INTRODUCTION

Smoking is a social evil and most smoking (tobacco)-related lung diseases including chronic obstructive pulmonary disease (COPD) and lung cancer are dose-dependent, where a cumulative dose of tobacco determines the risk. Pack-year (PY)-like parameters have been used to express the exposure to tobacco smoke, where PY means one packet of cigarettes or 20 g of tobacco smoked everyday over the course of 1 year. The variability in the number of cigarettes or bidis in the Indian market brings a nonuniformity, and hence, a smoking index is used where the number of bidis or cigarettes smoked per day in relation to the number of years (duration) of smoking is accounted for. Spirometric measurements show pulmonary physiological abnormalities, such as bronchial hypersensitivity, are reversed in those with higher smoking index. This is further confirmed by experimental, clinical, and epidemiological studies that a relationship exists between cigarette smoking and a wide range of respiratory diseases. Smoking is not only responsible for lung cancer but also is directly linked with enhanced morbidity and mortality from other non-neoplastic respiratory diseases, such as chronic bronchitis, emphysema, cor pulmonale, and respiratory infections. Some known facts regarding tobacco smoking are as follows:

• Tobacco-related diseases cost 1.04 lakh crore per year.
• India has the second largest number of tobacco users globally.
• 16.4 crores take smokeless tobacco and 6.9 crores smoke tobacco. 50% of smokers exist in china, India and Indonesia.
• The World Health Organization (WHO) tobacco tax is 75%, while the Indian tobacco tax is 53–56% only.

SMOKING EFFECTS ON PULMONARY FUNCTIONING

Structural changes include increased mucous formation due to hypertrophy and hyperplasia of mucous glands of large airways. Sputum production has increased, mainly because of tar contents of cigarettes. Small airways get inflamed; there is hyperplasia of goblet cells, and airways get closed because of intraluminal mucous formations. Experimental studies have demonstrated that tobacco smoke damages the tight junction of airways epithelium and facilitates epithelial permeability. This is further supported by the fact that abnormal permeability decreases after cessation of smoking. The abnormal permeability enhances the absorption of inhalant toxins and other aerosols resulting in exaggerated bronchial hyperresponsiveness to inhaled methacholine in both symptomatic and nonsymptomatic smokers. The damage caused to alveolar walls by smoking leads to centrilobular emphysema. This may result in an increased influx of neutrophils, which release neutrophil elastase and also activate alpha-1 antiprotease.

Functional changes due to tobacco smoking result from small airways disease, manifested by an increased closing volume and closing capacity. Small airways dysfunction can occur even in asymptomatic patients. In advanced cases, expiratory flow rates are reduced and the forced expiratory volume in 1 second (FEV₁) can be used as a predictor of development of obstructive airways disease. Discontinuation of smoking reverses the fall in FEV₁, similar to nonsmokers, in patients before the age of 40 years. Carbon monoxide (CO) in bidi is 4.5 times higher than in cigarettes.

    Chronic Bronchitis uppercaseand Emphysema

It is now an established fact that COPD is a smoking-related disease. The pattern is similar in female smokers in the West. The prevalence of chronic bronchitis is high among Indian smokers. Various studies conducted in Mumbai, Northern India, Odisha, and Andhra Pradesh have shown similar rising trends of COPD among smokers. Airways obstruction and increased production of phlegm are commonly seen in smokers; the airway obstruction reversibility becomes difficult in susceptible smokers. For those with bronchial asthma, the response to treatment is poor among smoking patients. A steep fall in FEV is observed in smokers with hyperbronco reactivity. Hypertension and tobacco usage are common risk factors for pure motor strokes (lacunar syndrome) and executive dysfunctions (postlacunar syndrome) in two-thirds of patients (Box 1).

ENVIRONMENTAL TOBACCO SMOKE

Passive smoking or environmental tobacco smoke (ETS) is involuntary or secondary smoking that causes impairment in lung functions and thus exposes people to higher rates of respiratory illness and chronic airways disease. ETS has been associated with lung cancer and bronchial asthma in children and is also responsible for the increased severity of the disease. ETS adversely affects the treatment of asthmatic patients. Airway obstruction worsens due to reflex stimulation of parasympathetic pathways by smoke particles. ETS increases bronchial responsiveness even in nonasthmatic patients, and the respiratory symptoms are more pronounced in these patients. It has been observed that wives of smokers have increased bronchial reactivity to inhaled bronchoconstrictor aerosols due to increased epithelial permeability, which starts with increased absorption of most tobacco combustion by-products that they inhale in the company of smoking husbands. This would explain partially the prevalence of chronic respiratory disease and lung cancers in nonsmoking subjects, especially the women in our country. Similarly, parental smoking badly affects and exacerbates respiratory diseases in children. The rate of lower respiratory illness in children has been found to be linearly related to maternal smoking. There is twice the risk of pneumonia and bronchitis among the children of smoking parents during the first year of life. Heavy smoking during pregnancy may have a direct effect on the offspring’s subsequent lung functions. Asthmatic children of smoking mothers have lower expiratory flow rates than those of nonsmoking mothers. These observations emphasize the adverse effects of exposure to ETS in children.

Exercise tolerance is reduced by smoking even in asymptomatic subjects. The effect is observed even with a single bidi or cigarette smoked. This reduction goes further in bronchitis patients if smoking is continued due to increased levels of carboxyhemoglobin. Lung infections such as pneumonia and influenza are enhanced in smokers. Postoperative complications are more in smokers. Smoking is an important cause of spontaneous pneumothorax. In synergism also with certain occupational exposures, such as coal mine dust, grain, and cotton or wool dust, smoking can produce airways obstruction following chronic bronchitis. Significant airways obstruction can be produced by tobacco smoke in silica workers. It increases the risk of lung cancer following chronic occupational exposure in these workers.

TOBACCO AND “P”

Tobacco affects five “Ps,” i.e., poverty, people, politics, policies, and professionals (medical). Although the effects of tobacco are known to all and everyone, it has not been possible to eradicate this social evil because of its unique power that is enjoyed the world over. Those who favor this evil are virtually involved in its cultivation and processing. Tobacco cultivation does not require intensive irrigation and the income generated by the government along with the livelihood of the people connected comes in the way of the efforts to eradicate this preventable malady. 90% of revenue from tobacco is good for farmers and good for the government through exports but is bad for the nation’s health. But how can the government of the people snatch the right of its people to breathe air that is free of tobacco smoke, the smoke that contains a complex mixture of as many as 4,000 individual constituents including carcinogens, irritants and ciliotoxic substances, and poisonous gases such as CO? There is no dearth of information regarding the health hazards of smoking tobacco, such as its role in chronic respiratory disease, heart disease, cerebrovascular, malignant, and nonmalignant disorders. Let us accept the fact that medicine is not a science but a learned profession charged with an obligation to apply the same for the benefit of mankind. It becomes a basic and foremost duty of each and every person engaged in the profession of healthcare delivery system to boldly expose the bare facts without consideration for finance, fame, or false credit. The impact of a statutory warning loaded on a cigarette pack is the minimum, as it is printed in a barely visible manner. To be more straightforward, for those who are interested in reading the same, it has to be a bigger pictorial disclosing the nicotine quantity. The advertisements from the tobacco industry in the media are too tempting for everybody, a teenager in particular. Therefore, such warnings become diluted and remain inconsequential, although a smoker has taken for granted per day being warned 3,650 times in a year. One can see no implementation of the Supreme Court’s order of not smoking in public places, and that too, in the presence of caretakers of law. The higher literate urban society seems to be nonbothered about the law, the situation is still worse and saddening in illiterate rurality where such warnings and laws remain unnoticed and unwarned. What would be much better than giving such a warning is to levy more taxes on cigarettes, which would decrease smoking and indirectly generate more revenue that can potentially be used in smoking prevention and health promotion campaigns. Let the campaign start with doctors—let the hospitals be made tobacco-free zones. Health education should be given to those who smoke to quit, to bring down the frequency of disease, and help raise the health status of the community and ultimately the nation at large. The government needs to address this issue seriously. Problems need to be attended adequately, not less important than attending to human immunodeficiency virus (HIV) disease. 10% of the world population is suffering and is estimated to die of illnesses from tobacco use. Intervention at schools and community gatherings can help in changing behavior.

The gravity of the situation must be significantly valued for the potentiality of dangers to life that it carries. Smoking represents the most extremely documented cause of disease ever investigated in the history of biomedical research, where 50,000 citations, summarized in more than 8,000 pages in two reports from the Surgeon General are lying in the office of the United States on smoking and health’s bibliographical database. The solution does not seem to be so close until and unless we become sincere to solve the same.

Young smokers (27%) are far more likely to become alcoholics. The trio of social evils such as alcohol, alternative sex, and (abnormal smoke) tobacco can be controlled by religious commitment and participation that can eradicate this triple evil from the society, right from the roots. Let us strengthen our religious cum cultural roots. What is required is to take the initiative at least. The conflict between professionals and the tobacco industry is evident as the ill effects on innocent people are unnecessarily thrown upon. The losses caused by tobacco and the sufferings, miseries, tragedies, and ruining of the economy narrate a number of stories with enormous magnitude, and yet a single moral, but there is hardly any effect on the people in the government. Can we say that those elected politicians by the people do not remain the people of the people and turn into politicians who do not realize the reality of the gravity of damages and the greatest epidemic of the present time that is arising out of use of tobacco? Smoking abstinence is by far the single preventable cause of lung cancer. Who will tell them? Doctors need to perform their duty. They need cleansing and disciplinary operation among themselves. They must realize that their duty and contribution do not end with disease management alone; they need to extend their responsibility toward the community as well as toward opinion makers of the society to create and develop a healthy atmosphere.

An epidemic of tobacco-related cancers, vascular, heart, and lung diseases including obstructive lung disorders can only be prevented by creating a national coalition of doctors, teachers, religious leaders, and opinion makers to work sincerely in this direction. The Food and Drug Administration (FDA)-approved technique for Parkinson’s disease is helpful in smokers as well. Transcranial magnetic or current stimulation of the brain has been used to bring down 20 cigarettes to 2 cigarettes/day in smokers. The mechanism is to give current to the brain for excitation by anode and the cathode takes the current from the brain to take energy from the brain to reduce excitation. Those who are afraid of political bosses due to their pressure and distasteful experience would lose the battle by default. The political people are our people, they can be made to understand the gravity of the damage caused by tobacco. They can be explained the health effects of tobacco-free environments. They need to be stressed that this can only be achieved through their help and by their action. After all, politicians are also responsible people; they are also open to arguments and pressure, and the suggestions which are purely based on medical facts and meant simply for the community well-being. They must be made to understand the ugly heads of tobacco products, which are being projected and becoming the fashion of every house. They will surely confirm to lend their hand of help to save 3 million deaths every year that occur because of tobacco—the social evil. Can we dream of such a tobacco-free society where no one, not even Bollywood stars, politicians, or common man, would bow before these tobacco people? Let us not compromise with the health of the people at least and give every citizen the right to breathe air without tobacco smoke.

Results of Quit Tobacco helpline no. 1800 112356 and tobacco-related information help no. 104 which have been thrown open in Punjab are yet to be seen. Nevertheless, Current Indian data on 31st May, 2016—the no tobacco day—is not much encouraging as:

• 150 lives are lost per hour in Southeast Asia.
• 27.5 crores go for tobacco as kids.
• 10 lakh Indians die per year.
• 20% Indian children are tobacco consumers.
• 30% cases have near cancer in tobacco consumers in India—Indian Council of Medical Research (ICMR).
• Unable to prevent cancer because we are unable to check tobaccosis. The risk of coronary artery disease (CAD) and ischemic heart disease (IHD) also increases
• Risk of bulla formation in the lungs is the main risk factor.

CONCLUSION

Tobacco smoke is dangerous to cardiopulmonary health. Who can better know the ill effects of smoking than doctors. Hence, they need to act as leaders in the prevention of lung cancer where tobacco stands as a solitary cause. So, doctors have the duty to create a tobacco-free environment advising people with a presentation of medical facts about tobacco and not to buckle under pressure from officials or corporate houses and hence help to save the next generation, providing healthy air to breathe. They need to practice the highest standard of religiocultural heritage gifted from forefathers to explain the dangers of passive smoking of tobacco, especially the carcinogenic risk to the unborn, prevent the risk of low birth weight, miscarriages, premature babies, and even sudden infant death syndrome in addition to nonmalignant and malignant respiratory disorders. Let’s all get sensitized to be humane.

SUGGESTED READINGS

1.   Bhatia RS, Vijayan VK. Tobacco and health: what can the medical profession do? Lung India. 1994;12:178-85.

2.   Bhatia RS. Cardiopulmonary manifestations of tobacco. In: Thakur BB (Ed). Medicine Update, volume 10. API; 2000. pp. 716-18.

3.   Datta R, Singh S, Joshi A, Marwah V. Concept of BIDI years: Relevance to the perioperative period. Lung India. 2022; 39(4):337-42.

4.   Praveen CK, Manu M, Mohapatra AK, Pentapati KC. Power of BODE index in predicting future exacerbation of COPD: J Assoc Physicians India. 2019;67(4):14-6.

5.   Bhatia RS, Kant S. COPD. Lucknow: JBS Foundation; 2014.

6.   Shukla RK. Association of clinical symptoms with smoking quantity in northern Indian COPD patients at tertiary care hospital. Intl J Biolog Pharm Res. 2012;3(4):545-49.

7.   Sundar U, Ghuge V. Lacunar Syndrome—where is the lesion? J Assoc Physicians India. 2015;63(6):41-4.

8.   Bhatia RS, Surya Kant (Ed). Bronchial Asthma, 1st edition. New Delhi: Peepee Publishers and Distributors (P) Limited; 2008.

9.   Sharma P, Murthy P, Shivhare P. Nicotine quantity and packaging disclosure in smoked and smokeless tobacco products in India. Indian J Pharmacol. 2015;47(4):440-3.

10. Bhatia RS. Wanted a national coalition against tobacco. Lung India. 1992;10:119.

11. Bhatia RS. Smokeless tobacco—a challenging smoke. J Assoc Physicians India. 1994;42(4):344.

12. Kant S, RS Bhatia. Update on Lung Cancer. Lucknow: JBS Foundation; 2019.

13. Bhatia RS, Singh H. Cardiopulmonary effects of tobacco. Cardiopulmonary Topics. New Delhi: Peepee Publishers and Distributors (P) Limited; 2008.

14. Anadkat M, Thanki A. Study of Lipid Profile in Chronic Smokers. J Assoc Physicians India. 2019;67(4):11-2.

15. Hosseinzadeh Asli R, Aghajanzadeh M, Lahiji MR, Hosseinzadeh Asli H, Foumani AA, Pourahmadi Y. Results of the surgical treatment of pulmonary bleb and bullous disease: A retrospective study. Lung India. 2022;39(5):455-59.