Turn the Seat Around

First, I must confess. I fear that what I am about to write might appear hypocritical, or at minimum incongruent.

I did it. I was the one who turned my son's car seat around. Against my husband's wishes. After months of trying to persuade him, I just did it-- without shared decision-making, without permission, without blessing. I was in the parking area outside of my mother's house, and I simply unclipped the seat, flipped it around, and clipped it back in. It took my husband a week to notice.

My son was two-and-a-half at the time, and my arguments were definitely not evidence-based. My primary motivations were convenience and annoyance: I was frustrated by not being able to hear what he had to say when I was driving; I was forever trying to reach my right arm back in impossible positions to wipe his runny nose; I was traumatized by the one time he threw up and I had no idea until I got out of the car; I wanted to see his eyes in the rear view mirror.

My husband and I bickered about this transition for months. Each time we traversed the topic, he threw my own words at me, the very evidence-based information I had shared with him after a lecture I had attended on motor vehicle safety years before: "He is safer facing backwards. The longer the better". Gosh, why doesn't he remember so clearly all the other things I want him to remember? My husband still gets emotional when the topic of the car seat comes up-- he even threatened, as I was writing this entry, to turn him back around.

And he is right. No doubt about it.

Children are safer facing backwards. Adults are safer facing backwards. Shoot, if the driver could be facing backwards and still drive, the driver would be safer too. Here's why.

We have made great strides in motor vehicle safety since my family drove across country in 1982. I was five at the time; the dog and I were carefree and entirely seat belt-free in the backseat area of our VW Rabbit. The seat was even removed for our comfort! It was a play land of books-on-tape, baby dolls and art projects, and it turned out to be both a fun and uneventful trip. Nowadays, our children are strapped in five-point harnesses just to run to the grocery store. And, though annoying and restrictive, this is a good thing. Car safety has been a great public health success story.

I don't think you'll be terribly surprised to learn that pediatric motor vehicle accident deaths have been cut in half in the last thirty years. Yes, in half. Car seats work. (Can I hear "Woot woot" for car seats!?) And while we should definitely celebrate this amazing improvement, motor vehicle crashes are still the leading cause of death in children in the US (see here for the data).  In 2009, 1314 children ages 1-14 were killed in car crashes, and an estimated 179,000 were injured. I think you would agree that one child dying in a car crash is too many.

Until recently, it was recommended (in the US) that infants and toddlers be kept in rear facing car seats (RFCS) until at least age one year and a minimum weight of twenty pounds. Once children reached those milestones, parents were told (often by their doctors) that they could keep their children rear-facing but only if the car seat could accommodate them, based on height and weight. If not, they were advised to use a front facing car seat (FFCS). As most RFCS had weight-limits around 22 pounds, many  parents interpreted this counsel to mean not only that they could turn their child around, but in fact they should. And they did.

Even with the old recommendations, it was reported at the time that 30% of children were turned around before the age of one.

In March 2011, the American Academy of Pediatrics (AAP) together with the National Highway and Traffic and Safety Administration (NHTSA) updated their recommendations. They did so based on several US and European studies showing that children facing backwards (in RFCS) are simply safer than children in any other type of seat in any type of crash.

Much of the data already existed for decades--extracted from Volvo test data done in Sweden-- showing that RFCS are safer. In a Swedish study, looking at accidents involving 3670 children from 1987-2004, ages 0-15 years, testers found the most protection for RFCS (90%, compared to unrestrained child). Boosters for children ages 4-10 were found to be 77% effective (compared to unrestrained). Please do note that they are not comparing RFCS to FFCS. (Here are links to the studies, if you are interested: Jacobsson et al. 2007, Isaksson-Hellman et al. 1997).  As a result, in Sweden, it is standard practice for all children to be facing backward until age four and then transitioned immediately to a booster seat. It's tough to even find a FFCS!

The big US study that turned the tables was published in the Journal of Injury Prevention in 2007 (Henary et al. 2007) and found the following key findings:

• Children in FFCS  were more likely to be injured than children in RFCS in all crash types (rear, frontal, and side)
• In side-crashes, children in FFCS were  5.5 times more likely to be injured than children in RFCS
• In frontal-crashes, RFCS were marginally safer, 1.2 times safer than FFCS (but, interestingly, this was not noted to be statistically significant).
• Looking specifically at children between the ages of one and two (previously many were turned around), this age set was also 5.5 more likely to be injured in FFCS compared to RFCS
• The overall effectiveness of RFCS was 93%, compared to FFCS, which was 78%

A 2009 paper published in the British Medical Journal (BMJ) was titled "Advise use of rear facing child car seats for children under 4 years old". Similar to the US, standard in Great Britain has been to turn children around at 9 kilograms (19.8 lbs, which is 8 months of age for an average boy).

Why are RFCS better?
 Babies are shaped differently than adults. They are more head and less body (see image below). They also have weaker necks than we do and are not designed to withstand high impact crashes even at relatively slow speeds. RFCS have been shown to better support torso, neck, head, pelvis, and to distribute the  impact of a crash throughout the entire body rather than just at sites of belt contact. Because of their disproportionate head and weaker necks, providing targeted support changes outcomes. It keeps children safer.
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Add caption

Thankfully, these days, most of the newer infant car seats actually have new weight limits (up to 40 pounds), making it more convenient to keep children rear-facing. However, I cannot even tell you how often parents look at me sheepishly, tell me they've already turned their child, and basically state they have no intention of turning them back around.

Personally, I start counseling my parents about the updated recommendation to keep their children facing backward at the 6-month well-child visit. I remind them that driving our kids around town is literally the riskiest thing we do to them. This is no joke.  I repeat the message at the 9-month and 1-year visits. Why be so redundant? Sometimes I feel like a nag, but I am trying to catch families before they make the switch-a-roo. Because it's virtually impossible to go back. And because, for reasons that are kind of unclear, people have a hard time with this issue.

When I counsel people to reconsider, parents often give me similar reasons to the ones I gave my husband. They want to see, hear, and physically access their child while driving. The child seems happier; they don't cry so much. They also more often than not shrug and say, "Well, he is just too big to have his feet crammed up there against the seat like that." My response? Does your child ever complain of achy knees or a stiff back? Doubt it. Most little ones have no idea that they are supposed to "feel uncomfortable" with their legs up against the seat. They are comfortable in almost any crazy, bizarre, and twisted position. I mean, do you ever watch them sleep? I am sorry, but this is a projection problem-- in other words, my adult self definitely would feel uncomfortable in that position for any length of car ride; therefore, my child must feel terribly cramped too.

http://babyology.com.au/wp-content/uploads/2011/04/Child-seats.jpg

In fact, my son (it's been not quite six months since he was turned around), still positions his two feet up on the front seats with his legs extended in exactly the same way he was positioned when he was facing backwards. With rare exceptions, as exemplified in Sweden, where it is standard practice to keep ALL children facing backwards until age 4, children  of all sizes do just fine crammed into that rear facing seat.

Please make an informed decision and at least consider the implications of turning your child around before the age of two. Remember, as my husband correctly says, "He is safer facing backwards. The longer, the better."

And for more information on which car seats to how to install them, check out this site.

http://farm2.static.flickr.com/1204/1024886238_c9321f8bf6.jpg

Additional References
http://injuryprevention.bmj.com/content/13/6/398.full (injury prevention)
http://www-nrd.nhtsa.dot.gov/pdf/esv/esv19/05-0330-O.pdf (swedish study)
http://www.cdc.gov/features/passengersafety/


https://sites.google.com/a/umich.edu/cpsbestpraci/resources/rear-facing-child-restraints
http://community.nytimes.com/comments/www.nytimes.com/2011/03/22/health/policy/22carseat.html
http://www.carsafetyrules.com/swedes-save-more-lives-with-policy-of-keeping-one-year-olds-with-rear-facing-car-seats/0403/

E Cigarettes

Harm reduction is a term we use often in both medicine and public health. The idea is a simple one: rather than offer one smack-down solution to a risky behavior (i.e. "Stop that"), we offer modifications to that behavior that are aimed at reducing bad outcomes (i.e. "If you are going to do that, let's help you do that more safely"). Those of us who are parents use a hybrid of the smack down and harm reduction on a rotating basis.  For example, in certain circumstances, we might find ourselves saying, "I am sorry, little dude, you are never ever allowed to jump off that curb on your skateboard into the street again."  But in a slightly different version of events, we may also find ourselves saying,"Okay, if you are going to keep jumping off the curb, let's at least get you a helmet and wrist guards, and please pick a curb that isn't a death trap."

http://constructbirmingham.files.wordpress.com/2010/03/kid-skateboarding3.jpg

Examples of harm reduction supported by current public policy include exchanging needles for people using injection drugs (to prevent the spread of HIV and Hepatitis C), supplying sex-workers with condoms (to prevent the transmission of sexually transmitted diseases), and teaching adolescents to use designated drivers when out drinking (to prevent accidents). These approaches are very different from the 'just say no' smack-down approach, and for some people, the idea of doing anything that supports peoples' bad behaviors rubs them really wrong. Crazy wrong.

Opponents to harm reduction argue that in tolerating risky behaviors (e.g. injection drug use, underage drinking), we send people the message that these are acceptable behaviors, and in framing the behavior as acceptable,  more vulnerable populations (e.g. children) will be initiated into those behaviors. Supporters of harm reduction argue that we must diversify our methodologies: avoidance of risky behaviors would be ideal, but it is essential to have options that can improve safety even if those options do nothing to extinguish the actual behaviors.

In my role as a family doctor, I have learned that if I don't consider the possibility of middle ground, I often find myself stuck in the same place (and all alone)-- this is particularly true with patients who aren't able or ready to make the changes that I am asking them to make. Then I fail. And so do my patients. So, right here, right now, I will confess that it's not entirely outside of my clinical repertoire to condone one of my alcoholic patient drinking a single beer every other day or my diabetic patient eating an occasional bowl of ice cream. Yes, you heard me right, harm reduction is in my bag of 'doctor tricks'.

This brings us to the latest harm reduction debate: E-Cigarettes.

http://www.ecigaretteuser.com/wp-content/uploads/2012/12/what-is-an-electronic-cigarette.jpeg

E-Cigarettes (short for "electronic cigarettes") are battery-powered devices that deliver nicotine not through combustion or smoke, but rather through vaporizing or "vaping". Basically, a battery powers a heating element, which vaporizes a liquid solution (aka E-juice). E-juice usually contains a combination of  propylene glycol and/or vegetable glycerin, and/or polyethelyne glycol 400, some flavors and some varied concentration of nicotine (see box below for more specifics on these ingredients).

Most E-cigarettes are designed to look and feel like a 'real cigarettes', including the experience; the user actually gets a hot puff of gas when he/she inhales and sees a puff of vapor (not smoke) when he/she exhales. Some taste like a favorite brand.

There is no nasty smoke for a neighbor to inhale, no stink on your smoking jacket, and few official regulations. In fact, currently there is no federal or California law that restricts where people can use e-cigarettes (see this link for more details). In stark contrast to cigarette smoking, which is highly regulated, you can actually use e-cigarettes in most public places, like the airport, a restaurant, or even your doctor's office. Local jurisdictions can impose restrictions by adding e-cigarettes to their local definitions of "cigarette smoking", but many have not yet done so. 

"Starter kits" cost between $50-70 online, e-liquid refills cost around $2.50 for a 30mL bottle. Informal research shows individuals on average "vape" between 2-5ml/day, making e-cigarettes significantly cheaper than a pack per day habit of cigarettes (under $1/day for E-juice versus $6.45 for a pack of cigarettes in California).

I have several patients-- all long-time cigarette smokers-- who LOVE the e-cigarette alternative: many have never successfully quit tobacco, and they feel strongly that vaping is a healthier alternative to smoking. They spend less money on e-cigs than 'real cigarettes', they cough less, they stink less, and the world isn't nearly as annoyed with them and their vaping as they are with their cigarette smoking.

In fact, just this week, one of my e-cigarette smoking patients (with a history of smoking 2 packs per day for the last 40 years, now switched entirely to e-cigarettes) pulled one out and puffed right in front of me. I would have had no idea that anything happened if I hadn't been sitting there watching him do it.

Contents of E Cigarettes
Propylene glycol	A man-made liquid substance that absorbs water. Officially per the FDA, "generally recognized as safe" rating in food (GRAS), used as preservative in food, tobacco products, a solvent in drugs. But also found in antifreeze and solvents. More info here.
Vegetable glycerin	Made directly from vegetable oil (usually coconut, palm), used in manufactured food for sweetness, to keep things moist, also moisturizers (cosmetics), herbal essences, and common in cough medicines
Polyethylene glycol 400	Low molecular weight version of polyethylene glycol, often used industrial compound found in many consumer products, including automotive antifreeze, hydraulic brake fluids, some stamp pad inks, ballpoint pens, solvents, paints, plastics, films, and cosmetics.
Nicotine	A toxic colorless or yellowish oily liquid that is the chief active constituent of tobacco. Acts as a stimulant in small doses, but in larger amounts blocks the action of autonomic nerve and skeletal muscle cells. Nicotine is also used in insecticides
Water	You know what this is!

Is this all creepy or awesome?

Depends on who you ask.

The Federal Drug Administration (FDA) and other public health agencies want e-cigarettes regulated. Initially, the FDA tried to block the sale of e-cigarettes entirely in the US, claiming that they were unapproved "drug and drug delivery combinations". E-cigarette manufacturers successfully challenged the FDA's position in court, and e-cigarettes were allowed into the US market in 2007.

Interestingly, e-cigarettes were not originally manufactured or distributed by the tobacco industry; in fact, they were invented in China in 2000 (legend says the pharmacist inventor's father actually died of lung cancer, and he was looking for an alternative to tobacco) and were direct competition with big tobacco when they arrived on the US market.  However, this year, three big tobacco companies have joined the mix and are now marketing their own e-cigarettes (see this story). 

Phew, thank goodness! I was starting to convince you (and myself) to actually like e-cigarettes. Now that we have big tobacco involved, things are automatically creepier. No doubt about it.

In 2010, a federal appeals court held that e-cigarettes could be regulated by the agency as tobacco products rather than as drugs or drug delivery combinations. Because e-cigarettes are now labelled as tobacco products, state and local governments officially have the authority to regulate the them under the Family Smoking Prevention and Tobacco Control Act. This means, for example, that it is prohibited to sell e-cigarettes to minors. Most recently the FDA is also threatening a ban on selling e-cigarettes on line.

The FDA would prefer that e-cigarettes be officially considered a "tool for smoking cessation" and/or nicotine replacement (i.e. things people use quit or cut back on smoking, like nicotine patches or nicotine gum) because this labeling would make the companies liable to FDA oversight. But e-cigarette companies are super duper smart--and a little slippery. They make no claim anywhere that e-cigarettes are designed to help people stop smoking. Instead, they offer e-cigarettes as a "recreational alternative" and  "safer alternative to smoking cigarettes" and/or "designed to be specifically used in places where people are not allowed to smoke" (increasingly in public places, airports, etc). This way, they skirt the FDA's oversight power. Hmmm. . .

States and local jurisdictions are definitely getting hip to the situation and are passing their own regulations. For example, in 2013 New Jersey enacted a law becoming the first state to prohibit the use of e-cigarettes in indoor public places and workplaces. King County, WA passed a similar local law. In 2012, the state of Oregon passed a law prohibiting the use of tobacco products (including e-cigarettes) in state agency buildings and on state agency grounds. The US Department of transportation banned the use of e-cigarettes in airplanes. Thanks!

What are people worried about?
As far as I see it, people against e-cigarettes have three basic objections:
1) E-cigarettes are inherently bad
2) E-cigarettes are an open doorway to 'real cigarettes' and other tobacco products (which are inherently bad)
3) There is so much money involved, the e-cigarette industry is booming (over $1billion last year, expected to triple this year to over $3 billion), and if there is that much money involved, something bad must be happening.

Well, are they that bad? I already told you what was in them (see box above), and they definitely seem less bad than cigarettes. But do we really know how bad they are? Many anti-smoking groups argue that just because there is not data showing e-cigarettes are safe doesn't mean they are actually safe. Possibly true. Everywhere you look, the powers that be say "this has not been studied". Well, true and not true.

A paper published in 2011 by the Journal of Public Health Policy set out to review the current information on e-cigarettes at the time. Much to the dismay of many health agencies in town, they concluded the following fairly convincing arguments that e-cigarettes may not be so bad after all:

1-There isn't much dangerous in e-cigarettes. As of 2011, more was known about the contents of electronic cigarettes than we know about the chemicals in tobacco cigarettes. As of 2011, sixteen studies had been done characterizing the contents: propylene glycol, glycerin and nicotine. The two agents the FDA has expressed most concern about tobacco-specific nitrosamines (TSNAs)  and diethyelene glycol  (DEG, a toxic agent found in antifreeze and breaks down to toxic agents). TSNAs, one of the main classes of cancer-causing agents known to be in tobacco, were found trace amounts, equivalent to that found in the nicotine patch and orders of magnitude lower than the TSNA levels found in cigarettes (500-1400 fold reduction). In addition, DEG was found in only 1 of 16 studies. Definitely concerning to find DEG at all in the e-cigarettes but hardly an overwhelming problem. Perhaps the presence of these chemicals has been exaggerated?
2-E-cigarettes may actually decrease tobacco craving. There is a small study showing that e-cigarettes may decrease the quantity of cigarettes and aid current smokers in smoking cessation (shhh, manufacturers don't want this word out). Another small study showed evidence that e-cigarettes reduce tobacco cravings.
3-Carcinogens are present in only trace amounts. A direct quote: "Thus far, none of the more than 10,000 chemicals present in tobacco smoke, including over 40 known carcinogens, has been shown to be present in the cartridges or vapor of electronic cigarettes in anything greater than trace quantities."

In addition, most anti-tobacco groups argue that smoking e-cigarettes is a gateway to smoking other cigarettes and tobacco products. This correlation has not been studied (yet), but it's probably a reasonable concern. The e-cigarette industry has come under fire for marketing techniques around e-cigarette flavoring (chocolate and strawberry, seem quite enticing to young people). Additionally, opponents also worry that the mere action of vaping an e-cigarette simulates the habit of smoking (in contrast to nicotine replacement like gum or patch, which is entirely different).

http://www.e-cigarettepedia.com/wp-content/uploads/2009/03/ecigpedia-illustration-2-1006x1024.jpg

What do I think?
I will take a tripolar stance on this one. All are equally valid:

Opinion #1, My smack down: People should not ever ever ever start smoking or vaping cigarettes of any type. Smoking is gross and addictive and dangerous and does nothing to make humans healthier or happier. 

Opinion #2, The mom in me: I would not want my son to smoke either 'real' or electronic cigarettes. The e-cigarette industry is clearly booming, and I worry that young people are the most vulnerable to be advertised to, enticed to, and sold on their ability to make the world a better place. I think we should all be acutely aware of the power of marketing, and we should stand firm in our message to young people that even e-cigarettes are not sexy.

Opinion #3, The harm reducer: For current smokers, quitting smoking altogether is hands-down the best possible action they can take for their health. However, sometimes it is just not going to happen. Let's be honest. For those long-time smokers who are doing their best to fit into this smokeless world and just cannot seem to find a way to kick the habit, I say, e-cigarettes seem like a pretty reasonable alternative. They are probably safer, definitely cheaper, and for sure better for their lung disease (and their friends and neighbors).


Additional References:

https://www.health.harvard.edu/blog/electronic-cigarettes-help-or-hazard-201109223395
http://www.palgrave-journals.com/jphp/journal/v32/n1/full/jphp201041a.html
http://www.webmd.com/smoking-cessation/features/ecigarettes-under-fire
http://www.wisegeek.com/what-is-vegetable-glycerin.htm
http://changelabsolutions.org/sites/default/files
http://changelabsolutions.org/sites/default/files
http://changelabsolutions.org/sites/default/files/E-cigarette_FactSht_FINAL_%28CLS_20120530%29_October21_2011_0.pdf
http://publichealthlawcenter.org/sites/default/files/pdf/tclc-fs-regulatory-options-e-cigarettes-2013.pdf