The big picture and the little picture

Abstract

The last quarter of 2005 and the beginning of 2006 have seen major changes in health legislation in the UK. Following the lead of many countries from around the world (New Zealand, Ireland, and Italy among others) the UK government, pushed along by individual members of Parliament, have decided to ban smoking in enclosed public spaces such as bars, pubs, and restaurants. This is a victory for the workers in these places and members of the public who visit, and the wider healthcare community who clearly expect there to be a decrease in smoking. One less obvious and yet more important result is that now there is a clear, coherent, and unified message coming from doctors, government, and workers that smoking is harmful and it should not and cannot be tolerated in a modern society. There will be a backlash from the tobacco companies. They might produce “healthier than ever” cigarettes, they might reduce cost, or more likely they will lobby very hard behind the scenes to limit damage and reduce the impact of the strong public health statements being made. Moreover, the tobacco industry might turn its back on the West and concentrate on the developing countries of the world where there is increasing affluence and a fertile market for cigarettes, particularly among younger women. This is the big picture. The world is becoming a difficult place to sell cigarettes, as more states in the US at least partially ban smoking and European countries individually take action. So what about our patients? They form the little picture. What is being done for them and for the future patients with COPD? There is no wonder cure for COPD but there are effective therapies. These are both drug-related and non-pharmacological. We are rapidly increasing our understanding of the disease, both its basic mechanism and its physiology as a systemic disease. For the individual COPD patient, small and individually insignificant improvements will accrue and over time they will stabilize and possibly improve. Of particular importance is nutrition. This rather neglected area now has been demonstrated to be a key indicator of mortality and can be used as a response to treatment. Parallels could be drawn with the modern management of cystic fibrosis. Survival of patients with this disease has risen significantly in the last 20 years and yet there has been no major breakthrough, no cure. Small changes and attention to detail in each individual patient have led to incremental improvements in lung function and survival. We must do the same for the COPD patient. We must concentrate on what patients can achieve and encourage them to do more, we must give them the correct drug regimen, we must help them get to and maintain an ideal bodyweight, and exacerbations must be treated promptly and effectively. Through inspirational and insightful research, new therapies will emerge, new management approaches will be tried and tested, and, we hope, the lives and the expectations of our patients can be slowly but surely improved.