissues which causes ischemia resulting into the ischemic pain and frequently gangrene of the distal part in the limbs. The organs like the toes and hands which are having hair pin like arrangement of the blood vessels are more prone to ischemia and gangrene. Gangrene due to smoking is usually dry gangrene but whenever these patients have associated diabetes and if they become secondarily infected then it becomes wet gangrene.
Pain at times gets relieved by increasing the dose and consumption of tobacco at an early-stage but becomes refractory to even high doses at the later stage. Due to this problem these patients indulge in other substance abuse. This causes further problems to the patients who then get trapped in multiple substances abuse practice.
Author had the experience of treating a middle aged patient who was having a habit of consuming bhang, smoking beedi, cigarette and drinking alcohol almost on regular basis since teenage. He had already got his right below knee amputation due to blockage of the arteries, due to the habits of smoking and drinking. In spite of that, the patient has not stopped any of his habits. Last week he reached to my OPD with severe pain and gangrene of the third toe which was not getting relief with the common painkiller and even with the narcotic drugs. Ultimately he was subjected to mid foot amputation in an attempt to salvage his only weight bearing limb to maintain his mobility.
Due to the narrowing of blood vessels there are high chances of poor wound healing and further necrosis of the incisional wound and even sometimes precipitation of gangrene of the operated site requiring revision amputation at a higher level. It is pertinent to mention that such patients should not blame the doctor, as it is common practice in our country, but should blame their body and themselves as a result of their prolonged substance abuse. This problem gets further accentuated if a patient is elderly, diabetic, hypertensive, having poor immunity because of any reason and taking steroids or immunosuppressant drugs for any pre-existing diseases. Such patients should be given counselling before surgery and they should be informed about the possibility of such complications. If these patients develop infection and have poor pre-operative poor general condition then they can also succumb to these complications. Most habits whether good or bad are mainly formed in teenage. Therefore it is the responsibility of the parents, society and the government to do everything to prevent the habits of smoking, tobacco consumption and alcohol drinking because prevention is better than cure.
(The author is an orthopaedic surgeon based in Dehradun. Views expressed are personal)
