KARL MARTIN SALCEDO MD 2020
Cigarette smoking remains the leading cause of preventable mortality worldwide, contributing to the death of approximately 480,000 Americans annually. Since its ugly side effects have surfaced, countless cessation efforts have been tried and largely failed to address the wealth of behavioral and social components to cigarette addiction. (franck, filon, kimmelman, grad, & eisenberg, 2016) We are facing the biggest public health threat the world has ever faced and we need all the help we could get. (WHO, 2019)
The WHO recommends using the 5A’s of intervention when dealing with smokers. The first “A” stands for ASK where every health care provider should ask every patient regarding his smoking status every visit. At this point a lot of health care providers have already failed. (WHO, 2019)
Coleman shares with us the general practitioner’s reasons for not giving smoking advise: (1) Patients are often not motivated to stop (2) Patients often don’t listen to advice (3) Stopping smoking is often not a priority for smokers (4) Lack of time (5) Unwanted advice can annoy patients (6) Difficult to impress on patients the importance of not smoking (7) Do not know how to deal with smokers who are not motivated to stop. (coleman, 2004) This list mostly deals with the physician’s ability to give advice and convince smokers to but another aspect was not listed.
It is not uncommon for some health professionals to use the old fashioned combustible cigarettes. According to a study published in 2010, the prevalence of smoking among health professionals in Italy is 44%, more than double that of the general population, and this is not only due to the high prevalence in nurses (48.2%), but it is also observed in medical doctors (33.9%), medical students (35%) and postgraduate students (52.9%) (Cattaruzza & west, 2013)
According to a local study by both cardiologists and pulmonologists recognize their roles as examples to their patients and to the community and that there is no significant difference between smokers and non-smokers in their knowledge, attitudes and practices towards smoking and smoking cessation. Physicians who do not smoke are more likely than those who do to provide advice to quit. (Jorge, 2001)
This finding is not peculiar to Italy, as high prevalence of smoking (>29%) was also observed among medical students in Spain, Poland and Germany. Two different patterns of physician smoking prevalence seem to exist. (Cattaruzza & west, 2013)
The first applies to most developed countries that have experienced a steady decline, like USA, Australia and UK. Doctors have notably been among the first to reduce their smoking rate (now <10%), usually preceding a decrease in smoking rate among the general public. However, trends are not uniform across all countries, and there are important exceptions like Italy, France and Japan, where physician smoking prevalence rates are >25%. On the other hand, some newly developing countries like China, Bosnia/Herzegovina, Turkey and India have high male smoking prevalence rates, approximately 50%. (Cattaruzza & west, 2013)
This is a key problem from a public health perspective, not only because the physician is an important model for patients, colleagues and medical students, but also because physicians’ personal use of tobacco impairs interactions with patients about smoking. (Cattaruzza & west, 2013)
Statistically significant associations have been observed between physician’s smoking status and beliefs and clinical practice in an international survey of general and family practitioners. It is reported that smoking doctors were significantly less likely to view smoking as harmful than their nonsmoking colleagues and less likely to discuss smoking at each patient visit. In Italy, in 2012, only 14% of smokers had received unsolicited advice to quit by their physicians. This percentage has declined from 20% in 2009, and smokers are less likely to receive such advice when their physicians are smokers (Cattaruzza & west, 2013)
In many countries, the prevalence of tobacco smoking among health professionals is extremely high, more than other professional categories, and this could be partly attributed to a low weight that tobacco smoking has in the medical curriculum of future physicians, which will contribute in a determinant way to healthy choices of their patients. (Cattaruzza & west, 2013)
The three reasons for smoking in the general population is social goads, associative processes and craving but for health care professionals the most important is cognitive enhancement. Studies have shown that nicotine can improve attention and vigilance and they usually smoke to increase their cognitive abilities either above their baseline ability or to restore their cognitive abilities after nicotine deprivation. Other reasons for smoking among health care professionals are social goads, positive and negative reinforcement and affiliative attachment. (Tan & Dy-Agra, 2009)
Despite the massive evidence against combustible smoking. This public health threat is still far from gone but recently, all eyes are turned to the Electronic cigarette which was developed by a Chinese pharmacist named Hon Lik after his father died of lung cancer. (kim, yoo, & cho, 2018) (Consumer advocatesfor smoke free alternatives, 2019) The electronic cigarettes, also known as e-cigarettes, e-vaporizers, or electronic nicotine delivery systems, are battery-operated devices that people use to inhale an aerosol, which typically contains nicotine flavorings, and other chemicals. (Department of Health, 2019) It has been argued that the use of e-cigarettes may help smokers quit smoking or reduce tobacco consumption by relieving withdrawal symptoms or replacing some rituals associated with smoking habits. (kim, yoo, & cho, 2018)
It has been 16 years since then and the newer generations of the e-cigarette have been evolving more and more, making their products more enticing to the public and health sector as a smoking cessation tool. According to the 2014 TUS-CPS (Tobacco Use Supplement of the Current Population Survey), a large scale, online, nationally representative survey including about 54,000 households and over 150,000 individuals in the US, the prevalence of ever E-cigarette smokers was 7.7%, current smokers (at least 1 of the last 30 days) is 2.1% and regular smokers (at least 20 of the last 30 days) is 0.9%. This implies that 27.0% of ever users were current users of which 45.3% were regular users. (david, yuan, & li, 2017)
Considering the exponential growth in awareness and use of e-cigarettes coupled with aggressive marketing by tobacco companies, physicians are increasingly engaging patients who smoke cigarettes in conversations relating to the use of e-cigarettes (franck, filon, kimmelman, grad, & eisenberg, 2016)
The problem is that conflicting research results regarding the efficacy of e-cigarette use raise a question on its safety. There is a concern that e-cigarette use will lead non-smokers to smoke or weaken the willingness of smokers to quit. (kim, yoo, & cho, 2018) E-cigarettes are also believed to have similar toxicity as existing nicotine replacement therapies but the generalizability of these findings remains unclear given the absence of standardized manufacturing practices and the proprietary nature of industry studies. (franck, filon, kimmelman, grad, & eisenberg, 2016)
The public health community remains divided concerning the appropriateness of endorsing a device whose safety and efficacy for smoking cessation remain unclear. Many of the physicians lack the required knowledge and familiarity to provide informed and consistent advice for patients and their families. (franck, filon, kimmelman, grad, & eisenberg, 2016) In one study, 38.5% of current E cigarette smokers believed the U.S. Food and Drug Administration had approved e-cigarettes for cessation, and 18% reported a provider had supported e-cigarettes as a cessation aid. (Brown-Johnson, et al., 2016)
On April 10th 2019, the Philippine FDA issued an advisory that E cigarettes is not a proven nicotine replacement therapy and reiterating the WHO's statement that there is no scientific evidence to confirm the product’s safety and efficacy. WHO Tobacco-Free Initiative Officer Dr. Florante E. Trinidad, during the ASEAN Regional Forum on NCDs stated that more studies should be conducted to establish the safety of electronic cigarettes as a consumer product. (Department of Health , 2019)
In a study on the prevalence of e-cigarette use among medical students in Germany and Hungary, Prevalence of use was 0.9% (95% CI 0.5–1. 2%) with only 12 daily users (0.4%). Slightly more than one-third of the e-cigarette users considered their health status to be very good or excellent. (balogh, et al., 2018)
This makes us wander if the road of E-cigarettes will lead us to the same outcome as combustible smoking or is it the remedy we are waiting for, to help us overcome combustible smoking. E-cigarettes remain an enigma for public health and a call for more studies in the matter is being promoted. The question is, will we be late again in addressing the issue?
The Philippine government has been vocal in its stand against vaping. It has banned vaping in public places and eyes equal taxation with combustible cigarettes but a former official from the WHO claimed that E cigarettes are less harmful than traditional cigarettes and that Filipinos should not be deprived of the chance to quit smoking using these products. (Department of Health, 2019)
Sources:
(2019, April). Retrieved from Department of Health : https://www.doh.gov.ph/node/64
balogh, e., faubl, n., reimenshnieder, h., balazs, p., bergman, a., Cseh, k., . . . kiss, i. (2018). Cigarette, waterpipe and e-cigarette use among an international sample of medical students. Cross-sectional multicenter study in Germany and Hungary . BMC Public Health, 1-10.
Brown-Johnson, c., Burbank, a., daza, e., wassmann, a., chieng, a., rutledge, g., & prochasca, j. (2016). Online Patient–Provider E-cigarette Consultations. american journal of preventive medicine, 882-889.
Cattaruzza, M., & west, R. (2013). Why do doctors and medical students smoke when they must know how harmful it is? European Journal of Public Health, 189-190.
coleman, t. (2004). Cessation interventions in routine health care. british medical journal.
Consumer advocatesfor smoke free alternatives. (2019). A Historical Timeline of Electronic Cigarettes. Retrieved from A Historical Timeline of Electronic Cigarettes.
david, l., yuan, z., & li, y. (2017). The Prevalence and Characteristics of E-Cigarette Users in the U.S. international journal of environmental research and public, 1-17.
Department of Health. (2019, november 15). Electronic cigarette. Retrieved from Department of health: doh.gov.ph/node/64
franck, c., filon, k., kimmelman, j., grad, r., & eisenberg, m. (2016). Ethical considerations of E-cigarette use for tobacco harm reduction. Respiratory research, 1-9.
Garfinkel, L., & Stellman, s. (1986). Cigarette Smoking among physicians, dentists, and nurses. CA-A CANCER JOURNAL FOR CLINICIANS.
Geletko, k., myers, k., Brownstein, n., jameson, b., lopez, d., sharpe, a., & bellamy, g. (2016). Medical Residents’ and Practicing Physicians’ e-Cigarette Knowledge and Patient Screening Activities: Do They Differ? Health Services Research and Managerial Epidemiology , 1-6.
(2015). Global Adult Tobacco Survey: Country Report 2015. Department of Health.
Habib,, E., Helaly, M., Eishaer, A., Ahmad, M., Mohamed, M., & Obeidat, a. (2020). Prevalence and perceptions of e-cigarette use among medical students in a Saudi University. Journal of Family Medicine and Family Care.
Jorge. (2001). Knowledge, Attitudes and Practices of Pulmonologists and Cardiologists on Smoking and Smoking Cessation. Phil. J. Int Med,.
Jr., W. C. (n.d.). Medical Definition of Hippocratic Oath. Retrieved from medicinenet: https://www.medicinenet.com/script/main/art.asp?articlekey=20909
Kanchustambham , V., Saladia, S., Rodrigues, J., Fernandes, H., patolia, s., & santosh, s. (2017). The knowledge, concerns and healthcare practices among physicians regarding electronic cigarettes. JOURNAL OF COMMUNITY HOSPITAL INTERNAL MEDICINE PERSPECTIVE, 144-150.
kim, b., yoo, s., & cho, S. (2018). Association between stages of change for smoking cessation and electronic cigarette use among adult smokers: A nationwide cross-sectional study in Korea. Plos one, 1-11.
Meshefedjian, G., Gervais, A., Tremblay, M., Villanueve, D., & O'Loughlin, J. (2010). Physician Smoking Status May Influence Cessation Counseling. REVUE CANADIENNE DE SANTÉ PUBLIQUE .
organization, W. h. (2019). tobacco. Retrieved from https://www.who.int/news-room/fact-sheets/detail/tobacco
Pentz, R., & Berg, C. (2010). Smoking and Ethics: What Are the Duties of Oncologists? The Oncologist.
Salgado, M., Mejia, R., Kplan, C., & Stable, E. (2016). Smoking-Related Attitudes and Knowledge Among Medical students and recent graduates in argentina. Society of General Internal Medicine.
sheratt, f., newson , l., & field, j. (2016). Electronic cigarettes: a survey of perceived patient use and attitudes among members of the British thoracic oncology group. Respiratory research, 1-8.
Sherratt, Sherratt, f., newson, l., & field, j. (2016). Electronic cigarettes: a survey of perceived patient use and attitudes among members of the British thoracic oncology group. respiratory research, 1-8.
shin, w., kim, y., & kim, s. (2016). Lung cancer specialist physicians’ attitudes towards e-cigarettes: A nationwide survey. PLOS, 1-11.
Tan, M. L., & Dy-Agra, G. (2009). SMOKING BEHAVIOR AND PRACTICES AND SMOKING CESSATION. Phil. J. Internal Medicine, 129-135.
van Gucht, d., & baeyens, f. (2016). Health professionals in Flanders perceive the potential health risks of vaping as lower than those of smoking but do not recommend using e-cigarettes to their smoking patients. harm Reduction journal, 1-8.
WHO. (2019). TOBACCO. Retrieved from https://www.who.int/health-topics/tobacco