Thoughts on our Healthcare

“It is forecast that by 2030, the global consumption of antibiotics will rise by more than 30% (200% if it continues at current growth levels). By 2050, the annual death rate will have risen from 700,000 to 10 million with no action.”

 

It is a humbling situation when one realises how fragile we are in the face of nature and how little we really know in the battle to protect ourselves.

My generation have the unique honour of having grown up at a zenith of medical know-how. As a child, I often reassured myself that, if I or anyone I knew ever became unwell, everything would be fine. I always comforted myself that, should it be needed, there would be the medical expertise somewhere to cure anything. I was confident that the medical care and consensus behind every treatment was solid and complete; its efficiency spotless. Now I realise that this was simply a form of therapeutic self-delusion.

The truth is that, although our capabilities far exceed the wildest dreams of Hippocrates and Aristotle, we are far from perfect. What we don’t know far outweighs what we do. Treatments remain speculative, their quality reliant upon where we fall at any one time on the curves of demand and supply. Despite officious regulation, treatment remains highly subjective according to who treats you (bearing in mind this may be an exhausted doctor or nurse running on empty), and could still be based on faulty or unreliable evidence. We can’t guarantee a cure for your cancer and we can’t always tell for sure why you’re feeling so tired and achy, so sometimes we have to guess a bit.

Our exaggerated opinion of our own ability as a species extends beyond just medicine of course. While that can be catastrophic in other fields, it does at least provide some benefit in a healthcare setting. Confidence in physicians can be a therapy in itself. Despite what I have said, this trust is important and well placed. Though not perfect, we are better than nothing! And yet, when something like the Covid-19 pandemic hits – something so undeniably out of our control – it highlights those cracks that we’ve otherwise consciously chosen to ignore. 

What has struck me most about the Covid-19 pandemic is our reaction to it. While in some places it has highlighted tremendous courageous and community spirit, in others it has merely brought out human attributes that are the polar opposites of the aforementioned. For me, it has emphasised the prospect (and quite possibly the need) for fundamental change in how we utilise the medical expertise and the knowledge we have accumulated.

The meaning of ‘our NHS’ has become a bit warped in recent times. When someone has been treated with kindness and care, it is the NHS that gets the thanks. In reality, it is the people that work for the NHS who should be thanked as well as the organisation as a whole; a distinction that I feel too often gets overlooked. Obviously this is semantics and very often that is what people will mean when they praise the NHS. But in merging the two, a powerful message is being lost.

The people that work in healthcare, whether it be within or without an NHS, deserve all the praise they are getting. Likewise, the idea of a National Health Service that provides universal, comprehensive and free healthcare should also be praised. The problem is, at its inception in 1948, the idea of comprehensive healthcare is very different from what it is now.

In 1948, paracetamol was yet to become readily available, open heart surgery was 4 years old, statins had not yet been invented and antibiotics were in their infancy. Fast forward to the present day and we are seeing around 200 heart transplants a year in the UK, an entire pharmacy of medications available to us at our beck and call, lifesaving emergency services 24/7 and access to state of the art intensive monitoring equipment. Around half of the UK population takes at least one regular prescription medication. If your hips or knees go, you are entitled to have metal replacements inserted for no extra charge. If you have a rash, you can have it seen to or if you want your ingrowing toenail sorted, you can have it clipped or lopped off. If your ears are blocked, someone will clear that for you too.

With our population increasing and growing older, it is little wonder that the whole thing is beginning to creak. The outcome…? You have to wait a long time for your hip replacement, you might be denied the chance to have your bunions sorted out because it is a low funding priority. Your GP is running late by 20 minutes or even a bit longer. That may seem a bit insensitive or flippant (or both) but believe me, I’m not happy about it, certainly if it means people are waiting for treatments in agony. While some have a rational grip on such situations, others will not. Those are the ones that abuse the staff who are only trying their best in impossible circumstances.

Demand has far outstripped supply already. At current levels of funding, the promise of delivering a comprehensive service is no longer accurate. But that is only if we all agree on what counts as comprehensive.

We have been rather spoilt with the NHS, rather like a child who is given one sweet and then pleads for several more, never content with what they are given. The level at which our baselines have shifted (there is an actual concept know as shifting baselines syndrome that one could probably apply to much that is wrong with the world) is significant. Consider 100 years ago, antibiotics were non-existent, surgery was more dangerous than beneficial and not long before that there wasn’t even the luxury of an anaesthetic. Just read the 1810 diary account of Fanny Burney, the English novelist, who developed Breast cancer and underwent a mastectomy without anaesthetic to see what I mean.

Antibiotics and our use of them serve as a perfect microcosm to demonstrate my point. For all they have given us, they have also contributed to levels of antibiotic resistant infections that kill 700,000 people a year globally. Don’t get me wrong, antibiotics are great; a lifesaver in fact. Prior to their widespread utilisation, a cut or scratch could become infected to life threatening degrees and as such they have arguably become the single most important tool in our therapeutic arsenal (vaccination is arguably more important). And yet they have suffered a severe case of mission creep. They lend a hand in all sorts of unexpected ways. Caesarean-sections and routine hip replacements would be rather more hit and miss in terms of survival without them. Not content with saving lives, in fact they have become somewhat of a luxury, whether it be to shorten a cough or a bout of diarrhoea or to fatten up our animals so their meat is better.

In the UK, at least 20% of antibiotics prescribed in primary care are inappropriate (I would probably argue that figure is higher depending on your definition of inappropriate). At any one time, a third of patients in hospital are on an antibiotic. 

Resistant organisms transfer at will from one person to another, or to food and animals. As they do, we edge ever closer to a circumstance in which we are unable to treat them at all. There are already strains of TB and gonorrhoea that cannot be treated even by the antibiotics reserved as last resort.

The WHO cites antibiotic resistance as the biggest threat from global pandemic. Considering what is going on at the moment that should prick some ears.  Just as there are warnings about antibiotics, so there were for coronavirus. A pandemic such as the one we find ourselves in isn’t exactly a surprise and yet to a large extent, we have all been caught napping.  I liken it to sitting on a beach with a bag of popcorn, admiring the spectacle of a tsunami rolling in. Suffice to say, a tsunami of antibiotic resistance is far less palatable than the comparative swell of coronavirus we are seeing now.

It may therefore be time for some realism and some hard choices. This includes both those at the very highest levels but also, I’m afraid, for us all. Who knows in what shape we’ll emerge from the current saga.

In an ideal world, the government would pledge a suitable amount of money for the NHS to cater perfectly for everything from the largest and most severe of our medical needs down to the smallest and most trivial. Failing that, management of the entire system must get realistic and we must allow it to do so. No one wants to see a privatised NHS, (including the government if what they say is to be believed). Clarity of mission alongside acknowledgement of the problems– not spin – is what we need. Without this, whispers and rumours of privatisation will continue. If measures are to be painful, in my opinion telling people that is far better than trying to sneak it under their noses. Better still, a cross party approach in order to depoliticise proceedings is preferable so election success no longer rides on it. What we don’t want to see are more layers of management. Time and time again, we experience instructions from those at the top, far removed from the realities and often the progress we make is in spite of these targets instead of because of them. In any situation, the more layers you add, the more complex it becomes and the easier it is to trip over yourself. A bit like the game Tetris – a certain amount of blocks at the right speed will build something solid but as soon as the rate and number of bricks increases, it all runs away from you.

Just as importantly, perhaps even more so, is our individual role in all of this. As we clap our health workers every Thursday evening while in lockdown, perhaps take a moment to consider what we ask of them under normal circumstances. A large proportion of GP consultations are unnecessary and could be dealt with either by a pharmacist, or by the patient themselves. The NHS website has the information available if people were only to access it.

Between February and March, there has been a 22% fall in A&E attendances, many of would have been unnecessary anyway and would have taken up valuable resources and time.  General practice and outpatient secondary care has also seen a sharp drop in demand for routine enquiries. Many issues will have gone away on their own, or have been dealt with using online advice. Still more infections will have settled without antibiotics. We must harness this new way of using the health service.

This current situation may therefore serve as a not so gentle reminder of what are reasonable expectations in terms of our healthcare. That said, between early and late March, there has been a fall of 150 patients per day presenting with symptoms of heart attack. Now, it is unlikely that the Covid-19 pandemic has somehow cured heart disease altogether and though many people with chest pain turn out to be fine, there will be some within that cohort of 150 who have had real heart attacks; heart attacks that are currently going untreated.

Lack of presentation for this sort of thing, or indeed other worrying symptoms of things like cancer (loss of weight and appetite or a change in bowel habit to name just three), means the health impact of this pandemic will not be just related to Covid-19. For anyone with worrying symptoms like this, you absolutely must not ignore them just because of the outbreak.

We need to use the NHS sensibly. Not too much, but not too little. We have swung from one extreme to the other in the last few months. Once we emerge from this, we must all consider how best to use it going forwards, and focus on the bigger issues at hand, no doubt at a time of great change. Self-care is a big part of that, not just in how we deal with an acute medical situation but also in how we look after ourselves in general. Smoking alcohol, diet and exercise are the key areas that cost nothing to improve.

As a nation, our perspective in terms of the scope of our healthcare has run away from us. Some expect miracles – you don’t need to go to your GP if you have a cold. Nor do you need to go to A&E with a broken fingernail or a year old rash. Meanwhile, the threshold for others is far too high and there is a proportion of people that will hold off in coming to a doctor when they actually need to be seen.

As doctors we want to ensure that everyone who needs to be seen, and who we can help, presents to us appropriately. At the same time, we would request that others, who might reasonably be able to manage their own minor issues, do so. It is a fine balance and even writing this makes me uneasy that some may stay away for fear of overusing the service. The level of disparity in comprehension of how best to use the NHS is, in my experience, remarkable.

Nevertheless, I think we all could perhaps do with shifting our baselines back a hundred years or so. As doctors, we need to look at how we are using our resources and considering whether far more significant changes are necessary. Antibiotics use is just one example. Fundamental change at the top is needed to streamline the provision of healthcare and cut out the obfuscating bureaucracy. Difficult lines must be drawn. Leaders must consider taking more than half a glance at the deeper issues facing us – after-all from our current position, an antimicrobial resistant pandemic suddenly doesn’t sound as far-fetched as it did a few months ago. If that change is severe then so be it. Sometimes you have to go backwards to go forwards. In that case, we all have a responsibility to understand it and adapt, though politicians must realise that we cannot be expected to do that if left in the dark.

Urgent care must remain a priority for the service as a whole, but how we look after an ageing population effectively is just as vital. Prevention of health problems is key. One of the best ways to help therefore is to look after yourselves properly (we can only do so much in that respect) but also to seek help when appropriate in order to avert bigger health issues down the line. Staying away isn’t always the answer (particularly at the moment) although granted, there is a fine balance. That balance has always been upset one way or another and we all need to contribute in order to redress it. Now might be the time to set it straight.

 

 

 

 

 

 

How to Use the NHS

Some now expect miracles – there is no benefit and therefore no point in going to your GP if you have a cold. Nor do you need to go to A&E with a broken fingernail or a year old rash (these are real examples).

It may be a bit of an understatement to mention that a lot has changed recently. No more so than for those working in the health service and, while many are unwell with Covid-19 and while those that need it most struggle to get the PPE they need, the everyday aspects of their jobs have somewhat fallen by the wayside. Figures for February and March show a 22% fall in A&E attendances. General practice and outpatient secondary care have also seen a drop in demand for routine enquiries.

While this has freed up resources for the issue at hand, some may notice that many of the issues for which they might normally have sought help and advice have gone away on their own. Others have been able to find the answer to their questions online. The sore throat that you had might have cleared up on its own without antibiotics. That painful ankle might have cleared up with measures you followed from the NHS website.

This unusual set of circumstances has highlighted an area that perhaps we can all learn from as we emerge from this crisis (though there is a long way to go yet). As a nation, we have become somewhat spoilt by the free healthcare we can expect; our perspectives have shifted over time as more becomes possible. Some now expect miracles – there is no benefit and therefore no point in going to your GP if you have a cold. Nor do you need to go to A&E with a broken fingernail or a year old rash (these are real examples).

In 1948, at the inception of the NHS, paracetamol was yet to become readily available, open heart surgery was 4 years old, statins had not yet been invented and antibiotics were in their infancy. Fast forward to the present day and we are seeing around 200 heart transplants a year in the UK, an entire pharmacy of medications available to us at our beck and call, lifesaving emergency services 24/7 and access to state of the art intensive monitoring equipment. Around half of the UK population takes at least one regular prescription medication. If your hips or knees go, you are entitled to have metal replacements inserted for no extra charge. If you have a rash, you can have it seen to or if you want your ingrowing toenail sorted, you can have it clipped or lopped off. If your ears are blocked, someone will clear that for you too.

With our population increasing and growing older, it is little wonder that the whole thing is beginning to creak. The outcome…? You have to wait a long time for your hip replacement, you might be denied the chance to have your bunions sorted out because it is a low funding priority. Your GP is running late by 20 minutes or even a bit longer. That may seem a bit insensitive or flippant (or both) but, believe me, I’m not happy about it, certainly not if it means people are waiting in agony for treatments. While most people have a rational grip on such situations, a few do not. Those are the ones that sometimes abuse staff who are only trying their best in impossible circumstances.

This current situation may therefore serve as a not so gentle reminder of what are reasonable expectations in terms of our healthcare. That said, between early and late March, there has been a fall of 150 patients per day presenting with symptoms of heart attack. Now, it is unlikely that the Covid-19 pandemic has somehow cured heart disease altogether and, though many people with chest pain turn out to be fine, there will be some within that cohort of 150 who have had real heart attacks; heart attacks that are currently going untreated.

Lack of presentation for this sort of thing, or indeed other worrying symptoms of things like cancer (loss of weight and appetite or a change in bowel habit to name just three), means the health impact of this pandemic will not be just related to Covid-19. For anyone with worrying symptoms like this, you absolutely must not ignore them just because of the outbreak.

There have been some cases of people cancelling urgent cancer referrals due to concerns over the virus. While one can understand the anxiety surrounding this, these referrals are there for a reason. Do not delay them.

We need to use the NHS sensibly. Not too much, but not too little. We have swung from one extreme to the other in the last few weeks. Once we emerge from this, we must all consider how best to use it going forwards, and focus on the bigger issues at hand, no doubt at a time of great change. Self-care is an enormous part of that, not just in how we deal with an acute medical situation but also in how we look after ourselves in general. Smoking, alcohol, diet and exercise are the key areas that cost nothing to improve.

As doctors we want to ensure that everyone who needs to be seen, and whom we can help, presents to us appropriately. At the same time, we would request that others, who might reasonably be able to manage their own minor issues, do so. It is a fine balance and even writing this makes me uneasy that some may stay away for fear of overusing the service. The level of disparity in people’s views of how best to use the NHS is, in my experience, remarkable.

In summary then, urgent care must remain a priority for the service as a whole, but how we look after an ageing population effectively is also vital. Prevention of health problems is key. We should look after ourselves properly as far as is practicable but also seek help when appropriate in order to avert bigger health issues down the line. Staying away isn’t always the answer (particularly at the moment) but there is a balance to be achieved. Now might be a good time to redress that balance.

Healthcare After Covid-19

“Just as important as the government’s role in the NHS as it emerges from Covid-19 is the responsibility all of us have. We must shift our baselines back a hundred years – maybe more”


As a civilisation, humanity knows so much. To have in our arsenal an understanding of physics that includes relativity and all of its applications alongside our almost infinite artistic creativity is testament to our intelligence. These examples only scratch the surface of what we can do. So it is hugely humbling when we experience something like the Cvoid-19 pandemic.


As powerful as we are, we are still painfully fragile in the wider context – something we have a tendency to forget. It was not so long ago that we had to undergo operations without the luxury of anaesthetic and before antibiotics, we were faced with the rather uncivilised prospect of fighting infections using just our own immune systems.


Indeed, so uncivilised has the idea of being even slightly unwell become, that people now will seek medical help for a few days of cough and sore throat. The expectation for these worried well is that it is their right to expect an immediate cure. “Surely if we can do all of these marvellous things with technology, there is no disease we cannot sort out if we put our minds to it,” these people think. But these people are living in a different world, one of their own imagination. Others more prudent, sensible or experienced will realise that what we can do falls far short of this idealistic expectation.


We as a species go further. We harm ourselves willingly and then expect our medical professionals to pick up the pieces – even become angry when they can’t. Smoking, lack of exercise, poor diets – take your pick. That these things are bad for us there can be no question.


Of course one cannot wholly blame individuals for this. Capitalistic society is to blame here as much as anything. Profit and competition introduce temptation at the expense of welfare. I am not preaching socialism here – far from it. I simply point out that the drive for business to gain custom at any cost is a huge flaw in the system and in our health.


Whichever way one looks at it, we have become spoilt. Our perspectives on what we might expect from our healthcare have been shifted gradually but significantly over the last century. Only now are we being brought down to earth with a more humbling realisation; the thin facade of our supposedly advanced age has been withdrawn. There is even a name for this sort of thing – shifting baselines syndrome. It could be applied to many things. We have come to accept the nonsense and bile that comes from Donald Trump’s horrible little mouth as just the way it is these days. The baseline has shifted.


Just in the same way, many have been spoilt by the healthcare provision that they expect as a given. What we expect as a free benefit from our NHS nowadays (toe nail surgery, access to a GP to tell them about your cough, state of the art surgical procedures, cures for cancer and lifesaving emergency response within minutes) would have been the stuff of dreams for our ancestors. That the ever-expanding achievements of the last 50 years of medicine has caused the entire system to creek under its own weight is not surprising.


When I was younger, I reassured myself that if I or anyone I knew ever became unwell, it would be fine because there would always be someone somewhere that could cure whatever ailment had befallen them. My impression of medicine was that it was water-tight and so much more precise than the reality. A reality that slowly dawned on me during medical school. Much of it is guess work. Barely any treatment is 100% effective. What we don’t know far outweighs what we do know. The assumption is that there will always be a medicine to solve all problems. In a profession that revolves around trust in the doctor or nurse (a reassurance that can be therapeutic in itself) it is difficult sometimes for us to admit that we don’t have all the answers and can only do so much. Perhaps it is time we were more open with its limitations or else we make a rod for our own backs.
One might argue that what we now provide under its umbrella has gone far beyond the boundaries of what is sensible. To argue that we can effectively achieve 100% of what we aspire to medically is not possible. The issue is, the more superfluous and luxurious perks we add in, it edges out or at best blunts the core services that are most important.


At a time in which we are faced with something as dangerous and universal as Covid-19, we must heed a wake up call. The work the NHS is doing at the moment is what it is there for. Add to that health prevention, basic surgical treatments, mental health support, serious disease detection and treatment (including cancer), dignified end of life care, and social care.


Beyond the essentials, it is time for government to look at what the NHS really stands for and what it can really achieve. (Or preferably a cross party response to side step the political distractions). In an ideal world it would do everything to maximum efficiency. If a government wants to invest enough to make this possible, then great. The reality though means that the healthier a population is, the older it gets. Add to that the ever increasing scope of potential therapeutic options and one may argue that we could reach a point where a line must be drawn in how far we go in prolonging life. Should we become reliant of a system of health to such an extent (and perhaps we have already reached that point), the consequences of that system and it’s resources failing do not bear thinking about.


Governments need to look at this, decide where the line is drawn in what the NHS does and is expected to do. More importantly, they must be open about this. To back the NHS in a blind head long rush into the future, pledging vague sums of money that don’t make any sense to those in the know – none of this is helpful in any other way than to win elections. To acknowledge the need to be sensible about what is achievable and what is not seems difficult for politicians. Hence back room deals, rumours of privatisation etc. No one wants to see a privatised NHS. If the politicians are to be believed then they are included in this group, so why the cloak and daggers? The public deserve transparency and straight forward answers. Most understand that there is no definite right answer to a problem, even more so if it is explained to them. Without this, conspiracy and disquiet will breed.


Just as important as the government’s role in the NHS as it emerges from Covid-19 is the responsibility all of us have. We must shift our baselines back a hundred years – maybe more. This is urgent. Everyone must consider how we use our health service. That cough or rash that you might normally have seen your GP about – seems to have gone now doesn’t it?! That lack of exercise, my poor diet, that smoking habit – I can do something about that myself. No one else can help and we shouldn’t have to hold your hand. (Of course we do this and will continue to do so). Self care has been important during this lockdown. And yet, it shouldn’t be any more so now than any other time.


The problems with the health care system are clear. We all know about them. Covid-19 has affected us all and is scary. But perhaps it is the wakeup call that we all need.

Just Another Cigarette

When you really think about it, that well-known pastime we call smoking is actually quite bizarre. It is the act of inhaling and exhaling the fumes of burning plant material. For me, thinking about it in that purely literal sense makes it seem as weird as it does when you say the word ‘iron’ over and over again until it loses its meaning and just becomes a sound. (A psychological phenomenon, incidentally, that has been labelled ‘semantic satiation’)

It is even more so when you think of the fact that smoking, specifically tobacco, has been responsible for around 100 million deaths in the last century. Why then have we as a species become so intertwined with this strange habit and, for that matter, such a harmful one?

For a start, we didn’t always know that it was harmful. As far as we know, people have been smoking as far back as 5000BC – we know this from various drawings depicting the act. Tobacco specifically is native to the North and South American continents and was used by natives long before the “new world” was discovered by Europe. It was brought over here in the 16th Century when it was smoked in pipes and cigars. Some doctors at the time even thought it helped to prevent cancer, though I hasten to add this was not the universal opinion.

In 1880, an American chap named James Bonsack patented a cigarette rolling machine that was quickly picked up this side of the pond and the modern story of the cigarette began. These days, around 15 billion cigarettes are smoked every day.

It wasn’t until the Royal College of Physicians, in 1962, announced that cigarettes caused lung cancer and other diseases that we realised fully the harmful effects of smoking. By then, however, the manufacture and supply of cigarettes was a global industry and its sheer momentum has made it very difficult to combat over the years.

Just how harmful and costly to our health smoking is cannot be underestimated. Tobacco is the single biggest avoidable cause of cancer in the world. Each cigarette contains around 5,300 chemicals according to cancer research and 69 of these are known to cause cancer. Lung cancer is the most prominent but the habit also causes, amongst others, cancer of the larynx, oesophagus, bladder, pancreas, kidney, stomach, cervix and bowel as well as some leukaemias.

If it doesn’t cause any of these, you can expect to suffer from one or more of the following…

  • Heart disease and strokes
  • Chronic Obstructive Pulmonary Disease – leaving you with chronic coughs and progressively struggling for breath.
  • Peripheral vascular disease – cold and blue feet and legs at risk of ulcers and chronic pain
  • Premature ageing of skin by 10 to 20 years
  • Weak and brittle bones
  • Reduced fertility and impotence (smoking while pregnant causes miscarriage, premature birth and stillbirth and increases the chance of cot death)

I could probably go on, but I think you get the picture. Ultimately, up to two thirds of smokers will be killed by their habit.

By far the best way to stop smoking is to avoid starting in the first place. In the past, this has been made more difficult by advertising of tobacco products. Furthermore, the habit tends to be passed down in families. The very idea of smoking has been normalised to a huge extent – it has been glamourised in popular culture and films especially. Even knowing what I know, I have to admit that the cigar makes 60s era Clint Eastwood look far more impressive than he would without. But we’ve all grown up to accept that. This social conditioning is part of the problem and may have something to do with the whole ‘reckless and carefree is cool’ attitude.

The trouble is that reality catches up with the fantasy eventually and between 2016 and 2017 there were 484,700 admissions into hospital due to smoking and in 2016 there were 77,900 deaths.

Once started, the nicotine contained within is the culprit that makes stopping so difficult. It has both stimulating and tranquillising effects on the brain and creates new pathways that stimulate pleasure centres that begin to rely on the presence of nicotine to work. If a smoker stops suddenly, they will begin to experience withdrawal symptoms. These symptoms may include cravings, depression, anxiety, insomnia and lack of concentration. All that means it is far easier just to light up a fresh cigarette and carry on where they left off.

All the while, the carbon monoxide in the smoke binds to our haemoglobin, the protein in our blood that transport oxygen around the body, and reduces its oxygen carrying capacity. It’ll make running for your train let alone that marathon pretty difficult.

Fortunately, tougher laws on advertising now mean that cigarette packets now have to display warnings about the harm smoking causes. This transfers the responsibility of the harm they do from the tobacco companies onto the smokers who pay for them. It is a bizarre situation in which the companies themselves are now trying to make their tobacco products as undesirable as possible, some countries even going so far as to pick Pantone 448 c, the ‘world’s ugliest colour’, to adorn the sides of their packets.

Such is the reliance induced by smoking that people still spend on average around £140 each month on cigarettes, meaning they could save about £1,700 each year – the equivalent of a pretty decent holiday or a large contribution to the deposit on a house for example.

Practically all forms of smoking are harmful. Whether you smoke it from a pipe or a cigar or even chew it, you are at risk. Shisha is also known to cause cancer. This puts the tobacco companies in a predicament and we are entering a new age in which e-cigarettes and vaping are emerging as safer alternatives. While certainly thought to be safer, e-cigarettes are still new enough that longer term trial data are unavailable.  Meanwhile, the NHS party line is that they are better than other tobacco products at least.

Of course, the best option is to quit altogether. If you do so before 30, then you may be lucky enough to experience the same length of life as an average non-smoker. You will be able to taste and enjoy food more, your breathing and general fitness will improve, and the appearance of your skin and teeth will improve. After a year your risk of heart disease will halve and after 10 years your risk of lung cancer will also halve. At 15 years, your risk of heart disease will be the same as someone who has never smoked.

Going cold turkey is the least successful method. If you are serious about stopping, you may benefit from following a smoking cessation plan. Nicotine replacement products can be obtained through one of these and sometimes certain medications (Champix or Zyban) may also offer support. Visit www.smokefreelifeoxfordshire.co.uk for more information on all of this. Ultimately you have to really want to give up, otherwise you probably won’t succeed. And it may interest you to know that, in contrast to many of his film characters, 89 year old Clint Eastwood is actually a non-smoker.