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e-Cigarettes

are e-cigarettes healthy

What is an electronic cigarette?

  • Designed by Chinese pharmacist Hon Lik in 2003
  • Electronic device that simulates the act of smoking a real tobacco cigarette by producing an inhaled vapor offering the “freedom to smoke anywhere”
  • Gives the appearance, physical sensation, and even flavor of a real cigarette

How does it work?

  • User inhales on the mouthpiece, triggering the liquid to be heated, and the atomizer turns the liquid into a vapor
  • The vapor is inhaled by the user, which gives the effect of smoking a real cigarette
  • Users are “vaping,” not smoking

What’s the attraction?

Price difference:

  • Price of cigarettes are past $5.00, and a major factor in people’s choice to switch to change to e-cig is that economical advantage.
  • The cartridge to refill an e-cig is roughly $3.00 apiece and can last three to five times as long as a traditional pack of cigarettes.
  • Many estimates say an e-cigarette habit costs one-third as much as a smoking habit.
  • One benefit is also that you are in charge of how much you smoke. You don’t have to smoke the entire cigarette in one sitting, you can take one or two puffs and be done.

What do people see in them?

  • No burning tobacco
  • No CO2 in your lungs; no secondhand smoke
  • Adjust the amount of nicotine
  • More economical (user can take as many “hits” as desired and need not smoke the entire thing in one sitting)

Attraction to youth:

  • The economic reason above appeals to high-schoolers
  • Attractive for youth to smoke however much they want
  • Students MAY feel there is a lower risk of addiction
  • No smoke smell and feeling in lungs
  • Easy to buy online or in a mall and come in flavors ranging from chocolate to bubble gum; you can buy them in pink, gold, or blue
  • Presumption of safety because it is not burning tobacco, even though its consequences are not known

The negative aspects of e-cigarettes

  • After the FDA analyzed brands, it found diethylene glycol and other cancer-causing agents in some samples

  • The nicotine cartridges emit an inconsistent amount of nicotineLike secondhand smoke, particles from the vapor can land on surfaces like clothing, furniture, and carpets and have the same effect as secondhand smoke

    • For example, if you are using a low-strength nicotine cartridge, you may actually receive the same amount as a higher dose
  • The FDA remains concerned about how e-cigs are marketed and about how they are encouraging youth tobacco use

  • Essentially no data on use as cessation strategy (J Med Case Rep 2011; 5:585) n=3

  • Harm-reduction data limited (BMC Public Health 2011; 11:786) n=40

Cardiologist’s Conclusions

May be harmful to public health.
Smokers have been advised by the FDA not to use them.
E-cigs promote increased airway resistance after five minutes of use
More research is needed on the cost/benefit equation of these products and the appropriate level and type of regulation for them. The harms have tended thus far to be overstated relative to the potential benefits.
Concern over repeated inhalation of propylene glycol.
Concern that e-cigarettes may promote continued smoking by allowing smokers to cope with no-smoking environments is countered by the observation that most smokers use these products to try to quit and their use appears to enhance quitting motivation.
Concerns over low nicotine delivery are countered by evidence that the products provide significant craving reduction despite this in some cases; and e-cigarettes may help reduce toxin exposure to nonsmokers.
E-cigarettes are a new trend on high school campuses.

To Vape or Not To Vape?

  • Although “vaping” might be safer than smoking, e-cigarettes are definitely not healthy.
  • E-cigarettes might work as a strategy to quit smoking, similar to nicotine replacement, like the Nicotrol inhaler. If you try it, commit to short-term use.
  • If you are interested in quitting smoking, try evidence-based treatments such as counseling and nicotine replacements like a patch or gum, rather than e-cigarettes.
  • It may be called an e-cigarette, but it’s still a cigarette!

Preventing a Second Stroke

Identifying the cause of a stroke

Patients want to avoid stroke because of the debilitating effects it can have on functional status and quality of life. Efforts to prevent a second stroke are enthusiastically embraced by patients. Identifying the cause of the first stroke helps your doctor prescribe the best treatment for preventing a second. But finding the cause of a stroke is not always easy.

A cryptogenic stroke is a stroke that’s cause cannot be determined. Cryptogenic strokes account for approximately one third of all strokes in the U.S. Treatment with anticoagulants in this patient population is not recommended UNLESS the cause of the stroke is the common, irregular heart rhythm atrial fibrillation (AF).

On the other hand, if atrial fibrillation is NOT detected, treatment with aspirin or other anti-platelet drugs is used. These drugs are inferior to anticoagulants if AF is the cause.

The problem lies in the difficulty of detecting atrial fibrillation after a stroke. Physicians often fail to identify AF as the root cause of an initial stroke.

Prolonged heart rhythm monitoring

Two recent studies in the New England Journal of Medicine showed that prolonged heart rhythm monitoring (30 days or 6 months) increased the detection of atrial fibrillation and allowed more patients to be started on anticoagulants for stroke prevention.

In the trial of 30 days of recording with an external (carried) monitor, detection of AF was 16.1%.

In the trial of the implanted recorder, detection of AF was:

  • at 6 months 8.9%
  • at 12 months 12%
  • at 36 months 36%

The strategy of prolonged monitoring with an external device for 1 month or with an implanted device for 6 months is an unresolved question. Adoption of the small subcutaneous device (pictured below) will be limited by its cost, until further studies showing stroke reduction can be completed, justifying the high cost.

Testosterone Replacement Therapy

Advertising hormone replacement therapies

There has been a fair amount of direct-to-consumer advertising for manufacturers of testosterone replacement therapies on the benefits of testosterone replacement. These ads foster the idea that age and a decline in sexual hormones (testosterone in men, estrogen in women after menopause) may contribute significantly to health issues such as:

  • vitality
  • strength
  • general well-being

Sexual health issues such as libido and erectile function have significantly contributed to an interest in these therapies.

Estrogen replacement therapy for women

With estrogen replacement therapy for women, it was thought that the therapy might not only affect women’s well-being and an improvement in menopausal symptoms such as hot flashing, but might also have significant benefits on bone strength and cardiovascular health. Unfortunately, the opposite has been shown. Use of estrogen or hormone replacement therapy (HRT) has been shown to increase cardiovascular risk and may also increase the risk of breast malignancy. These therapies are no longer recommended.

Testosterone replacement therapy for men – “Been there; done that.”

There have been two recent studies which have raised concerns about the safety of these testosterone replacement therapies for men. A Veterans Affairs study published in November of 2013 showed that the risk of death, heart attack or stroke was higher in men who received testosterone compared to men who were not treated with these therapies. There was a 5.8% absolute risk increase in these problems in the men who received testosterone. *

What does that mean? Every 17 men who are treated with testosterone would have one of these unfortunate outcomes.

A second study in June of 2014 of over 50,000 men showed the incidence of heart attack at 90 days after initially being treated with testosterone replacement therapies being significantly higher for heart attack risk. The authors of this study did an interesting comparison looking at whether use of drugs for treatment of erectile dysfunction like Viagra, Cialis or Levitra caused any increased hazard. There was no significant increased risk. **

Both of these studies have been criticized by physician and industry supporters of testosterone therapy because these studies were what is called “observational studies.” These studies do not strictly control the differences between the treated group and the group that does not receive the treatment. The FDA and others have called for randomized control trials to assess the definite safety and efficacy of testosterone replacement.
The Endocrine Society and American Association of Clinical Endocrinologists have included a testosterone therapy recommendation in the recently published “Choosing Wisely” guideline.

The statement on this issue is:
Don’t prescribe testosterone therapy unless there is biochemical evidence of testosterone deficiency.

Many of the symptoms attributed to male hypogonadism are commonly seen in normal male aging or in the presence of comorbid conditions. Testosterone therapy has the potential for serious side effects and represents a significant expense. It is therefore important to confirm the clinical suspicion of hypogonadism with biochemical testing (measurement of blood levels of testosterone). Current guidelines recommend the use of a total testosterone level obtained in the morning. A low level should be confirmed on a different day, again measuring the total testosterone. In some situations, a free or bioavailable testosterone may be of additional value.

The current consensus appears to be that we should clearly avoid testosterone replacement therapies in older patients, frail patients or patients who have definite coronary disease. In addition, use of testosterone replacement should be carefully guided with laboratory testing for other hazards.

In my practice, I have now recently seen two men less than age 60 on testosterone replacement therapy who had heart attacks. The linkage is suspicious since the patient did not have other significant coronary risk factors.
Caution is strongly recommended with this treatment until more information is known about its safety and efficacy.

 

* Vigen R, O’Donnell CI, Barón AE, et al. JAMA. 2013;310(17):1829-36.

** Finkle WD, Greenland S, Ridgeway GK, et al. PLoS One. 2014;9(1):e85805.

See also:

http://www.cardiosource.org/News-Media/Publications/CardioSource-World-News/2014/04/Straight-Talk-Testosterone-Replacement-Therapy-Deja-Vu-All-Over-Again.aspx

http://www.choosingwisely.org/doctor-patient-lists/the-endocrine-society-and-american-association-of-clinical-endocrinologists/

 

Aspirin for Primary Prevention

How does your doctor help you avoid cardiac events like heart attacks or strokes? Establishing a prevention strategy is important to lessen the risk of such dangerous events. Doctors generally define prevention strategy as either primary or secondary:

Primary Prevention – No cardiac events have occurred in the patient. The doctor wants to prevent an initial cardiac event.

Secondary Prevention – A cardiac event has happened in the past. The doctor will try to prevent another event from occurring.

For instance, a patient who has had a heart attack or stroke is generally treated with secondary prevention using drugs like aspirin, cholesterol lowering medications to reduce the chance of another event occurring. Patients who have not yet had an event such as a heart attack or stroke are at much lower risk. Finding the appropriate level of prevention in these patients is often difficult because of this lower risk.

Aspirin for Primary Prevention

It has been the practice for decades now to use low-dose aspirin, particularly for adults over age 50. This approach has been felt to reduce the chance of a heart attack or stroke, mostly by providing a slight blood thinning effect. Aspirin acts as a blood thinner by inhibiting the actions of platelets in the blood. This antiplatelet effect has been shown to be very significant for patients having a heart attack or for after having a heart attack. The logic therefore was extended to include patients who are at risk for heart attacks.

We have generally recommended aspirin at low dose (81 mg) for primary prevention for patients over age 50. The data was felt to be reasonably strong for men and less strong for women.

New FDA Recommendations

Now, the FDA no longer recommends that this practice be continued. The May 2014 FDA statement says:

“The FDA has reviewed the available data and does not believe the evidence supports the general use of aspirin for primary prevention of a heart attack or stroke. In fact, there are serious risks associated with the use of aspirin, including increased risk of bleeding in the stomach and brain, in situations where the benefit of aspirin for primary prevention has not been established.”

Here is the link to the FDA statement from May 2014.

The FDA did caution patients not to stop aspirin without consulting their physician. They also tried to educate the public about the differences between primary and secondary prevention and have clearly stated that this new recommendation only pertains to primary prevention. Patients who had prior evidence of vascular disease with heart attack, stroke, prior angioplasty or other vascular procedure, or even with imaging evidence of significant vascular disease in the carotid arteries or vascular disease of the legs, should continue aspirin if recommended by their physicians.