Smoke and Mirrors The Perils of Water-Pipe Smoking and Implications for Western Countries Janice M. Leung, MD Don D. Sin, MD, MPH, FCCP Vancouver, BC, Canada
Nicotine is addictive and dangerous.1 Similar to heroin and cocaine, it possesses both stimulant and relaxant properties and alters mood. When smoked, nicotine reaches the brain within 7 s where it cajoles the midbrain to unleash an army of chemical messengers, such as dopamine and b-endorphins, that induce (pleasant) psychotropic effects.1 With repeated use, there is downregulation of these chemoreceptors, leading to desensitization and habituation and coaxing individuals to smoke increasing numbers of cigarettes to achieve similar central effects. Attempts to quit cause very unpleasant withdrawal symptoms that compel smokers to take up the habit again.1 Globally, cigarette smoking kills 6 million people per year.2 Despite the known health hazards of tobacco, there remain . 1 billion smokers worldwide with one-third living in China.2 In response, governments around the world have implemented various measures to curb smoking rates, including high taxation of cigarettes and smoking bans in indoor workplaces, public transport systems, and shopping centers.2 Although these efforts have been effective in reducing smoking rates in westernized countries, alternative modes of nicotine delivery are rapidly gaining popularity and usurping the vacuum left behind by cigarettes.3 These devices have received far less scientific or regulatory scrutiny and are being promulgated widely to the public on the implicit notion that they are safe.
AFFILIATIONS: From the University of British Columbia James Hogg Research Centre (Drs Leung and Sin); and Division of Respirology (Dr Sin), St. Paul’s Hospital. FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. CORRESPONDENCE TO: Don D. Sin, MD, MPH, FCCP, University of British Columbia James Hogg Research Centre, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada; e-mail: [email protected] © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-0603
journal.publications.chestnet.org
Against this backdrop of uncertainty, the study by She et al4 published in this issue of CHEST (see page 924) is a cautionary tale on smoking devices that for now escape regulatory scrutiny and the fury of public health campaigns. In this study, the authors reveal the considerable (and previously underestimated) dangers that come with water-pipe smoking, with COPD being 10 times more likely to develop in water-pipe smokers than in nonsmokers. Alarmingly, this relative risk is larger than that imposed by cigarette smoking and, similar to cigarettes, exposes innocent bystanders (mostly family members) to secondhand smoke. These data contradict and confront the widely held public misconception that Chinese water pipes are somehow safer than traditional cigarettes because they lack charcoal. Indeed, the present study shows that water pipes expose individuals to greater levels of carbon monoxide, heavy metals, and polycyclic aromatic hydrocarbons than cigarettes. These data unequivocally put to rest (with an exclamation mark) the notion that the water filtration system of Chinese water pipes protects smokers from harm. Although the use of water pipes is rare outside of China, the present study nonetheless provides some important lessons for those living in western countries. The findings by She et al4 highlight how little we know about safety when it comes to alternative smoking devices and, furthermore, how inadequate current public health regulations are in combating the potential harm related to these devices. For instance, in the United States, there is an epidemic of hookah smoking and, most importantly, e-cigarette smoking. Despite valiant efforts to ban cigarette smoke in public locations like restaurants and bars in recent years, little legislation exists to ban these forms of smoking. Hookah smoking, related to water-pipe smoking, is associated with higher rates of COPD and lung cancer than conventional cigarette smoking,5 yet it is allowed to continue unabated in 90% of the American cities that have enacted cigarette smoking bans.6 The laxity surrounding the hookah flies in the face of clear and compelling scientific evidence that hookah smoke carries four times as many polycyclic aromatic hydrocarbons and aldehydes as cigarette smoke.7 Similarly, tough advertising policies that restrict tobacco companies have yet to be applied to the e-cigarette industry, which alone spent $20.8 million on advertising in 2012 (a number that has since grown considerably)8 and whose sales now top $1.7 billion, with the fastest growth among young students.9 In spite of the dearth of evidence regarding their safety, the
875
allowance of television advertising for e-cigarettes with glamorous and beautiful Hollywood stars and the frequent (and potentially misleading) message of harm reduction in online e-cigarette advertisements10 pose a serious challenge for public health advocates today. There are no long-term studies evaluating the risk of COPD, lung cancer, and cardiovascular disease from smoking e-cigarettes. In the meantime, there are credible reports that e-cigarettes produce inconsistent amounts of nicotine in products inaccurately labeled by manufacturers,11 not to mention heavy metals,12 silicate particles,12 and diethylene glycol.11 The argument that e-cigarettes may help cigarette smokers to quit is, at this time, simply not established enough in the scientific literature13 to permit unregulated sales and advertising. Until studies similar to that of She et al4 evaluate the long-term health risks associated with alternative smoking devices, we call upon legislators to toughen their stance against the tobacco industry, including those that manufacture and disseminate e-cigarettes. In this vein, we applaud the recent regulations set in place by the European Union that will ban the advertising of e-cigarettes beginning in 2016, compel manufacturers to print explicit health warnings on packaging, and limit the amount of nicotine in each product. In North America, such proposals are glaringly absent but hopefully forthcoming. To begin with, the 2010 federal appeals court decision striking down the US Food and Drug Administration’s attempt to categorize e-cigarettes as drug-delivery devices must be reversed, particularly if claims that e-cigarettes can reduce tobacco smoking rates continue to be promoted unchecked. This would subject e-cigarettes to the same rigorous scientific testing that all health-care devices are required to undergo by the Food and Drug Administration. Furthermore, the same advertising restrictions placed on cigarette manufacturers should apply to e-cigarettes, at least until further information is known about their downstream health effects. These welcome regulations, however, would only touch upon the ever-growing landscape of smoking products. Water pipes, hookah, and e-cigarettes still remain uncharted territory for the public health arena. The study by She et al4 is a sobering reminder that safe modes of nicotine delivery may be an illusion. Until safety is firmly established with credible and robust scientific data, noncigarette-based nicotine delivery devices must be regulated, taxed (at a high rate), and sold only to adult smokers. Without such provisions, today’s dream of safety will turn into a public health nightmare tomorrow.
876 Editorials
References 1. Benowitz NL. Nicotine addiction. N Engl J Med. 2010;362(24): 2295-2303. 2. World Lung Foundation. The Tobacco Atlas. 4th ed. World Lung Foundation website. http://www.tobaccoatlas.org. Accessed March 12, 2014. 3. Centers for Disease Control and Prevention. Notes from the field: electronic cigarette use among middle and high school studentsUnited States, 2011-12. MMWR. 2013;62(35):729-730. 4. She J, Yang P, Wang Y, et al. Chinese water-pipe smoking and the risk of COPD. Chest. 2014;146(4):924-931. 5. Blachman-Braun R, Del Mazo-Rodríguez RL, López-Sámano G, Buendía-Roldán I. Hookah, is it really harmless? Respir Med. 2014; 108(5):661-667. 6. Primack BA, Hopkins M, Hallett C, et al. US health policy related to hookah tobacco smoking. Am J Public Health. 2012;102(9):e47-e51. 7. Daher N, Saleh R, Jaroudi E, et al. Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: sidestream smoke measurements and assessment of second-hand smoke emission factors. Atmos Environ (1994). 2010;44(1):8-14. 8. Elliott S. E-cigarette makers’ ads echo tobacco’s heyday. The New York Times. August 29, 2013:B1. 9. Richtel M. E-cigarettes, by other names, lure young and worry experts. The New York Times. March 4, 2014:A1. 10. Richardson A, Ganz O, Vallone D. Tobacco on the web: surveillance and characterisation of online tobacco and e-cigarette advertising [published online ahead of print February 14, 2014]. Tob Control. doi:10.1136/tobaccocontrol-2013-051246. 11. Westenberger B. Evaluation of e-Cigarettes. St. Louis, MO: Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research, Division of Pharmaceutical Analysis; 2009. 12. Williams M, Villarreal A, Bozhilov K, Lin S, Talbot P. Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PLoS One. 2013;8(3):e57987. 13. Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet. 2013;382(9905):1629-1637.
From the Echo Bed to the Pulmonary Vascular Bed Dobutamine Testing in the Noninvasive Laboratory Lawrence G. Rudski, MD Eduardo Bossone, MD, PhD, FCCP David Langleben, MD Montreal, QC, Canada
Cardiovascular physiology, in its simplest form, can be summed up by two very basic equations: right 5 left and V 5 IR (where V indicates voltage, and IR indicates the product of current and resistance). The former equation states that, in the absence of shunt, the left heart can only pump what it receives from the right. The latter equation, Ohm’s law, is transposed in cardiology as pressure 5 flow 3 resistance. In vivo, of course, this relationship is
[
146#4 CHEST OCTOBER 2014
]
Nicotine is addictive and dangerous.1 Similar to heroin and cocaine, it possesses both stimulant and relaxant properties and alters mood. When smoked, nicotine reaches the brain within 7 s where it cajoles the midbrain to unleash an army of chemical messengers, such as dopamine and b-endorphins, that induce (pleasant) psychotropic effects.1 With repeated use, there is downregulation of these chemoreceptors, leading to desensitization and habituation and coaxing individuals to smoke increasing numbers of cigarettes to achieve similar central effects. Attempts to quit cause very unpleasant withdrawal symptoms that compel smokers to take up the habit again.1 Globally, cigarette smoking kills 6 million people per year.2 Despite the known health hazards of tobacco, there remain . 1 billion smokers worldwide with one-third living in China.2 In response, governments around the world have implemented various measures to curb smoking rates, including high taxation of cigarettes and smoking bans in indoor workplaces, public transport systems, and shopping centers.2 Although these efforts have been effective in reducing smoking rates in westernized countries, alternative modes of nicotine delivery are rapidly gaining popularity and usurping the vacuum left behind by cigarettes.3 These devices have received far less scientific or regulatory scrutiny and are being promulgated widely to the public on the implicit notion that they are safe.
AFFILIATIONS: From the University of British Columbia James Hogg Research Centre (Drs Leung and Sin); and Division of Respirology (Dr Sin), St. Paul’s Hospital. FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. CORRESPONDENCE TO: Don D. Sin, MD, MPH, FCCP, University of British Columbia James Hogg Research Centre, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada; e-mail: [email protected] © 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-0603
journal.publications.chestnet.org
Against this backdrop of uncertainty, the study by She et al4 published in this issue of CHEST (see page 924) is a cautionary tale on smoking devices that for now escape regulatory scrutiny and the fury of public health campaigns. In this study, the authors reveal the considerable (and previously underestimated) dangers that come with water-pipe smoking, with COPD being 10 times more likely to develop in water-pipe smokers than in nonsmokers. Alarmingly, this relative risk is larger than that imposed by cigarette smoking and, similar to cigarettes, exposes innocent bystanders (mostly family members) to secondhand smoke. These data contradict and confront the widely held public misconception that Chinese water pipes are somehow safer than traditional cigarettes because they lack charcoal. Indeed, the present study shows that water pipes expose individuals to greater levels of carbon monoxide, heavy metals, and polycyclic aromatic hydrocarbons than cigarettes. These data unequivocally put to rest (with an exclamation mark) the notion that the water filtration system of Chinese water pipes protects smokers from harm. Although the use of water pipes is rare outside of China, the present study nonetheless provides some important lessons for those living in western countries. The findings by She et al4 highlight how little we know about safety when it comes to alternative smoking devices and, furthermore, how inadequate current public health regulations are in combating the potential harm related to these devices. For instance, in the United States, there is an epidemic of hookah smoking and, most importantly, e-cigarette smoking. Despite valiant efforts to ban cigarette smoke in public locations like restaurants and bars in recent years, little legislation exists to ban these forms of smoking. Hookah smoking, related to water-pipe smoking, is associated with higher rates of COPD and lung cancer than conventional cigarette smoking,5 yet it is allowed to continue unabated in 90% of the American cities that have enacted cigarette smoking bans.6 The laxity surrounding the hookah flies in the face of clear and compelling scientific evidence that hookah smoke carries four times as many polycyclic aromatic hydrocarbons and aldehydes as cigarette smoke.7 Similarly, tough advertising policies that restrict tobacco companies have yet to be applied to the e-cigarette industry, which alone spent $20.8 million on advertising in 2012 (a number that has since grown considerably)8 and whose sales now top $1.7 billion, with the fastest growth among young students.9 In spite of the dearth of evidence regarding their safety, the
875
allowance of television advertising for e-cigarettes with glamorous and beautiful Hollywood stars and the frequent (and potentially misleading) message of harm reduction in online e-cigarette advertisements10 pose a serious challenge for public health advocates today. There are no long-term studies evaluating the risk of COPD, lung cancer, and cardiovascular disease from smoking e-cigarettes. In the meantime, there are credible reports that e-cigarettes produce inconsistent amounts of nicotine in products inaccurately labeled by manufacturers,11 not to mention heavy metals,12 silicate particles,12 and diethylene glycol.11 The argument that e-cigarettes may help cigarette smokers to quit is, at this time, simply not established enough in the scientific literature13 to permit unregulated sales and advertising. Until studies similar to that of She et al4 evaluate the long-term health risks associated with alternative smoking devices, we call upon legislators to toughen their stance against the tobacco industry, including those that manufacture and disseminate e-cigarettes. In this vein, we applaud the recent regulations set in place by the European Union that will ban the advertising of e-cigarettes beginning in 2016, compel manufacturers to print explicit health warnings on packaging, and limit the amount of nicotine in each product. In North America, such proposals are glaringly absent but hopefully forthcoming. To begin with, the 2010 federal appeals court decision striking down the US Food and Drug Administration’s attempt to categorize e-cigarettes as drug-delivery devices must be reversed, particularly if claims that e-cigarettes can reduce tobacco smoking rates continue to be promoted unchecked. This would subject e-cigarettes to the same rigorous scientific testing that all health-care devices are required to undergo by the Food and Drug Administration. Furthermore, the same advertising restrictions placed on cigarette manufacturers should apply to e-cigarettes, at least until further information is known about their downstream health effects. These welcome regulations, however, would only touch upon the ever-growing landscape of smoking products. Water pipes, hookah, and e-cigarettes still remain uncharted territory for the public health arena. The study by She et al4 is a sobering reminder that safe modes of nicotine delivery may be an illusion. Until safety is firmly established with credible and robust scientific data, noncigarette-based nicotine delivery devices must be regulated, taxed (at a high rate), and sold only to adult smokers. Without such provisions, today’s dream of safety will turn into a public health nightmare tomorrow.
876 Editorials
References 1. Benowitz NL. Nicotine addiction. N Engl J Med. 2010;362(24): 2295-2303. 2. World Lung Foundation. The Tobacco Atlas. 4th ed. World Lung Foundation website. http://www.tobaccoatlas.org. Accessed March 12, 2014. 3. Centers for Disease Control and Prevention. Notes from the field: electronic cigarette use among middle and high school studentsUnited States, 2011-12. MMWR. 2013;62(35):729-730. 4. She J, Yang P, Wang Y, et al. Chinese water-pipe smoking and the risk of COPD. Chest. 2014;146(4):924-931. 5. Blachman-Braun R, Del Mazo-Rodríguez RL, López-Sámano G, Buendía-Roldán I. Hookah, is it really harmless? Respir Med. 2014; 108(5):661-667. 6. Primack BA, Hopkins M, Hallett C, et al. US health policy related to hookah tobacco smoking. Am J Public Health. 2012;102(9):e47-e51. 7. Daher N, Saleh R, Jaroudi E, et al. Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: sidestream smoke measurements and assessment of second-hand smoke emission factors. Atmos Environ (1994). 2010;44(1):8-14. 8. Elliott S. E-cigarette makers’ ads echo tobacco’s heyday. The New York Times. August 29, 2013:B1. 9. Richtel M. E-cigarettes, by other names, lure young and worry experts. The New York Times. March 4, 2014:A1. 10. Richardson A, Ganz O, Vallone D. Tobacco on the web: surveillance and characterisation of online tobacco and e-cigarette advertising [published online ahead of print February 14, 2014]. Tob Control. doi:10.1136/tobaccocontrol-2013-051246. 11. Westenberger B. Evaluation of e-Cigarettes. St. Louis, MO: Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research, Division of Pharmaceutical Analysis; 2009. 12. Williams M, Villarreal A, Bozhilov K, Lin S, Talbot P. Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PLoS One. 2013;8(3):e57987. 13. Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet. 2013;382(9905):1629-1637.
From the Echo Bed to the Pulmonary Vascular Bed Dobutamine Testing in the Noninvasive Laboratory Lawrence G. Rudski, MD Eduardo Bossone, MD, PhD, FCCP David Langleben, MD Montreal, QC, Canada
Cardiovascular physiology, in its simplest form, can be summed up by two very basic equations: right 5 left and V 5 IR (where V indicates voltage, and IR indicates the product of current and resistance). The former equation states that, in the absence of shunt, the left heart can only pump what it receives from the right. The latter equation, Ohm’s law, is transposed in cardiology as pressure 5 flow 3 resistance. In vivo, of course, this relationship is
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146#4 CHEST OCTOBER 2014
]
