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Respiratory Problems - Smoking

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - At the ripe old age of 50, and after numerous attempts, I have finally managed to give up smoking. I say this every year of course, but in 2016 I seem to have stayed quit for longer than ever - 3 months and counting! This time the difference is my trusty e-cigarette - I got a Vape for Christmas and with it by my side I have no doubt I can ditch the tobacco for good. But I do wonder whether there's been any research on vaping and diving. Is it actually safe for me to continue? I don't do anything extravagant, just recreational stuff at 30m max in warm waters generally. What do you think?

A - Herbert Gilbert is the chap credited with the invention of the electronic cigarette, way back in 1965. His original patent application makes interesting reading, describing a "battery powered cigarette (which) uses no tobacco and produces no smoke. A replacement tip, moistened with harmless warmed chemicals, could simulate the flavour of anything from root beer to rum. The smokeless cigarette also has medical potential. For example, asthma patients could be given internal medication through the lungs merely by moistening the tip with the medicine."

Of course, at the time, big tobacco saw this as a threat to their profits and the device was met polite non- committal interest (for which read scorn and derision). Changing attitudes and a popular Chinese e-cig called Ruyan led to a huge uptake of this nicotine delivery system in the mid-2000s, and now "vaping" is brisk business the world over. The principle is simple enough: a tiny heating element at one end vapourises whatever liquid the user decides to place in the refillable cartridge at the other end, and the resultant flavoured steam can be inhaled or puffed in much the same way as a traditional cigarette. In the case of nicotine, this method can handily deliver the "hit" of a fag without the additional 70-plus carcinogenic chemicals that burning tobacco produces. A review by Public Health England in 2015 concluded that "E-cigarettes are 95% less harmful than tobacco and could be prescribed on the NHS in future to help smokers quit."

There's no research on this and diving, so far as I know, but I cannot see any empirical reason that it would be unsafe; and if we are to believe the positive benefits then perhaps we should be encouraging all divers to transfer their allegiance to e-cigs. The only note of caution I would highlight is that nicotine withdrawal can cause a lot of unpleasant symptoms, including dizziness, anxiety, sleep disorders, depression, fatigue and muscle pains; so best not to be diving whilst undergoing a withdrawal programme as such. Congratulations though on kicking the habit so far - keep it up and your lungs will be forever grateful.

Q - Common sense tells me it's not a good idea to smoke tobacco as a diver, but does that apply to things like shisha pipes and cannabis as well? It's not that I smoke these things all the time, but I have in the past, and want to know whether this would cause me any harm if I dived afterwards. What is it that's the problem, the smoking process or what it is that's smoked? Hope I've explained my question clearly enough…

A - You have indeed. Shisha, hookah, hubbly bubbly – all refer to filtering smoke through a pipe, often via a water-filled bowl to cool and humidify it (contrary to popular belief, the water doesn’t filter many of the real nasties out). What is smoked can vary enormously, with a mixture of tobacco, dried fruit, spices and treacle most common. Although the percentage of tobacco is therefore reduced, a typical hookah session lasts way longer than a cigarette, and delivers vastly more smoke, tar and nicotine. So in many ways it’s actually worse for you. Common sense should also tell you it’s not a good idea to smoke cannabis either, for obvious reasons – being stoned and narced at the same time could have pretty dire consequences. In answer to your question, ultimately it’s a combination of the smoking process AND what’s being smoked that leads to problems. Best to avoid it altogether.

Q - I've been diving for 30-odd years and was a smoker until five years ago (I'm now 48). Unfortunately I think I left giving up a bit too late: I was diagnosed with chronic obstructive pulmonary disease (COPD) six months ago. The docs say it's mild but because I smoked for 20 years (an average of 40 a day) it's likely to get worse. I do wake up coughing and have to clear some fairly putrid-looking oysters (sorry) in the morning, but otherwise I'm pretty fit (still run and cycle to work). Can I still dive?

A - Your typical COPD case is picked up in those aged 45 or older, with a smoking history of at least 20 pack-years. (Pack-years is a quick way of estimating long term smoking exposure; one pack year is equivalent to smoking 20 cigarettes a day for one year, so in your case you have a 40 pack-year history.) Early symptoms such as frequent throat clearing, breathless on mild exertion and an irritating cough are often blamed on aging or lack of fitness. Progression to chest tightness and wheezing may take years, but other behavioural signs may appear first – avoiding the stairs in favour of the lift, taking longer to mow the lawn etc.

Lung infections become more common and severe as time wears on. Your major achievement has been to stop smoking, which is the most important treatment. There’s nothing you can to do to reverse the damage, but at least it won’t accelerate now. Medications can help widen the airways and treat infection, and no doubt these have been discussed with you. I’m afraid your diving days are numbered though; poor lung function will reduce exercise tolerance and put you at risk of barotrauma. Borderline cases with very mild symptoms and satisfactory lung function tests might get away with it, but it’s difficult to be certain of safety and personally I wouldn’t risk it. Time to hang up those fins.

Q - Being honest, I'm one of those annoying on-off social smokers who's always scabbing cigarettes off people at parties and never buys their own. Normally I go out on Thursdays and don't smoke Friday so it clears my system before I dive on the weekend. This year though, I've been getting bunged up on Saturdays and Sundays and had loads of equalising problems and sinus squeeze. But last week we went out Friday, I smoked a pack and was fine diving: it's almost like it cleared everything out. What's all that about?

A - Being honest myself, it’s always difficult to give concrete explanations for quirky individual symptoms like this. I suspect though that after a day of withdrawal (your usual Friday off the fags), your lungs are beginning their recovery and consequently your respiratory tract produces more mucus, causing congestion in your ears, nose and sinuses. By smoking that pack last Friday you beat your poor cilia back down into submission, so rendering the system “clear”. Sadly this delaying tactic will only postpone inevitable (and bigger) problems. Social smokers run pretty much the same risks as full timers – they tend to take more drags, and inhale deeper and for longer, so their overall exposure is similar. The same goes for smokers of “light” cigarettes - research suggests they still get as much heart disease and lung cancer. Giving up totally is really the best option.

Q - I'm in the process of trying to quit smoking (again…). I'm 42 now and have given up for a year or two before, but somehow always end up having a cheeky one in the pub and falling off the wagon. This time I'm going to use something to help. Bearing in mind I'm a technical diver, what do you recommend is the best way to go? Patches, gum, Champix, Zyban or anything else?

A - Nicotine replacement therapy, in whatever form, has been shown to help people stop smoking, and for good. It’s not a substitute for willpower but does take away some of the unpleasant physical side effects of withdrawal. Nicotine does cause a short-term increase in blood pressure, heart rate, and the flow of blood from the heart, and it narrows the arteries too. All of these effects do put some extra strain on the heart, but no more than a cigarette would, and without having to contend with a load of carbon monoxide as well. No effect of pressure on the release of nicotine from the patch has been demonstrated (it might easily fall off if it gets wet though). So there’s no real danger in diving whilst using them. Champix and Zyban both have a list of undesirable side effects as long as a Portuguese Man o’ War, some of which could be detrimental to underwater safety, particularly in a technical setting. You’d be best off avoiding these, or at least minimising your inert gas load whilst taking them and seeing your dive doc before you embark on any deep wreck stuff.

Q - Like many divers who enjoy a holiday in the Red Sea, I have partaken in the local custom of smoking on the hubbly bubbly pipe otherwise known as shisha, or hookah. Can you clarify to me whether or not smoking these things can or will damage a person's health. Some people I have spoken to believe it is the same as smoking cigarettes whilst others say that the tobacco contains no harmful substances. It is quite relaxing after a days' diving to sit down with a beer and a pipe and enjoy some of the local entertainment but am I being naïve to think this pastime is harmless? Your advice is most welcome.

A - There can’t be many visitors to Egyptian shores (or the Edgware Road) that haven’t been tempted by, or at least curious about, these splendidly ornate stemmed water pipes. They do elevate smoking from a squalid habit to what some deem a fine art. The expatriate British lawyer William Hickey, renowned for his thoroughly debauched existence, wrote this about hookahs in 1775, after arriving in India: ‘The most highly-dressed and splendid hookah was prepared for me. I tried it, but did not like it. As after several trials I still found it disagreeable, I with much gravity requested to know whether it was indispensably necessary that I should become a smoker, which was answered with equal gravity, "Undoubtedly it is, for you might as well be out of the world as out of the fashion. Here everybody uses a hookah, and it is impossible to get on without" [... I] have frequently heard men declare they would much rather be deprived of their nightly sex than their hookah.’

As to the wisdom of a pipe after a days’ diving, the crux of the matter is whether they use tobacco or not. Shisha comes in various lurid and herbaceous guises, but unfortunately most of them are around a third tobacco, with the rest made up of spices and fruit pulps. Thus you are effectively smoking flavoured cigarettes. Many studies have shown that the health risks are similar to cigarette smoking, indeed potentially worse – the average shisha session (try saying that quickly) of 40 or more minutes can deliver considerably more smoke than a pack of cigarettes, and the cooling effect of the water combined with the intoxicating fruity aromas may lull those who indulge into a false sense of security. The water filter does not rid the smoke of any impurities or nicotine (most of the toxic chemicals and nicotine are not water soluble). The pipe sharing aspect does also expose the smoker to gum infections or cancers.

For the hardened hookah hedonist there is hope, however; tobacco-free flavoured herbal blends are available, which are theoretically less harmful, and various attachments can be added to the basic device to filter out the nasties. A number of Smoking Research Institutes (which I envisage are rooms full of white-coated scientists furiously dragging on nefarious nicotine delivery devices) are looking at the long term effects of hookah smoking, but at present the jury is out.

So smoking a shisha with tobacco is most definitely not harmless, it carries the same risks as smoking cigarettes.

(other dive medical questions)


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