E-cigarettes – deterrent or path to addiction

Recently, the CDC published its 2014 National Youth Tobacco Survey – which looks at smoking in middle and high school students in the US.  As a physician, but more as a parent of a newly minted teenager, the results were of great interest – and concern.  While cigarette use declined in high school students, e-cigarettes and hookah use tripled – and surpassed cigarette use for the first time.  E-cigarettes are not regulated by the FDA or subject to current tobacco marketing laws – allowing companies to market directly to teens with flavors more like candy than tobacco – something traditional tobacco companies have not been able to do since the 1970s.
The increase is not surprising – e-cigarettes are marketed as safer, they are easier to access and less expensive than cigarettes.  The real question, and one that comes up frequently in the office, is if they can help people quit smoking regular cigarettes, and are they safer?

Are e-cigarettes safer? 

There is not great data available yet.  What we do know is that the vapor produced contains particles that can irritate the lungs, and that it contains chemical byproducts such as formaldehyde – but in much lower concentrations than traditional cigarettes.  They also contain nicotine, the same addictive drug in cigarettes.  Nicotine affects brain development, may promote tumor growth and interfere with chemotherapy.  Nicotine also constricts blood vessels and increases blood pressure.  That increases stresses on any plaque buildup in a blood vessel – a precursor to heart attack and stroke.

Do e-cigarettes help you quit?

Again, the studies are still in progress.  There is some data that smokers who switch to e-cigarettes refrain from tobacco longer than those who try to quit while still using tobacco.  Neither the World Health Organization or the American Heart Association recommend e-cigarettes as a smoking cessation method.  There is no information yet as to whether those who switch to e-cigarettes quit nicotine completely, or have simply switched from one addiction to another.

How does this affect us?

So, while we await studies to more definitively address the safety question, what am I telling patients about safety?  Obviously, the best choice is not using any nicotine product.  If you are deciding between tobacco and e-cigarettes, it is reasonable (but not proven) to assume there is a lower lung cancer risk with e-cigarettes, but no data on oral or head and neck cancer.  However, since there is nicotine in both products, I advise people that there is still similar heart disease risk.  There is also no path to stopping e-cigarettes, unlike other nicotine replacement methods like the nicotine patch – which gradually reduces the dose delivered.  Studies are ongoing, so hopefully we get good information to make healthy decisions.  In the meanwhile, the FDA is seeking ability to regulate these products, and limit their marketing to children.
The path to wellness begins with a proper diagnosis

Addiction and Substance Abuse

Of all the illnesses I treat, conditions I diagnose and problems I am presented with, one of the most difficult is addiction. Addiction can be to many things – alcohol, illegal drugs, prescription drugs, smoking, food, exercise, gambling and other behaviors. Addiction affects not only the person involved, but their entire network of friends and family.

One of the biggest challenges in diagnosing addiction is that the person may not admit there is a problem. A family member may speak to me, but the conversation usually ends with – “don’t tell them I spoke to you, I just wanted you to know what is happening…” I can not force a patient to come speak to me, nor can I tell that family member anything about what I may have discussed with the patient (without their permission). After awhile, their addiction becomes a palpable element in the room that no one can speak about. I will ask about it, but if the patient will not acknowledge an issue, there is little to be done.

What causes addiction?

Addiction is defined as a chronic, relapsing disease characterized by compulsive drug seeking and use despite harmful consequences as well as neuro-chemical and molecular changes in the brain.    Addiction crosses lines of race, economics and education.  In 2010 it was the 15th leading cause of death in the United States.

When exposed to a potentially addicting substance, the brain produces a substance called dopamine.  This activates the brain’s “reward circuitry” which will begin to create cravings.  Some people are genetically predisposed to be more susceptible to this, so addiction can run in families.

In addiction to the reward center, cognition and understanding are affected.  The prefrontal cortex of the brain – the higher brain involved in thinking and reasoning becomes affected as well.  A phenomenon called Restricted Awareness occurs – the addicted person becomes unable to fully grasp the deficits their behavior has created – so there is a neuro-chemical issue and not just denial at work.  Similar changes are triggered by high fat/high sugar foods as are by drugs.

Drugs of abuse - from the National Institute of Drug Abuse
Drugs of abuse – from the National Institute of Drug Abuse

Physical effects of addiction

The changes in the brain are consistent across substances.  Different substances can have different effects on other parts of the body.  While this is not a comprehensive list, some commonly abused substances and their physical consequences are:

  • Marijuana can damage the lungs just as cigarettes do
  • Cocaine increases plaque building in the arteries, increasing the risk of heart attacks
  • Heroin suppresses breathing
  • Prescription pain killers slow down the digestive system, as well as potentially cause liver and kidney damage
  • Alcohol damages the liver
  • Any drug that is injected, especially when needles are shared, increases the risk of Hepatitis B and C (which can cause liver failure and liver cancer) as well as HIV

How is addiction treated?

Treatment for addiction begins with a patient recognizing that their behavior is affecting their life in a negative way, and that they are unable to control it without help.  Treatment programs can be inpatient – meaning admission to a facility for detoxification and treatment with 24/7 monitoring or outpatient – meaning going to appointments with physicians and counselors while remaining in the community.

Regardless of the setting, treatment involves

  • Detoxification – stopping the substance of abuse and treating physical withdrawal
  • Counseling to help the addicted person process what they have been through and develop coping strategies for the stresses that led to the addiction
  • Medications may be used either short or long-term to block the effects of drugs of abuse, prevent activation of the rewards center in the brain or treat other issues related to substance abuse

Successful treatment can reverse the brain changes that occur with addiction, just as smoking cessation reduces the risk of heart attack, stroke and lung cancer.

Brain scan showing near normal activity after14 months of sobriety
Brain scan showing near normal activity after 14 months of sobriety. Source: National Institute of Drug Abuse


How does this affect us?

Substance abuse takes many forms, and I need to be alert to signs that there may be issues – clues from behavior as well as physical findings.  Direct questions from a physician are usually answered with some truth.  That can begin a conversation about starting a treatment program.

In the case of prescription drug abuse, physicians have some additional tools.  Several states have databases that physicians can register for to see if prescriptions are being filled by multiple doctors and from which pharmacies and on what dates.  When you can show a person what their behavior has been, it again can be the beginnings of help.  A physician also needs to have a plan about stopping addictive prescriptions to prevent or end the cycle of abuse a person is in.  As a friend of mine who once became addicted to prescription pain killers told me that he hoped that a doctor would “catch” him so that he could get the help he knew he needed but did not know how to ask for.

If you or someone you know needs help:

National Institute of Health information of drugs of abuse – http://www.drugabuse.gov/publications/term/160/InfoFacts

Narcotics Anonymous – https://www.na.org

Or see your physician and ask for help!

The path to wellness begins with a proper diagnosis