“I have smoked for so long and so much,

what is the use in quitting now?�?/EM>

Smoking's Impact on the Lungs

To add a little more perspective to the demonstration, here is another way to see how much tar actually gets into the lungs from smoking.  Below is the picture of a smoking machine.

This machine smokes 2,000 cigarettes a day, mimicking smokers puffing patterns to capture equivalent amounts of tar as would a smoker.  In one day the machine captures the amount of smoke in the picture below.

The bottle above with the tar collected from 2,000 cigarettes.  If a diluted form (diluted, not concentrated is as often done in animal experimentation to demostrate that chemicals are carcinogens) of this tar is painted on the skin of mice, 60% of the animals developed cancer of the skin within a year.

Many chemicals currently banned for human consumption were removed from usage if they even caused 5% or less cases of cancer in similar experiments.  Cigarette tars contain some of the most carcinogenic chemicals known to man.  Consider this when watching people smoking and exhaling only 10% of the tars they actually take in.  Not only are these chemicals being painted into the lung, but smoker are also constantly painting them up on their lips, tongue, larynx, swallowing some and thus painting it in the esophagus and throughout the digestive tract.  Smokers have increased incidents of cancer in all of these exposed sites.

Now that you know what it looks like on a large scale and feels like, lets take a look at the microscopic level of things that happen in the lung from smoking.

The following series of slides illustrate microscopic changes that happen when a person smokes.  The first slide is showing an illustrated blow-up of the normal lining of the bronchus.

On the top we see the cilia, labeled (H).  They are attached to columnar cells, labeled (I).  The cilia sweep the mucous produced in the goblet cells, labeled (J) as well as mucous coming from deeper glands within the lungs and the particulate matter trapped in the mucous.  The bottom layer of cells, labeled (L) are the basal cells.

Below we start to see the changes that occur as people begin to smoke.  You will see that the columnar cells are starting to be crowded out and displaced by additional layers of basal cells.  Not only are fewer cilia present but the ones that are still functioning are doing so at a much lower level of efficiency.  Many chemicals in tobacco smoke are toxic to cilia, first slowing them down, soon paralyzing them all together and then destroying them.

As you see with the cilia actions being diminished, mucous starts to build up in the small airways making it harder for the smoker to breathe and causing the characteristic smokers cough in order to clear out the airways.

Eventually though, the ciliated columnar cells are totally displaced.  As can be seen below ominous changes have taken place.  Not only is the smoker more prone to infection from the loss of the cleansing mechanism of the cilia, but these abnormal cells (O) are cancerous squamous cells.  These cells will eventually break through the basement membrane wall and invade into underlying lung tissue and often spread throughout the body long before the person even knows they have the disease.

If a smoker quits before cancer actually starts, even if the cells are in a precancerous state, the process is highly reversible.  Cilia regeneration starts in about 3 days once smoking stops.  Even if cilia has been destroyed and not present for years, the lining tissue of the windpipe will start to repair.  Even the precancerous cells will be sloughed off over time, reversing the cellular process to the point where the lining tissue goes back to normal.  But if a smoker waits too long and cancer starts, it may be too late to save his or her life.

Following are actual pathological slides showing these same damaging effects.

The little pink hairlike projections on the top is the cilia and if you compare this image with the illustrations above you should be able to see the mucous secreting cells and the separation of the lining tissue from the underlying lung tissue.

Below you can see the same area of tissue from a smoker's lung who has totally destroyed the cilia in this tissue.

Again note, where there used to be two layers of well formed and orginized basal cells, now numerous layers of disorganized squamous cells has replaced the normal defensive tissue.  These cells are precancerous and if the continued irritation (cigarette smoke) is not ceased can go to that final stage where they become malignant and invade into the underlying lunng tissue as seen below.

Then it is only a matter of time before it leaves the lung and spreads throughout the body.  If the smoker quits smoking before this last cellular change occurs, before a cell turns malignant, the process seen in this last slide can be avoided.  In fact much of the damage seen in the second picture here is highly reversible.

In three days cilia start to regenerate and usually within 6 months the normal cilia function is returned.  Also over time, the extra layers of cells will be sloughed off and the lining tissue of the bronchus will return to normal.

Unfortunately, if a smoker waits until a malignancy has started, the outlook is grim.  The overall 5 year survival rate for lung cancer is only 14%.  Lung cancer, is a disease that while once uncommon, is now the leading cancer killer in both sexes.

Cancer is actually many different diseases with many different causes.  If we look at cancer trends over the last century we see some amazing changes.  While cancer was always around, it was different sites that were primary problems.  Lung cancer, at the turn of the century was almost unheard of.  If a doctor saw a case he would have easily gotten it printed up in a medical journal.  Now, it is the major cause of cancer death in our society, killing more men and women than any other site.  The primary difference between now and then is smoking.  Before the turn of the century smoking was a limited practice.  A very small percentage of people smoked and even the ones who did smoked many fewer cigarettes.  Cigarettes were not even mass produced till the very end of the 1900’s.

We always hear of a cancer epidemic, how more and more people die of cancer every year.  Actually, if you pull the smoking related sites out of the equation, cancer deaths have been on a decline.  Some sites, like stomach the incidence dropped dramatically, not fully understood as to why.  Other sites, like breast, even though the morbidity rate (number of cases) didn't drop, because we now have better treatments and earlier detection, the mortality (death) rate has dropped.

But the smoking cancers; lung, mouth, lip, tongue, throat, larynx, pancreas, esophagus, pharynx, urinary bladder have all seen marked increases over the 20th century.  These cancers have gone from obscurity to some of the major causes of death in our country.  Actually, for the first time in a hundred years we are starting to see an early decline of morbidity and mortality because we are seeing fewer smokers now with the drop in the percentages of adult smokers.

Men

women

You see a dramatic difference in men and women, especially in lung cancer rates.  The reason is women started smoking much later than men, about a 30 year time delay before it became socially acceptable for women to smoke.  Male smoking rate jumped dramatically between World War I and another big boost during World War II.  Free distribution of cigarettes to soldiers was a big factor.  Women smoking rates happened much later and the time delay is reflected in the time delay in cancer and otehr diseases going up too.

The above pictures were primarily about how smoking causes cancer of the lung and other sites.  But the assault on the lungs from the tars in tobacco are not just limited to causing cancer.  Other lung diseases are directly caused by smoking, the most well known are the chronic obstructive lung diseases.

The most well known smoking induced COPD is emphysema.  This is another one of those diseases that primarily happen to smokers.  Over 90% of the cases are smoking induced.  There are cases in some families where there does seem to be a genetic predisposition, where non-smokers get it too.  This is from a rare condition, a lack of a blood enzyme called alpha1antitrypsin.  This again is rare, but if you do have family members who never smoked a day in their life get emphysema there may be a genetic tendency.  But again, over 90% of emphysema cases are simply caused by smoking.  Eradicate smoking and you eradicate the risk of the disease.

To get a sense of how a long is altered by smoking to cause emphsema look at the pictures below.  The first  is a picture of an inflated non-smoker city dweller's lung.

As in the normal picture of a lung above, you can see carbon deposits collected throughout from pollution effects.  But when contrasted with a smoker's lung with emphysema...

...there is a very dramatic visible difference.  Not only is the discoloration the issue, but the lungs have literally been ripped out of shape making breathing extremely difficult and eventually impossible.  To get a sense of what it feels like to breathe with emphysema take a deep breath and hold it.  Without letting out any air, take another deep breath.  Hold that one too.  One more time, take one more breath.  Okay let it all out.

That second or third breath is what it feels like to breathe when you have advanced emphysema.  Emphysema is a disease where you cannot exhale air.  Everyone thinks that it is a disease where you cannot inhale but in fact it is the opposite.  When you smoke you destroy the lungs elasticity by destroying the tissue that pulls your lung back together after using muscles that allow us to inhale air.  So when it comes time to take your next breath it is that much more difficult, for your lungs could not get back to their original shape.

Imagine going through life having to struggle to breathe like those last two breaths I had you take.  Unfortunately, millions of people don't have to imagine it, they live it daily.  It is a miserable way to live and a slow painful way to die.

Hopefully when you breathe normally today you are not in pain and you are not on oxygen.  If you don't smoke you will continue to give yourself the ability to breathe longer and feel better.  Never lose sight of this fact.  To keep your ability to breathe better for the rest of your life always remember to - NEVER TAKE ANOTHER PUFF!

Joel

© Joel Spitzer 2001
Page last updated by Joel Spitzer on August 25, 2003

How does smoking impact circulation?

Smoking and Circulation

While most people equate smoking deaths to cancer and lung disease, in fact many more people will die from circulatory conditions from smoking than die from cancer or other lung diseases.  Also, in general, they will die at much younger ages from these problems.  We would have many more lung cancers than we do if smokers could live long enough to get them.  When many people with fatal heart attacks or strokes are autopsied, there are often precancerous lesions found that indicate that if these people had a few more years to live they would have eventually succumbed to these smoking induced diseases.

As for heart and other circulatory diseases, the two chemicals in cigarette that stand out as the biggest problems are nicotine and carbon monoxide.  Nicotine, besides being addictive, has very powerful effects on arteries throughout the body.  Nicotine is a stimulant, speeding up the heart by about 20 beats per minute with every cigarette, it raises blood pressure, is a vasoconstrictor which means it makes arteries all over the body become smaller making it harder for the heart to pump through the constricted arteries and it causes the body to release its stores of fat and cholesterol into the blood.

The heart has to work harder to overcome all of these effects.  To work harder the heart, like every other muscle in the body, needs extra amounts of oxygen for the additional workload.  The oxygen has to be transported through the blood.  But carbon monoxide from tobacco smoke literally poisons the oxygen carrying capacity of the blood.  So this results in the heart having to work harder to get more blood to itself to work harder, because it's working harder.  This is a circle.  A vicious and deadly circle when it comes down to it.

Below we see the cross section of a normal artery.  Usually we have nice big openings in the artery to carry oxygen as well as all other nutrients to all the tissues of the body.

If you compare this artery to the one below...

 

You can see the blood clotted blocking the blood flow to whatever organ or tissue this artery was leading to.  Without being able to get circulation, that tissue will literally suffocate in a matter of minutes and basically be left as useless tissue.  Sometimes the artery involved is a coronary artery, one that supplies the heart with the blood it needs to function.

Below is a picture of a coronary artery attached to the heart...

If we look at a close up view of the artery...

Here we see the blood clotted and blood flow to the section of the heart that this artery was supplying was cut off.  What will result is that a portion of the heart muscle that was supposed to get that blood flow suffocates and dies within a matter of minutes.

Above we see infarcted (dead) heart muscle (myocardial infarction).  The tissue is literally brittle as illustrated by the cracking effect.  Instead of being able to pump blood, this area whole section of muscle is no longer able to be utilized for its life sustaining function.  Again, smokers get this much more often because of the effects of nicotine and carbon monoxide.  Nicotine having all the direct effects on the heart itself, carbon monoxide robbing the oxygen supply, and both chemicals increasing clotting as well as clogging factors in the blood.  If the section of the heart affected was larger enough the smoker would die from the first attack.  Often smaller areas are affected and the patient can survive but has lost that specific section of the heart and may have permanent impairments from the now limited supply of heart tissue.

Cigarette smoking increases risks of blood clots significantly.  If the blood clots in an artery and blood can no longer get through, the tissue that is supposed to be supplied with blood has lost the source of its oxygen and nutrients and dies in minutes.  But clots are not the only way these arteries can be blocked.  Another way is by clogs.

As opposed to clots where the blood actually coagulates and becomes an obstruction, clogs are where deposits of fat gradually build up.  In the first picture below you can literally see the start of a artery getting a fat buildup.

 

Over time, this opening can get narrower and blood flow gets more and more impeded.  This of course adds to the workload of the heart to pump through smaller arteries with increased resistance.  But this clogging does not only happen to the coronary arteries, it literally happens all over the body.  Remember, nicotine is not only a vasoconstrictor, making arteries go into constrictions every time it is administered, but it also causes the body to release its own stores of fat and cholesterol.  Besides this, carbon monoxide has an effect that makes the fat stick to the arteries.  The reason is carbon monoxide lowers the oxygen level of the blood (hypoxia) and hypoxia seems to have an effect making fat stick to artery walls.

Eventually over time arteries can become totally blocked with fat as seen in the slide below.

As in the case with a clot, blood cannot get through and the body part that was contingent on that blood supply for survival is lost.  If this artery lead to your heart as in the case of the clotted coronary arteries above, the result would be a heart attack with a loss of heart muscle that if large enough would be fatal.  But the heart is not the only organ affected this way.  Another common site of problems are the arteries leading to the brain.  Below is a picture of the base of a health human brain.

The arteries to the brain are very small here and clear, very difficult to see in fact.  The arrows are pointing them out.  To see them clearer here is a close up shot of these arteries...

Again note, these arteries are very thin and clear.  Smoking increases the fat deposits to these arteries so often, instead of looking like this, they can look like the slide below...

 

With the fat build up the arteries are much easier to see.  But this build up if complete cuts off circulation to your brain and as is the case with the heart, the part of the brain that no longer gets circulation dies.  This is what happens in the case of a stroke.  Circulation gets cut off from the brain either through a clog or a blood clot.  The section of the brain that gets cut off suffocates and dies.  If this part of your brain controlled speech, you will not talk anymore, if it controlled some form of motor function, these abilities will be lost and leave the patient impaired or crippled.  If the section of the brain affected controlled some life sustaining function, the patient will die, again, within minutes of when the circulation cut off is complete.

The clogging and clotting effects of nicotine and carbon monoxide are the primary reasons why smokers are at such a higher risk of this condition.  But this clogging/clotting effect is not limited to just major organs like the heart or brain.  These chemicals affect arteries throughout the entire body.  These affects may not be as deadly as cutting off circulation to the heart or brain, but in a real way they can show the true potential of the grip of the nicotine addiction.

Peripheral circulation, arteries going to the extremities are also highly susceptible to the vasoconstrictor effects of nicotine as well as the increase of clots and clogging risks posed by smoking.  Smoking is a primary cause of much of the peripheral vascular disease seen as well as a powerful aggravating factor for people who have other preexisting conditions causing circulation problems to the extremities.

One condition though stands out as being truly unique and in many ways, demonstrates the real addictive nature of nicotine better than any other cause.  The condition is known as Buerger’s Disease (thromboangiitis obliterans.)  Buerger’s Disease is a condition where there is a complete cutoff of circulation to the finger or toes, resulting in gangrene.

Once gangrene occurs the only course of action is to amputate the affected area.

 

The most common age bracket that this disease strikes is in people between the ages of 20 to 40, normally young to get circulation problems that result in amputations.  While it is much more common in men, women are affected to.  What makes Bueger’s Disease unique is that it is a disease that is basically exclusive to smokers.  There are almost no documented cases of this disease happening in a non-smoker.  Smoking is the primary etiologic factor.  This is a rare disease, but noteworthy because of this unique nature of happening only in smokers.

If a smoker gets lung cancer, the person and other people can sometimes think, “well non-smokers sometimes get lung cancer too, maybe cigarettes didn’t cause it.�?  Same thing with heart attacks or strokes, non-smokers get them too, smokers just get them much more often.  But again a certain level of denial can be exhibited and there is no way to conclusively prove that cigarette did it.  But Buerger’s Disease, having no other known cause and basically never happening in non-smokers does not lend itself to such denials.  When a doctor determines he or she is dealing with a Buerger’s Disease patient, a basic ultimatum is going to be delivered—quit smoking or lose your limb—your choice!  If we were dealing with simply a bad habit, how many people given such an ultimatum and knowing it is true would continue doing the particular behavior given such consequences?

While Buerger’s Disease is much more common in men, I have personally had two women who were Bueger’s Disease patients in my clinics.  My first actual encounter with a Buerger’s Disease patient was with a woman who was 38 year old when I met her, which was about 24 years ago.  Three years before I met her, at the age of 35 she was diagnosed with Buerger’s Disease.  This is actually relatively late to first be diagnosed.  Her doctor had told her she had to quit smoking, but she did not comply and within a few months she had her right leg amputated.  The circulation in her left leg was also badly affected, and after the hospitalization from the amputation she did quit smoking and had no further circulatory complications for the next three years.

Then one night at a party, a friend offered her a cigarette.  She figured that since she had been off cigarettes for so long, she now had control over her habit.  If she liked the cigarette, she would smoke one or two a day.  If she didn't like the cigarette, she just wouldn't smoke anymore.

Well, she took the cigarette.  She didn't particularly like the cigarette, but the next day she was up to her old level of consumption.  Four days later she lost circulation in her left leg.  She knew the reason.  After three years with no problem and only four days after going back to smoking her circulation was affected.  Her doctor told her that if she did not quit immediately, she would probably lose her other leg.

This is when I met her.  She enrolled in a smoking clinic that week and quit smoking.  Almost immediately her circulation improved.  The doctor took her off anti-coagulant drugs and vasodilators he had put her on a few weeks earlier to try to slow up the process even though they were highly ineffective at stopping the likelihood of gangrene and amputation.  But once she quit smoking she no longer needed them.  Soon, her circulation was back to normal.

Nine months later, I called to ask her to serve on a panel.  At that time, she sluggishly replied, "I can't come.  I have been in the hospital the last two months." When I asked what had happened, she hesitantly replied, "I had my toes amputated." She had gone back to smoking.  She tried one because she just couldn't believe she would get hooked again.  She was wrong.  She lost circulation, had her toes removed and eventually had her leg amputated.

I have had other clinic participants with similar experiences, being told to quit smoking or lose limbs who did not quit smoking.  The reason I talk about this particular woman again and again is about a year after she had the second amputation, she came back into a clinic I was conducting and told me she had quit again and was now off about 9 months.  I told her I was surprised, I thought she had permanently lost control.  After all, she had her leg removed, the toes from her other foot, and eventually her second leg.  When I confronted her with that information she replied, "The doctor finally convinced me.  He said, 'You might as well keep on smoking, I'll just take your arms off next.'" That scared her into quitting smoking.  Her next comment to me was unbelievable.  She looked me straight in the face, dead seriously, and said "I DIDN'T NEED A HOUSE TO FALL ON ME TO TELL ME TO QUIT SMOKING."  

I had periodic contact for the next 15 years at which time she moved away.  She was fine over that whole time period.  Whenever I brought up that conversation, we both found ourselves amazed that she could ever have made such an irrational statement.  She happened to be a very rational, bright and inspirational individual.  She would get around on wooden legs, socializes, and even occasionally would sing and dance on stage. Once she had broken free of the drug's effects and the smoker's psyche, she knew she could do anything.

Frequently, I would encounter people who quit smoking on their own.  When I ask how they did it, they tell me of this marvelous lady they met who told of how she used to be hooked on smoking.  Hooked so bad, in fact, that she had her legs amputated from a smoking related illness.  It usually turns out to be the same person.  By spreading her story, she offers inspiration and hope to countless smokers to break the habit before the habit breaks them.

Her story represents the real power of the addiction.  She could not deny any where along the way smoking wasn’t the cause.  Not only would every doctor and all the research she could do pinpoint smoking as what was causing her problem, but she had quit, was fine, relapsed and within days lost her circulation—twice!  The second time she actually lost her toes and her foot and then her lower leg.  There was absolutely no way she could deny the cause and yet it took another 9 months for her to quit again.

Her continued smoking and ease of relapsing shows nicotine dependency at its worst.  This overpowering nature of nicotine should not be lost on anyone here.  You probably don’t have a condition that is obvious as to force you to make a decision almost immediately upon relapse.  In many ways this is worse, for cigarettes are quietly and insidiously destroying you, sometimes with little warning, or at least ones you will acknowledge.  The first symptom to many circulatory diseases caused by smoking is sudden death.  You may get no second chance.

Once you have a quit smoking, do everything in your power to make it last.  You don’t know that you will have the desire, strength or worst of all, the opportunity to quit next time.  A tragic and fatal disease may get you first.  Always consider the full danger of smoking and power of the addiction and your likely choice will be to - NEVER TAKE ANOTHER PUFF!