By: Michael Zapf, D.P.M., M.P.H., F.A.C.F.O.

Those of you who read this column regularly know that I prefer to take a light style in writing. I tell about a patient with a routine problem and explain how it gets solved and, usually, end with a funny line. Today’s column will be different. I am writing about smoking and the effect it has on the feet. I am warning you it will not be pretty, but it has to be said.

When it comes to smoking related problems, lung cancer, emphysema, discolored teeth and even bad-breath seem to get all the attention. No one mentions feet. But as every podiatrist will tell you, some of the most heart breaking problems involve these often neglected parts of the anatomy.

Arteries are the tubes that bring fresh oxygen-filled blood to the tissues of the body. The biggest is the aorta which is the main artery attached to the heart itself. The further arteries get from the heart, the smaller they are. The farthest structures from the heart are the feet and they have the smallest arteries. If anything hurts the arteries "just a little" it will often show up first in the feet. This is why, of course, podiatrists care a lot about arteries.

Wide-open arteries are best. For most of us they are wide-open at birth. As we go through life they ever so slowly clog up. With proper diet, exercise and the right genes, the process can happen so slowly that we virtually outlive the slow accumulation of damage to our blood vessels. I tell my jogging patients that their vessels may clog up someday, but not until they are 150 years old.

Smoking changes this equation dramatically. Every cigarette, cigar or pipe-full of tobacco increases the rate of artery-clogging. Smoke enough and you will be like Lillian. Lillian is 58 years old and her feet are in trouble. They are cold and dark. The skin is shinny and has no hair growth. In the two places where I can normally find a pulse, there is only stillness. She knows she is in trouble. She has had two by-passes on her legs to bring in more oxygen. Both have failed. By-passes are only good for relatively large vessels. Lillian’s tiny arteries, called arterioles and capillaries, are too clogged to work. She knows exercise will help but she cannot walk more than a block before her legs scream in pain from lack of oxygen and her lungs hunger for more oxygen. We both know what is going to happen the next time she develops an infection or an ulcer on her legs. As I drove home from the office that day I thought about the role cigarettes played on Lillian’s feet. As she drove home, she lit up.

Lillian is proof positive of the dangers of cigarettes. She started smoking as a teenager and has never been able to quit, although she has tried every method. She knows she is going to lose a toe, foot or her leg and she cannot quit smoking. And even if she could, the damage has been done. For as much pleasure she has gotten from her habit, it cannot possibly make up for a life without feet.

Lillian is not the only one. Tobacco use is the single greatest cause of lower extremity amputations that could have been entirely prevented. Prevented by not smoking. I think of this every morning when I drive by a local high school. Out in front there are teenagers acting very adult by smoking. I worry about them. They are so very active and full of life. They feel indestructible. And I know that if she were 16, Lillian would be one of them. Looking back Lillian has expressed regret at ever starting to smoke. Some of these kids will too. I only wish that they had the wisdom that comes with age at 16. A life of smoking cannot possibly be more exciting than spending the last 20 years in a wheel chair.