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Patients Who Smoke

Dr. Frederick Ross of Winnipeg must have become a household name. He has been extensively interviewed and quoted in the media. And his recent actions have rekindled the debate about individual’s responsibility to his own health and physician’s responsibility to educate his patients on preventive medicine.

What did Dr. Ross do?

Three months ago, he informed all his patients that he would not treat smokers who are unwilling to give up the deadly habit. They were given 90 days to quit. The deadline was last week. That’s when Dr. Ross hit the headlines. Some people complained that Dr. Ross’s action was unethical. Manitoba’s licensing body for Physicians thinks otherwise.

As we know, tobacco use is the leading preventable cause of death in Canada. It is responsible for one in five deaths. Half of regular smokers die prematurely of tobacco-related disease. Many patients continue to smoke although they have known or experienced ill health due to smoking.

What are the obstacles to quitting?

The main obstacle to quitting is the addictive nature of nicotine, says an article in the New England Journal of Medicine (NEJM).

Nicotine causes tolerance and physical dependence. If you quit smoking then expect withdrawal symptoms like irritability, anger, impatience, restlessness, difficulty concentrating, insomnia, increased appetite, anxiety, and depressed mood. These symptoms may vary widely in intensity and duration.

The withdrawal symptoms begin a few hours after the last cigarette, peak two to three days later, and wane over a period of several weeks or months.

The second obstacle to quitting is the psychological factor – tobacco use is a learned behaviour, cigarettes become part of a person’s daily routine, says the NEJM article.

It is associated with events, such as finishing a meal; handling stress and negative emotions such as anger or anxiety. To stop smoking, a smoker must learn new coping skills and break old patterns.

Smokers who have good intention to quit have two problems: staying free of cigarettes for a long period of time and putting on weight.

What is effective in encouraging smokers to quit?

A physician can do what Dr. Ross did. But scientifically, two approaches have been found to be effective: counselling and nicotine replacement therapy. Each is effective by itself, but the two in combination achieve the highest rates of smoking cessation, says the NEJM article.

Studies have shown that a physician’s advice to stop smoking increases the rates of smoking cessation among patients by approximately 30 percent.

One report in the Medical Post says that half the specialists surveyed never counselled patients on smoking cessation. That burden seemed to fall on the family physicians, who were eight times more likely to ask patients about a quit date than other physicians.

Nicotine replacement therapy comes in different forms: gum, skin patch, a nasal spray, and a vapour inhaler. Combination of counselling and drug therapy achieves typical rate of cessation at 40 to 60 percent at the end of drug treatment and 25 to 30 percent at one year.

Changing public behaviours is difficult. “The first reform is to stay healthy,” says Mazankowski report. We know that relatively small changes in our lifestyle can markedly reduce several major diseases. But are we ready to do that?

Through these columns and through CHAT TV’s “Medical Moments” we have tried to send the same message of self-help and improvement in once life-style. The slogans we have used are: help your doctor to keep you healthy and if you take care of ELMOSS then ELMOSS will take care of you!

So, what did you do today to keep yourself healthy?

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Vitamin B12

Dear Dr. B: Thank you for your columns on Vitamin C and other vitamins. What about vitamin B12? Many people are on B12 injections on regular basis. Why is B12 important? Yours, Ms. B12.

Dear Ms. B12: Vitamin B12 deficiency is a common problem that affects the general population and the elderly in particular. Persons with the deficiency may have no symptoms or may have symptoms related to blood disorder or disorders of the nervous system including psychiatric problems.

Vitamin B12, also known as cobalamin, was first isolated in 1948 and was immediately shown to be effective in the treatment of pernicious anaemia. Recently, interest in the vitamin has been renewed because of the recognition that B12 deficiency occurs in 3% to 40% of the general population.

Vitamin B12 is essential for good health. It is obtained primarily from animal proteins (i.e., red meat, poultry, fish, eggs, and dairy). But the vegetarians can get enough of it from legumes. The cause of B12 deficiency is not usually poor diet but problems with absorption in the gastro-intestinal tract.

Absorption of vitamin B12 from foods is complex; a defect in any step can lead to deficiency. In the stomach, gastric acid and pepsin is required for digestion of B12. In the upper small intestine, pancreatic enzymes and an alkaline pH is necessary. B12 is absorbed from the terminal ileum (last part of the small intestine where it joins the colon).

The liver contains most of the body’s B12 (about 1.5 mg), followed by the kidneys, heart, spleen, and brain. Normal body stores of vitamin B12 range from 2 to 10 mg; daily losses are 2 to 5 micrograms. The stored B12 can last us two years in conditions where our body is deprived of B12.The latest Recommended Dietary Allowance (RDA) for vitamin B12 is 2.4 micrograms/day for persons aged 14 to 70 years; the average diet contains about 5 micrograms daily.

The diagnoses of B12 deficiency is made by checking the blood levels in patients who have symptoms or who are prone to B12 deficiency. Treatment is by B12 injections on regular basis for the rest of person’s life.

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A reader wants to know the following:

What is the difference between micrograms (ugm.), milligrams (mg.) and International Units (IU)?

1000 micrograms is 1 milligram.

International unit (IU):
Is a unit used to measure the activity (that is, the effect) of many vitamins and drugs. For each substance to which this unit applies, there is an international agreement specifying the biological effect expected with a dose of 1 IU. Other quantities of the substance are then expressed as multiples of this standard. Examples: 1 IU represents 45.5 micrograms of a standard preparation of insulin or 0.6 microgram of a standard preparation of penicillin. Consumers most often see IU’s on the labels of vitamin packages: in standard preparations the equivalent of 1 IU is 0.3 microgram (0.0003 mg) for vitamin A, 50 micrograms (0.05 mg) for vitamin C, 25 nanograms (0.000 025 mg) for vitamin D, and 2/3 milligram for vitamin E. Please note: for many substances there is no definite conversion between international units and mass units (such as milligrams). This is because preparations of those substances vary in activity, so that the effect per milligram of one preparation is different from that of another.

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Essential Vitamins

More people consume vitamin supplements now than ever before. Do we know what is the right vitamin to take and how much of it do we need?

This issue is discussed in a Clinical Practice article in the New England Journal of Medicine (NEJM) titled, “What vitamins should I be taking, doctor?”

Medical teaching says that a healthy individual, who eats a good diet, does not require vitamin supplements. He should be able to meet his vitamin needs from his healthy diet. But the public interest in vitamin supplements is enormous – sometimes due to misguided reasons. Almost 30 percent of our population takes vitamin supplements. And there is no control over it.

Because the food we eat contains too many nutrients, it would be almost impossible to conduct double blind trials to see if vitamins do have improved clinical outcomes. Also the users of vitamin supplements may have healthier lifestyles or behaviours than nonusers. This would distort any clinical trial results.

The good thing about vitamin supplements is that there is greater likelihood of good than harm and cost of supplements is not that high so the authors of the article in the NEJM recommend the following vitamin supplements for healthy individuals. There is substantial evidence that higher intake of:

1. folic acid (400 ug/day),
2. vitamin B6 (2 mg/day),
3. vitamin B12 (6 ug/day), and
4. vitamin D (400 IU/day) will benefit many people, and a
5. a multivitamin will ensure an adequate intake of other vitamins for which the evidence of benefit is indirect.

The authors say a multivitamin is especially important:

-for women who might become pregnant
-for persons who regularly consume one or two alcoholic drinks per day
-for the elderly, who tend to absorb vitamin B12 poorly and are often deficient in vitamin D
-for vegetarians, who require supplemental vitamin B12 and
-for poor urban residents, who may be unable to afford adequate intakes of fruits and vegetables.

Physicians who encourage their patients to take vitamin supplements should also educate their patients regarding healthy life style and about healthy nutritious diet. Foods contain many additional important components, such as fiber and essential fatty acids and vitamin pills cannot be a substitute. Vitamin pills do not compensate for the massive risks associated with smoking, obesity, or inactivity, say the authors of the NEJM.

What about vitamin E?

The authors feel that vitamin E supplements are reasonable for most middle-aged and older individuals who are at increased risk for coronary artery disease. Although the final verdict on its benefit in prevention of heart disease is not in, the authors feel that it is reasonable to take 400 IU of vitamin E daily. But this should be reviewed annually as more information becomes available.

The authors do not recommend any additional vitamin supplements at present, as the evidence required to make such recommendation is far from complete.

The message here is pretty clear. First practice healthy lifestyle: regular exercise, healthy diet (high fibre, low fat diet with lots of fruits and vegetables), no smoking, weight control, and stress management (remember ELMOSS?). Then spend money on vitamin supplements.

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Surgery for Snoring

Surgery for snoring – is it available in Medicine Hat?

Yes, it is done by Dr. Neil Harris, ear, nose and throat surgeon (Otolaryngologist). I asked him about his approach to patients who snore. This is his response:

Hi Noorali:

My approach to the management of sleep apnea and snoring is to first get a detailed history of the patient’s problem. This includes general health, daytime activity, daytime nasal obstruction, hours of sleep, frequency and severity of snoring, and frequency and duration of any witnessed breath-holding spells.

General health considerations include fatigue, excessive drowsiness, hypertension, obesity, any respiratory or cardiac illness and smoking.

It is also important to assess how disruptive the patient’s problem is on family members. Severe snorers tend to become hypertensive so treatment is not only for the benefit of the spouse or family.

Medications, alcohol consumption, and dietary considerations are important. If weight is contributing to snoring and apnea, weight management is discussed.

If true obstructive or central sleep apnea is suspected on the basis of the history, then the patient should be referred for sleep lab testing. If the results confirm sleep apnea then the patient should try CPAP. Surgical treatment for sleep apnea is also an option but surgery works better for snoring without significant apnea.

Most patients with poor sleep, fatigue, and daytime drowsiness are simple snorers and these patients generally do very well with surgical treatment.

Patients are advised before surgery that swallowing will be different for a short while after surgery and few patients have temporary nasopharyngeal reflux, or regurgitation of fluids into the back of the nose if they drink too fast. This has never been a permanent problem for anyone.

Most patients have no trouble at all. Also it is explained that the procedure is not a guarantee that the patient will not make any more noise when sleeping or that snoring will be eliminated forever.

Snoring can return as aging causes further laxity of throat tissues.

The operation is called uvulopalatopharyngoplasty or just pharyngoplasty, and takes about fifteen minutes. It can be done by laser with only local anaesthesia or under general anaesthetic in the operating room using electrocautery. The actual technique is similar with either method. I prefer to do the surgery with the patient asleep to ensure careful trimming of lax tissue and placement of dissolving sutures.

The rim of the soft palate is injected with local anaesthesia and steroid to prevent post-operative pain and swelling. The mucosal rim of the soft palate, the uvula and the part of the posterior tonsillar pillars are trimmed, and sutures are placed, leaving a smooth arch at the back of the throat.

The patient is routinely discharged from hospital on the day of surgery, with a prescription for a liquid antibiotic to prevent infection and a liquid analgesic.

When patients return for follow-up in about three weeks most are pleased with the results. They generally have longer periods of deep, restful and quiet sleep. They wake easier and have greater daytime energy and stamina.

Many have told me that their mood has improved. Some have been able to discontinue blood pressure medicine. Spouses sleep better, too. The results are not quite as good in true obstructive apnea but surgery can still be done in addition to the use of CPAP or if CPAP cannot be tolerated. Central apnea should be managed medically.

Pharyngoplasty is an easy, safe and effective operation. In properly selected patients it significantly improves the quality of life.

Noorali, I hope this information will be useful to readers of your column.

Neil Harris

This is the third column dedicated to the subject of snoring and sleep apnea. I hope after this people will get help and sleep in silence and keep their spouses happy. Good luck and sweet dreams!

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