The lungs like many other organ systems also bear the brunt of the changed life style.  Whether the changes involve the food or the clothing, the transport or the housing and the personal habits or the hobbies, they are bound to affect the health including the respiratory health.  The respiratory system of any living organism, including man, in fact is exposed through the act of breathing to the surroundings all the time – during both the awake and the sleep periods.  Any change in the surroundings therefore, is bound to affect the lungs.

Besides the atmosphere there are many other factors related to the style of living which influence the respiratory health.  Some of the important factors are enumerated in this chapter.

1.  Tobacco smoking:    In spite of the availability of an increased evidence of the risks of smoking, the consumption of tobacco has markedly increased.  In India, about 30 percent of adult men smoke and another 30 percent consume nonsmoking forms of tobacco.  The habit is catching fast even among the women.  A major concern is the prevalence of habit of tobacco use among the youth who associate smoking with the “cool image” of a modern person.

Besides its effects on the heart and other systems, tobacco smoking is an important cause of chronic respiratory symptoms, disability and death.  It causes chronic cough and breathlessness, precipitates and/or aggravates asthma and predisposes to frequent respiratory infections.  Prolonged consumption of tobacco is associated with chronic obstructive lung disease and several forms of respiratory cancers.  Tobacco smoking is the most important preventable cause of death.  For the lungs, it can be rightly considered as the enemy number one.

2. Atmospheric pollution:  The atmosphere in which we live is influenced by the

changes in our way of living.  The excessive vehicular emissions which pollute the atmosphere constitute one such example.  There is a tremendous, rather logarithmic increase in the number of vehicles plying on the roads.  This is a direct manifestation of the modern life necessitating both the luxury and the need of vehicles.  There is an obvious dependence on the private vehicles as well as the public transport systems to commute to different places.  Atmospheric pollution from their emissions is an unintended problem associated with the use of vehicles.  Exhausts from various industrial units especially those within the vicinity of residential areas add to the air pollution caused by the vehicular exhausts.

The respiratory system bears the main brunt of the atmospheric pollution.  One can willingly choose or reject a food, a drink or a luxury, but there is no choice of the air one breathes.  Whatever is present in the atmospheric air is inspired into the respiratory system.  All the noxious material, gases, fumes and chemical particles are inhaled along with the air.

Air pollution causes nonspecific symptoms such as the repeated throat and nose cleaning, eye and throat irritation, cough, sputum production and heaviness of the chest in about 20 percent of adults living in highly polluted zones.  Children may suffer from recurrent respiratory tract infections, wheezing, bronchitis and asthma.  Chronic exposures may cause more serious and chronic respiratory problems and disability.

3.  Sick Building Syndrome – The menace of modern housing:    The multi-storeyed housing with a number of flats crowded together, is possibly a need of the modern times but certainly a factor adverse to the human health.  The inside air is generally stale due to the closed surroundings.  There is a significant pollution of the indoor air resulting from various exhausts and expired air of those living inside.  The indoor air pollution could in fact be even more injurious that the outdoor air pollution.

Recognition of indoor air pollution is relatively recent.  It is not uncommon to experience a feeling of ‘suffocation’ in a closed environment.  It is often ascribed to lack of oxygen but this is not true.  The composition of air is remarkably constant all over the world.  There is about 79 percent nitrogen and 21 percent oxygen in the air – the other gases form a very small fraction.  Carbon dioxide exhaled out of the lungs may accumulate in a closed and over-crowded place.  But such an increase is usually small and temporary unless the room is really airtight.  Exposure to poisonous gases such as carbonmono-oxide may occur in a closed room heated through burning of coal inside.  This may in fact prove to be fatal.

What is more common in a poorly ventilated home is a vague constellation of symptoms described as the “sick-building syndrome”.  It is characterized by a general feeling of malaise, dizziness and irritation of mucus membranes.  It may also be accompanied by nausea, itching, aches and pains.  Psychological problems especially headaches, mental irritation, lack of concentration and depression are common.  Compounded by loneliness, it may even lead to suicidal tendencies.

Sick building syndrome is common in small houses which are generally over furnished.  Some of the important pollutants whose indoor concentrations exceed those of the outdoor, include gases such as carbon mono and dioxides, oxides of nitrogen, organic substances, spores, formaldehyde, hydrocarbons, consumer product aerosols, radon and allergens.  The sources are attributed to a variety of construction material, insulations, furnishings, adhesives, cosmetics, volatilization, house dusts, fungi, molds and other indoor products.

By-products of fuel combustion are important in houses with indoor kitchens.  It is not only the burning of dried dung and wood which is responsible, but also the kerosene and liquid petroleum gas.  Oxides of both nitrogen and sulphur are released from their combustion.

Smoking of tobacco in the closed environment is an important source of indoor pollution.  It may not be high quantitatively, but significantly hazardous for health.  There are over 4000 chemical constituents in the tobacco smoke which have been identified.  Most of these chemicals are harmful for human health.  Exposure to the environmental tobacco smoke occurs significantly in the children and spouses of smokers.  It has been shown to be associated with an increased incidence of lung cancer, chronic bronchitis, lung function impairment and higher morbidity from bronchial asthma.  It is the relationship of several medical problems with environmental tobacco smoke exposure (passive-smoking) that has compelled several countries to enforce laws either to prohibit smoking in public places and offices or to create separate areas for smokers and nonsmokers.

Radon and radon decay products (called radon ‘daughters’) have been identified to bear a significant relationship with incidence of cancers, especially the lungs.  The common indoor source is the construction material and water.  Its concentration may vary from place to place and that may actually determine the variations in the prevalence of cancers at different places.

Chemical compounds such as formaldehyde, acetone, ammonia, toluene, benzene and others bearing a high indoor concentration may have subtle health effects such as the increased production of sputum, eye irritation, watering and neuro-psychiatric symptoms including headaches, aches and pains.  Mineral synthetic and asbestos fibres emanating from insulation and fire retardant material are quite hazardous and responsible for lung fibrosis and tumours.  Asbestos fibres are non-destructible and may cause the disease after several years of the initial exposure.

Micro-organisms and allergens are of special significance in causation and spread of diseases.  Most of the infective illnesses may involve more persons of a family living in common indoor environment.  These include viral (such as influenza, measles) and bacterial diseases such as tuberculosis.  A classic example of an epidemic due to indoor pollution was the Legionnaire’s disease where the causative organisms responsible for a severe pneumonic illness, first involving members attending an American Legion Conference in Philadelphia and killing a many, was traced to the air duct system.

Other indoor air problems include the allergic problems of the respiratory system, skin and eyes.  Hypersensitivity pneumonias such as the air-conditioner and water-cooler lung may result from allergens present in these fittings.  Similarly, mosquitoes breeding in water coolers may spread diseases such as the malaria and the dengue fever.

The spectrum of indoor air pollution is wide and its effects devastating.  It not only causes an increased morbidity and mortality from diseases but threatens the quality of life.  It is apt to say that the ‘sickness’ of the building is transferred to the sickness of inhabitants.  The architects, the builders and the inhabitants need to look into the health of the indoor air as much as into the interior design.

4.  Physical inactivity:   There is a great increase in sedentary habits among both the youth and the children.  The marked increase in television programmes, video games and computer use has resulted in indoor confinement of people who should otherwise be out in the playgrounds, parks or fields.  Furthermore, there is an excessive dependence on vehicles for transportation from place to place.  Even within the campuses and large buildings, people would use motorized mechanisms, escalators, conveyor belts and lifts rather than exercising their legs.  Regular exercises and games are rather limited to the few in this country.

A comparative assessment of the major risk factors for non-communicable diseases made for the three mega countries i.e. India, Bangla Dash and Indonesia is rather revealing.  The magnitude of physical  inactivity was the most pronounced in India.  When physical inactivity was graded as per severity, only 11 percent people had vigorous or modern activity, while 89 percent were found to possess sedentary habits.  On the other hand, sedentary habits in the developed countries are found in less than 10 percent individuals.

Physical inactivity is the obvious cause of the poor development of the respiratory reserve.  It results in breathlessness, respiratory deconditioning and chronic respiratory debility.

5.  Obesity:  Closely related to the physical inactivity is the problem of obesity.  While excessive eating especially of the fatty and junk foods is directly responsible for obesity, the lack of exercise compounds the problem.  These days, there is an over dependence on fast foods.  Even the regular foods served in star restaurants and hotels contain an excess of oils and sugars.  Further, the consumption of an excessive amount of desserts, sweets, chocolates and creams add to the high caloric intake.  Invariably, the weight increases unless the food is balanced and calories are burnt with a good amount of exercise.

Obesity results in a significant increase in the load on the cardio-respiratory system.  Breathlessness is the most common symptom.  Gradually, the lungs and the heart are unable to cope up with this burden and tend to fail.  While gross obesity itself can lead to respiratory failure, even milder obesity would act as a contributory factor.

Obesity is also a cause of excessive snoring due to transitory occlusion of the upper respiratory tract.  It may also result in short episodes of choking and cessation of breathing during sleep – the so called obstructive sleep apnoea syndrome.

How to void the problem?

 ‘Prevention is better than cure’, is a simple dictum understood by even the most ill-informed individual.  Yet, prevention is the most inadequately and inefficiently adopted practice.  But there is no short-cut to the preventive steps.  Health is the most valuable and precious thing in one’s life.  It needs preservation at all costs.

Preventive steps for respiratory health are easy to count: Avoid or stop smoking; improve both indoor and outdoor atmospheric air and avoid pollution; regular exercises, balanced food and avoidance of obesity.  Many of these issues are discussed elsewhere in the book.  I would dwell upon two important topics – smoking control and good physical activity.

A. Tobacco control – Problems & Strategies

Smoking is an addiction rather than a harmless ‘habit’.  Nicotine, the chief constituent of tobacco, has all the characteristics of an addictive substance similar to that of other addictive agents e.g. alcohol, marijuana, opium etc.  These are: 1, Immediate pharmacologic reward (the ‘kick’); 2, Rapidly increasing tolerance to this effect (provokes increasing consumption over time); 3, Definite withdrawal symptoms on leaving and thus having a strong tendency to reuse.  Over the last 20-30 years, a variety of approaches have evolved for control of tobacco consumption:-

(i) Group of clinic-based programmes usually with an educational and/or behavioural modification approach;

(ii) Individual treatment which includes psychotherapy, behavioural modification or hypnosis;

(iii) Information disseminated by the mass media; (iv) Drugs which help or reduce the withdrawal symptoms; (v) Self-help approaches.

Broadly, tobacco control has several aspects such as the socio-behavioural, economic, medical and political.  On socio-behavioural front, every effort should be made to decrease the social acceptability of smoking at home, at work places or at social gatherings.  This requires a concerted effort by each member of society aided by the governmental policies and laws.  Happily, some welcome steps have been taken up by several state governments in promulgating laws to ban smoking in the enclosed areas such as the cinemas, the public transport, educational institutions and hospitals.  The government of India does not allow smoking on domestic flights.  Any advertisement of tobacco is banned on the All India Radio and the Door-Darshan.  More educational programmes specially focused on the target young, non-user population are required through a patient, extensive and persuasive campaign.   Our mass media, voluntary agencies, women’s organizations, educational and religious bodies can play an important role in this matter.

While the gains of tobacco are seen in terms of employment generated and the revenue collected, the losses are numerous in terms of costs incurred in providing health care to people and loss of productivity caused by diseases and death from tobacco related diseases.  Use of wood in tobacco curing also has implications in the form of environmental degradation.  It has been estimated that the costs of providing health care, setting up diagnostic and therapeutic facilities outweigh the apparent economic benefits from tobacco industry.

Besides the above mentioned socio-economic aspects of tobacco control, it is even more important to help an individual smoker to quit smoking.  Once appropriately motivated by socio-behavioural interventions, a smoker needs some extra help to get out of this addiction.  Nicotine has definite withdrawal symptoms which vary from smoker to smoker.  The withdrawal symptoms include bradycardia (low heart rate), irritability, anxiety, lack of concentration and mood abnormalities, increase in appetite, weight gain and insomnia (inability to sleep).  A ‘craving’ for nicotine is the most common cause of failure of smoking cessation.  Most of these symptoms would subside in about 2 week time provided the person continues to refrain from smoking.  Other forms of medical aid available in smoking cessation programmes are given below:

A strong political and administrative will is required to effectively control the

tobacco use.  Nonsmokers’ rights have to be protected in the face of now established harmful effects of “passive smoking”.  Tobacco control programme requires involvement of politicians, administrators, scientists, agriculturists, industrialists and in fact, of each citizen of the society.

B. Exercise and Physical Activity

Both the lungs and the heart have a tremendous potential of increasing their activities in response to a stress.  The volume of air breathed by the lungs and the blood pumped by the heart per minute can expand several fold during exercise.  This obviously puts a great strain on the system.  But the relative increase shall differ in those who are accustomed to exercise, than those who are not.  Therefore, the symptoms of stress are tolerated much latter by the acclimatized people.  Athletes, sportsmen and those who exercise regularly have slower heart and respiratory rates.  Their lung capacities are higher and blood pressures towards the lower limits of the normal.  They have therefore, a much greater scope of improving their functions in case of an unaccustomed event.

Exercise not only helps in avoiding symptoms but keeps the mood elevated.  It helps in building confidence and removing mental fatigue and tension.  It is of special importance for students when their studies are hard and time-consuming.  A short period of play goes a long way in improving literary performance.

Physical exercise is also essential for normal activities of neuromuscular system, joints and bones.  It helps to increase the blood circulation and develop collateral supplies to different organs.  This not only helps in prevention of diseases such as heart attack and osteoporosis, but also promotes better control of diseases such as asthma, diabetes and hypertension.  It is important here to warn that exercise in the presence of a disease must be undertaken only under guidance of the treating physician.  Any exercise is an additional burden, which, a diseased organ may not be able to cope with.  It may be counter-productive in diseases of the lungs, heart and the joints.  For example, it is a common misnomer among people that respiratory exercises are good for all lung diseases.  This is not true.  Exercise consumes excess oxygen, which a diseased lung may not be able to contribute.

Therefore, exercise for patients with medico-surgical diseases, need to be regulated.  In some, it is required to be restricted forever.  In others, a clearly structured programme is essential for rehabilitation.  Exercise-prescription in patients has to be specific for its type, intensity, duration and frequency.  Further, the progression from mild to moderate and severe exercises need to be gradual and guided by the body’s response.  There is no reason as to why a patient should not resume normal life style and physical activities.  This is essential for a good quality of life.  But this cannot be allowed at the cost of disease control.   Obviously, most patients are keen to go back to a state of normal physical activity.  But this may or may not be achieved.  It also depends on the disease state, the patient’s enthusiasm and understanding.  Above all it is the patient’s pre-morbid level of exercise which determines the outcome.  A person who had been less active physically in health before, would continue to remain shy after the illness.  The fact of the matter is that exercise is far more important in health than in disease