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

Lung Cancer Screening?

More people in the US die from lung cancer than any other cancer. Yup, it’s true. Our number one cancer killer is not breast or prostate cancer (#2, for women and men, respectively), not colon cancer (#3 for both) or skin cancer (doesn’t even make the top ten). In fact, the lung cancer mortality rate (the number of deaths per 100,000 people) is more than double the rate of the number two cancer killers. Just to give you an idea, in the US in 2009, there were 205,974  people diagnosed with lung cancer: 110,000 men and over 95,000 women. In that same year, 158,000 people died of lung cancer.

This means that most of us know someone who has had lung cancer. Don’t you?

When I was thirteen, my godfather (a career bus driver for Golden Gate Transit and gifted salmon fisherman) died just three months after being diagnosed with lung cancer. He was a lifelong smoker. Almost ten years later, my mother’s mentor (a grandmother-figure for me) also died less than six months after being diagnosed. She was a prolific artist and a retired kindergarten teacher; she had been a smoker for over 40 years but had quit about 15 years before her diagnosis.

As a family doctor, I see lung cancer with some frequency. Just last week,  I was working at the hospital and a healthy 50-ish woman came in after several months of feeling short of breath. She, too, had been a long-time cigarette smoker but had quit eight years ago when her own mother died of lung cancer. Because she had no health insurance (cue for another post: uninsured in America),  her family doctor tried to avoid an expensive evaluation (a single chest radiograph can cost over $150), treated her for bronchitis, pneumonia, then COPD (chronic lung disease from smoking). Eventually, an x-ray showed an unmistakable lung cancer.

Last year, one of my favorite patients, a garrulous retired umpire and amateur historian who always had at least one joke for me during our clinic visits (usually clean jokes but occasionally a little off-color) passed away from metastatic lung cancer. Amazingly, he survived for more than 18 months after his diagnosis and was able to get a few things ‘in order’ before he died. Most important to him was  to donate his body to a medical school so that medical students could learn from him . And he did it! (cue another post: body donation)

And, in the plus column of cancer advances, also last year, one of my dearest patients was actually declared ‘cancer free’ from his inoperable lung cancer five years after he went through intensive chemotherapy and radiation.

Unfortunately, most everyone you or I have ever known with lung cancer has been really quite ill by the time they were diagnosed. (Studies show that 75% of people with lung cancer present ill with metastatic and/or incurable disease at time of diagnosis). And, unlike breast cancer (though, mammograms aren’t perfect-- another future post: mammograms) and cervical cancer (pap smears and HPV testing have revolutionized us: pap smears), historically we just haven’t had good ways to screen ‘healthy people’ for lung cancer.

Well, the new news in lung cancer is maybe times are changin’.  

We may actually start screening our highest risk patients for lung cancer. Soon.

Just to be clear remember that a SCREENING test is a test of totally well person to ‘screen’ for a disease, while a DIAGNOSTIC test is as test on a patient who comes in with symptoms (e.g. cough, weight loss, etc).

Just this week the United States Preventive Task Force (USPSTF-- you should know that  the USPSTF is one of my favorite go-to bible-sources. I consider them one of the most unbiased, non-partial, uninfluenced by finances official body who makes recommendations about various medical conditions) put out a DRAFT new recommendation, updated from their previous recs in 2004, in support of annual lung cancer screening, using annual low dose CT scans, for people ages 55-79 who have at least a 30 pack year smoking history (and have smoked in the past 15 years).

Why did they make this change?

There have been seven studies in the last 15 years looking at low dose CT scan screening for lung cancer. The largest, the National Lung Screening Trial (NLST) published in 2011, looked at 53,454 current or former smokers. This study showed that patients getting a low-dose helical CT scans  every year for three years had a 20% lower risk of dying from lung cancer  (and  a 6.7% lower risk of dying from all causes) than people who received chest X-rays every year. They reported that we need to screen 320 patients one time with a CT scan to prevent one lung cancer death. (This is called the NNT) Of note, three smaller European studies (all with under 5,000 patients) patients found no benefit to screening.

What does this mean for me?

Well first, off, I will stick with a hard party line. If you don’t smoke, don’t start. If you do, then quit. Now. Then you hardly have to worry about this stuff! However, if you are between the ages of 55 to 79 and are either a current smoker (for at least 30 pack years) or quit in the last 15 years, you might want to talk to your primary care doctor about getting a low dose CT scan. Remember, there is still radiation involved and no test is without risk The good news from a financial perspective is that the current ACA (Obamacare) agrees to cover All Grade A and B recommendations, so this study should be covered if you have health insurance (including Medicare, CMSP, MediCal, etc)

What are the risks?

Radiation exposure: radiation associated with one low dose CT ranged from 0.61 to 1.50 mSv

False positives: remember not every test result that comes back bad means there is something bad actually happening. This is one of the trickiest areas of medicine because people really want to trust tests, but tests are not perfect.

False reassurance: Screening tests don't necessarily pick up every cancer either, so just because your CT scan was normal doesn't mean you don't have cancer (yup, that's an uncomfortable one to swallow).

Overdiagnosis: Just like with other types of cancers (and even less worrisome illnesses like herpes or strep throat), the more we screen for the things, the more we find. We may find that some lung cancers picked up screening would have never progressed to make anyone sick, but it would be impossible to tease that out.

How does this change the game?

In two major ways: 1) If the USPSTF rating remains at B, then lung cancer screening will join other common cancer screenings (like breast and colon cancer screening) as covered entities under the Affordable Care Act (i.e. it will be covered by your health insurance) and 2) Smokers are going to get quite a few CT scans in their lifetime.

So, I have a better idea, how about you just put out that cigarette and call it quits, keep yourself out of this risk pool and call your mom?

Reference:

http://www.cdc.gov/cancer/lung/statistics/

http://sonoma.networkofcare.org/ph/indicator_detail.aspx?id=lung_canc_in&c=7

http://apps.nccd.cdc.gov/uscs/toptencancers.aspx

http://annals.org/article.aspx?articleid=1721248