Friday, March 27, 2015

Can e-cigarettes help me quit smoking and are they safe?

I have been doing a lot of research into electronic cigarettes since that is what my next book will be about. There have been many confusing headlines, some saying that they are just as harmful as tobacco cigarettes, while other headlines will tell you they will help you quit. The truth is somewhere in the middle.
The controversies that make headlines are often not the real issues, such as-cig containing formaldehyde--that chemical was only created at very high temperatures--a temperature that no vape users would realistically use.  While w-cigs do have some carcinogens, they are amounts that are 9 to 450 times less than traditional cigarettes.
1. The biggest problem is dual use long term, using electronic cigarettes while you are continue to  smoke and continuing this practice long-term instead of quitting smoking. Using an e-cig for short term while trying to quit, probably isn't a problem, but with dual use, even reducing the number of cigarettes doesn't help with the damage smoking does to your cardiovascular system. Unlike cancer where exposure to a carcinogen is linear (the more exposure, the greater the risk of developing cancer), heart disease is not linear: 50 to 80% of the damage to the cardiovascular system from smoking occurs within the first 3 to 5 cigarettes. For those who do use e-cigs to quit smoking but continue to use them long term, there are no long term studies as to the health effects. Very likely it will not be the same as smoking but e-cigs will have their own unique disease profile and associated risk.
2. The cig-a-likes don't deliver enough nicotine to really help with cessation. The mods or tanks do a better job of that. A lot has to do with the particle size in the vapor. If the particle is either too small or too large, the vapor isn't absorbed. For example, the MarkTen offers some of the highest nicotine content (44mg) but very little of that is absorbed by the smoker, so you can't count on the nicotine content. It is not what is in the liquid but what is absorbed that is important. Almost all users start with a cig-a-like and either find them unsatisfying and go back to smoking, or they switch to a tank/mod which delivers enough nicotine to satisfy.
3. While there are some health risks with nicotine, the real problem is with the flavorings. Vapor shop owners will say that the flavorings are "FDA" approved--which most are--as a food, but not as an inhalant. (Actually flavorings are not FDA approved but approved by FEMA--Flavoring and Extract Manufacturing Assoc and given a "no objection" letter by the FDA). Digestion and inhalation are two very different delivery systems. When eaten, a flavor goes through the stomach and digestive tract where it is subject to gastric juices and then is filtered by the liver where toxins are removed. When inhaled, substances go straight to your blood system with no filtration. Some flavorings are toxic when inhaled--like cinnamon, buttery flavor and cherry. There are probably more but little or no testing has been done on the over 7000 e-cig flavors available. 
4.Users like the hand to mouth use of e-cigs and when compared to the nicotine inhaler which also mimics this motion, users say that e-cigarettes give a better throat hit than the nicotine inhaler, (which is an FDA approved cessation device for cessation). A common issue with people using NRT is that they don't get enough nicotine from one delivery system, so we now suggest combination therapy, such as the patch or bupropion with either the inhaler, gum, lozenge, or nasal spray. This pairs one long acting agent with a short acting one. I have heard of many people using both chantix and bupropion together with great success but I haven't seen any research studies on it, only anecdotal.
5. Up to 90% of these devices are made in China (regardless of what the label says--no one is looking to see if the labels are true), where there are no manufacturing standards, the batteries can be defective and blow up, poorly made atomizers can leach metals into the vapor, contents of the e-liquid can be very different than the label--for example instead of using pharmaceutical grade nicotine, a less pure grade could be used or instead of propylene glycol, they could use diethylene glycol--which is cheaper but toxic. Plus there are many counterfeits on the market, so even if the manufacturer is one who is trying to create a good product, you may not know if the one you buy is real or counterfeit. This is a common problem with products made in China: Lumber liquidatorstoothpastedog and cat treats.
Having said all that, I do believe that once some of these issues are addressed through FDA regulation, there is a place for e-cigarettes as a harm reduction device which will help a smoker quit tobacco cigarettes and hopefully will only be used for a short time instead of continuing a nicotine addiction. 

Wednesday, March 25, 2015

Do the cravings (for nicotine) ever stop?

A. has been quit for 6 months yet she still gets cravings just as strong as the first day she quit. She asks,

"Will it ever get better or will it a battle forever?"
You need to stay vigilant and work on changing your self talk. When a craving comes up--if you keep saying--"this is just like day one" and questioning if it will ever get better--that thought process can lead you back. Instead reframe it to: "I've made it 6 months and most of the time, it is easier but since I'm still having craving, maybe there is something more to learn about my addiction to nicotine." Then see if you can trace back your thoughts to what trigger it in the beginning. After 6 months, it's probably not a "habit" cigarette but one that is attached to strong emotions, (positive or negative) and/or stress. 
This is an activity from my book  How To Win at Quitting Smoking:

Activity: Five steps to train your brain to think of smoking in a different way.

You need to recondition your brain to stop the automatic thoughts that nicotine has planted. It takes time. If you only change your behavior and not your thinking, you may relapse or turn to something else such as food.
Write these five steps down on a card and carry them with you. Whenever a craving comes up use these steps to change what you tell yourself when you think about smoking or have a craving. You can use these steps when you first quit and at any time in the future:
1. “I’m having a desire to smoke right now.” Having a desire to smoke is normal and the craving will go away whether or not you smoke. Just let it run its course.
2. “I can smoke at any time, I’m not deprived.” Nobody is taking your cigarettes away from you. It is your choice and you are working towards what you really want and it’s not the cigarette. Remember what smoking is depriving you of that is more important: money, health, freedom.
3. “I’m a puff away from a pack a day.” It’s easy to fall into the trap of having “just one”. Do not kid yourself.
4. “Right now I have a choice to make for myself. Either I give in to this temporary discomfort and go back to the constant misery of smoking, or I can accept this temporary discomfort and work through it for (. . . name one of your Benefits of Becoming Smoke-Free).”
5. “At this moment, I willingly accept this temporary discomfort because I want (. . . then list your Benefits of Becoming Smoke-Free).” Focus on what you truly want.

You always have a choice! When a craving comes up, you will always have two choices:
• You work through it and remain smoke-free, or
• You slip and smoke a cigarette. 
If you choose the latter, again you have two choices:
• You resolve to remain smoke-free and learn from the slip, or
• You blame yourself, beat yourself up, feel guilty and smoke another cigarette.
If you choose the latter, your next two choices are:
• You renew your resolve to become smoke-free and start anew, or
• You relapse and become a smoker again. Realize you need to work on your motivation, make changes in your Action Plan and/or set another Quit Date when you’re ready.
You can choose to see a slip as a failure or as a learning experience. You can choose to let the events of your life control you, or you can take control of your life. The choices you make are determined by who you think you are, and the benefits and expectations you bring to the situation.

Monday, March 16, 2015

Is Nicotine an Alternative Vice and Should We Prohibit it's Use?

A colleague of mine shared that she had met a man who had quit spit tobacco by switching to nicotine gum. He uses 3 or 4 pieces at a time. He was happy that he quit spit and had no desire to stop using the gum. She wondered what she could say to him about his addiction to nicotine gum. Other colleagues gave her suggestions as to how to get the NRT user to change his behavior but no one really answered WHY he should change his behavior. Here is my thoughts: 

When compared with continued smoking/chewing, there is no question that long term use of NRT is preferable but when you compare it to using nothing, I don't think we really know what the relative long term risk of using medicinal nicotine (see links below). We talk about nicotine being a poison yet---the poison is in the dose.  How harmful are low doses of nicotine over a long term? 

In the FDA webinar this week, a presenter made the statement that he thought that within 10 years, if we could get e-cigarettes properly regulated and manufactured to deliver sufficient nicotine, that we could put the tobacco companies out of business. Wouldn't that be a good thing? The very next day during a different webinar, someone posed the question --"How do we put the e-cig manufacturers out of business?" Is this in a smokers best interest or is tough regulation better? 

With e-cigarettes there are other components in the vapor that need to be studied. But I think the long term use of both in regards to nicotine is similar----NRT was not designed for enjoyment as e-cigarettes are, but people do use nicotine (NRT) for their enjoyment. Is nicotine really the demon we need to be fighting, even though it is addictive? It seems to me that there are some people in tobacco control who want to prevent the use of nicotine for enjoyment in any form regardless of it's relative risk strictly because it is addictive or is it our puritanical nature to deny people its pleasure? If addiction is the only criteria, is that enough to warrant its prohibition and the desire to put e-cigs out of business?

Humans use a variety of substances for enjoyment from alcohol, caffeine, marijuana, and now nicotine. With the invention of e-cigarettes, I see using nicotine as a new (or alternative) vice for some. Should it be our job to stop them? Or is this a futile attempt at prohibition again? Although I'm not really sure we can compare nicotine to any other substance. We want to stop the addiction to heroin, meth, cocaine because of the detrimental health effects but so far we don't see that with nicotine addiction. Years ago the policy at the Betty Ford Center (not sure if this is still in effect) was to deny patients all access to caffeine--but they could smoke. To me this is giving the message that ingesting caffeine is more dangerous than nicotine. We know that nicotine is more addictive than all these other substances but is that reason enough to want to prohibit its use?