Questions assertions that cigarette smoking causes Buerger's Disease. Notes that even though a large percentage of those with the disease also smoke cigarettes, not enough is known about the disease to claim causation. Argues that claims that Buerger's Disease rates are rising with the prevalence of smoking are "not consistent with the observation of a professor of medicine that 'when the total number of heavy smokers in the general population is considered, the actual number in whom [Buerger's Disease] develops is exceedingly small." Adds that the rates of the disease in women are extremely low even though their smoking rates have increased. Mentions that many diseases have similar symptoms as Buerger's Disease and the increased rates may be due to misdiagnosis. Argues that other factors may be involved in developing the disease, such as genetics or the environment. Includes bibliographic references.
~UERGER" S DISEASE
Thromboangiitis obliterans or Buerger's Disease is an
inflammatory condition of the: small and medium-sized blood vessels
of! the arms and legs, leading to an insufficient supply of blood
to the tissues. One of t~e: charges against cigarette smoking is
that it causes! Buerger's. Disease. This claim is basedi, in part,
on reports alleging that a. high. percentage of patients! with the
disease smoke cigarettes. Despite such claims, the cause of
Buerger's. Disease is not yet known.1 Moreover, problems. created
by frequent misdiagnoses: a~d questions raised! by the incidence: or
occurrence rates and!other suggested~theoriesofcausationindicate
that the causal hypothesis concerning Buerger"s Disease: and smoking
True Buerger's Disease is. rare, even among young males
in whom it reportedly occurs most frequently,2 and misdiagnosis is
common. For example, an American researcher who reviewed. 205! cases
diagnosed as Buerger's. Disease at one hospital between 1933 andl
1963. concluded~:hat only33 (16%). had a clinicalpicturecompatible
with the criteria, for' the dlsease.3 One explanation for such a,
largenumber of misdiagnosedl cases maybe that there are ma'nyother
conditions and diseases with symptoms similar to those seen in
Buerger's. Disease patients. These conditions and diseases, which
Page 2: 2028382640
include atherosclerosis (vascular blockage caused by cholesterol
plaques), frostbite, gout, erg,otism (poisoning from the: misuse or
accidental ingestion of ergot, a type of rye plant fungus, used for
medicinal purposes), arterial embolism, scleroderma (a skin
disease), an immunological disease called periarteritis, nodosa,
andi occupational trauma., are,: not generally associatedl with smoking
in. the lilterature. For example, atherosclerosis, one of tha
diseases that is often co~nfused with Buerger" s Disease, is
associated with. high cholesterol levels and risk factors such as
hypertension and diabetes mellitu~s..4 Accordingly, studies which
suggest a strong association between Buerger's Disease ~and smoking~
may be flawed because ~t is likely that they include a number of
casesi in their analyses that are not a,ctually Buerger's Disease.
I, ncidence o~f Bu.eruer's Disease
Claims are made that the incidence of Buerger"s Disease
has risen andl is. increasing concurrently with the prevalence of
smoking. However, this~ assertion, is not consistent with the
observatilon of a professor of medicine that "when the total number
of heavy smokers in the general population, is considered., the actual
number ~n whom thromboangiitis, obliterans develops is exceeding.~y
small."5 Furthermore, this claim, is not substant~atedl by reports
that the incidence of Buerger's Disease in women, is extremely low,
Page 3: 2028382641
even. though their smoking rates have increasedl dramatically in:
more: recent years. For example, a 19173 worldwide literature review
of female patients covering a period of almost 50 years reportedly
found only 22 cases with, microscopic findings that were compatible
with those: specified for the diagnosis of Buerger's D~sease. Of
those: 22: cases, only eight were considered to; be "probable"
Buerger's Disease while: the remainder were class~f.led either as
"possible" or only "doubtful."6 Between 197'3 and 1986, only four
additional cases of the disease in women were, reported in the
English-speaking literature. 7 In 1986., however, a much higher
incidence of Buerger's Disease was noted by an. American researcher,
who reported that 11 percent (:12 out of 109 cases) of the patients
.registered with the d~sease at the: well-known Mayo C~inic in.
Rochester, Minnesota, between 1981 and 19815 were women.8 A~though
he speculated that. the apparent rise in the incidence of the: disease
among~ U.S. women might be related to their ~ncreased use of tobacco.,
the incidence o£i the disease in these women has not. risen at. the
same rate as their prevalence of smoking. Therefore, this does
not appear to be a. satisfactory explanation..
The true incidence of Buerger's Disease in the general
population iis difficult to determine for numerous reasons. These
include the possibility that a history of smokingl has been! a
significant source of diagnostic bias among members of the medical
profession because of the assumption that a smoker who presents
Page 4: 2028382642
with symptoms suggestive of Buerger'S Disease is more likely to hav.e
the disease than some other disease or condition with the same or
similar symptoms. For example, a patient who may actually have,
for example, peripheral vascular d!isease may be more likely to be
diagnosed with Buerger's Disease largely because that individual
also happens to smoke:. Another reason is that the incidence rates
reported in the literature are subj!ect to certa,in population biases
arilsing from the fact that most cases diagnosed as Buerger's D~sease
are referred to the care of health-care providers specializing in
vascular diseases. Since the occurrence of the disease among such
indiwidUa,ls or among those with peripheral vascular disease is
likely to be~ higher than in the general population, applying those
rates to the general, population will likely ~ead to an artificially
h~igh overall rate.
There may be still other factors affecting the number of
Buerger's Disease cases reported~ that have little to. dio: with the
tru.e incidence of the disease. This is suggested by the dramatic
changes in the reported incidence of the disease in. the United
States since it was first fully described by Dr. Buerger in an.
article in a medical journal in, 19089 and discussed more completely
in his monograph in 1924!.10 Between ~925 and 1945, one American
physician c~aimed to have seen over 1,4001 cases, of Buerger's
Disease, all in smokers.II In later years, however, the number of
reported cases dropped d'ramatically.. The reason for this drop. is
Page 5: 2028382643
unclear, although ~t has been speculated that the "popularity''~ of
the disease as a medical d~agnosis decl.~ned, perhaps in part because
of the medical profession's greater adherence to stricter diagnostic
criteria,.12 For example, in one study at the well-known. Mayo
Clinic, in Rochester, Minnesota, the prevalence rate dropped from
i04!/i0~,00i0 registered patients in. 1947 to 13/i00,0i00 patients in
1986, even though the clinical and pathologic criteria for the
diagnosis of the disease remained the same.13
Tobacco and' Bu,erqer's Disease
Tobacco use: has been implicated, in the literature, as a
magor cause of Buerger'~s Disease because of its reported temporal
relationship with the clinical course of the disease. That is.,
many have. suggestedl that the disease~ will progress w.~th the
continuation of smoking and that it will not progress, if tobacco
use is discontinued. However, a number of researchers hav.e reported
th~is not to be the case. For example, in a study of Buerger's.
Disease: in the United States Army during andi after' World War I~, "n,o
significant association" between smoking habits, of the patients
after diagnosis, and subsequent amputation rates was repo:rted.14
Three years later, it was noted that a ".careful" study of smoking
habits in 81 patients, with Buerger"s Di~sea,se attending a British
c1.~n~c "failed to. find any effect o:f smoking on the course o:f the
disease:.''15 Similarly, in another case study of a woman~ with
Page 6: 2028382644
Buerger'S Disease in~ England, there was no progression o:f the
disease during a period of some years, despite, the fact that she
continued to smoke. ~6 The physicians who reported her case stated
that in their experience, "the disease continues in, some well,
established cases, despite the cessation o:f smoking and also. goes
into. remission despite continuation of smoking.",17: Furthermore,
in a 1988. paper on their' retrospective study of 3128 patients with
Buerger"s Disease, two Japanese researchers,. Ohta and Shionoya,
[N']o progression of symptoms was observed in
about one-ha,lf of the patients, who continued
smoking, and a. few patients suffered from
ischaemic ulcers even though they had abstained
from tobacco. 18
Other questions about the relationship between~ toba,cco~ and
Buerger's Disease a~so raise doubts about the causa~ hypothesis.
For example, if tobacco: causes Buerger's Disease, how does one
explain the cases reported among' nonsmokers, even in~ very young
children?19 Furthermore, how does one explain the differences
seen over time in the ratio of male to. female smokers with, the
disease?20 In. 1936, the ratio of women to men smokers, in the
United States was estimated at 1:6 whi~e the ratio of women to men
with Buerger's Disease was estimated! at 1:70 to 1:500. In ~950, the
ratio of women to men smokers fel.1 to 1:4, yet there was "no
pr.oportionate increase" in the incidence of the disease among women
Page 7: 2028382645
This suggests factors
other than smoking must be
Finally, some have claimed that since cigarette smoking~
has been related to Buerger's Disease, other forms of tobacco
probably also play a role i~the disease.. However, a ~974 report
on the results of a 20-year study of 25,000 snu'ffl users and/or
tobacco chewers, in the state of Tennessee, where the use of! these
products is common, concluded that there was "'no relationship
between the use of unsmoked tobacco per se and intermittent
c~audicatioln.,,212 Intermittent c~a~dication (pain in the foot or.
calf after exercise: of the affected muscle), is one of the first
symptoms noted by a patient with: Buerger's Disease.23
Based. on such observations, 'two British physicians, who.
describe Buerger's Disease as "a disease of unknown aetiology,"
concluded that the association between cigarette smoking~ and the
disease~ "is~not as clear as has been suggested in the past."24
Buerger's Disease is reportedly more common in the
Orient, Eastern, EuropeandtheMediterraneanthan, North America and.,
although "no. explanatiom has ever. been offered for this peculiar
geographic distribution of disease,"2:5 it suggests the possible
Page 8: 2028382646
involvement of genetic differences or environmental factors. A
genetic influence: is also suggested by the cases! observed in
nonsmokers, and by the occasional familial occurrenceofthe d~sease
reported in the literature.
Furthermore, a number of. other suspects have been
suggested, as a cause of Bu,ergelr"s Disease. These include fungal
infections, socioeconomic class and/or occupation26 and internal
Despite cla£ms, regarding Buerger's. Disease: and the use
of tobacco, the role of tobacco, if any, has. not been determined.
True Buerger's Disease is a relatively rare: occurrence in relation
to the: wor.~d's population of smokers. Moreover, the issues of
m~sdiagn.osis, incidence rates, and other possible ris~fa,ctors andl
reports that the disease progresses even after smoking
discontinued raise many questions, about, thehypothesis that tobacco
causes Buerger's. Disease.
Page 9: 2028382647
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Siofer, B.,. Zinger, H..,. Dayan,, M. andl Mozes, E., "Cellular
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Page 11: 2028382649
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