Hey functional medicine clinicians, what do you think about e-cigs? A few thoughts plus a couple of case briefs.
Look. I’m all about harm reduction. Make the best possible choice you can at any moment: Got a sugar craving that you’re going to give in to? Choose a cronut or 70% dark chocolate. A no-brainer. And so it goes with nicotine. Smoker trying to quit? I’m all in for e-cigarettes. At least I was. Now, after walking through the e-cigarette experience with a few patients, my opinion — and concerns — are evolving.
As with most things medical, there is no one-size-fits-all answer.
The mainstream medical community has been weighing in heavily on e-cigarettes. In fact for this blog, I searched my Outlook box and have over a ½ dozen articles from MedPage Today alone. Generally speaking, the greater medical community, and in particular the American Heart Association (AHA), is against the e-cig phenomenon, and is voting for very strict regulation or an outright ban.
Their concerns are multifold, and include the ability for minors to purchase ecigs, ecigs as gateway drugs, lack of product regulation, absence of long-term safety data, and minimal understanding of the impact of e-cig additives on the lungs.
And a recent study also showed that higher voltage e-cigs produce A LOT of formaldehyde.
These issues are legitimate.
BUT as toxic as inhaling a lung full of formaldehyde is, it still pales in comparison to a lung full of a conventional cigarette smoke with its 4500 chemicals, carcinogens and toxins (including formaldehyde, tar, cyanide, arsenic and DDT).
Being firmly in the harm reduction camp, my opinion has been that the larger medical community is burying its collective head in the sand with regard to the utility of e-cigs as a safer alternative to tobacco. Are they suggesting we ban e-cigarettes and keep tobacco? Doesn’t make sense to me. Yes, regulate e-cigarette “juice” (the nicotine/flavor mixture used in the device), which is often imported from China and has been demonstrated to contain harmful (and unknown) compounds in addition to nicotine. But if a tobacco cigarette smoker is willing to switch, it’s a better choice.
And then I started looking a little more closely at the few patients in my practice using e-cigs.
Samantha is 47. She has a 20-pack-year history of smoking, stopped for a decade, then started again. In an effort to quit, she recently switched to e-cigarettes. I wasn’t particularly surprised or concerned when anxiety emerged while she was going through a recent stressful event, given her history of mild anxiety. I expected we’d see improvement as life events resolved. But instead, in addition to the anxiety, she began complaining of low-grade nausea, headaches and rather severe brain fog. The brain fog was impacting her ability to work, she stated.
As we spoke, Samantha revealed that she was using the e-cigarettes far more often than she had the tobacco cigarettes. She smoked in her car, in bed, while watching TV, when out with friends, while cooking dinner, and on and on.
Turns out, Samantha had pretty quickly increased the use of e-cigs many times over that of tobacco cigarettes.
She explained that the lack of odor and smoke made it possible for her to use the e-cigarette virtually all of the time. Because of the reduced toxicity from e-cigs, she didn’t think this increased smoking was a big problem. Initially, she stated, she noted a reduction in her anxiety with the e-cigarettes; but overtime, everything seemed to worsen.
It’s thought that the nicotine in e-cigs is much less than that of tobacco cigarettes. However, there is significant variability among products and how they are used by the smoker (i.e., how deeply the e-cig is inhaled). Some studies demonstrate blood nicotine levels comparable to tobacco smokers. These trials generally compare discrete time periods using an e-cig that mimic the duration of smoking a regular cigarette.
What these trials miss, though, and what I haven’t seen addressed elsewhere, is the potential for incessant use of e-cigarettes given their acceptability, and the development of chronic, low grade nicotine toxicity.
In addition to the non-nicotine toxins, chronic, low grade nicotine toxicity will probably be a huge issue with some e-cig users.
So while I am all for harm reduction, we need to be vigilant against creating new harms in our efforts to reduce old ones….
Back to Samantha. I explained to Samantha that I thought her symptoms were the result of nicotine toxicity. She was loath to let the e-cigarettes go, but did eventually transition to the patch with the expectation of fully tapering from nicotine. Her brain fog, headaches, anxiety and nausea? Gone. Almost immediately after stopping e-cigs.
Another quick case. Lucy is 44 and has ulcerative colitis. She’s a new patient. At the time she scheduled, she was in a terrible flare up, having lost 11 pounds from her already petite 5’ 1”, 110 pound frame over the course of about six weeks. By the time I saw her, however, she said she was 80% better: less pain, bleeding, diarrhea and no more weight loss. Her *cure*? E-cigarettes, she says. She started smoking at the suggestion of her girlfriend (who read about it online) and noticed an almost immediate benefit.
Arguably, e-cigs are not the best approach for UC. But who can blame Lucy for her choice? And there is a pretty good body of literature on nicotine and UC. For now, while we start the process of “drilling down” into what’s causing her UC, Lucy will continue with the e-cigs in a controlled way.