Sleep Apnea

In ancient Greek, pneuma meant the breath of life and apnea meant the cessation of that breath. Pneuma in modern medicine is only a fragment of many words related to breathing but apnea has made the transition from the ancient lexicon unchanged.  It means no breathing. Sleep apnea is a condition in which breathing halts over and over during sleep, sometimes hundreds of times a night. The resulting disruption of sleep and respiratory physiology triggers chronic health problems like high blood pressure, cardiovascular disease and strokes. Other negative results are psychosocial and accidental, stemming from chronic daytime sleepiness. Motor vehicle accidents are but one example.

My first exposure to someone with sleep apnea was during childhood, in my grandparents’ house, where visiting grandchildren were divvied up among the adult rooms for sleeping.  My grandmother was a Camel smoker who read the New Jersey tabloids late into the night. I knew she was finally asleep when her snoring began, at first softly with a regular cadence, and then gradually increasing in volume and depth, building to a crescendo that would suddenly end…in silence. I tried holding my breath as long as she held hers, but seldom made it to the point when she would suddenly snort, inhale in a ragged fashion and then settle back into the snoring rhythm, building up to another period of no breathing. I gave up worrying about whether or not she would restart, because she always did. I wondered why my grandfather, a Lucky Strike smoker snoring away in an adjoining bedroom, breathed steadily, never stopping like she did.

The upper airway is the problem

While smoking can cause snoring, my grandmother stopped breathing intermittently because her upper airway was anatomically different from my grandfather’s and it became obstructed when the muscle relaxation caused by sleep made her throat go slack. In 1965, upper airway obstruction was finally discovered to be the cause of the marked daytime sleepiness that often affected obese people, whose airways collapsed under the excess neck fat when they lay down and fell asleep. Charles Dickens made this kind of  hypersomnolence famous in the 1800s by  his creation of the character Joe the Fat Boy in The Pickwick Papers.

Sleep research begins

The discovery of the cause of daytime sleepiness in obese people happened to coincide with the development of interest in and funding for research into sleep disorders. The first sleep lab was begun at Stanford University in 1964. Prior to that time not much was known about normal sleep, let alone disordered sleep.  By the 1970s the hundreds of awakenings interrupting the sleep of people with upper airway obstruction had been demonstrated. Sleep cycles were continuously disrupted in these patients, and sleep apnea was on its way to being tagged as a common disorder with serious consequences in terms of morbidity and mortality.

Risk factors

Who suffers from sleep apnea? According to one estimate, approximately one quarter of people between 30 and 70. Despite the increased awareness of sleep apnea in the last few decades, experts also estimate that 70-80% of people who suffer from the condition remain undiagnosed. Men are about four times more likely than women to be affected. Obesity is the largest risk factor because increasing body fat encroaches on the upper airways. Smoking irritates sensitive tissues, making them swell and further narrowing the throat. In some people, the jaw shape and position are anatomical culprits. Sleeping medicines and alcohol consumption can also alter breathing patterns in sleep and contribute to sleep apnea.

Snoring is the first symptom

Not every snorer will develop sleep apnea, but snoring is the first phase of the condition. When the snoring becomes associated with breathing cessation, problems begin.  Apnea causes an immediate fall in blood oxygen and a rise in carbon dioxide. Rising carbon dioxide triggers the respiratory drive center in the brain. The sleeper wakens in order to breathe, though he may not be aware of it.  Multiple awakenings interfere with normal cycling through progressively deeper stages of sleep back up into lighter stages of dreaming sleep, cycles that are necessary for mental and physical health.  Over time, lack of normal sleep cycles takes significant physical and mental tolls. Levels of inflammatory markers and hormones associated with stress rise; the vascular changes that lead to heart disease speed up; heart rhythms become erratic; blood pressure goes up and stroke risk rises.  Profound daytime sleepiness results in attention deficits, errors of omission, motor vehicle accidents, mood disorders and memory problems.

Other clues

Might you suffer from sleep apnea? If people complain about your snoring, if you awaken with headaches and feeling unrested, if you are lacking in energy though not ill and if you cannot stay awake once you are not physically up and about – for instance when you sit down to read or watch TV, you might want to talk to your doctor about the possibility of sleep apnea, especially if you are also overweight.


The definitive diagnostic test for sleep apnea is an overnight stay in a sleep lab, where polysomnography – multiple measures of physiologic function including electroencephalography or brain wave testing are monitored while the subject is sleeping. Treatment will depend on the severity of the findings. How many awakenings occur per hour? Are there associated heart rhythm or brain wave abnormalities during the apnea?

Treatment works

In mild cases, lifestyle treatments such as weight loss, cessation of smoking, alcohol and sleeping pills, and avoidance of sleeping on the back are all that will be advised. In other cases, the addition of a mask and device that pumps continuous positive air pressure (CPAP) into the upper airway is necessary. CPAP treatment is very effective, and improvements occur rapidly. Less commonly, mouthpieces to alter jaw position, or surgery to increase airway space are advised.

I never noticed daytime sleepiness in my grandmother.  She weighed no more than 100 pounds and was an Irish whirlwind of housekeeping activity. Until she developed an autoimmune disease in her 70s, she was, to all appearances, healthy, despite the ever present cigarettes. Sleep apnea is a medical condition on a continuum, dependent not on just the upper airway obstruction component but on other aspects of the sufferer’s health. As with all physical problems, differences in disease severity reflect differences in the whole people in which the problems occur.

Breaking the Tobacco Smoking Habit


We are now 100 years into an epidemic of avoidable, tobacco-induced health problems and over 50 years into the attempt to stop it, with more knowledge accumulating every year about the toll tobacco smoking takes on every part of the human body. Each year, smoking costs US society $130-170,000,000 in medical care, $150,000,000 in lost productivity and 400,000 lives lost prematurely. Over 160 million people live with serious, smoking related illnesses. Still, 20% of adults smoke regularly, and young people continue to join their ranks. If you never picked up the habit, be glad. If you have picked it up and managed to kick it, congratulations. You are part of a slow public health success story, and, by understanding the smoking habit, you may be able to help someone else quit.

The evolution of cigarettes

Tobacco was the first crop sold for profit by the American colonists, who introduced Europeans to pipe-smoking and tobacco chewing in the 1600s. However, the smoking habit did not begin in earnest until the invention of a cigarette rolling machine in 1883. By the 1940s smokers in the United States lit up 300 billion cigarettes per year and during WWII, soldiers’ ration kits included cigarettes. By the 1950s, 44% of US adults smoked regularly. Psychiatry texts in the 1960s urged doctors to light up with their patients and, by then, cigarette consumption topped 500 billion per year. Older adults today recall being raised in smoke-filled houses, driven around (without seatbelts) in smoke-filled cars, and sent to the corner store to buy cigarettes for their elders.

Recognition of the problem

Though the 1964 Surgeon General’s report confirmed what many people by then knew – that tobacco was bad for health, wrinkled skin prematurely and caused lung cancer, other lung problems and vascular disease  – cigarette consumption rates continued to climb well into the 1980s. But then decades of educational, political, legal and economic pressures on smokers began to work. By 2012, public places were largely free of tobacco smoke, ex-smokers outnumbered active smokers, and cigarette consumption rates had fallen back to the 1940’s levels. Anti-smoking advocates are rightly proud of their efforts, but the credit must also go, in great measure, to the individuals who did battle with the smoking habit and succeeded. Breaking the smoking habit is difficult, often requiring many attempts and relapses before the goal is achieved.

Nicotine is addictive

Smoking becomes a habit because tobacco contains nicotine, which changes the chemistry of the brain in a way that makes the tobacco user uncomfortable when the nicotine level falls. Tobacco companies have exploited the addictive qualities of nicotine by manufacturing their products to diminish negative physical effects and enhance addictive ones. Menthol soothes the smoke-irritated throat. Nicotine is added in just the right dose – not enough to provoke toxic symptoms like nausea, vomiting dizziness and diarrhea, but just enough to ensure the desire for more.

In addition to physical addiction, smokers develop psychological addiction, a learned desire or craving for smoking that arises from the association of smoking’s pleasure with certain situations such as social gatherings, meals, stressful or anxiety provoking circumstances or boredom. Sophisticated advertising techniques add to the social cachet of smoking and subtly enhance these psychological cravings. The combination of physical and psychological addiction means a two-pronged attack is often necessary to help a smoker who wants to quit.

Two-part attack on a two-part addiction

    Physical addiction to any substance produces withdrawal symptoms when the substance is no longer available to the body. In the case of tobacco, irritability, anxiety, insomnia, abdominal cramps and depression occur within hours of smoking cessation. These symptoms peak and begin to diminish within several days and will stop in a predictable period of time – about 2-4 weeks – after the last does of nicotine.

    Since nicotine can be delivered to the brain without the many carcinogenic chemicals in cigarette smoke, nicotine replacement therapy (NRT) is helpful to someone who is trying to stop a smoking habit, allowing time to deal with the psycho Nicotine is available in non-prescription gums, lozenges and skin patches. Nicotine inhalers and nasal sprays require a prescription. Eventually, though, the physical withdrawal symptoms will have to be suffered when the ex-smoker decides to give up the nicotine.

    E-cigarettes also deliver smoke-free nicotine, by vaporizing it in water. They are highly engineered products containing plastics, ceramics and metals and their long term risks are as yet unknown. Unlike the other nicotine delivery systems, e-cigarettes involve regular smoking behaviors and cannot be expected to help diminish the psychological cravings involved in the habit. 

    Psychological cravings that prompt smoking are often far longer lasting than physical withdrawal symptoms – and more responsible for relapse. In most studies of smoking cessation, behavioral therapy is key to long term cessation. Such intervention can take many forms, including one-on-one counseling, supportive group therapy and even online group participation. Many online resources are available to help smokers cope with this aspect of tobacco addiction. (see list below).

Two drugs are also commonly prescribed to help smokers quit. One, varenicline (Chantrix), attaches itself to nicotine receptors partially stimulating them and relieving withdrawal symptoms and at the same time blocking a sense of reward from inhaled nicotine. Another drug, Bupropion (Wellbutrin), is an antidepressant. These drugs improve smoking cessation rates slightly, and are more effective if used in conjunction with NRT. Both, however, are associated with some troublesome reports of behavioral changes, now noted in black box warnings on their packaging.

The cold turkey method- just as effective 

While public health measures have contributed significantly to decreasing smoking rates, breaking the smoking habit remains an individual project and the single most effective measure a smoker can take to improve health. One curious smoking cessation statistic confirms what many doctors have long observed – that cold-turkey quitting is as effective as any of the assisted methods. It appears that the whole-hearted decision to stop, once made without any reservations, could be the most important factor in long term success. This method has no unwanted side effects or risks and does not require withdrawal of nicotine replacements once the psychological smoking habit is tamed. Non-smokers can play a large role in aiding people whom they care about to make this final decision.

Resources for Smokers Who Want to Quit

Why Cancer Happens

    According to Greek mythology, Cancer was the crab that the goddess Juno immortalized in the night sky after the lowly creature sacrificed himself in a fabled battle between Hercules and the nine-headed Hydra.  Since Juno was stingy with the number of stars she allotted to the crab’s constellation, the amateur astronomer often looks in vain for a body with claws. Nevertheless, first century physicians, searching for picturesque language to describe their patients’ ailments, found in the crab constellation a name for hard masses covered with tortuous veins – particularly those that seemed to burrow deeply into the body.  And so we came to know cancer, the disease that inspires today’s most sophisticated research in cell biology, by a name that has no scientific meaning whatsoever.

The biggest risk factor: age

Cancer is a problem of birth, growth and death of cells, and occurs because our bodies are in a constant state of renovation, from development as tiny embryos until death many decades later. At first we grow and change shape. Then shape becomes fixed but body maintenance requires cell replacement on a regular, repetitive timetable. The master plans laying out instructions for regular destruction and reconstruction of cells lie in the DNA coiled into chromosomes.  Just as job-site blueprints get smudged, torn and stained, DNA accumulates damage over time. External agents such solar, cosmic and X- radiation, toxic chemicals, some hormone use, and some viruses add to the innate wear and tear.  In some people DNA code errors are built in from birth, handed down from one generation to the next.  Errors in the blueprint lead to the imperfect cells which give rise to cancer.

Errors in cell reproduction are visible everywhere. We call them signs of aging. Crinkles around the eyes, sagging skin, “liver” spots, bunions and so on – all are external, visible reminders that internally, similar changes are underway. It is no coincidence that tobacco smoking, single-handedly responsible for most cancer deaths, also produces conspicuous, premature aging.  The most remarkable thing about cancer is that it occurs so infrequently despite billions of cycles of error-producing cell reproduction in each person.  Fortunately for us, DNA also contains numerous safeguards for getting rid of error-ridden rogue cells before they get out of control.

What makes a cancer diagnosis

While cancer cells are identified under microscopes by changes in their appearance, looks alone do not make a cancer diagnosis. Until abnormal cells acquire the ability to grow unchecked, and to travel to other parts of the body (to metastasize), they are precancerous.  In many cases, pre-cancerous cells never make the transition to cancer, but we are unable to predict with 100% accuracy which ones will and which ones won’t.  A large number of breast abnormalities detected on mammograms will not go on to run wild, but few women will comfortably forgo treatment without 100% accurate prediction of the growth potential of their abnormal cells.

Difficulties in prediction

In addition to the breast, the prostate gland in men and the colon in both sexes are the sites of cell growth abnormalities that can, but do not always, result in cancer. Prostates enlarge with age and develop nodules of cell growth called adenomas. Colons develop polyps – enlargements of the lining protruding into the colon on flat or narrow stalks, with or without adenomas on their surfaces. Intuitively, it seems as if detecting these abnormalities and removing them before they have a chance to become cancerous is a good idea. This thinking drives the screening studies aimed at early treatment of cancer. But many of these common cancers are very slow and indolent in their growth and epidemiologic studies do not bear out the intuitive bias.  Unless a patient is young at the onset of a slow growing cancer, treatment does not necessarily lengthen life. Routine prostate cancer screening has fallen out of fashion because, while removing a cancerous prostate may prevent death from prostate cancer, treated patients do not outlive untreated ones.  Decisions about treatment have to be weighed carefully, with attention paid to age and the potential for harm and diminished quality of life that can go along with cancer treatment.

While all cancers begin slowly, some escape the body’s control mechanisms more easily and become aggressive and difficult to treat.  Primary brain, liver, pancreatic and ovarian cancer fall in this category. Toxic external factors that alter DNA may render cancer cells more resistant to the body’s methods of keeping slower growing cancers in check. Lung cancer from smoking, blood cancers secondary to radiation and some viruses, ovarian cancers stimulated by hormone use, and asbestos-induced lung tumors  gallop along compared to the slow movers like prostate and colon cancer.


Currently cancer treatment consists of removing cancers surgically and/or intervening with drugs or radiation to kill the abnormal cells. Both approaches leave something to be desired. Surgery removes a tumor already developed, but not the underlying biology that produced the tumor. Chemotherapy that seems effective at first is often followed by a relapse in which the cancer is less responsive – not surprising since the cells surviving the first rounds of treatment are resistant to the drug’s actions. Radiation induces cell damage in all exposed tissues and accounts for cancer development years later in people who have survived the first bout.

The new paradigm for thinking of cancer is as an age and genetics related derangement of cell growth that is also influenced by environmental factors.  Effective, tolerable treatments require understanding of the individual biology of each person’s cancer.  As the interior of living cells give up their secrets to researchers, we are beginning to see some real successes with drugs such as Gleevec (used for chronic myelogenous leukemia) – drugs aimed at specific pathways in the life of microscopic cancer cells – and also with immunotherapy in melanoma.  Perhaps we will eventually  be able to retire the image of the crab to his home in the sky.


Factors in cancer development

Under your control

Not under your control

Avoiding tobacco  Your genetic makeup
Using sunscreen The passage of time
Maintaining normal weight Cosmic radiation
Choosing high quality foods, low in sugar Accidental radiation exposure
Eating and exercising enough to avoid constipation (avoiding slow transit of waste through the colon) Exposure to carcinogenic agents not currently recognized as carcinogenic


Minimizing post menopausal hormone use Bad luck
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