The World No Tobacco Day may have been observed nearly a fortnight ago but its message remains very relevant irrespective of when the occasion was marked. Smoking, dhumapana (literally "consuming smoke"), has been practiced for at least 2,000 years in India and also finds mention in the Atharva Veda.
The practice of inhaling smoke was employed as a remedy for many different ailments and it was recommended to promote general health and is prescribed in Ayurveda.
Before the advent of modern times, smoking was done with pipes with stems of various lengths, Hookah or chillums.
Today the means of dhumapana have been replaced almost entirely by cigarette smoking. Beedi, the hand rolled tendu (Diospyros melanoxylon) leaf herbal cigarette filled with dry crushed tobacco is a modern descendant of the historical dhumapana. Tobacco was introduced to India in the 17th century. It later merged with existing practices of smoking (mostly of cannabis).
Tobacco smoking affects the health of blood vessels. Smoking causes narrowing of the arteries. These arteries carry oxygen to various tissues and organs by binding with haemoglobin. Nicotine reduces the capacity of haemoglobin to carry oxygen from lung to peripheral tissues.
Once narrowing of the vessels occur due to any reason, the healing capacity in any tissue of the body is disturbed. Due to this, there is impaired healing of any tissue such as skin, muscle or bone in smokers.
From the orthopaedic point of view, fracture healing is one major issue with such people and the other common issues are back and leg pain. The back pain is usually associated with claudication and smokers can have both, vascular and neurological.
The smokers initially walk without pain but gradually they start feeling pain radiating to their lower limbs and this pain forces them to stop walking or they have tendency of developing some subjective weakness of muscles after walking and sometimes they feel that they will fall if they keep on walking or standing.
Even if they undergo surgery for such a cause they usually do not get same amount of relief as a non smoker would get. They are at increased risk of recurrent back pain and/or persistent back pain even after spine surgery.
Smoking is known to cause increased chances of osteopenia and osteoporosis. The incidence of fractures increases in smokers in old age and it is directly related with the increasing time of tobacco exposure. Smoking can also adversely affect the longevity of joint replacements.
The leg fractures are known for more complications in comparison to other long bones due to its subcutaneous nature. The complications of wound healing, fracture healing and infections are more in a smoker than in non-smokers. The result of soft tissue coverage if required in such patients like flap surgery is not as successful in smokers as in non-smokers.
Smoking also causes peripheral arterial disease. Fifty per cent of it is attributed to smoking. It is more marked in lower extremities. It is more common in cigarette smokers than in smokers of beedi.
In advanced cases of peripheral arterial disease, if there is a small wound on the toe or foot then such wounds usually do not heal because the blood supply to the tissues is compromised in such patients and ultimately it can also lead to complications such as infection and gangrene rather than healing in the usual way.
Such situations often need to be treated medically in early stages and they usually also require surgical intervention in late stages like repeated debridement, prolonged antibiotic administration and prolonged hospitalisation which increases the cost of treatment.
Sometimes in spite of spending time and money, the patient ends up losing a limb or at times even life. Nowadays, amputations are mainly being done due to complications of smoking induced peripheral arterial diseases.
It has been proven in many scientific studies that smoking is in important risk factor for development of post operative respiratory complication after major surgical procedure.
The incidences of complications are more after general anesthesia but they are seen with regional anesthesia too. The surgeons should motivate the patients to quit smoking as soon as possible prior to surgery so that they can get better surgical outcome and also till he achieves good wound healing after surgery.
The overall numbers of smokers have reduced in India due to the efforts of the government and non governmental organisations. Education is also playing an important role in reducing the number of new smokers. According to a WHO report of 2015, there are almost 12 crore smokers in India which amounts to nearly 10 per cent of the population. More than a crore people die every year in India due to smoking related diseases.
There are many campaigns which are run throughout the year where the general public are told about the risks associated with smoking. The general public perception is that the smoking causes only lung cancer but it is also an important factor in causing oral cancer, oesophageal cancer and cervical cancer in females.
Smoking not only affects the survival of a smoker but that of others as well who are exposed to second hand smoke. The incidence of smoking related diseases are increased almost in 25 per cent in the passive smokers. Smoking reduces the life expectancy by almost 10 years in comparison to that of a non-smoker.
All kinds of habits whether good or bad, usually start in teenage years of individuals because this is a transitional phase due to new hormonal surge. The teenagers start having tendency to take risks to try out new things and this makes them more vulnerable.
Nine out of 10 smokers smoke their first cigarette well before the age of 18 years. The awareness programme is most needed at this age to convince them not to indulge in the habit of smoking.The smokers above the age of 35 should be motivated to quit the smoking because in a study it was found that if smoking is stopped before the age of 40 years, it reduces the risk of dying from smoke related disease by 90 per cent.
Many such smokers will require a multi-disciplinary team approach for smoking cessation, including group counselling or behavioural therapy.
Doctors are having a special social status in society all over the world but in India, traditionally, the doctors are considered to be next to god by many.
A doctor can have the unique opportunity to initiate a conversation with patients, their family and their friends to make them aware about harmful effects of smoking during their consultations. The interaction within self help groups is also an effective tool to motivate the smokers to quit smoking.
(The author is an orthopaedic and joint replacement surgeon based in Dehradun)