Cancer
Oddly, no research has yet been undertaken to determine the importance of humor and laughter in either preventing cancer or helping battle the disease among individuals already diagnosed with cancer. This is in spite of the fact - as we have already noted - that several studies have now demonstrated that humor does boost the activity of natural killer cells (which seek out and destroy tumor cells) and strengthen the immune system in general. Also, immunotherapy has in recent years shown promise as a tool in battling certain cancers. Immunotherapy typically uses drugs like Interleukin2 to stimulate the immune system - boosting the body's own ability to battle the cancer.
The one exception to this void in research is the recent study of a very large group of individuals followed over a seven-year period in Norway. Among individuals diagnosed with cancer during this period, those scoring higher on a sense of humor test had a 70% higher survival rate than those with a poorer sense of humor (as assessed at the beginning of the seven years).127
Many cancer patients have taken it on themselves to use their sense of humor to at least help them cope - if not to directly battle the cancer. An increasing number of hospitals also are now making an active effort to bring humor to their cancer patients. Over the past 15 years, I have done many programs for cancer patients (generally for National Cancer Survivors Day, in early June). After virtually every program, someone comes up to me and says, "You know, you're right! If it weren't for my sense of humor, I wouldn't have survived the treatments - let alone the disease." Increasingly over the past 20 years, cancer patients have gotten the message that it is important to keep your spirits up and laugh whenever the opportunity presents itself.
Evidence has recently been obtained documenting the high percentage of cancer patients who believe in the importance of humor. Among one group of cancer patients in the rural Midwest, 50% of patients indicated that they used humor to cope with the stress of cancer.128 Among another large group of breast cancer patients, 21% said they used humor to cope with their cancer.129
More than 25 years ago (just about the time researchers first began to study the possible contribution of humor to health), Allen Funt was filming a segment for his Candid Camera TV show at a meeting of an organization called The Wellness Community, attended by many cancer patients. He asked those present if anyone really believed that laughter made a difference in their health. One person said,
"I know laughter is good for me. I don't know if it is helping me get better, but it makes me feel better - not only mentally but physically as well - and it takes my mind off my situation. Life and its pleasures have become very real to me and I know just how important it is to enjoy each minute. So when something strikes me as laughable, I laugh. I want to be conscious of every joyful part of life.
Before cancer, I only paid attention to the problems of life . . . and I took the pleasant and joyful parts of life as routine and as my due.
That's all different now. Now I accentuate the positive and eliminate the negative. . . Most importantly, I make sure that I am aware of the good times when they come along. So when something is funny, I laugh; and that reinforces my certainty that life is good."130 [Italics are McGhee's throughout.]
Pulmonary Health
Very little research has been done on the pulmonary benefits of humor and laughter. But even in the absence of research, it seems safe to assume that if you are already in good health, the contribution of humor and laughter to pulmonary health is probably negligible. For individuals with a respiratory illness (or who are confined to a bed or simply inactive day after day), however, the picture may be quite different. Such individuals are more likely to have a shallow breathing pattern, which leaves a larger (than desired) volume of what is referred to as "residual air" (the air that remains in the lungs when your outward breath is replaced by the next inhalation) in the lungs. More active individuals breathe out more of the residual air and replace it on a regular basis with new oxygen-enriched air.
The risk associated with excess residual air in the lungs on an ongoing basis lies in the fact that there is a progressive buildup in this air of both water vapor and carbon dioxide. This leaves shallow breathers and chronically inactive people at greater risk of pulmonary infection. As this residual air stays in the lungs for longer periods of time, its oxygen content drops and the levels of water vapor and carbon dioxide increase.131 Again, the health risk here arises for individuals already prone to respiratory difficulties, since the increased water vapor creates a more favorable environment for bacterial growth and pulmonary infection.
You know from your own experience, however, that there is a dramatic change in your breathing pattern when you have a good belly laugh. When you laugh, you repeatedly (with each "ha") push air out of your lungs until you can't push out any more. Then you take a deep breath and start the same process all over again. This process is repeated over and over until the exhilarating feeling of amusement has passed. Each time you laugh, you get rid of the excess carbon dioxide and water vapor that's built up and replace it with oxygen-rich air. So frequent belly laughter reduces this risk of pulmonary infection by emptying your lungs of more of the air that's taken in.
Hospitalized patients with respiratory problems are often encouraged to breathe deeply and exhale fully, but nurses generally have difficulty getting them to do so. Most patients enjoy a good laugh, though, so many nurses have learned to tell them a joke from time to time or give them a comedy tape to view. This automatically achieves the respiratory goals the nurse has for the patient. This is one reason why many nursing homes now provide comedy programs to their residents on a regular basis (especially humor from their early adult years that still makes seniors laugh).
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If you've ever had a good belly laugh in the midst of a cold, you're sure to have noticed that the laughing quickly turns into coughing. The laughing and coughing reflexes are very similar, so the laughter is quickly overtaken by persistent coughing. This laughing-coughing link is normally just an annoyance, since coughing is not nearly as enjoyable as laughing.
There are some conditions, however, in which the laugh-cough connection is a good thing. For example, nurses and respiratory therapists often encourage certain patients to cough to help discharge mucous plugs accumulating in the respiratory tract. The problem is that even well-motivated patients have a difficult time following through on the advice to cough periodically. But if you can get patients laughing from time to time, this problem takes care of itself. The laughter triggers coughing and automatically achieves the goal of clearing mucous from the respiratory system - and the patients have a good time in the process.
A pulmonary researcher has emphasized to me, however, that there are good coughs and bad coughs when it comes to many pulmonary conditions.132 A good cough is one that clears out mucous plugs; a bad one is irritating and actually causes more inflammation. In cases where the lungs are already inflamed, repetitive coughing (which is likely to be triggered by laughter) just worsens the irritation and inflammation.
COPD
Intuitively, you would assume that strong belly laughter would not be a good idea for patients with chronic obstructive pulmonary disease, or COPD - a condition (which may result from emphysema or chronic bronchitis) characterized by generally irreversible airway obstruction (air trapping), resulting in a slowed rate of exhalation. In COPD, the bronchial passages are seriously impaired in their ability to rid the lungs of air, leading to hyperinflation. "Pursed lip" breathing is often recommended to help patients get a good exchange of air in the lungs. Bronchodilators are also used to help empty air and reduce the level of hyperinflation. On the one hand, you might expect the forcefulness of hearty laughter to help force more air through the bronchi and reduce the level of trapped air. We know that laughter does reduce the level of residual air in the lungs in healthy individuals.133 But if the laughter does not successfully push out trapped air, it could actually cause more air to get trapped in the lungs. When a healthy person laughs hard, a series of expiratory pushes (the "ha ha's") rapidly forces air out until we run out of air. We then take a rapid deep breath and continue pushing air out until the hilarity settles down. For a COPD patient, if the lungs do not permit this rapid expulsion of air, the deep inspirations could actually increase the level of trapped air. This is why slow and steady breathing is generally seen as the way to go for these patients.
One very recent study (2008) has taken the first step toward determining the possible value or harm of laughter for COPD patients.134 Lung volume was measured in both patients with severe COPD and healthy controls both before and after a performance by a clown (within the hospital). (COPD patients generally have greater lung volume in their residual air, as well as immediately after a full inspiration - defined as "total lung capacity" or TLC). This was a very funny clown who worked well with adults, and a lot of laughter occurred among both patients and the control adults. Total lung capacity was significantly reduced among the COPD patients, but not in the controls group. (This reduction in TLC was relatively short-lived, however; it was no longer present two hours later.) Among those patients showing the greatest amount of reduction of TLC (10% or more reduction), there was a sharp drop in residual air volume. This suggests that a reduction in air-trapping did occur for them.
Since one concern prior to this study was whether laughter would even be safe for COPD patients, it should be noted that the researchers concluded that laughter is safe for this patient group - even for patients with severe COPD. But they also found that patients showing the most intense laughter actually showed increased hyperinflation. It was "gentle" laughter that was associated with reduced lung volume. This suggests that COPD patients should be cautioned to restrict their laughter to more moderate levels. Of special interest is the finding that those patients who showed the greatest reduction in trapped residual air smiled more than patients showing minimal reduction in trapped residual air. So smiling actually seems to be more beneficial than laughter in helping COPD patients get rid of trapped air and breathe more easily. These researchers specifically recommended that smiling-while-breathing be considered as an additional breathing technique, along with the traditional pursed-lip breathing. To be most effective, this should be encouraged in the context of comedy videos, friendly banter, or any other approach to generating amusement in patients.
Asthma
One pulmonary condition for which researchers have just recently come to see a health-promoting benefit from humor is asthma. This is an especially important area of research, given the rapidly growing number of people suffering from asthma across many segments of the population. Asthma is a chronic respiratory condition in which breathing becomes impaired because of muscle spasms, mucous and inflammation of the airways. The inflammation of the airways makes the paths through the lungs smaller, resulting in coughing or chest tightness and difficulty moving air in and out. In the year 2000, asthma was found to affect over 17 million Americans, resulting in 5400 deaths and half a million hospitalizations annually.135
The new interest in humor's impact on asthma sufferers lies in the fact that we have long known that stress and negative emotion lead to constriction of the airways among individuals with bronchial asthma.136 One's emotional state, of course, is just one trigger (among numerous others) for asthmatic attacks. But given humor's power to quickly pull you out of a negative emotional state and substitute a positive one in its place (discussed in Humor and Nursing II), it would seem to be an ideal tool to help asthmatics gain some control over this particular cause.
The best demonstration of humor's potential in preventing (or reducing the severity of) attacks of bronchial asthma was provided by a Japanese researcher. Hajime Kimata administered a substance (metacholine) known to cause bronchoconstriction (resulting in increased airway resistance and greater difficulty breathing) to both healthy individuals and people suffering from asthma.137 All subjects in the study then watched both a humorous and a control (nonhumorous) video. The funny video reduced the level of both healthy and asthmatic subjects' negative mood and increased their positive mood (the two mood measures were obtained separately). While the funny video did not have any impact on healthy subjects' airways, it significantly reduced the level of bronchial constriction among asthmatics. So humor enabled them to breathe more easily.
These are exciting findings for asthma suffers, but it may be premature to conclude that humor is a key tool in managing attacks for everyone suffering from asthma, since the act of laughter itself has been shown to trigger asthmatic attacks in some people - about 1/3 of asthma patients, according to one study138 and 56% in another.139 The key here may be how hard you laugh, with extended or hearty belly laughter bringing on the attack. The research is just not yet clear on this point. In the Kimata study, all participants laughed during the funny video, but the laughter was certainly not the kind of extreme laughter we have all experienced at times - where something is just so funny you just can't stop laughing. It has been suggested that asthmatic children may be especially vulnerable to this kind of laughter.140 If this is the case, then humor obviously becomes a health risk for these individuals - not a source of healing and wellness.
Humor (in the absence of extreme laughter) is not alone in its capacity to help alleviate asthmatic symptoms. Other positive emotional states have similarly been shown to relieve airway constriction in individuals with bronchial asthma.141 On the other hand, there are also studies showing that non-humorous forms of positive emotion sometimes increase airway resistance (making it more difficult to breathe).142 When this restriction of airway passages does occur in response to positive emotion, however, it is generally less severe than that which occurs in response to negative emotion.
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The key to making sense out of these apparent inconsistencies in asthma research seems to be not whether the emotion experienced is positive or negative, but the level of "emotional arousal" experienced in connection with either kind of emotion.143 It appears to be events that are highly emotionally arousing that create breathing problems for asthmatics, not events that are mildly arousing. In the case of humor, then, moderately funny humor accompanied by mild laughter should support good pulmonary function among asthmatics, while extreme funniness accompanied by extended hearty laughter should interfere with it. This is the same conclusion reached for COPD.
The unique nature of laughter also contributes to the confusion about its role in triggering or relieving asthma attacks. Laughter is a vigorous muscular activity, but - as discussed earlier - also causes muscle relaxation (some muscles relax while you're laughing; others relax after you stop). In the case of asthma, it used to be assumed (two decades ago) that any form of behavioral relaxation would improve lung function - and that it would relax the bronchi, leading to easier breathing.144 There is no evidence, though, to support the view that muscle relaxation elsewhere in the body relaxes the bronchi.145 In fact, the opposite turns out to be the case. For both healthy and asthmatic individuals, muscle activity or exercise causes dilation of the airways. The key here seems to be that brief (rather than extended) muscle activation should occur to get the dilation effect. For example, simply briefly activating the facial muscles is an effective tool in facilitating breathing among asthmatics, leading one expert in the field to suggest that "…brief dynamic exercise of the facial muscles should be practiced to induce bronchodilation." 146 (Italics are McGhee's.) Mild laughter and its accompanying exercise of several facial muscles would seem to be just what the doctor ordered. However, if you notice that other forms of mild exercise trigger asthma attacks in an asthma patient, you should probably suggest that they make an effort to stifle their laughter since this form of exercise is likely to trigger an attack, as well.147
There is evidence that chances of laughter causing an asthmatic attack depends on how well a patient's asthma is under control at the time.148 Patients have reported that they can laugh longer without symptoms when their asthma is well controlled. This means that laughter-induced asthma (especially when the laughter is mild) may be used as a signal that the patient needs to get the asthma under better control.
As noted above, strong negative emotion is a common trigger for asthma attacks. While the role of emotion in asthma is complicated to begin with (in that the intensity of the emotion seems to be more important that the positive or negative nature of the emotion), it becomes even more complicated in view of evidence that suppressing negative emotions can worsen breathing problems for asthmatics. One researcher concluded after an extensive review of the research on causes of asthma attacks that "suppression or inadequate expression of emotions is far more important in the precipitation of attacks of asthma than the type of emotion experienced."149 This puts asthmatics in somewhat of a "can't win" situation. Both expressing and holding in anxiety or anger can cause an attack. But this really does make sense, since holding in negative emotions just keeps us stewing in our emotional juices - sustaining or even increasing the level of emotion experienced.
Another key for asthmatics, then, is to find a way to manage their emotions on a regular basis - a way that helps prevent negative emotions from occurring and pulls them out of negative moods when they do occur. Humor is ideally suited to achieving this goal.
