Dr Chris considers the evidence.

Is Smoking a disease?

IS SMOKING A DISEASE?
A IDEA FOR DISCUSSION RATHER THAN A SCIENTIFIC PAPER!

Smoking: Habit or addiction?
Twenty years ago, smoking was regarded purely as a habit, and doctors expected their patients with smoking related illnesses to stop smoking when they advised them to. With this minimal intervention, succes rates were very low, even though the patient might be suffering horrendous personal diseases such as limb amputation or advanced chronic obstructive lung disease.

Obviously, smoking was far more than just a "smelly dirty habit" and in 1977 the Report on Smoking and Health, from the Royal College of Physicians in England stated ".... tobacco smoking is a form of drug dependence, different from but no less strong than that of other drugs of addiction." This then explains why cigarette smokers found it difficult to cease smoking in the prescence of advanced tobacco related pathologies.

Seven years later, in 1984, the author was faced with a dilemma regarding the prescribing of nicotine chewing gum (Nicorette) for smokers who wanted help in giving up their cigarettes. At that time in the UK, nicotine gum was a prescription only medicine a POM. It was in fact the only POM amongst thousands that could not be prescribed at NHS expense, in other words it was not reimbursable under the socialised medicine system that was in effect at that time in the UK.

A Department of Health committee, known as the Advisory Committee on Borderline Substances recommended that Nicorette should not be allowed on NHS prescription, because it decreed that "Anti smoking preparations are not regarded as drugs." The author regarded that nicotine was most certainly a drug and a powerful one at that, and so prescribed nicotine gum on NHS prescriptions for those motivated smokers who wanted to give up smoking. As a result of 'breaking the rules' the author faced various disciplinary hearings eventually having to present his case to an Tribunal of Independent of Referees. At that tribunal a statement for the Secretary of State for Health read as follows: "Smoking is a habit it is not a disease or condition even though It may be a contributary cause of, or may aggravate, a disease or condition such as bronchitis, carcinoma of the lung, arteriosclerosis and so on."

The tribunal referees conclusions were:

IN THE MATTER OF DR. C. STEELE v THE SECRETARY OF STATE
Our Conclusions to:
Is tobacco dependency a disease?

* We find it ought to be so considered.
* We find that nicotine prescribed for this purpose has both a pharmacological and a therapeutic effect.
* We find that this method of treatment is the most effective that has so far been evolved. 6th. July 1984.

Although the Dept. of Health did not regard smoking as a disease in 1984, by 1989 it had changed it's attitude when it was reported in the BMJ of 23rd Sept: "The Dept. of Health has launched a criminal prosecution against a company selling an anti smoking spray. The case against the company has dragged on for months whilst lawyers argued about whether smoking is a disease, and therfore the spray was supplied for a medicinal purpose under the terms of the Medicines Act.

By Dec. 2nd the Crown Court jury had decided, after hearing expert evidence, that smoking is a disease or adverse condition. The company was fined 5,000 plus 2,000 costs.

Other evidence.
Tobacco dependence is also listed as a disease in the International Classification of diseases (ICD 9), and the Diagnostic and Statistical Manual of Mental Disorders (DSM III R) of the American Psychiatric Association lists nicotine dependenceas a 'Psychoactive substance use disorder'.

The doctor's work model.
Taking the example of a doctor seeing a patient who presents with a history of possible hypertension, the basic working 'model' involves the following steps:
1. Measure a parameter eg blood pressure. 2. Detect an abnormal reading.
3. Prescribe a suitable medication for that problem.
4. Measure that parameter at a later date.
5. Expect the parameter to have returned to normal.

This basic working model not only applies to hypertension, but also several other disorders, such as hyperglycaemia, hypercholesterolaemia, hypertriglyceridaemia etc etc. In each case the doctor follows the same procedure:
1. Measure.
2. Detect abnormal reading.
3. Prescribe specific medication.
4. Measure parameter again.
5. Expect return to normal level.

'Medicalising' smoking.
Using the above procedure this model could be applied to the smoker. The parameter to be measured is blood Carbon Monoxide levels. When cigarette smoke is inhaled the carbon monoxide from the burning tobacco is inhaled and dissolves in the blood 200 times faster than oxygen it has a very high affinity for haemoglobin, combining with it to produce carboxyhaemoglobin (COHb). Thankfully the level of carbon monoxide breathed out in the expired air closely correlates to the level of carboxyhaemoglobin present in the blood.

A carbon monoxide monitor, known as the 'Smokerlyzer' is currently available (Manufactured by Bedfont Scientific Ltd, Holywell Lane, Upchurch, Kent ME9 7HN, England.) for measuring expired air carbon monoxide levels. The patient holds their breath for about 10 seconds, and then forcibly blows as much air out their lungs, until they can blow no further expired air.

The highest reading, which occurs after about one minute is then taken as that patient's reading. A non smoker will usually have levels below 10 ppm of CO in their expired air this is equivalent to a blood COHb of 2%. Whereas a smoker will have much higher levels eg of 30 ppm of CO, equivalent to 6% COHb. The highest reading I've encountered in a heavy smoker was 110ppm which is 22% COHb!

Because valuable haemoglobin is being taken up by the carbon monoxide, the body compensates for this 'deficit' by producing more haemoglobin. The consequences of this are that smokers have higher haemoglobin levels, which produce an increased packed cell volume, and an increase in the whole blood viscosity with consequent deleterious effects upon peripheral circulation, and an increased tendency to thrombotic events in the coronary arteries and cerebral arteries. The average smoker, therefore, suffers from a raised CarboxyHaemoglobin level, and as the patient with raised lipid levels has Hypercholesterolaemia so the smoker suffers from 'HyperCarboxyHaemoglobinaemia', or to keep it simple a raised blood CO level.

The American "Know your Number" campaign for blood cholesterol levels was extremely succesful, as many people became interested in having their cholesterol checked, in order to "know their number". A similar campaign could be aimed at smokers to have their CO levels checked, and hence "know their number". This could create a great deal of interest in smoking and may well influence many smokers to try and give smoking, once they have been taught about the consequernces of their raised CO.

On stopping smoking the CO level drops rapidly, so that within 24 hours of quitting cigarettes, their expired CO is indentical to a non smoker, even though they may have smoked 40 cigarettes a day for 40 years! This is very positive feedback to the patient, as all other parameters, such peak flow readings, packed cell volume, plasma viscosity and plasma fibrinogen take much longer to return to normal levels.

Advantages of measuring expired CO.
* The expired carbon monoxide level is an objective parameter, which easily demonstrates the difference between smoking status and non smoking status.
* It is personal to that patient, and it's always extremely important to try and personalise the problem.
* It 'medicalises' the problem, which is good for doctor as he is now treating a disease, Hypercarboxyhaemoglobinaemia, and it is also good for the patient to see that they do have something which is abnormal, but yet normal or lower in the non smoker.
* Measuring the expired CO is also a way of assessing the level of addiction of the patient to nicotine. Obviously, a patient who is inhaling cigarette smoke deeply and frequently to obtain high levels of nicotine, will also have high levels of expired CO. Hence a smoker with a CO reading of 110ppm will be more heavily addicted to nicotine than the smoker with a reading of 30ppm. This could forewarn the physician, that the former patient will probably need higher doses of nicotine than the latter. In such circumstances, combination therapy, ie nicotine gum plus nicotine patch may have to be considered.
* Only measured expired CO, can show the patient the early benefits of stopping smoking, as their CO levels drops quickly within 24hrs to the level of the non smoker.
Treatment of HyperCarboxyHaemaglobinaemia (or raised CO). The obvious way to reduce blood COHb levels in a smoker is to stop smoking. This be done by going 'cold turkey', with hypnosis or acupuncture, or using any other safe intervention, or by using Nicotine Replacement Therapy, such as nicotine gum or any of the nicotine skin patches currently available. Nicotine replacement therapies have doubled success rates, and have to be seriously considered as first line treatment in smoking cessation.

Nicotine therapies can be prescribed by the doctor, so this type of treatment fits in perfectly with the doctors working model:
1. Measure ...... expired Carbon Monoxide.
2. Abnormal levels ..... usually, only detected in smokers.
3. Prescribe .... nicotine replacement therapy.
4. Measure ..... expired Carbon Monoxide after stopping smoking.
5. Normal .... Expired CO is at the non smokers normal level.

Medico legal implications.
As all smokers have HyperCarboxyHaemoglobinaemia, then is a doctor who ignores the smoking problem guilty of negligence in not addressing a serious medical condition? Could a patient successfully sue a doctor for not receiving any medical treatment and/or counselling for their addiction to tobacco which has produced abnormal haematological changes, that can be objectively measured and recorded.

In countries where socialised medical systems exist, such as the NHS in the UK, could the Dept. of Health or the Minister of Health be taken to court for not allowing smokers with HyperCarboxyHaemoglbinaemia to receive treatments that have been proven to work, such as nicotine replacement therapy, on NHS prescription. After all, other addicts such as alcoholics and heroin addicts, receive their treatments at NHS expense!

Similarly, in countries with private medical schemes, would the medical insurance companies allow nicotine replacement therapies to be reimbursed, as treatments for the condition of HyperCarboxyHaemoglobinaemia, as well as treatment for the actual dependence on tobacco?

And, finally, would the International Classification of Diseases list HyperCarboxyHaemoglobinaemia as a disease?


IMPORTANT NOTICE : This content is from the Dr Chris Steele personal archive and is provided for convenience only. Information contained here may no longer agree with the most up to date medical advice. Please check with a medical professional before taking any action.

More like this
Illnesses
Stop Smoking
Use this page



Privacy Terms | Advertisers | Legal Disclaimer | Contact
© 2007 TheFamilyGP.com