Tag Archives: cigarette smoking

Heart Attacks and E-cigarettes: Are America’s Teens Putting Themselves At Risk?

Many of the skeptical cardiologist’s patients managed to quit cigarette smoking by using e-cigarettes . They often continue to vape, prolonging their addiction to nicotine but overall I felt they were probably better off than smoking cigarettes. However,  a couple of recent articles have me very concerned about the overall effect of e-cigarettes on public health.

The first article came from the PR department at  UCSF with the headline:

Smoking E-Cigarettes Daily, Doubles Risk Of Heart Attacks”

It focused on an abstract presented in Baltimore in February 2018 by Stanton Glantz, UCSF professor of medicine and director of the UCSF Center for Tobacco Control Research and Education. The abstract (paper yet to be published) was an observational study of about 70,000 individuals. Since it was observational the causality implied by the headline is not justified but the findings are still worrisome:

When adjusted for other risk factors, daily e-cigarette use was associated with significantly increased odds (Odds Ratio: 1.79) of having had a heart attack (myocardial infarction), as was daily conventional cigarette smoking (OR: 2.72). Former and occasional e-cigarette use were not associated with significant changes in the odds of having had a heart attack, while the same categories of cigarette smoking were associated with smaller increases in risk than for current smokers.

So e-cigarettes might be safer than real cigarettes but if you don’t quit smoking you are worse off:

“E-cigarettes are widely promoted as a smoking cessation aid, but for most people, they actually make it harder to quit smoking, so most people end up as so-called ‘dual users’ who keep smoking while using e-cigarettes,” said Glantz. “The new study shows that the risks compound. Someone who continues to smoke daily while using e-cigarettes daily has an increased risk of a heart attack by a factor of five.

Juul and The Rise In Teenage Vaping

The second article was from The New Yorker and is fascinating. Entitled “The Promise of Vaping and the Rise of Juul.” ,  it details an alarming rise in teenage vaping which often involves a particular brand of e-cigarette, Juul,  which resembles a flash drive.

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“Smoking is gross,” a high schooler said. “Juuling is really what’s up.”Photograph by Elizabeth Renstrom for The New Yorker

To Juul (the brand has become a verb) is to inhale nicotine free from the seductively disgusting accoutrements of a cigarette: the tar, the carbon monoxide, the garbage mouth, the smell. It’s an uncanny simulacrum of smoking. An analyst at Wells Fargo projects that this year the American vaporizer market will grow to five and a half billion dollars, an increase of more than twenty-five per cent from 2017. In the latest data, sixty per cent of that market belongs to Juul.

Scientists Warn of E-cigarette Health Risks 

In March, a congressionally mandated report on the health effects of e-cigarettes  from the National Academies of Sciences, Engineering, and Medicine concluded:

Evidence suggests that while e-cigarettes are not without health risks, they are likely to be far less harmful than conventional cigarettes, the report says. They contain fewer numbers and lower levels of toxic substances than conventional cigarettes, and using e-cigarettes may help adults who smoke conventional cigarettes quit smoking.

With respect to cardiovascular diseases, their conclusions were:

  1. We don’t currently have evidence that e-cigarettes increase risk of stroke or heart attack or subclinical atherosclerosis
  2. There is good evidence that in the short term the nicotine in e-cigarettes raises systolic and diastolic blood pressure and heart rate
  3. There is limited evidence that e-cigarettes increase biomarkers of oxidative stress, increase endothelial dysfunction and arterial stiffness. All of these factors are known to contribute to the development of atherosclerosis.

Long term, it is anyone’s guess what the consequences of vaping on the cardiovascular system will be.

As the New Yorker article makes abundantly clear, however, the youth of America are taking up vaping and Juuling increasingly and the National Academies are appropriately worried:

However, their long-term health effects are not yet clear. Among youth — who use e-cigarettes at higher rates than adults do — there is substantial evidence that e-cigarette use increases the risk of transitioning to smoking conventional cigarettes

Are Your Kids Vaping?

In 2015 there was a 40% chance your middle school or high school child had used e-cigarettes. The chart below from the CDC shows how rapidly rates are climbing.

The surgeon general/CDC issued a warning in 2016, writing:

E-cigarette use among U.S. youth and young adults is now a major public health concern. E-cigarette use has increased considerably in recent years, growing an astounding 900% among high school students from 2011 to 2015. These products are now the most commonly used form of tobacco among youth in the United States, surpassing conventional tobacco products, including cigarettes, cigars, chewing tobacco, and hookahs. Most e-cigarettes contain nicotine, which can cause addiction and can harm the developing adolescent brain.

Compared with older adults, the brain of youth and young adults is more vulnerable to the nega- tive consequences of nicotine exposure. The effects include addiction, priming for use of other addic- tive substances, reduced impulse control, deficits in attention and cognition, and mood disorders. Furthermore, fetal exposure to nicotine during pregnancy can result in multiple adverse consequences, including sudden infant death syndrome, altered corpus callosum, auditory processing deficits, effects on behaviors and obesity, and deficits in attention and cognition. Ingestion of e-cigarette liquids con- taining nicotine can also cause acute toxicity and possibly death if the contents of refill cartridges or bottles containing nicotine are consumed.

Stealth Vaping Devices

Vaping devices no longer clearly look like cigarettes. Here are some examples from the CDC report.

 

 

 

 

 

 

 

 

Note, however, that the Juul is not depicted.

By Mylesclark96 [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)%5D, from Wikimedia Commons
It doesn’t look like a cigarette or a device that would be facilitating your child’s addiction to nicotine. And it has a USB port so it can be recharged from a laptop.

 

 

This wasn’t an issue as far as I can tell when my children were teens but I’m pretty sure if I had teenagers I would ban vaping and would confiscate anything that resembled an e-cigarette including  flash or thumb drives that aren’t flash or thumb drives.

Skeptically Yours,

-ACP

Is Not Wearing A Bike Helmet As Stupid As Smoking Cigarettes?

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The “Route” from my house to the great urban park, Forest Park, around and back. Sans incursions into the dangerous paths less traveled

Several weeks after  my cycling misadventures which resulted in non cardiac chest pain, I climbed back in the saddle again and rode the route that had resulted in my calamitous fall.

This time, I avoided the mysterious path less traveled.

As I approached  Washington University an elderly man riding a bike and wearing a bike helmet came up beside me. He was clearly very irritated by the fact that I was not wearing a bike helmet and kept gesticulating at his helmet to indicate that this was the proper choice of head gear.

I had, as is my usual practice, chosen not to wear a helmet  and this man had taken it upon himself to nonverbally lecture me on what he perceived was inappropriate risky behavior.

As I continued my ride I began ruminating on my decision to engage in  bike riding without a helmet and wondering if I was being like my patients who continue to smoke cigarettes despite my warnings of the health consequences of that behavior.

There can only be two reasons for an educated person not to wear a helmet:

1. S/he believes there is no or insufficient evidence that wearing a bike helmet will reduce their risk of serious head injury while riding.

2. S/he accepts that helmet wearing reduces injury but is willing to accept this risk because not wearing the helmet is more pleasurable or convenient.

Similarly, my cigarette smoking patients may either reject the (overwhelming) evidence of the dangers of this behavior or they may believe it is dangerous but feel that smoking is so pleasurable they decide to continue.

Not wearing a bike helmet lacks the addictive element that cigarette smoking contains but otherwise I think it is a reasonable analogy.

Do Bike Helmets Reduce Injury ?

Despite widespread public health advise to wear bike helmets, I have maintained  in previous posts that evidence for bike helmets reducing injury is lacking.

I’ve spent a fair amount of time since this gentleman upbraided me for being helmet-less reviewing the data again. I was prepared to regularly wear one if the data supported it. But it doesn’t.

A commonly cited statistic is that bike helmets reduce serious head injuries by 85% and brain injuries by 88%.  This comes from an observational  study  published in 1989 which has serious limitations and has never been reproduced. For an exhaustive critique of these data see here.

I think a fair summary is in this British Medical Journal editorial which is behind a paywall but can be reviewed as a PDF here (bmj-june-2013.pdfbicycle helmets and the law)

Cowritten by David Spiegelhalter, the Winton professor for the public understanding of risk at the London School of Hygiene, the editorial was commenting on a paper in the same issue which reported that a Canadian mandatory bike helmet law had minimal effect on cycling-related head injuries.

The writers note that this contradicts previous observational studies which have suggested a benefit from helmet wearing.

Like all observational studies, these bike helmet studies are “vulnerable to many methodological shortcomings”:

  1.  If the controls are cyclists presenting with other injuries in the emergency department, then analyses are conditional on having an accident and therefore assume that wearing a helmet does not change the overall accident risk
  2. Observational studies cannot account for confounding variables that are unmeasured. For example, people who choose to wear bike helmets may be more cautious than those who don’t and so less likely to have a serious head injury regardless of wearing a helmet. (A 1997 study found that adolescents who smoked cigarettes were more likely to use smokeless tobacco, have multiple sexual partners, and not use bicycle helmets)

Many states and countries have passed laws mandating helmet wearing but people who are forced by legislation to wear a bike helmet may wear it in a sloppy , ineffective manner. Their behavior may also change   through “risk compensation” wherein they behave more irresponsibly in the believe that they are protected from injury.

A single study has also reported that car drivers give a larger clearance to cyclists without a helmet.

I have concluded that my not wearing a bike helmet is due to lack of evidence to support the health consequences of that behavior. This happens to perfectly align with my disdain for bike helmets which chafe my forehead, make my head sweat and reduce my ability to hear (both charming and lethal) things.

Do Cigarettes Cause Death?

Cigarette smokers, on the other hand, can find no serious scientist or physician who is not convinced of the danger of this lethal habit because the scientific data are overwhelming. The CDC estimates cigarette smoking is responsible for 480,000 deaths per year and that it causes 90% of lung cancers and 80% of chronic obstructive lung disease. The only possible explanation for continuing is the element of addiction combined with the pleasure obtained from smoking.

Public Health Laws: Bike Helmets and Cigarette smoking

Australia and New Zealand are the only countries to have mandatory helmet laws. In the US, according to helmets.org, bike helmets are mandatory in 22 states.

In St. Louis County, they are mandatory for children under the age of 17. In some St. Louis municipalities (Creve Couer for one) they are mandatory for all are groups.

To date, there is no evidence that mandatory bike helmet laws reduce head injuries so why are they being passed?

On the other hand, the dangers of cigarette smoking are clear and there are no countries or states which make it illegal.

To those who would shame we non helmet wearers I say: “Spend your time shaming those who smoke cigarettes”.

By the way, whenever public policy doesn’t seem to correspond to the evidence, we should look for bias and special interests.

It’s obvious in the world of tobacco that the bias and special interest  toward allowing smoking comes from the tobacco industry.

In the cycling world, the bias and influence comes from the manufacturers of bike helmets.

Helmet free and loving it

-ACP