Heartfelt with Dr Melissa Walton-ShirleyView all posts »
The E-cigarette: Should cardiologists add this to our bag of tricks?Aug 25, 2012 09:00 EDT
When I opened my exam room door a couple of years ago, there he sat. The entire office staff, unbeknownst to me, were waiting and listening for my reaction. He smiled, holding his brand-new shiny electronic cigarette between his teeth, then tilted his head ever so slightly, keeping his eyes on mine as he slowly exhaled. He then removed it in a dramatic sweeping fashion, sort of like Thurston Howell III on my favorite Gilligan's Island episode in a smoking jacket with his wife Lovey at his side. A vapor wafted slowly from the end of the curious thing protruding from his mouth. "Well, what do you think?" he asked, chuckling. I replied, "I can tell you one thing. You are the first person in the history of my being a private-practice cardiologist to ever smoke anything while sitting on my exam-room table." Everyone laughed on both sides of the door, obviously with ears pressed. Until today's presentation by Dr Konstantinos Farsalinos, from Athens, Greece, I really didn't know what to think.
On that fateful day with my first interface ever with the device (other than an attempted sale by a hawker in an outlet in Orlando, FL a few years back), my patient quizzed me for more information. I told him we had no long-term data to attest to the safety of the "e-cigarette," and based on that fact, I really couldn't recommend it. Today's presentation made me soften toward it, although we don't have large randomized controlled trials or any long-term follow-up to back it. Even in this day and age, with our obsession with and addiction to "quality" data, some things are still just intuitive. As a testimony to the unknown long-term side effects, we banned "e-cigarettes" as well as all smoking in public venues in our hometown of Glasgow, KY around three years ago.
The presenters who preceded the e-cigarette study today gave an impressive review of information reaffirming that tobacco exposure at any dose can be lethal. An adolescent study revealed significant adverse effects on the vasculature of nine- to 20-year-old primary smokers with relatively little tobacco exposure, with only as much as a weekly indulgence. Another study mirrored the Helena MT US data that demonstrated that one in four STEMIs could be prevented by tobacco-smoking bans. But what about the e-cigarette? Should I as a practitioner recommend or allow it? Should I wait for my patient to bring it up, or should I recommend it as a first-line "treatment" for tobacco addiction?
The study today was disappointingly small, comparing cigarette smokers with "seasoned" e-cigarette smokers. It demonstrated no significant adverse effects on hemodynamics such as diastolic function by Doppler echo, heart rate, and systolic blood pressure compared with tobacco cigarettes. He noted that seasoned e-cigarette users smoke the device more than first-time users and thus did not want a novice population to taint the data. He is now analyzing data from 2-d speckle tracking and will add that information later to his studies.
I asked the presenter just about anything I could think of on the topic. Before I could get the question out of my mouth about the person in Florida who supposedly lost part of his tongue and a few teeth from an "explosion," he addressed it. The presenter offered that explosions are known to be a downside of lithium batteries, "not unique to the e-cigarette." "What about formaldehyde in the vapor and therefore cancer risk?" I asked. "You would have to smoke e-cigarettes for eight to 10 months in order to equal the exposure of one cigarette," he countered. "What about the fact that not all e-cigarettes are created equally?" I asked. "I have read that some contain nicotine, some don't. Others have flavorings, others don't. Should there be some regulation?" "Yes, I believe there should be regulation," he agreed. A journalist in the front of the room asked if he felt it might impact the number of house fires started by those who smoke in bed, and he answered "Yes, it would likely impact it, since it turns itself off after a few seconds of inactivity and heats up to less than 200º vs 800º as seen in tobacco cigarettes, in a matter of seconds." The sense was conveyed that feelings of repulsion and disgust we feel toward the habit of adults sucking a cigarette or a device to satisfy the basic behavioral and psychological yearnings seen in this addiction must be put aside. The sooner we accept it as an alternative, the better.
So, shall I add the electronic cigarette to my cardiologist's bag of tricks alongside varenicline (Chantix, Pfizer), bupropion, patches, gum, inhalers, and lozenges? Should I place it at the top or hide it in the very bottom, only bringing it out in a final act of desperation? Today's presentation suggests that the first step is to open up my bag of tricks and willingly dump in the e-cigarette, hinting I might now start to "allow it" and perhaps even bless it in the future as better than tobacco-smoke inhalation. After today, it certainly seems better and perhaps safer than tobacco, period. Now maybe I need to contact my patient and tell him he's welcome to "smoke" his e-cigarette on my exam-room table. On second thought, that might still be just a bit too much.