Smoking - health risks

Reviewed by Dr Gavin Petrie, consultant chest physician
Why quit smoking?

Smoking kills over 120,000 people in the UK each year. Cigarettes contain more than 4000 chemical compounds and at least 400 toxic substances. While the smoker is inhaling, a cigarette burns at 700 degrees Celsius at the tip and around 60 degrees in the core. This heat breaks down the tobacco to produce various poisons. As a cigarette burns, the residues are concentrated towards the butt. The products of a cigarette that are most damaging to health are tar (which can cause lung cancer), carbon monoxide and nicotine (cardiovascular disease), and the components of the gas and particulate phases, which cause chronic obstructive pulmonary disorder. The effects are influenced not only by the number of cigarettes, but also how the cigarettes are constructed (with or without filters) and how the tobacco has been prepared. Paradoxically, the 'side-stream smoke' that comes off a cigarette between puffs carries a higher risk than directly inhaled smoke. Clearly, there are many health-related reasons to give up cigarettes - not only from the point of view of smokers, but also to protect those around them.

Smoking affects how long you live
Research has shown that smoking reduces life expectancy by seven to eight years. An interesting calculation predicts that on average, each cigarette shortens the life of the smoker by around seven to eleven minutes.
Non-smokers and ex-smokers can also look forward to a healthier old age than smokers.

Major diseases caused by smoking
Cardiovascular disease

Cardiovascular disease due to atherosclerosis is the main cause of death due to smoking, with an overall increase of death of 1.7 times. Atherosclerosis is the term used to describe the clogging up of the arteries with fatty material, leaving them narrow, blocked or rigid. It can take many forms depending on which blood vessels are involved, and all of them are more common in people who smoke. Coronary thrombosis is a blood clot in the arteries supplying the heart. Approximately 30 per cent of cases are caused by smoking. Nine out of ten people who require a heart bypass operation are smokers or ex-smokers. The vessels to the the brain can become blocked, which may lead to collapse, stroke and paralysis. If the kidney arteries are affected, then high blood pressure or kidney failure results. Blockage to the vascular supply to the legs may lead to gangrene and amputation. If a patient quits smoking, their chances of survival improve. A Swedish study showed that patients suffering from atherosclerosis in the legs were more likely to survive if they gave up smoking, when the risk of dying from this disease was reduced from approximately 40 per cent to about 5 per cent.

Cancer

The risk of getting cancer is generally greater for smokers than non-smokers by a factor of 2.24. This is particularly true of lung cancer, cancer of the throat and cancer of the mouth, which hardly ever affect non-smokers. Eighty-five percent of all cases of lung cancer are related to smoking and a smoker is 12 times more likely to develop lung cancer. If a smoker quits, it will take approximately 15 years before their risk of getting lung cancer is the same as a non-smoker.

There are several other types of cancer that are more common amongst smokers than non-smokers. These are: cancer of the oesophagus, cancer of the kidneys, cancer of the pancreas, cancer of the cervix and cancer of the bladder. It is estimated that 94.5 per cent of 20-a-day smokers have some emphysema if the lungs are examined after death and more than 90 per cent of non-smokers have little or none.

Smoker's lung (COPD) typically starts when a person is 35 to 45 years of age. At that age, lung function starts to decline even in non-smokers, and in susceptible smokers, the rate of decline in lung function can be three times the usual rate. As lung function declines, then breathlessness on exertion starts. At first, smoker's lung consists of a cough and sputum, which are the symptoms of bronchitis. As the condition progresses, the person feels short of breath climbing stairs, walking up a slope or even when walking. Severe short-term problems will usually require several periods of hospital care. The final stage is a very distressing death due to slow and relentlessly progressive breathlessness. Too many people die every year from this disease which, in 80 per cent of cases, is caused by smoking.

Giving up smoking at any stage reduces the rates of decline in lung capacity and postpones disability and handicap. Anti-smoking measures are very important in preventing smoker's lung and all the other adverse effects caused by smoking. It is difficult for many addicted smokers to quit. Nicotine replacement treatment in the form of gum, skin patches or nasal spray help some people to quit successfully. Bupropion (Zyban) is a medicine that is now licensed in the UK to help smoking cessation. Behaviour modification and alternative therapies including acupuncture and hypnosis are also in use, but there is no best buy for smokers who are thinking of trying to kick their habit. The weight of evidence suggests that smokers should set a date to stop, then do their best to quit completely from then on. This is a difficult strategy to adhere to, and additional treatments such as those outlined above provide support.

Other risks caused by smoking
Nicotine in cigarettes increases the amount of cholesterol in the blood, which may cause the arteries to clog up with fatty tissue called atheroma (see section on major diseases above).
High blood pressure or hypertension, which are related to heart attacks and stroke.
Smoking causes an acid taste in the mouth and contributes to the development of ulcers.
Couples who smoke are more likely to have fertility problems than couples who are non-smokers.
Generally smokers have 25 per cent more sick days year than non-smokers.
Smoking also affects your looks: smokers have thicker and rougher skin.

How smoking harms children

Babies born to mothers who smoke:
are twice as likely to be born prematurely and with a low birth weight (below 2.5kg or 5lb 8oz).
have a birth weight on average 200g (7oz) less than those born to non-smokers.
have organs that are smaller on average than babies born to non-smokers. This is particularly evident in the case of the lungs of a newborn baby which do not function as well as the lungs of a baby whose mother does not smoke.
are twice as likely to die from cot death. There seems to be a direct correlation between cot death and parents' smoking.
are ill far more frequently than non-smokers' children.
get painful diseases such as inflammation of the middle ear and asthmatic bronchitis more frequently in early childhood.
may become addicted to the nicotine in their mother's smoke before they are born.
are more likely to become smokers.
have a higher risk of developing allergies.
children who are exposed to passive smoking every day if one or both of their parents smoke have twice the risk of getting asthma and asthmatic bronchitis.

Other benefits of quitting smoking
General health improves - tiredness and headaches can be linked to smoking.
The sense of taste and smell improve.
The heart will be less strained and work more efficiently.
An increase in self-confidence, knowing that you have beaten an old habit.

What are the effects of passive smoking?
Passive smoking irritates the eyes, nose and chest, and can cause headache.
Children exposed to passive smoking are more likely to have allergy and asthma, while those under two years old are more prone to severe respiratory infections and cot death.
Small reductions in lung function are also seen in children, although there is substantial difficulty in interpreting the various studies available.
For adults there seems to be a small increase in the risk of lung cancer, but the evidence for increased heart disease is not conclusive at present.

References Peto R, Lopez AD, Boreham J, Thun M, Heath Jr C. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet 1992; 339: 1268-78. Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years' observations on male British doctors. British Medical Journal 1994;309:901-911 Doll R, Crofton J, eds. British Medical Bulletin: Tobacco and Health. London: The Royal Society of Medicine Press, 1996; (vol 52). Cook DG, Strachan DP, Anderson Ross H. Series of papers: health effects of passive smoking. Thorax 1997-1998. Eds Britton JR, Weiss ST. Based on a text by Dr Carl J Brandt,

Drug abuse and addiction

Written by Dr John Powell, MRC Psych, specialist registrar

What is drug abuse and addiction?

Drug abuse refers to the use of a drug for purposes for which it was not attended, or using a drug in excessive quantities. Drug addiction is a state of physical or psychological dependence on a drug.Physical addiction is characterized by the presence of tolerance (needing more and more of the drug to achieve the same effect) and withdrawal symptoms that disappear when further medication is taken. All sorts of different drugs can be abused, including illegal drugs (such as heroin or cannabis), prescription medicines (such as tranquilisers or painkillers), and other medicines that can be bought off the supermarket shelf (such as cough mixtures or herbal remedies).

What causes drug abuse and addiction?

This depends on the nature of the drug being abused, the person taking the drug and the circumstances under which it is taken.Some medications - for example certain sleeping pills or painkillers - are physically addictive. They have a specific effect on the body which leads to tolerance and withdrawal symptoms. Others may lead to a psychological addiction if people have a craving for the effect that the drug causes.There has been some speculation that some people may be more prone to drug abuse and addiction than others. Research is being carried out into whether there may even be genes that predispose certain people to addiction.Social circumstances are important in drug abuse. Peer pressure, emotional distress and low self-esteem can all lead individuals to abuse drugs. Ease of access to drugs is another influence.People abuse drugs for a reason. Understanding what the person's motivation is helps to explain why that person is abusing drugs.

How is drug addiction treated?

The first step in treatment is recognition by the individual that they have a problem. The person's GP will be able to advise on treatment for drug addiction. He or she may suggest that they see a specialist.Effective treatments are tailored to the needs of the individual. There is no one therapy that is used in all cases. The choice of treatment will also depend on which drug is being abused. Treatments include psychological therapies, such as behaviour therapy and medication to help the individual's withdrawal symptoms.Specific areas that may be focussed on during treatment include:
detoxification (coming off the drug if physically addicted)
preventing relapse
coping with relapse
longer term rehabilitation.

Key sources of evidenceLeshner AI. Science-based views of drug addiction and its treatment. Journal of the American Medical Association. 1999;282:1314-1316.US National Institute on Drug Abuse. Principles of drug addiction treatment - a research based guide. US National Institutes of Health. 1999.February 2000.

Do I drink too much alcohol?

Written by Dr Dan Rutherford, GP

It can be hard for someone to tell exactly how much they normally drink. Accustomed drinkers are less aware of feeling drunk, so it may be a good idea to keep a diary of alcohol consumed over a period of time and make a note every time you have a drink.

Safe drinking

Present advice on safe drinking is:
What counts as a unit of alcohol?
Half a pint (250ml) of average strength beer.
125ml glass of wine.
One standard pub measure of spirits (25ml).
25ml of fortified wine, such as sherry or port.
no more than two units of alcohol per day for women
no more than three units per day for men
you should have at least two drink-free days a week.

When drinking at home, people are almost always more generous, so it’s a good idea to get into the habit of using a spirit measure. Staying within the ‘safe’ limits does not mean that a person is capable of driving a motor vehicle. When driving, it is best not to drink at all.

Advice for pregnant women

Pregnant women are advised to drink no more than one to two units of alcohol once or twice a week. Heavy drinking during pregnancy can cause the baby to be born with a condition known as foetal alcohol syndrome (FAS). FAS causes growth deficiencies, central nervous system defects, lowered IQ and facial malformations.

If I don't feel drunk, I don't have a problem - do I?

Alcohol tolerance can lead someone with a dangerously high consumption to be falsely reassured that as long as they don’t feel drunk, they will be fine. The reverse is true. Needing a lot of alcohol to get drunk proves that you are already drinking too much, too often. Alcohol tolerance can be compared to a lack of the ability to feel pain. If you didn't feel pain, you wouldn't immediately remove your hand from a hot stove and notice it was burnt until it was too late. If you have developed a tolerance for alcohol, you can no longer trust your body's signals to tell you when you've had too much. Instead, you will have to keep count of drinks to know when you've drunk too much.

How do I reduce how much I drink?

A person who drinks too much may feel it is impossible for them to reduce their alcohol consumption. If a drinking habit is very heavy, it is often hard work to reduce it - simply because it is always difficult to change habits. You may not even be sure whether you want to cut down. Fortunately, there are many different ways to reduce alcohol consumption and most people are able to find a way that suits them.

A step-by-step guide to reducing alcohol consumption

Keep a record of all alcohol consumption. Work on ways to make it easier to reduce the alcohol intake. Talking to a partner or friend could flag up some self-help ideas.
I can stop drinking alcohol on weekdays.
I can stop drinking alcohol during the day at work.
I can substitute every second drink with water, non-alcoholic beer, coffee or a soft drink.
I can take a different route home, so I won't be tempted to visit a pub.
I can visit my family instead of my drinking friends.

What if I can't reduce my drinking by myself?

It may be difficult for a person to reduce their alcohol consumption without outside assistance. There are several places where it is possible to get help and counselling. A GP will be able to help by:
giving advice and drug prescription

referring a heavy drinker to a counsellor or an organisation that can provide help, such as Alcoholics Anonymous.

Dedicated alcohol detoxification facilities are rare in the NHS, but there are several private units. These are expensive and it is unusual for the NHS to fund placement, but it does occur.

What about withdrawal symptoms?

For a very heavy drinker, stopping alcohol abruptly can be dangerous. In addition to the anxiety that abrupt withdrawal can cause, a small proportion of people develop a potentially serious condition called delirium tremens (DTs). This can cause confusion and even convulsions. Patients at risk of DTs are best managed by planned withdrawal from alcohol in hospital, along with supportive counselling and drug therapy to counteract the physical effects.

Is there a drug to stop me drinking?

Antabuse (disulfiram) is a prescription-only medicine that's designed to deter people from drinking. Antabuse does not remove the craving for alcohol, but it will help a drinker avoid being tempted in a weak moment.

Will it help me?
For some people, Antabuse is a good idea and a safety measure. Ex-drinkers who have used Antabuse say it is a relief to know they can't drink. It allows alcoholics to focus on things other than not drinking too much. However, Antabuse is a controversial medicine. It does not help everyone who takes it, nor is it the only way to give up alcohol. This is because if a person drinks while they are taking Antabuse, it will cause serious and unpleasant symptoms such as:
severe headache
blushing
a feeling of pressure in the chest
breathlessness
palpitations
nausea
in the worst cases, shock and collapse.In the event of shock, treatment will be required from a doctor or in a hospital emergency department.

Acamprosate is another drug that may be helpful to deter drinking. It works in the brain where it is thought to act by reducing the desire to drink alcohol. It doesn’t produce the same effect that Antabuse does if alcohol is consumed..

I think I have a drink problem. How do I find help?

If you drink more than the recommended amount and you find it difficult to cut down, there are several places you can turn to for advice and guidance. Throughout the country, there are local alcohol advice centres where you can ask for help. They can put you in touch with clinics where you will find specialists, nurses and social workers who can help. Phone numbers are listed in the telephone directory or can be obtained from the local health trust or your GP.

What help can I get at a clinic?
You may know you need help cutting down and want to go directly into treatment. You may want to speak to people at the clinic to judge the seriousness of your problem or get advice about what possibilities are open to you. You can also make contact if you are worried about one of your relatives or friends, who you think may have a drink problem.

Alcoholics Anonymous (AA)

Alcoholics Anonymous is the world's biggest union of self-help groups concerned with alcohol abuse. The therapy in these groups takes place without the interference of public bodies, doctors, psychologists or other professionals.Attending the meetings is on a voluntary basis. The only requirement is an honest desire to quit drinking. You will meet people who have been through the same hardships as yourself. You can contact AA on 0845 769 7555 or by visiting www.alcoholics-anonymous.org.uk.

Smoking - cutting down or quitting

Reviewed by Dr Gavin Petrie, consultant chest physician


Addiction to tobacco is both physical and psychological. Every smoker knows how difficult it is to stop smoking or even cut down.
Reducing the amount you smoke is a start - and better than nothing, but the ultimate goal should be to quit altogether. And, as many ex-smokers will tell you, it is possible.

There are two parts to addiction:
Physical addiction occurs because you become addicted to the nicotine in the cigarette. This addiction causes real withdrawal symptoms if you cut down or quit.
Psychological addiction occurs because smoking becomes part of your daily routine. This means if you want to cut down or quit, you will have to change your habits.

Tackling physical addiction
Research has shown that using nicotine replacement therapy such as nicotine patches or chewing gum can reduce the number of cigarettes smoked and cut down the amount of dangerous smoke inhaled.
However, there is a slight risk the body will get used to this new form of nicotine. For this reason, it's important to keep an eye on how much of the substitute you're using.
Bupropion (Zyban) is an antidepressant medicine that is also effective in relieving the symptoms of nicotine withdrawal.

Tackling psychological addiction
Dealing with cravings
Here are some ideas to help you cope with cravings for a cigarette:
call a friend
chew some gum or eat something healthy
take a walk
brush your teeth
take a shower
take a deep breath
write a letter
occupy your hands by doing something such as sewing or knitting.

There are several ways smokers can help break a psychological addiction.
Decide how you want to quit - either by cutting down gradually or, preferably, stopping completely on a pre-determined date .
Make a list of reasons why you want to quit. Carry this with you at all times. When you have an urge for a cigarette, read your list and it will help strengthen your resolve.
Choose a date when you want to quit and stick to it.
Tell your family and friends - that way you'll have to keep to the date.
Find someone who can support you, for example a family member, friend or doctor.
When the day arrives, do something active - throw out your cigarettes and remove all ashtrays, lighters and matches. And spoil yourself by doing something you enjoy, such as going to the cinema or shopping.
Find something else to do for the times when you usually smoke a cigarette.

I've tried to give up before - it didn't work!
You're not the only one. The chances of success get better every time you try to quit. Most people need four attempts or more before they finally succeed. If you fail, just think of it as a rehearsal before you really quit.

How do I remain an ex-smoker?
Keep referring to your list of reasons to quit.
Update your list with any new reasons.
Avoid spending too much time around smokers.
Be proud of yourself - celebrate after each week, month and year that has passed since you quit.
Avoid drinks that make you feel like smoking, such as alcohol and coffee.
Don't let one slip ruin your whole quit plan.

How long does it take before the cravings disappear?
After just a few days the need for a cigarette will get less. And for some people, it may have completely vanished after just two to four weeks.

Will I gain weight?
You may gain a little weight, but don't let that put you off. A few extra pounds is nothing compared to the health advantages stopping smoking gives you.
Avoid dieting unless your doctor tells you to do so, because this will increase your desire to smoke. If you snack, choose something healthy and low fat. Be more active and work off the extra calories through exercise.

Isn't it enough to switch to a low tar brand?
Tar is just one of more than 4000 toxic substances contained in cigarettes. Tar holds the other toxic substances together and is one of the biggest causes of lung cancer.
The risk of getting some diseases may be smaller the less tar you breathe in.
By comparing tobacco mixtures and cigarettes you can see the amounts of tar and nicotine that each contain.
High tar contains more 20mg of tar per cigarette.
Medium tar contains 15-20mg of tar per cigarette.
Low tar contains less than 15mg of tar per cigarette.
However, even if you change to lower tar cigarettes, you will still be at risk of contracting any number of smoking-related diseases.
There is no 'safe' number of cigarettes to smoke, other than zero.

Click here for more support and advice to help you quit, including NetDoctor's free 90-day Stop Smoking Programme.

References
United States Department of Health and Human Services. The health benefits of smoking cessation - a report of the Surgeon General. US DHHS. Public Health Service, Centers for Disease Control. Center for Chronic disease prevention and health promotion. Office on smoking and health. DHHS Publication number (CDC) 90-8416,1990.

Silagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement therapy for smoking cessation. The Cochrane Library, Issue 3, 1999.

Based on a text by Dr Carl Brandt,

Coping with smoker's lung

Written by Dr Carl J Brandt, GP

Smoker's lung is a chronic inflammation of the lungs. It is also known as chronic bronchitis, emphysema or chronic obstructive pulmonary disease (COPD). It causes the respiratory passages to be swollen and irritated, increases mucus production and may damage the lungs. The symptoms are coughing and breathlessness that gets worse over time. The main cause of this disease is smoking, but it can also be aggravated by air pollution or allergies.

What can I do to prevent it?
If you smoke - stop. Your doctor or pharmacist can provide advice on smoking cessation products and techniques.
Get professional help if you need it.
Ease the symptoms with medicine and other treatments from your doctor.
Try to cope with the stress when it becomes difficult to breathe.
Learn to breathe more efficiently so you can continue with your daily activities.
Use less energy when doing activities.
Protect yourself against infections and items that may irritate your respiratory passages.
Acknowledge your emotions, and talk to a friend or a family member when you are angry or depressed.

Consider learning:

gradual muscle relaxation. Tighten, then relax, every set of muscles from your head down to your toes.
meditation. Concentrate on a word or a calm scene to help you relax.
biofeedback. Teach yourself to relax by using equipment that reveals muscle tension.

What kind of medication can be prescribed?

Medication is available that can:
widen the respiratory passages
fight lung infections
loosen phlegm
relieve anxiety
relieve pain.

Will oxygen therapy help?

Oxygen therapy may improve your life emotionally and physically, but it is only helpful in people who are severely limited in their physical ability. Oxygen therapy needs to be sanctioned by a consultant in chest disease, who will advise whether it is appropriate for an individual affected by COPD (or any other disabling lung condition). Once approved, oxygen therapy is provided on prescription from the NHS.

What to ask the doctor
Quitting smoking
I have smoker's lung - isn't it too late to quit smoking?
Stopping smoking at any age will have a beneficial effect on your lungs.

Tips to help you quit
Write down your reasons to quit on a piece of paper.
Keep a diary of when and where you smoke.
Try to find a pattern in your smoking habits.
Find someone who can support you, such as your doctor or friend.
Choose a method for quitting - remember, the only 'safe' amount to smoke is zero.
Nicotine patches or chewing gum may help.
Choose a date when you want to quit.
Tell people the date you've chosen, so you'll stick to it.
Ask about side effects from any medication that is prescribed.
Find out when you need to tell your doctor about side effects.
Keep an eye on changes to your condition and find out what to do if you notice any.
Learn how to recognise warning signs of a problem.
Ask questions about anything you would like to know about the condition or about medication, diet, exercise or breathing techniques.
Ask about non-prescription medicine.
How to take medication
Take your medicine strictly according to the prescription.
You must never increase, cut down or stop any treatment with prescribed medicine without talking to your doctor first.
Never change a fixed oxygen supply.
Don't use any medicines that aren't prescribed without first consulting your pharmacist or doctor.

How can I make breathing easier?

These techniques can help your lungs work more effectively and help you relax when you feel short of breath.
Breathe with the stomach
Place one hand on your chest. This hand should remain still when you breathe.
Place the other hand on your stomach with your thumb on your belly button. This hand should rise up and down when you breathe
Breathe in through your nose as you count to three. Breathe out as you count to six.
Repeat this for approximately 15 minutes.
Practice this as often as possible - learning to coordinate stomach movements and breathing takes time. You can breathe with the stomach while you are sitting, standing or lying down.
Tight-lipped breathing technique
Breathe in slowly through your nose.
Tighten your lips a little. Now breathe out slowly with a soft, hissing sound.
Try combining tight-lipped breathing with the stomach breathing.

How can I get rid of phlegm?

Controlled coughing can help you cough up phlegm without getting short of breath or damaging your respiratory passages.
Take a slow, deep breath through the nose.
Hold your breath for a couple of seconds.
Open your mouth a little and cough two to three short, forceful coughs.
Relax and repeat. Your nurse or physiotherapist will be able to teach you other techniques for loosening and getting rid of phlegm. Family members can also learn how to help you.

Does the food I eat make a difference?

Many people with smoker's lung have difficulty eating large amounts of food. Therefore, the food you eat needs to be nutritious and provide you with enough calories.

You can also:
vary the foods you eat every day and eat only healthy food.
have several small meals instead of a few big meals.
talk to your doctor if certain types of food give you problems. Cabbage, beans and corn may make breathing unpleasant.
drink lots of water, unless your doctor recommends otherwise.

Is exercise important?

People who are fit use less oxygen. Remaining active also helps you feel good about yourself. But remember to consult your doctor before starting an exercise programme - you will need to ask the following questions.
What kind of exercise do I need? (Walking is often recommended.)
How long and how often should I exercise?
Is it necessary to change doses of medication and/or oxygen when I exercise?
How can I avoid straining my lungs?
Try to avoid colds and influenza (the flu) by asking infected people to stay away until they're better.
Ask your doctor about immunisations against influenza and pneumonia.
Avoid contact with people who have a cold or the flu.
Call your doctor at the first sign of a cold or influenza. Signs could be: increased coughing, a stuffed-up nose, fever and yellow or green phlegm.
Avoid things that may irritate your breathing. These could include smoke from cigarettes or fireplaces, dust and smells from paint, exhausts or perfume, cold air, very dry or moist air, or air pollution.
Ask your doctor about air cleaners or air dehumidifiers.

Can I lead an active life despite my condition?
At work
Your condition should not prevent you from working.
Talk to your employer - a few changes in your workplace may be all it takes.
Consider training in another field if it is impossible to keep your present job.
Sex
Use a position that doesn't take much energy (such as side by side).
Use tight-lipped breathing.
Consider other ways of being intimate, such as cuddling, kissing, etc.
Rest before and after intercourse.
Travel
Ask your doctor about medical facilities in the location you plan to visit.
Ask your oxygen supplier where you can buy oxygen.
Remember to take prescriptions with you.
Tell the airline in advance if you may need oxygen.
Take some extra medicine in your hand luggage, in case your main luggage gets lost.
When doing manual work or housework
Conserve your energy.
After a hard task, do an easy task.
Break hard tasks into smaller parts. Rest every now and then.
Try using the tight-lipped breathing technique. Breathe out when you strain yourself.
Sit down as much as possible.
Keep the things you need close to you, so that you don't strain yourself more than necessary.
When possible, push and pull instead of lifting.
Use relaxation techniques.

How can family members help?
Share your emotions. You could be feeling the same way as the person with smoker's lung. You also need to talk about your emotions.
Give your full support if the person wants to quit smoking.
If you smoke, don't smoke anywhere near the person with smoker's lung - passive smoking is harmful.
Consider quitting smoking for your own sake.
Don't overprotect. Let the person who needs your help do as much as they can by themselves. Their self-confidence depends on it.
Help with the treatment. Ask the doctor or nurse how you can help at home.

Join a support group such as the British Lung Foundation. Talking to other families affected by smoker's lung can help you cope.

Alcoholic liver disease

Written by Dr Matthew Warren, specialist registrar in liver medicine and Professor Christopher P Day, professor of liver medicine

Alcohol consumption in the UKMost people in the UK drink alcohol. Total alcohol consumption per head in the UK rose steeply between 1950 and 1975 and then levelled off until the mid 1990s, when it again started to climb. The General Household Survey of 2001 found that 39 per cent of men and 22 per cent of women were likely to have exceeded the recommended daily maximum (4 units for men and 3 for women) in the week preceding interview. There has been a marked increase in the past decade in the proportion of women drinking more than 14 units weekly, the steepest increase being in those aged 16-24. (A unit of alcohol is a single measure of spirits, a half pint of ordinary beer or lager or a standard size glass of wine.)

What is alcoholic liver disease?

Excessive consumption of alcohol can cause liver disease, as well as harming many other body organs. The prevalence of alcoholic liver disease (ALD) in a population is usually determined by measuring death rates from alcoholic cirrhosis (in which healthy liver tissue becomes increasingly replaced by scar tissue).These rates have increased alarmingly in recent years. Death rates in the UK rose by up to 88 per cent between 1974 and 1994 with the highest increase in young men aged 35-44 (7.6 deaths per year per 100,000 people).

How much alcohol is harmful?

The amount of alcohol that can cause liver damage seems to vary widely between individuals. But it is certain that:
there is a genetically inherited susceptibility to the harmful effects of alcohol.
women are also believed to be more sensitive to the harmful effects of alcohol than men.
daily drinking, and drinking outside meal times is more harmful than only drinking at weekends.
there is good evidence that the more you drink the greater your risk of developing ALD.

How does ALD progress?

There are three main stages of ALD, although the progression through these stages is variable. Examining a sample of the liver under the microscope from a biopsy gives the most accurate measure of the degree of liver damage.
Minimal change, or fatty liver: heavy drinkers often develop fatty change in the liver. This is not linked to deterioration in liver function, but abnormalities may be seen in some of the blood tests that give an indirect measure of liver disease (also called ‘liver function tests’ or ‘LFTs’). Fatty liver is reversible with abstinence from alcohol, but it is the first stage in the progression to cirrhosis.
Alcoholic hepatitis: the effects of this condition can be mild but may also be life threatening. The LFTs will almost always be abnormal, and the patient may develop jaundice. As with fatty liver, abstinence from alcohol can reverse the effects, but those who continue to drink heavily have a high risk of developing cirrhosis.
Cirrhosis: this is the final, irreversible stage of ALD and is characterised by scarring of the liver and development of liver nodules. It severely affects liver function and reduces life expectancy. The LFT's are usually abnormal, there may be jaundice (yellow colouring of the eyes and skin) and sometimes bruising or bleeding caused by abnormalities of the blood clotting system. In an advanced stage of ALD (severe alcoholic hepatitis or cirrhosis) the remaining liver capacity is insufficient for it to carry out its normal functions, then the body’s metabolism becomes badly affected and the stage of ‘decompensated ALD’ is reached. Complications of this are discussed below.

What are the symptoms?

The symptoms of ALD are usually non-specific, and do not necessarily indicate the severity of the underlying liver damage. Many people will have vague symptoms such as fatigue, nausea and vomiting ( typically in the morning), diarrhoea or abdominal pains. Many patients, even with advanced ALD will have no symptoms and are detected by the finding of liver blood tests performed as part of routine health screening, or during the investigation of other conditions.Only in the more advanced stages of decompensated ALD will the sufferer present with more specific liver-related symptoms such as jaundice, ascites (fluid collecting in the abdomen, causing distension), haematemesis (vomiting of blood) or encephalopathy (confusion, reduced level of awareness and altered sleep pattern, eventually progressing to coma). These are signs of severe liver damage and require urgent medical treatment.

How is ALD diagnosed?

If there is a history of alcohol excess sufficient to cause liver damage, tests can establish the presence and severity of the liver damage. Blood tests can give an idea but they are not accurate predictors. Further tests in hospital can confirm the diagnosis and determine the severity of the disease. Ultrasound scans create an image of the liver and surrounding organs, which helps in taking a liver biopsy. The ultrasound scan can help to assess the severity of disease and exclude other common causes of abnormal LFTs such as gallstones.Liver biopsy is the most accurate test to determine the stage of ALD present and to ensure alcohol is the cause of the liver disease. Research has shown that in up to 20 per cent of heavy drinkers with abnormal LFTs an alternate cause of liver disease is found on investigation. Liver biopsies are performed under local anaesthetic, and provide a tiny sample of the liver for analysis under the microscope.

What else could it be?

The above investigations will rule out whether the symptoms are caused by any of the following:
viral hepatitis, including hepatitis B and C.
haemochromatosis (an inherited disorder of iron metabolism).
Wilson's disease (an inherited disorder of copper metabolism).
autoimmune hepatitis (a liver disorder caused by the immune system attacking the liver).
Good advice Nutrition: a good diet and a 'normal' body weight can significantly improve the outcome of ALD. Obesity seems to increase the risk of advanced liver disease in heavy drinkers. Many patients are severely malnourished, due to loss of appetite and nausea. In advanced liver disease (alcoholic hepatitis and cirrhosis) nutritional supplements have been shown to significantly improve the liver blood tests. A diet high in antioxidants such as vitamin E and selenium is thought to help prevent and treat ALD. These can be taken as supplements or by eating more fresh fruit and vegetables.

Abstinence: even in advanced liver disease, it is still beneficial to stop drinking. Compensated cirrhotics who continue to drink are far more likely to develop decompensated disease whereas the survival rates of those who stop are as high as 89 per cent. But a decompensated cirrhotic who continues to drink only has a 33 per cent chance of survival.Supervision may be required to safely reduce alcohol consumption. A rapid reduction can lead to a physical withdrawal syndrome in up to 40 per cent of cases, characterised by agitation, sweating, anxiety and fits. Up to 5 per cent of people will experience visual hallucinations known as delirium tremens, or the 'DTs'. The withdrawal syndrome can be life threatening. Sedatives and hospital admission may be necessary.

How is ALD treated?

The treatment for ALD depends on the stage of the disease:
Minimal change or fatty liver

Abstinence from alcohol and improved nutrition with avoidance of obesity.

Alcoholic hepatitis

This will depend on the severity of the alcoholic hepatitis. In mild cases only abstinence from alcohol and nutritional support are required. But in acute severe alcoholic hepatitis (characterised by jaundice, easy bruising, abnormal blood tests and sometimes the presence of extra fluid within the abdomen (ascites) hospital admission is necessary. Steroids can also help some of these patients, but even with steroids 90 per cent die within three months of developing the disease. Kidney failure, if it occurs leads to an almost 100 per cent mortality rate.

Cirrhosis

Cirrhosis of the liver can be 'compensated' or 'decompensated'. Compensation implies cirrhosis without complications. The complications that may develop include bleeding from varices (abnormal veins that form in the gullet), ascites, jaundice and encephalopathy (confusion, reduction in conscious level and coma). Compensated cirrhosis may be managed with abstinence from alcohol and nutritional support as above.

Treatment of decompensated cirrhosis

In patients with decompensated cirrhosis, specific treatments may be required to deal with the complications of the disease:
Bleeding varices

Bleeding varices may need treatment by endoscope (a flexible camera which can be passed into the stomach) to destroy the abnormal veins in the wall of the gullet. Long-term treatment with tablets such as beta-blockers (eg propranolol) may reduce the risks of further bleeding. Patients with alcoholic cirrhosis often have a 'screening' endoscopy test to identify any varices before a bleed occurs. Where varices are found, treatment with beta-blockers has been shown to reduce the risk of a first bleed.
Ascites

Ascites require a low salt diet, and reduction of fluid intake is often advised. Patients will usually be treated with diuretics (water tablets) and may require intermittent drainage of the fluid with a catheter or plastic drainage tube being inserted into the abdomen (paracentesis). In some cases these measures will be unsuccessful, and further interventions such as a liver transplant may be needed.
Encephalopathy

Usually linked to additional stress on the body. This may include the use of inappropriate sedating or painkilling medicines, bleeding from the gullet or stomach, constipation, infections or abnormalities in the salts (electrolytes) in the blood. The main factor involved in causing the encephalopathy is an increase in ammonia levels in the brain. The treatment involves correcting the underlying problem, and treatment with lactulose (a liquid laxative). Lactulose decreases the production of ammonia in the gut and its absorption into the body. It lowers ammonia levels in the blood and may need to be taken long term to prevent recurrence of the encephalopathy.
Liver transplantationIn some patients with cirrhosis, liver function continues to deteriorate despite abstinence from alcohol and they may be severely affected by complications. These individuals may need a liver transplant. But for patients to be considered for transplantation, they must:
have been abstinent from alcohol for six months.
have advanced liver disease with complications.
have no other organ damage.
have good social or family support.Approximately 85 per cent of appropriate patients reach the five-year survival rates following a transplant.

References Living in Britain - the 2001 general Household Survey. Department of Health. http://www.doh.gov.uk/public/livinginbritainsurvey.htm

Alcoholism

Written by Dr Dan Rutherford, GP

If you feel you can't function without a drink, seek help. Alcoholic drinks have been prepared and drunk for thousands of years, and the problems that can accompany excess alcohol intake have undoubtedly been around just as long.

Friend or foe?

High levels of alcohol consumption can lead to physical illness and psychological and social distress. Alcohol has therefore always had an ambivalent position in society. In moderation, it can be the oil that makes a social occasion go with a bit more flow or helps a shy person overcome their inhibitions. Small, regular amounts of alcohol also seem to have a positive effect on the heart and circulation. But too much alcohol is often a recipe for disaster. The increasing use of alcohol, along with other drugs of abuse, is a serious public health problem across all age ranges, but especially so in the young.

What is alcohol dependence?
CAGE questionnaire
The ‘CAGE’ questionnaire is a short list of questions that can indicate if alcohol dependence is a possibility.
Two or more positive answers to these questions suggests dependence.
Have you ever:
thought you should Cut down on your drinking?
felt Annoyed by others criticising your drinking?
felt bad or Guilty about your drinking?
had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Eye-opener.)
Alcoholism, or alcohol dependence is a medical term with a deliberately more precise meaning than the problems that can occur, sometimes as one-offs, through an uncharacteristic binge. In alcohol dependence a number of features come together in the behaviour of the person affected.
Drinking begins to take priority over other activities. It becomes a compulsion. Tolerance develops, so it takes more alcohol to produce drunkenness. Withdrawal symptoms such as anxiety and tremor develop after a short period without a drink, and are reduced by taking more alcohol.Often alcohol dependence remains undetected for years. Both the availability of alcohol and the way it is used (the social patterns) appear to be major factors in influencing the likelihood of a person becoming alcohol dependent. There may also be a genetic component, because alcohol dependence clusters in some families. However, it’s hard to be sure that this is not because of learned behaviour.

What problems are caused by too much alcohol?

Excess alcohol can lead to health problems including:
depression
liver cirrhosis
heart failure
damage to the brain and nervous system. Along the way there is often damage to relationships, finances and jobs and problems with the law.

Mental health and alcoholism

Mental health problems are common with alcoholism. Each can lead to or reinforce the other. Depression is a common cause of alcoholism as the depressed person seeks a way out of their problems or a relief from insomnia. Unfortunately, alcohol is itself a depressant, so the problem is only compounded. Anxiety can be temporarily relieved by alcohol, but this may lead to repeated intake and dependence. Without adequate attention to the mental health needs of a person with alcohol dependence, little progress will be made. Often alcoholism remains unsuspected even by the doctor, and it may come to light only when medical tests are done for other reasons.

Treating alcoholism

The difficulty of treating alcoholism should not be minimised – it can be very hard, even with support from family, friends and your GP. However, there are a a number of steps you can take including not drinking alcohol on weekdays.

Vitamins - what do they do?

Reviewed by Dr Dan Rutherford, GP
Recommended daily amounts (RDAs)Throughout this factsheet, recommended daily amount refers to the European Union recommended daily amounts (EU/RDA) for nutritional labelling of food products. Nutritional requirements are often slightly different for young children and adolescents, and during pregnancy and breastfeeding. Ask your doctor or pharmacist if you are concerned about your own or your children's vitamin intake.
Vitamin A (retinol) propertiesGood for:
eyesight
growth
appetite and taste.Signs of vitamin A deficiency:
night-blindness.Good sources of vitamin A:
liver
fish-liver oil
carrots
green leafy vegetables
egg yolks
enriched margarine
milk products
yellow fruits.Recommended daily amount: 800 micrograms.
Poisoning: vitamin A is a fat-soluble vitamin and so it is stored for a long time in the human body, especially in pregnancy. An overdose may be dangerous. Destroyed by: fatty acids.
Vitamin B1 (thiamine) properties Good for:
nervous system
digestion
muscles
the heart
alcohol-damaged nervous tissues.Signs of vitamin B1 deficiency:
tingling in fingers and toes
confusion
difficulties in maintaining balance
loss of appetite
exhaustion
weakened powers of concentration. Good sources of vitamin B1:
liver
yeast
rice
wholemeal products
peanuts
pork
milk.Recommended daily amount: 1.4mg.Poisoning: no poisoning dangers as the vitamin dissolves in water, so excess is excreted in the urine. Destroyed by: high temperatures, alcohol and coffee.
Vitamin B2 (riboflavin) properties Good for:
growth
skin
nails
hair
sensitive lips and tongue
eyesight
protein, fat and carbohydrate breakdown. Signs of vitamin B2 deficiency:
itching and irritation of the eyes
itching mucous membranes
itching lips and skin. Good sources of vitamin B2:
milk
liver
yeast
cheese
green leafy vegetables
fish.Recommended daily amount: 1.6mg.Poisoning: no danger of poisoning as the vitamin dissolves in water, so excess is excreted in the urine.Destroyed by: light (this is why milk-cartons are better than bottles) and alcohol.
Vitamin B6 (pyridoxine) properties Good for:
preventing skin conditions
nerve problems
helping the body absorb proteins and carbohydrates.Signs of vitamin B6 deficiency: skin inflammation.Good sources of vitamin B6:
fish
bananas
chicken
pork
whole grains
dried beans.Recommended daily amount: 2mg. Women taking the contraceptive pill may need more. Poisoning: may cause nerve problems in large doses, but current evidence is conflicting about the maximum safe dose. Discuss this with your pharmacist if you are concerned. Destroyed by: the contraceptive pill, roasted or boiled food, alcohol and oestrogen (the female hormone).
Vitamin B12 (cobalamin) properties Good for:
making red blood cells
the formation of the nerves. Signs of vitamin B12 deficiency:
tiredness due to anaemia
abnormalities of nervous tissue function.Good sources of vitamin B12:
fish
liver
beef
pork
milk
cheese. Vitamin B12 deficiency can arise in strict vegans because our dietary sources of vitamin B12 are animal in origin. The other main cause of vitamin B12 deficiency is pernicious anaemia.Recommended daily amount: 1 microgram. Poisoning: no danger as the vitamin dissolves in water, so excess is excreted in the urine. Destroyed by: water, sunlight, alcohol, oestrogen and sleeping pills.
Vitamin C (ascorbic acid) properties Good for:
the immune defence system
protection from viruses and bacteria
healing wounds
reducing cholesterol content of the blood
a natural laxative
cell lifespan
preventing scurvy. Signs of vitamin C deficiency:
tiredness
bleeding gums
slow-healing wounds. Good sources of vitamin C:
citrus fruits - especially kiwi fruit
berries
tomatoes
cauliflower
potatoes
green leafy vegetables
peppers.Recommended daily amount: 60mg. Poisoning: Large doses can cause diarrhoea and nausea. Some scientists have recently argued that 1 to 5g per day may influence your genes. Destroyed by: boiling food, light, smoking and heat.
Vitamin D propertiesGood for:
strong bones and teeth.Signs of vitamin D deficiency:
unhealthy teeth
osteomalacia (causes weakening of bones)
rickets in children.Good sources of vitamin D:
cod-liver oil
sardines
herring
salmon
tuna
milk and milk products
sunlight (the action of sunlight on the skin allows our bodies to manufacture vitamin D).Recommended daily amount: 5 micrograms.Poisoning: this vitamin is fat-soluble so can accumulate in the body and overdoses are dangerous. Destroyed by: mineral oil.
Vitamin E (tocopherol) properties Good for:
fighting poisons - vitamin E is a powerful 'anti-oxidant'.Signs of vitamin E deficiency:
weak muscles
fertility problems. Good sources of vitamin E:
nuts
soya beans
vegetable oil
broccoli
sprouts
spinach
wholemeal products
eggs.Recommended daily dose: 10mgPoisoning: there is a theoretical but slight risk of overdose, as vitamin E is fat soluble. Destroyed by: heat, oxygen, frost, iron, chlorine and mineral oil.
Folic acid properties Good for:
production of red blood cells
essential during the first three months of pregnancy to prevent birth defects such as spina bifida, cleft palate or cleft lip. Signs of folic acid deficiency: anaemia, red tongue.Good sources of folic acid:
carrots
yeast
liver
egg yolks
melon
apricots
pumpkin
avocado
beans
rye and whole wheat
green leafy vegetables.Recommended daily amount: 200 micrograms. Pregnant women and women planning a pregnancy should take a daily supplement of 400 micrograms, continued for the first 12 weeks of pregnancy.Poisoning: no danger of poisoning as it dissolves in water, so excess is excreted in the urine.Destroyed by: water, sunlight, oestrogen, heat.
Based on a text by Dr Carl J Brandt

Vitamins

Reviewed by Dr Dan Rutherford, GP
What are vitamins? The term 'vitamin' is derived from 'vital amine'. They are a group of substances required in small amounts for growth and development but which cannot be manufactured by the body.Without vitamins the human body would not survive. We all need vitamins in order to live a long and healthy life. Most of us get sufficient quantities of vitamins from our food, but it may be necessary for some people to take a vitamin supplement (eg pregnant women and the elderly).
How easy is it to get all the vitamins we need from our diet? A varied diet is essential if we are to obtain the nutrients we need. However, this is not always easy: fruit and vegetables age (an apple in a bowl loses vitamins hour by hour) and deep frozen products may often contain more vitamins than vegetables stored for a long time at room temperature. Therefore, it is especially important to eat a wide variety of fresh foods.Too little of just one vitamin may disturb the body's balance and cause health problems. But taking too many vitamins can also be dangerous. This is especially true of the fat-soluble vitamins A, D, E and K: it is harder to get rid of excess of these vitamins through urine - the most common way for us to eliminate body waste products.
Which vitamins do we know about?New vitamins are discovered occasionally, but presently we know of the following vitamins: A, B1, B2, B3, B5, B6, B10, B11, B12, B13, B15, B17, C, D, E, F, G, H, K, L, M, P, T and U.
Where do vitamin supplements come from?Most vitamin supplements have been extracted from natural foods. For instance, vitamin A comes from fish-liver oil. Vitamin B comes from yeast or liver. Vitamin C is often extracted from small berries in roses, and vitamin E is extracted from soy beans or maize. Vitamins may also be synthetically manufactured, but synthetic vitamins are not always as effective as their naturally-derived equivalent.
How should vitamins be stored?It is important to keep vitamins in a dark, cool place, or they will 'go off', just like apples in a bowl. The best place to store vitamins is in the refrigerator - make sure there is a lid on the container. A few grains of rice in the container will prevent moisture getting into the tablets.
When should you take vitamin supplements?The best time to take vitamins is during the day, after a meal. Never take vitamins on an empty stomach - they will quickly passed out in your urine. This is especially true for the B and C vitamins that dissolve in water. The fat-soluble vitamins A, D, E and K can be stored in the body for up to 24 hours and can sometimes be stored in the liver for even longer.
Are vitamins and minerals the same thing?Vitamins and minerals are two completely different things: minerals help the vitamins work. The 10 most important minerals are: calcium, iodine, iron, magnesium, phosphorus, copper, manganese, chromium, selenium and zinc. There is a specific recommended daily allowance for each of these, as well as for each of the vitamins. Based on a text by Dr Carl J Brandt, GP

Heartburn

Written by Dr Dan Rutherford, GP and Ove Schaffalitzky de Muckadell, consultant and professor of internal medicine
Heartburn occurs when the acid contents of the stomach pass backwards up into the food pipe (called the gullet or oesophagus). This is also known as stomach acid reflux. Most people have stomach acid reflux at some point in their lives, either as heartburn or acid regurgitation.
What causes heartburn? Heartburn typically occurs after eating a large meal or drinking a lot of alcohol. Some people get heartburn when they bend over or lie down. The frequency of stomach acid reflux varies from one person to another. For most people, it happens very rarely. But weekly or daily incidents of heartburn or acid regurgitation may occur.
Is heartburn dangerous? Heartburn is annoying and may have a detrimental effect on a person's wellbeing. Sometimes the tendency for heartburn may develop into a mucous membrane inflammation in the food pipe, also known as oesophagitis. In the worst cases, oesophagitis may become complicated with ulcers, which, in rare cases, may bleed or cause chronic anaemia. Occasionally, reflux oesophagitis may become complicated if scars cause a tightening or narrowing (stricture) in the food pipe. A gullet stricture can prevent swallowing. This is a serious condition, which requires immediate examination and treatment.
How does gastric acid end up in the food pipe? At the lowest part of the food pipe there is a ring of muscle (sphincter) where it passes through a hole in the diaphragm.
The diaphragm
The diaphragm is a thin sheet of muscle dividing the lungs from the stomach.
The diaphragm holds the gullet sphincter in place and the system works as a one-way valve.If the one-way valve does not function properly, acid from the stomach (gastric acid) will be able to pass up into the food pipe. This tendency increases if:
the stomach contains large amounts of food or fluids (especially if the food is fatty, the drink alcoholic)
there is something pressing on the stomach, eg such as occurs when people are overweight.
What increases the risk of heartburn? There is often no known reason for increases in heartburn. But occasionally one of the factors below may contribute.
Hiatus hernia
Other risks
Chocolate, peppermint, coffee and alcohol hamper sphincter function.
Tobacco hampers the function of the sphincter.
Constipation increases the chance of acid reflux.
This is the name for the condition where the upper part of the stomach has passed up through the hole in the diaphragm. This means the muscle fibres of the sphincter can't press on the lower part of the food pipe. As a result, the lower part of the gullet is normally open, when it should be closed.
ObesityIn people who are overweight, the fat in their abdominal cavity exerts more pressure on the stomach. This causes high pressure inside the stomach, and the contents of the stomach may then be pushed up into the food pipe. Weight loss will reduce the chance of stomach acid reflux.
PregnancyThe enlarged uterus (womb) presses on the stomach. This causes the same kind of high pressure inside the stomach as in people who are overweight. The change that pregnancy brings to the balance of the hormones also leads to a general relaxation of the gullet sphincter.
Large meal portionsThe risk of stomach acid reflux increases with more food in the stomach. The risk will be greater after large (and especially fatty) meals, where the food is in the stomach for a long time before it passes on to the intestines. If you avoid eating more than is necessary, the risk of stomach acid reflux is reduced.
Lying downIf you lie down, the chance of stomach acid reflux increases due to gravity. You can avoid this to some extent by raising the head-end of your bed (see tips below).
What can I do to help myself?
If you are overweight, try to lose a few pounds.
Avoid large fatty meals and try not to eat just before bedtime.
Try to cut down on coffee.
Avoid drinking too much alcohol.
Quit smoking.
If suffering from nightly symptoms, try using an extra pillow or putting a couple of books under the legs at the head of the bed.
If heartburn or acid regurgitations are rare (less than five times a month) medicines bought from a chemist such as antacids can be used.
What medicines treat heartburn?
Antacids Since heartburn is caused by acid from the stomach, one of the simplest ways to relieve the discomfort is to neutralise the acid with an antacid. Antacids usually contain a mixture of magnesium and aluminium salts, calcium carbonate or sodium bicarbonate. Those containing high amounts of sodium may not be suitable for pregnant women or those on a sodium restricted diet, such as people with high blood pressure or heart disease. Antacids are available as tablets that can be sucked or chewed and liquids. The choice is down to personal preference, but liquids may work faster and tablets may have a longer lasting effect. Antacids can reduce the absorption of certain other medicines from the gut, so if you are taking any other medicines you should always check with your pharmacist before taking an antacid at the same time.
AlginatesSome antacid products, eg Gaviscon, also contain sodium alginate. Sodium alginate is a substance that forms a ‘raft’ that floats on top of the stomach contents. The raft prevents stomach acid from passing back into the food pipe and protects the food pipe from the acid. Products containing alginates are particularly useful for heartburn caused by pressure on the stomach, such as during pregnancy. They are also available as tablets and liquid.
H2 antagonistsH2 antagonists include medicines such as cimetidine, ranitidine, nizatadine and famotidine. All of these can now be bought from pharmacies by adults over 16 years of age. They work by blocking histamine receptors in the stomach, which prevent the cells in the stomach from producing too much acid. This type of medicine may not be suitable for people with liver or kidney problems. They should only be used for a maximum of two weeks without consulting your doctor. Cimetidine has the potential to interact with various medicines, both bought and prescribed, so you should always check with your pharmacist before taking it with any of your existing medicines.
When should I consult my doctor? If heartburn or acid regurgitation occurs often, or the symptoms are very annoying, consult your doctor. You should also consult a doctor if you:
have trouble swallowing
are middle-aged or older and have new symptoms
have suddenly lost a lot of weight.Your doctor will decide whether a further examination or more effective medicine is needed.

Constipation

Reviewed by Dr Dan Rutherford, GP
Stomach pain is a common symptom of constipation.
What is constipation?Although constipation is a common term, from a medical perspective it is hard to define precisely. The dictionary definition is: ‘A condition in which bowel emptying occurs infrequently or in which the stools are hard and small or where bowel movement causes difficulty or pain.’ But defining infrequent is difficult when some 90 per cent of people in Western countries have a bowel pattern that ranges from three bowel movements a day to three per week. And it is possible to move your bowels every day and still be constipated if the stools are hard and difficult to pass. Equally, a daily bowel movement is by no means essential for, nor a sign of, good health. Provided the bowels move regularly and without discomfort, it doesn't matter if your natural bowel frequency is once every two or three days.
How common is it?Constipation is thought to affect a quarter of the population at some time. Constipation is more common in the elderly because:
the power of the bowel muscles diminishes with age
they tend to take more medicines that have constipating side effects.
Bypass diarrhoea
This happens when a hard plug of stool in the lower bowel (faecal impaction) stops a proper evacuation.
Only the more liquid stool from higher up in the bowel can then be passed.
For this reason correct diagnosis is important.
Medicine to slow the bowel down will make the condition worse if a person is actually constipated.
What are the symptoms of constipation?
Tummy pain associated with bowel movements.
A feeling of incomplete emptying of the bowel.
A bloated feeling in the stomach region.
Diarrhoea: constipation is one of the most common causes of diarrhoea, especially in the elderly in care. Diarrhoea caused by constipation is known as bypass diarrhoea.
What causes constipation?
Poor general health.
Immobility or an inactive lifestyle.
Insufficient fluid intake.
A diet low in fibre. Fibre retains fluid and makes the stools light and soft.
Irritable bowel syndrome (IBS).
Inadequate toilet facilities.
An underactive thyroid gland.
Spinal injury.
Multiple sclerosis.
Colon or rectal cancer.
Kidney failure.
Too much calcium in the blood.
Tumours and other lesions of the bowel.
Certain medicines, eg codeine-containing painkillers (co-dydramol, co-proxamol), morphine-like painkillers, antidepressants, aluminium-containing antacids, iron supplements, and anticholinergics such as procyclidine (used in Parkinson's disease).Constipation should not simply be accepted or ignored. Persistent constipation or any change in bowel habit (whether towards constipation or looseness) should be investigated, especially in adults over 40 years. However, for most people with long-standing constipation there is no identifiable cause.
What can help prevent constipation?
A well-balanced diet high in fibre, including bran, fruits and vegetables, is often helpful.
Cutting down on white bread, cakes and sugar.
Drinking at least 8 to 10 glasses of water a day. Hot beverages, such as coffee, tea or hot water may stimulate bowel movements.
Prunes and plum juice can also be beneficial.
Regular exercise improves digestion and reduces stress.
A regular bowel habit. The best time is usually the first hour after breakfast. Don't hurry and sit for at least 10 minutes, regardless of whether you manage to pass a stool. Don't strain.
What are the complications of constipation?
Haemorrhoids. These are swollen veins at the anus, caused by straining at a stool over a long period of time. If large enough they will be visible from the outside. They can be painful or cause local bleeding.
Dependency on laxatives. The bowel in someone who has abused laxatives over a long period of time becomes sluggish and eventually dependent on the use of these drugs.
Hernia (bulging of the abdominal contents through a weak point in the abdominal wall). This is made worse by too much straining when trying to get rid of hard stools.
A prolapse of the womb or rectum. These complications result from excess straining and weakness of the muscles in this area.
What medicines are used to treat constipation?
Bulking agents such as bran and ispaghula husk. These work gently and are the most common type of laxatives (examples are Fybogel and Regulan). They don’t need to be in the form of medicines – increasing the fibre content of your diet should be the main treatment. Bulking agents should always be taken with plenty of fluids.
Stimulant laxatives that cause the bowel muscles to contract such as senna or bisacodyl.
Osmotic laxatives (such as lactulose) that increase the amount of water in the stools by drawing water in from the bowel lining.
Detergents that break down surface layers in the stool, letting water penetrate and soften it (eg docusate).
Macrogols (polyethylene glycols). These are administered along with extra fluids, so they don't draw more water into the bowel from the body. Examples are Idrolax and Movicol. Macrogols may be of long-term benefit to patients with persistent constipation and faecal impaction.
Which treatment is best?
Laxatives
Large amounts of laxatives are bought over the counter every day.
This is due in part to the belief that it's desirable to move the bowels daily.
Laxatives of all types are among the most commonly prescribed medicines.
Yet little detailed medical research has been done to work out the best ways of treating constipation.
There are many different combination laxatives available both on prescription and over the counter. None of these laxatives is superior to any other, and in most people the choice is an individual one. Sometimes, a medicine prescribed for a separate condition may have constipating side effects. Changing this medicine will be all that's required to get rid of the constipation. Someone who has had a period of immobility will probably find their constipation improves once they are up and about again. References Kamm MA. Constipation and its management. British Medical Journal 2003;327:460-462. http://bmj.com/cgi/content/full/327/7413/459 Tramonte SM, et al. The treatment of chronic constipation: a systematic review. Journal of General Internal Medicine 1997 12: 15-24. Summary at http://www.jr2.ox.ac.uk/bandolier/band46/b46-3.html Based on a text by Dr Torben Nathan, Dr Carl J Brandt and Dr Ove Schaffalitzky de Muckadell, professor of Internal Medicine

Stings and insect bites

Reviewed by Dr John Pillinger, GP
Insect bites often cause one or more red bumps that are usually itchy and sometimes painful. Often there is a small hole in the middle of the bite, perhaps with the end of the sting sticking out. Apart from this local irritation, the bite is not usually dangerous provided the victim is not allergic to insect bites.
Bee and wasp stings are more likely to cause allergic reactions than other kinds of insect bites.
Bee and wasp stings are more likely to cause allergic reactions than other kinds of insect bites.
Which insects cause stings or bites?Stings or bites are caused by midges, horseflies, bees, wasps, ants, some spiders, fleas, lice, etc.
What does a bite look like? There will be one or more swollen red bumps on the skin. In the middle, you will often see a small hole, which might have the insect's sting sticking out of it.If you wake up in the middle of the night having noticed a painful or itchy lump, check to see if other parts of the body are affected. If there is only one bump, or four or five of them close together, you have probably been stung or bitten. Fleas often bite four or five times in the same area so you may find a couple of these clusters on your body. Some children's diseases can also cause bumps and red, swollen skin. If in doubt, consult your doctor.
What are the symptoms of insect bites?The skin becomes red, swollen, itchy and can be painful. These are the most common symptoms. Sometimes bites cause an allergic reaction. Bites can become infected by scratching. Look out for a rash or swelling that gets worse instead of better. If this happens, see a doctor.Call your doctor immediately if you notice any of the following symptoms:
the person has been stung by many insects at the same time
a rash or swelling that gets worse instead of better
if the site is red, tender and swollen
headache
dizziness
nausea (feeling sick)
pains in the chest
choking or wheezing
difficulty breathing. These may be symptoms of allergy and can be life-threatening if the victim goes into shock. See a doctor immediately or dial 999 for an ambulance.
How to treat an insect bite or stingRemove the sting. Use tweezers to prise it out or scrape it off with your fingernail, or a credit card. Do not attempt to press out the sting, as this will only help the poison spread under the skin.Wash the bite with soap and water, then cool off the skin with ice cubes or an ice-pack that has been wrapped in a cloth or thin towel. Rest the affected area and elevate it if possible to prevent excessive swelling. Do this immediately after the victim has been stung. If necessary, use a painkilling cream or gel or an antihistamine to soothe the itch. If you or a member of your family are allergic to insect bites, talk to your doctor or pharmacist before going on holiday. They may tell you to take an antihistamine with you in tablet form or as an injection. If so, make sure you ask how to use it correctly. Anyone who gets a rash or an itch requiring medical treatment, or who may simply feel unwell following a bite or sting should not drive, as there is a risk of passing out. If in doubt, consult your doctor.
Insect bites and allergiesPeople who are allergic to insect bites should carry a card, bracelet or necklace that lets other people know about their allergy. If the doctor has prescribed medication for you to be used in case of an allergic reaction, it is important that both you and your family know exactly how to use it.
How to avoid getting stung
If surrounded by a swarm of bees or wasps, move out of the way SLOWLY. Do not try to wave the insects away. Violent movements will only excite them and make them more aggressive and likely to attack.
Insect repellents are effective.
Never aim a blow at a wasps' or bees' nest or attempt to throw them because the insects will immediately attack.
Stay away from things that attract insects, such as flowers, trees, bushes and piles of wood.
Be extra careful if you are eating or drinking (especially sweet things) outside.
Smells and bright colours attract insects. Avoid scented creams and strong perfumes if you are going to spend time outside.
Long sleeves, long trousers, socks, shoes and gloves help protect you from stings.
Close the windows in the house and the car to keep the insects out.
Look out for insects' nests in your home or garden and have them removed immediately.
Protective gear such as mesh covers for the face can be very effective against the nuisance of the highland midge in summer for example.
Based on a text by Vibeke Manniche, paediatrician, PhD

House dust mite allergy

Reviewed by Dr Paul Klenerman, specialist and Professor Brian Lipworth, professor of allergies and respiratory medicine
What is house dust mite allergy? House mite allergy is a hypersensitive reaction to proteins in the excretion of dust mites. The protein attacks the respiratory passages causing hay fever and asthma. It will aggravate atopic dermatitis in people who have a tendency to this problem. House dust mites are found in all homes. They are microscopic organisms that thrive in warm and humid houses with lots of food - human skin. The mites prefer to live in beds and, because we spend about a third of the day in bed, we inhale large quantities of dust mite allergens.
How do you become allergic to house dust mites? The excretion of the mites contains a number of protein substances. When these are inhaled or touch the skin, the body produces antibodies. These antibodies cause the release of a chemical called histamine that leads to swelling and irritation of the upper respiratory passages - typical asthma and hay fever symptoms. The predisposition for allergy is often hereditary. Unlike pollen, dust mites are present all year round causing constant allergy - 'perennial' allergic rhinitis. The excretion from the mites dries out and can be launched into the air when someone walks over a rug, sits down in a chair, or shakes the bed clothes, giving allergic people immediate symptoms.
What are the symptoms of house dust mite allergy?
Hay fever, runny nose, itching, sneezing.
Watering eyes.
Asthma, difficulty in breathing.
Infantile eczema (a skin disease) may get worse.
What makes the symptoms worse?
Air pollution such as tobacco smoke or car fumes.
How does the doctor make the diagnosis? It is often enough to tell the doctor when, where and how you get the symptoms. Skin tests and various blood tests can be used for confirmation.
Good adviceIt is best to do everything possible to avoid hypersensitivity to house dust mites. People who have perennial rhinitis, inflamed mucous membrane of the nose, or are allergic to house dust mites should try to adapt their homes.
Have as little furniture as possible in which mites can live.
Clean walls, woodwork and floors with wet cloths. The floor can be polished.
Only use rugs that can be washed once a week.
Use bedding that can be washed often, cotton sheets, washable bottom sheets and synthetic blankets or duvets. Don't use woollen blankets or quilts.
Make sure your chairs are made of wood or plastic.
If you can, use plastic curtains and dust them daily.
Use wet cloths and a vacuum cleaner with a no bag vortex and allergen filter to clean the house thoroughly, preferably every day, but at least twice a week.
Avoid dust traps like teddy bears, cushions, dried flowers, bric-a-brac and toys.
Wash bedding etc at a temperature of at least 60°C to kill the house dust mites.
Leave bedding, duvets, pillows and mattress hanging outside for an hour every day or as often as practical.
Put duvets and pillows in plastic bags and put them in the freezer for 24 hours at least once a month.
You may want to sleep on a cheap mattress that you can exchange for a new one at least every six months.
Dust mites hate dry and cold air, so try to air the house every day and don't use an air humidifier, which will only make matters worse. If the lower edge of the window is moist when you wake up in the morning, there is too much humidity in the air.
Do not spray the house, it may worsen your symptoms.
Do not touch dusty objects like books and old clothes.
When you are likely to be exposed to substances that give you a reaction, eg when you are house cleaning, you should wear a mask.
Don't allow smoking in the house.
What complications are possible?
You are predisposed to other respiratory diseases.
You are also predisposed to otitis, inflammation of the ear.
You may have trouble sleeping and suffer from chronic fatigue.
Hospitalisation following a severe asthma attack.
Future prospects If you are allergic to house dust mites, it is important that you don't expose yourself to the dust mite allergen because it increases your chances of developing asthma. The best remedy against house dust mites is described under the heading 'Good advice' above. Your symptoms can be controlled by treatment, but you can't escape your hypersensitivity. If severe dust mite allergy is the only form of allergy you suffer from, your doctor may want to try hyposensitisation - a 'vaccination' against the allergen. This tolerance treatment involves regular allergen injections in increased doses over a period of five years, but is not routinely given and is not always successful.
What medicine is given?
Antihistamine tablets or syrup (eg loratidine, cetirizine). These lessen the allergic reaction by blocking the actions of histamine. They relieve hayfever symptoms.
Nasal sprays or drops containing sodium cromoglicate, corticosteroids (eg beclometasone) or antihistamines (eg levocabastine) can be used to reduce nasal inflammation and control symptoms in the nose.
Eye drops containing sodium cromoglicate, nedocromil, or antihistamines (eg azelastine) reduce eye inflammation and can be used if eye symptoms are a particular problem.
If the allergy causes asthmatic symptoms, some of the asthma medication below may be used
Relievers (bronchodilators): these are quick-acting medicines that relax the muscles of the airways. They are used when required to relieve shortness of breath.
Preventers: these act over a longer time and work by reducing the inflammation within the airways. They should be used regularly for maximum benefit. When the dosage and type of preventive medicine is correct, there will be little need for reliever medicines.
RelieversThere are three groups of these.
Beta-2 agonistsBeta-2 agonists cause the airways to relax and widen. Examples of those which act for a short time (3 or 4 hours following a single dose) are salbutamol and terbutaline. These medicines are inhaled from a variety of delivery devices, the most familiar being the pressurised metered-dose-inhaler (MDI). When inhaled, these types of medicines work within minutes to open the airways, making breathing easier.Longer-acting beta-2 agonists include salmeterol and formoterol. Their action lasts over 12 hours, making them suitable for twice daily dosage to keep the airways open.
AnticholinergicOne of the ways in which the size of the airways is naturally controlled is through nerves that connect to the muscles surrounding the airways. The nerve impulses cause the muscles to contract, thus narrowing the airway. Anticholinergic medicines such as ipratropium block this effect, allowing the airways to open. The size of this effect is fairly small, so it is most noticeable if the airways have already been narrowed by other conditions, such as chronic bronchitis.
Theophyllines and aminophyllineTheophyllines and aminophylline are given by mouth and are less commonly used in Britain because they are more likely to produce side effects than inhaled treatment. They are still in very wide use throughout the world. All three types of reliever can be combined if necessary.
PreventersThere are three main groups of these.
CorticosteroidsCorticosteroids (or 'steroids') work to reduce the amount of inflammation within the airways, reducing their tendency to contract. They are usually given as inhaled treatment, although sometimes oral steroid tablets may be required for severe attacks. Although steroids are powerful medicines with many potential side effects their safety in asthma has been well established. It is also important to balance the problems that arise from poorly treated asthma against the improvement in health which occurs when the condition is well treated.
CromonesThere are two kinds of cromones: sodium cromoglicate and nedocromil. They also act to reduce inflammation of the airways. They tend to be best for mild asthma symptoms and are more effective in children than adults. The medicines are given by inhalation and are usually very well tolerated.
Leukotriene receptor antagonistsLeukotriene receptor antagonists are compounds released by inflammatory cells within the lungs and which have a powerful constricting effect upon the airways. By blocking this effect with these antagonist medicines the constriction is reversed. There are two such medicines currently available: montelukast and zafirlukast.Most cases of allergic asthma are best controlled with an inhaled corticosteroid, eg beclometasone, which is taken at regular intervals as a preventative measure. A beta-2 agonist, eg salbutamol, is used in conjunction with this to relieve symptoms when necessary. For patients who have associated perennial or seasonal allergic rhinitis the use of an antihistimine, eg cetirizine, is often useful.
Based on a text by Dr Flemming Andersen