What should we think about e-cigarettes?

k300_flavors_fruitsMotherlode notes a trend in e-cigarettes and is concerned:

I was standing outside our neighborhood ice cream shop one recent evening when I noticed a plume of smoke rise above a gaggle of teenagers waiting in line ahead of me.

“Wow,” I thought, “that takes some serious chutzpah.” These kids were smoking in public without the fear of getting caught.

A few minutes later, I realized that it wasn’t actually smoke coming out of their mouths; it was vapor, being inhaled and exhaled from battery-operated electronic cigarettes.

E-cigs are devices that vaporize an addictive nicotine-laced liquid solution into an aerosol mist that simulates the act of tobacco smoking. Also known as “personal vaporizers” and “electronic nicotine delivery systems,” e-cigs are sold in trendy shops and are increasingly turning up in bars, clubs, workplaces and other spots where traditional tobacco cigarettes have long been outlawed.

As a mother, I find this terribly distressing.

I’ve spent years telling my children that smoking can kill you. And thanks to decades of sensible public health policies — including laws banning cigarette advertising and smoking in public places — as well as brutally graphic antismoking marketing campaigns, my 15- and 21-year-old kids have grown up in a culture in which puffing on cigarettes is stigmatized. Last year, cigarette smoking among teens fell to a record low.

Now, it seems, all that progress is about to vaporize. “Smoking,” at least in the form of vaping, is becoming cool again. This week, the Centers for Disease Control reported that 1.8 million middle- and high-school students said they had tried e-cigarettes in 2012 — double the number from the previous year.

Kleiman urges restraint in regulating e-cigarettes:

The FDA’s desire to have enough authority to require e-cigarette sellers to manufacture them properly and label them accurately, to limit marketing aimed at minors, and to be able to force the removal of unsafe product from the market, seems quite reasonable. What’s not reasonable, and what is likely to be bad, on balance, for health, is the idea that anything that delivers nicotine vapor should have the same rules applied to it as an actual cigarette.

At the same time, he acknowledges the unknowable:

None of this is simple or straightforward. I can imagine myself, five years from now, bitterly regretting not having spotted the e-cigarette menace before it got out of control. But regulations can do harm as well as good, and what I’m not hearing right now is much willingness to think carefully and proceed with caution. The principle of aggregate harm minimization, net of benefits (and nicotine does have benefits, including at least a temporary cognitive boost) still seems to me the right approach, for nicotine no less than for cannabis or cocaine. Unless and until someone can point to demonstrated and serious risks, rather than speculative ones, e-cigarettes ought to be thought of mostly as a part of the solution rather than as a part of the problem.

What does Kleiman mean by part of the solution? A recent study found that e-cigarettes outperformed traditional nicotine replacement for smokers trying to quit:

the New Zealand government funded a head-to-head comparison study. Chris Bullen and his colleagues at the National Institute for Health Innovation in Auckland gave e-cigarettes to 289 smokers who were trying to quit. A separate group of 295 people were given nicotine patches, while 73 received dummy nicotine-free e-cigarettes.

Six months later, the team asked participants if their attempts to quit had been a success. Those who had used the nicotine e-cigarettes had the highest success rate: 7.3 per cent had managed to stay away from tobacco. Of the nicotine patch users, 5.8 per cent had quit. And of those taking the placebo around 4 per cent were successful.

“The quitting rates were about 25 per cent better than patches for the e-cigarettes, but statistically we’re more confident with saying that they were comparable, rather than superior,” says Bullen.

Vaportrim-Fruit-Flavored-PuffsWhile we’re trying to understand e-cigarettes, manufacturers are embedding themselves in our culture. In the U.S., it’s been using b-list celebrities, appealing to current smokers’ sense of oppression and marketing them as a diet aid. In the U.K., they are using sport:

Merthyr Town Football Club is to rename its ground the Cigg-e Stadium after its sponsor, an electronic cigarette firm.

The Southern League club has signed a three-year deal with the company which has just opened a shop in the town.



The benefits of harm reduction are not as obvious as they seem

Warning: This Area Contains Tobacco Smoke
Warning: This Area Contains Tobacco Smoke (Photo credit: tbone_sandwich)

Theodore Dalrymple points out the inconsistency in the British Medical Journal’s vigorous advocacy for harm reduction where heroin is concerned and its squeamishness with harm reduction for nicotine. He pulls a passage from BMJ and inserts comments:

What, then, does the BMJ, so much in favour of harm reduction for heroin addicts, say about harm reduction for smokers?

A broad perspective suggests potential problems [from a public health perspective].

Firstly, the new nicotine containing products are not intuitively appealing; smokers will need to be persuaded of their benefits. For public health there is a key benefit: it is easier to use them than to   quit. Here I interject that the same is true of the methadone or other substitute for heroin. But for most smokers quitting is the best option and should be presented as achievable and attractive.

   So rolling out harm reduction puts public health in the contradictory position of having to emphasise both the difficulties and attractions of quitting. Why should harm reduction for heroin addiction be any different, one might ask? A related danger is that children will pick up on this apparent confusion. While previous generations were told simply that tobacco is bad, new ones would learn that nicotine is acceptable – just be careful how you access it. This is precisely the burden of public health “education” with regard to heroin and other drug addiction. Moreover, promotion of harm reduction might reduce the perceived “cost” of uptake. Would not the same effect apply to the medical treatment of drug addiction, to say nothing of the provision of free needles? Finally, the fact that e-cigarettes deliberately mimic conventional ones (even to emitting fake smoke) may result in the inadvertent modelling of smoking. Would not the prescription of injectable methadone not do the same? More broadly, the media, which in the UK have become a reliable supporter of comprehensive control measures, might also struggle with this more complex position. How much media effort, one is inclined to ask, ‘reliably’ goes into supporting ‘comprehensive control measures’ with regard to illicit drugs? Thus the benefits of harm reduction are not as obvious as they seem.

The article goes on to criticise harm reduction in tobacco because of the obvious, if not entirely consistent, commercial interests that the tobacco and pharmaceutical industries have in it.

Dead space is the part of the syringe where fluid is retained once the plunger is fully depressed. High-dead-space syringes retain fluid both in the syringe itself and in the needle; low-dead-space syringes expel all the fluid in the syringe, retaining only a small amount of fluid. (In low-dead-space syringes, the needle is not detachable.)

In experiments that mimicked drug injections, the high-dead-space syringes retained 1,000 times as many microliters of blood, even after rinsing. For people carrying HIV with viral loads between one million copies and 2,000 copies per milliliter, the capacious syringes could carry multiple copies of HIV, “whereas,” William A. Zule and his coauthors write, “low-dead-space syringes would retain even a single copy only a fraction of the time.”

What’s interesting here, is that needle exchange advocates have been so busy arguing that they are the obvious answer to injection disease transmission on pragmatic and moral grounds, while insisting that there are no social costs (ignoring the fact that needle sharing persists among exchange users, discarded syringes are a problem, they often ignore treatment access problems and that they make convey despair to addicts and communities), that they seem to have never stopped to ask if we could make syringes safer.

These low-dead-space syringes in universal use might be much more effective than needle exchanges and prevent transmissions through accidental pokes. If so, will they follow the evidence?

Nicotine replacement ineffective

A 21 mg dose Nicoderm CQ patch applied to the ...

A recent study found nicotine replacement ineffective:

In the prospective cohort study the researchers, including lead author Hillel Alpert, research scientist at HSPH, and co-author Lois Biener of the University of Massachusetts Boston’s Center for Survey Research, followed 787 adult smokers in Massachusetts who had recently quit smoking. The participants were surveyed over three time periods: 2001-2002, 2003-2004, and 2005-2006. Participants were asked whether they had used a nicotine replacement therapy in the form of the nicotine patch (placed on the skin), nicotine gum, nicotine inhaler, or nasal spray to help them quit, and if so, what was the longest period of time they had used the product continuously. They also were asked if they had joined a quit-smoking program or received help from a doctor, counselor, or other professional.

The results showed that, for each time period, almost one-third of recent quitters reported to have relapsed. The researchers found no difference in relapse rate among those who used NRT for more than six weeks, with or without professional counseling. No difference in quitting success with use of NRT was found for either heavy or light smokers.

“This study shows that using NRT is no more effective in helping people stop smoking cigarettes in the long-term than trying to quit on one’s own,” Alpert said.

This is on the heels of a report that Chantix should be limited to patients who have been unable to quit with other methods.

The book Change Anything has stuck with me. The application of the model is still a little fuzzy to me, but he offers a model for change composed of six cells made up of two columns and three rows. The two columns are motivation and ability. The three rows are self/personal, social/others and structural/things/organizational. It offers a helpful way of organizing tactics, tools and strategies to change something and maintain change. And, by the way, as I learn and think more about it, 12 step recovery has evolved in ways that address all six boxes. Pretty cool.

NRT would fall into the box for structural ability but the quitter still has to attend to the other five boxes. I wonder if people using NRT are less likely to attend to other boxes for some reason.

It’s also possible that an approach that fills one box may limit approaches in other boxes. Studies have found that willingness to tolerate discomfort predicts success in quitting smoking. (personal ability) Could use of NRT indicate unwillingness to tolerate discomfort? Or, even, undermine willingness to tolerate discomfort?

Chantix should be a last resort

A new study suggests that Chantix should be a last resort tool for smoking cessation:

The psychiatric side effects of a popular quit-smoking drug make it too dangerous to use as a first attempt to kick the habit, according to a new study. The authors suggest the drug should eventually be taken off the market altogether.

The new study on the safety of varenicline (Chantix), appearing in the journal PLoS One, found that when compared with other smoking-cessation treatments, including nicotine replacement and the antidepressant bupropion (Zyban), varenicline was associated with significantly more cases of suicide, self-injury and depression. Varenicline was linked to 90% of 3,249 reported cases of self-harm or depression in people using quit-smoking drugs between 1998 and 2010, the study found, compared with 3% for nicotine replacement and 7% for bupropion.

…Dr. Curt Furberg, professor of health sciences at Wake Forest Baptist Medical Center and an author of the latest study, notes that his analysis found that varenicline resulted in many more cases of mental disturbances than bupropion. Given its safety profile, he argues that varenicline should be used only as a last resort for smokers who have tried other methods — including behavior modification, nicotine replacement and bupropion — and still can’t quit.

The Veterans Affairs Administration already uses varenicline by these guidelines, and Furberg approves of the policy. “They got it right,” he says. “They have restricted use of Chantix to a last-resort drug. They say when you try to get people to quit, and if you need a drug, start off with nicotine replacement and then Zyban. If they don’t work, then use Chantix. But if you do, you need to monitor mental status to see if people are suicidal in any way.”