MD submitting a Clinical Inquiry article on e-cigs

[tigerlily]

but the stigma or contradition of being a smoker, professionally, is a tough thing to face. After I gave the presentation, one of my fellow Residents who knows me very well asked publicly ," so did you quit smoking" much to my dismay as this was not something I am super glad to share with my faculty and other peers so much. I smiled and moved onto the next question!

Don't you just hate that? Fact is, most of us probably started smoking when we were young and stupid. By the time we got older and wiser the addiction already had us. I face a similar situation with the profession I'm in.

Thanks for starting this thread. I found it very interesting. It's nice the medical profession is taking a look at this. I can tell you from my own personal experience that my doctor has been after me for years to quit smoking. She was thrilled when I told her I had taken up vaping instead. Although vaping may not be something she would have ever suggested on her own without the medical studies to back her up, she certainly didn't issue any warnings against it. In her opinion it is a much better alternative.

Good luck with your medical career!

 

[sailorman]

True to a point. However, the R&D to develop the drugs is only one cost. Meeting the FDA requirements to bring a drug to market is quite an expensive and time consuming process as well. I don't think universities are picking up the dime for all of that.

That is true, but pharma continually pumps out the propaganda that without their giant profit margins, they wouldn't be engaged in the search for new drugs. That's simply false. Well it's technically true, but nearly irrelevant. Without their massive profit margins, they might have to actually focus on useful drugs instead of drugs that are only new because they tweaked a molecule; the drugs whose main function is to maintain a patent.

Pharma spends more money on consumer advertising than it does on NDA. It's no coincidence that prices began to skyrocket when they were permitted to advertise directly to consumers.

 

[sailorman]

..... but the stigma or contradition of being a smoker, professionally, is a tough thing to face. After I gave the presentation, one of my fellow Residents who knows me very well asked publicly ," so did you quit smoking" much to my dismay as this was not something I am super glad to share with my faculty and other peers so much. I smiled and moved onto the next question!

Why don't you just tell them that, yes, you did quit smoking? It's not as if they asked you if you've kicked your nicotine habit. If you were using some other NRT and had not smoked in months, would you hesitate to tell them that you quit smoking?

You're lucky to posses the credibility to make it dawn on people that vaping is not in any way, shape or form, smoking.

 

[tbpeaceman]

Why don't you just tell them that, yes, you did quit smoking? It's not as if they asked you if you've kicked your nicotine habit. If you were using some other NRT and had not smoked in months, would you hesitate to tell them that you quit smoking?

You're lucky to posses the credibility to make it dawn on people that vaping is not in any way, shape or form, smoking.

You are right and I will continue to educate people about vaping. iterestingly, my recommendation to people not ready to quit has been met with luke wark respone to vaping. they are jsut not ready.

good point too about answering the question about quitting. , in hind site I should have said, yes, this really helps!, but the stigma is still there. The importance is not necessarily abstinence, but reduction in # cigs. Cutting down imporvs health outcomes., not as drastic as quitting, but still helpful. Even havingEVER been a smoker is off putting to many in the medical profession, not particularly in my peer group, but at large doctors can be very closed minded unfortunately. I am very open with my patients and share intimate personal experience of my own with them if it serves to be thearapeutic.

My particualr history with smoking is not typical. I have been and on and off smoker for 14 years, but never more than 2-3 cig every few days , few more when partyin, but spaced by bouts of non smoking for weeks at a time without nic withdrawl. I never escalated to more but could never seem to stop for good even at this low level when I decided that I wanted to , always would end up with a pouch somehow or another Now I am an on and off vapor, with low or 0 nic which basically cures the hand mouth, social ritual aspect. do I have an occasional analogue...yup, but way way less than years past. Any I feel a lot bette abot it too. So as you can see my answer to that question is not an easy one.

 

[elfstone]

Yes... but this is what we are up against: E-Cigarette or Drug-Delivery Device? Regulating Novel Nicotine Products This is an excellent example because every single phrase is forged in such a way as to deliver the most negative message possible. Every single fact is misrepresented to appear outrageous.

I sincerely doubt the medical community as a whole will accept vaping for what it is: a recreational activity that can perpetuate a nicotine habit in a safe(r) way. Doctors involved in public health, and especially those funded by such as the Legacy Foundation act like religious zealots, not scientists. Their goal is to impose their values onto the entire society, not to balance harm and consequence.

Re-introducing the topic of "e-cigarettes" as a "smoking cessation" aid is a double edged sword. Not only does it not do anything to prevent a ban, but it may, in a perverse way, fuel the arguments of the ban proponents - if some agents are trying to license a device for a medical purpose, they will use it as evidence that the entire class should be regulated as medical devices. This will be tantamount to a ban, because the FDA does not approve entire classes of devices. It may consider a pre-market approval for one individual device, even worse, for a "combined product" including the device and a certain individual juice.

I know Rolygate was recently talking about an e-cig manufacturer who is actually pursuing such licensing. They will more then likely become advocates for a ban themselves to protect their 3 million dollars. I don't think the "two tier" situation will be possible in the type of society we live in, a society where law making is a for-profit business... This will be achieved once nicotine is placed on a controlled substance schedule and all delivery devices, except for those approved, become illicit even when sold without nicotine containing solutions.

On this topic, a recent paper caught my eye: "Nicotine: not just an unregulated poison but now a potential chemical weapon." Eur J Public Health. 2011 Dec;21(6):681.

 

[elfstone]

I found this sort of funny, in a sad way:

“E-cigarettes are one of the most burning health issues [fascinating choice of words] at the moment because dozens of companies are trying to develop the nicotine market outside of pharmacies in Germany and other European Union countries,” said Dr Pötschke-Langer, who is also head of the World Health Organization’s Collaborating Centre for Tobacco Control in Heidelberg.

“The most important ingredient in e-cigarettes is nicotine, which is a drug produced by the pharmaceutical industry and also for e-cigarettes. There is no rational reason why the application of nicotine in the form of an e-cigarette should not be regulated, like nicotine patches, gums, inhalers, or tablets.”

In "Hanover bans e-cigarette use in civic offices amid calls for better safety data"

 

[elfstone]

One last thing. To the OP, I'm not sure if this is in your references. It is similar in scope and purpose, but different in conclusions, and is likely what the GP will find when they search for what to say about e-cigarettes. You must also consider the "liability and risk management" policy of your institution when you choose your words about e-cigarettes in a clinical encounter. I'm not trying to be devils' advocate here, "just sayin'"...

"Electronic cigarettes and thirdhand tobacco smoke: two emerging health care challenges for the primary care provider." Int J Gen Med. 2011 Feb 1;4:115-20

They conclude that:

• ENDS are not FDA approved as quit smoking devices.

• The vapors from e-cigarettes are complex mixtures of chemicals, not pure nicotine. Whether inhalation of the complex mixture of chemicals in ENDS vapors is safe is unknown.

• There is no evidence that ENDS help smokers to quit smoking.

• There is increasing resistance to the use of ENDS in public places and outright bans in a growing number of states.

• The promotion of ENDS may communicate a message to children and adolescents that “vaping” is harmless, inadvertently increasing the risk of nicotine addiction and tobacco use in a vulnerable population.

• Long-term abstinence from tobacco use is a goal that has been achieved by millions of people. Almost half of ever
smokers alive today are former smokers.

• Until more information about ENDS becomes available, use of e-cigarettes cannot be recommended.


On a related note, I can't figure out how they ALL can say in the same breath that the devices "do not provide nicotine to the user, and do not raise arterial nicotine levels" and that they are liable to get children hooked on nicotine...

 

[bushmasterar15]

Welcome to the ECF.

 

[wv2win]

I hope you have contacted CASAA as well as Dr. Seigal (Boston University I'm pretty sure) and Bill Godshall of Smoke Free PA. They all have a significant amount of information that could be helpful to you.

Good Luck

 

[tbpeaceman]

... all delivery devices, except for those approved, become illicit even when sold without nicotine containing solutions.

you get no arguements from me about this uphill battle and the woes of dealing with big govt infiltrating the personal apects of our lives a a crusade for "pubilic safety" on the coat-tails of moral subjectivity. It looks like the AAPHP is a group of physcians with the right idea however . the voice may be small but at least it is a voice. the grass roots revolution within the medical communtiy will come from each exam room in every liitle town across the world where docs actually see success and imporvement in their patients health. trouble is, there are still way too many people smokers and most are no where near the point of enlightenment that the average EFC member has arrived at. The average doc statistically speaking is not going to ever meet a true blue vaper. Saddly, like you say if all goes according to plan for big Pharma in the FDAs back pocket this message will be even further stifled.

But re: the devices, people use them with 0mg nicotine. A I mentioned prior, just like paraphanelia for mj, it is marketed for use wiothi tobacco product, btu we all what it really means, just a loop hole. I do not personally believe a different stance could be take on this topic, at least I hope not. The studies from the laboratories showed a short term reduction of even 0mg nic in dependancy symptoms, ie "urge to smoke" A long term controlled trial could find this modest effect and voila, there is your impetus to keep deviced on the free market.

 

[sailorman]

You are right and I will continue to educate people about vaping. iterestingly, my recommendation to people not ready to quit has been met with luke wark respone to vaping. they are jsut not ready.

That is interesting. Strangely, I wasn't all that interested in quitting when I quit. I had cut down from 3 packs/day to around 2 packs with Snus. When Snus started getting to expensive, I got an e-cig on a lark with absolutely no anticipation that I would quit and no particular desire to quit. The day I got my wimpy little 510 was the last day I ever smoked a cigarette, nearly 2 years ago.

.....My particualr history with smoking is not typical. I have been and on and off smoker for 14 years, but never more than 2-3 cig every few days , few more when partyin, but spaced by bouts of non smoking for weeks at a time without nic withdrawl. I never escalated to more but could never seem to stop for good even at this low level when I decided that I wanted to , always would end up with a pouch somehow or another Now I am an on and off vapor, with low or 0 nic which basically cures the hand mouth, social ritual aspect. do I have an occasional analogue...yup, but way way less than years past. Any I feel a lot bette abot it too. So as you can see my answer to that question is not an easy one.

Sounds like you still like those whole-nicotine alkaloids. My prescription is to try Snus. There is an immense conversation here on the forums with people who just can't kick that last couple cigarettes. Nearly all of them have had good success when they start using an occasional Swedish snus during those tough times, like in the AM or after meals or when drinking. I'm convinced that the combination of vaping the proper nic level and the use of snus is a pretty much foolproof way of eliminating combustibles.

My prescription: one 12mg Swedish snus as needed.

 

[sandybeach]

Thanks for doing this! When I told my M.D. I was vaping, he was horrified, and thought it was awful. Doctors need knowledge. I would love to see your PowerPoint, and maybe pass it along to my doc.

 

[tbpeaceman]

One last thing. To the OP, I'm not sure if this is in your references. It is similar in scope and purpose, but different in conclusions, and is likely what the GP will find when they search for what to say about e-cigarettes. You must also consider the "liability and risk management" policy of your institution when you choose your words about e-cigarettes in a clinical encounter. I'm not trying to be devils' advocate here, "just sayin'

"Electronic cigarettes and thirdhand tobacco smoke: two emerging health care challenges for the primary care provider." Int J Gen Med. 2011 Feb 1;4:115-20

yes I have seen that and it is a poor quality review article. It is taking on multiple unrealted topics and basically just is the authors publishing something for the heck of it. It really did not add anything to the issues at hand. The claim there being no evidence probably relates to the timing of this publication. the only actually trial looking at specific long term ( ie 24 weeks ) outcomes that are published, accessable and in a journal that will be noticed is
"Effect of an electronic nicotine delivery device(e-Cigarette) on smoking reduction and cessationPolosa, Caponnetto, Morjaria, Papale, Campagna and Russo, 2011"

and this is meary a low samle size prospective cohort withself reporting verified by exhaled carbon monixed of reduction in smoking....not a particuarly reliable outcome measure.

I think this was out after this review/editorial above article was published. If is is not a blinded ramdomize control trial, best if it compares placebo, industry standard and investigational product, with good control ,and evaluation of potential study bias ( ie who is the funding source ?manufacturer?) with a signifiant ( meaning p value <0.05) outcome then the evidence will either not be accpected for publishign or never submitted in the first place. mostly it is positive studies that get published. This leads to a skewing of results when meta analysies are done. If 100 studies say a drug is not significantly ( statistically speaking) helpful, then one or 2 come along and say it is and those are the only ones publish ,drug gets approved...in simple terms. If vapin g is goign to have a chance in the long run agains the boheimith of big business/govt tag team it is going tohav to start in univerisies with independant funding to get some adequate trials of long term ie 6 months- 1 year of the both safety and utility of the product. So is it the "medical commuintiy that needs to start this? " i dont know, seems to me it is the research side of things that need to get going with clinical trials if the medical communtiy is ever goign to jump on the bandwagon. but therein lies the catch 22. medical has to have a desire, and that is where I go back the grass roots office interaction that I mentioned prior as being a potential spark.

 

[tbpeaceman]

Thanks for doing this! When I told my M.D. I was vaping, he was horrified, and thought it was awful. Doctors need knowledge. I would love to see your PowerPoint, and maybe pass it along to my doc.

screw them! haha. pp link on page two of thread fyi

 

[wv2win]

Thanks for doing this! When I told my M.D. I was vaping, he was horrified, and thought it was awful. Doctors need knowledge. I would love to see your PowerPoint, and maybe pass it along to my doc.

When I told and showed my GP, he was thrilled and intrigued and ask me for more information. I got the information from CASAA and he now recommends vaping to his patients who smoke. My dentist actually asked me to provide information to his brother-in-law to help him transition to vaping.

 

[sailorman]

....
But re: the devices, people use them with 0mg nicotine. A I mentioned prior, just like paraphanelia for mj, it is marketed for use wiothi tobacco product, btu we all what it really means, just a loop hole. I do not personally believe a different stance could be take on this topic, at least I hope not. The studies from the laboratories showed a short term reduction of even 0mg nic in dependancy symptoms, ie "urge to smoke" A long term controlled trial could find this modest effect and voila, there is your impetus to keep deviced on the free market.

All I can say is, let them try to ban nicotine or vaping hardware. As long as China, freezers and the internet exists, they'll be fighting a battle that will be just as successful as the drug war. They'll never ban VG, PG, flavorings, batteries or battery holders. Atomizers can be built and rebuilt. Nicotine can be extracted or smuggled and kept in a freezer for years. In the event of a nicotine ban, I wouldn't be surprised to see pharmaceutical grade nicotine based pesticides in a PG base begin to show up on the market. They can't ban nicotine based pesticides.

The bad part is that if they crack down on nicotine, people will start smuggling 99% pure nicotine, a concentration they are totally unprepared to safely handle. So, just as a crackdown on softer drugs resulted in increased importation of more "condensed" harder drugs, the law of unintended consequences will come into play and people will die for it.

 

[tbpeaceman]

I hope you have contacted CASAA as well as Dr. Seigal (Boston University I'm pretty sure) and Bill Godshall of Smoke Free PA. They all have a significant amount of information that could be helpful to you.

Good Luck

oh I believe they do. you are all preaching to the choir here, and I will use my minor influence on every individual and family that I can to try and help them in a way that they are ready to recieve. All I can do as a GP is be that impetus for change for an individual and their inevitable social web.

My project with this brief lit review is to look at original research that answers the basic question of efficacy and safety. IT will be brief and unbiased. The published literature speaks for itself. Like I jsut meantion in the post, notice haow there are no "negative result" studies out there! there may be some that we have just never heard about? Who knows. but DA bench research and extrapolated editorials on those finding does not = long term outcomes with real world use of a product or risk. the medical commutiy is looking fior reliable research. It jsut needs to be done. If these indiviuals have specific controlled studies that have not been submitted for peer review then to Pub med and they are sitting on them then they should get them out there. But as of now the 5 trials I highlighted are the only ones that meet critrea, even marginal at that for being of certain quality adn relevance to the clinical question at hand. Siting a "web survey " for evidence is like scrapign the bottom of the barrel, but its all there is to work with. clearly the message can't be denied however as long as someone is biased with somethign to loose in a position of power to generate propaganda, we've got a struggle. One small step at a time will yield results, albeit slowly.

 

[tbpeaceman]

In the event of a nicotine ban, I wouldn't be surprised to see pharmaceutical grade nicotine based pesticides in a PG base begin to show up on the market. They can't ban nicotine based pesticides.

banning stock nic would = risky toxin exposure, like you say. not particulary "harm reducation" for public health

no matter you moral stance, this would be akin to making abortion illegal = dead women. People will find a way, a much less safe way. Not smart!, but then again, most people aren't
, especially the richer they get. ha

 

[elfstone]

notice haow there are no "negative result" studies out there!

There is a small experimental study showing some a drop expired NO and some decline in respiratory function after vaping for 5 minutes, but I think that's all there is (except for the one with intranasal nicotine and endothelial dysfunction, if you count that). No trials.

people will start smuggling 99% pure nicotine, a concentration they are totally unprepared to safely handle.

This is going to be the most paranoid thing I've ever said. I guess I'm joining the "who's more paranoid than Rolygate" contest. What do I win?

So... there is a thin but present trend to link nicotine to terrorism as I pointed out above. Therefore, couple that with the NDAA and you could face going to a military prison for the rest of your life for vaping!

OF COURSE I'm exaggerating beyond reason here, but ... you know...

 

[tbpeaceman]

When I told and showed my GP, he was thrilled and intrigued and ask me for more information. I got the information from CASAA and he now recommends vaping to his patients who smoke. My dentist actually asked me to provide information to his brother-in-law to help him transition to vaping.

and as such the web continue to grow....from the office as an axis point, person by person. IT is true that most of what doctors need to know thye learn from their patients....wished I'd know that before being up to my ears in debt haha!