Electronic Cigarettes—Patient Safety Concerns Rachelle Springer, MS, ARNP, CS, CPSN, LHRM
P
er the Food and Drug Administration (FDA), “Electronic cigarettes (E-Cigarettes, also referred to as: Vape Pens, e-Hookahs, Hookah Pens) often resemble traditional cigarettes but they use a heat source, usually powered by a battery, to turn ‘e-liquid’, a liquid that usually contains nicotine from tobacco and flavorings, into an aerosol that is inhaled by the user. The amount of nicotine in the aerosol may vary by brand. Little information about the safety of electronic cigarettes exists” (FDA, 2014). E-cigarettes have been available in the United States since 2008, and they currently generate approximately $2 billion in sales annually. It is expected that they will bypass cigarettes in sales by 2024. In June 2014, R. J. Reynolds launched a national campaign to promote the first American made digital vapor cigarette (Bolivarian, 2014; VUSE, 2014). E-cigarettes have the appearance of real cigarettes, but, instead of smoking them, the user “vapes” them. Popularity has increased as there is no tax on e-cigarettes in most states, and they are promoted as healthier. In addition, the users can vape indoors in many places where cigarettes are banned. Up to 20% of smokers have tried e-cigarettes, and they have been promoted as a smoking cessation tool (Bolivarian, 2014; Grana, Benowitz, & Glantz, 2014).
HEALTH SAFETY ISSUES Until recently, the majority of e-cigarettes came from one Chinese manufacturer with variable manufacturing and quality standards (Grana et al., 2014). E-cigarettes are not yet regulated by the FDA (although at the time of the writing of this article the FDA is considering extending
Rachelle Springer, MS, ARNP, CS, CPSN, LHRM, is president of RCS Consulting Group, Inc., and serves as a consultant to office-based surgical facilities for accreditation preparation nationwide. She is a licensed health care risk manager in Florida, where she works with office surgical facilities in preparation for state inspection or accreditation by state-approved accreditation agencies. She also works for the Florida Department of Health as an office surgical inspector. She has served as Director of Education for ASPSN and as a member of the editorial board of Plastic Surgical Nursing. The author report no conflicts of interest. The author has not received any funding for this work. Address correspondence to Rachelle Springer, MS, ARNP, CS, CPSN, LHRM, 2685 NW 48th St, Boca Raton, FL 53454 (e-mail: RCSConsult@ outlook.com). DOI: 10.1097/PSN.0000000000000067
Plastic Surgical Nursing
its authority to cover additional products that meet the definition of a tobacco product), and they are heavily promoted in print, on television and on the Internet. The advertising content for e-cigarettes resembles that used in the 1950s and 1960s to promote cigarettes before that promotion was banned in the 1970s (Fernandez, 2014). In terms of using e-cigarettes as part of a smoking cessation program, there is no data to support their therapeutic use for this purpose (Grana et al., 2014). Each e-cigarette puff, with the highest nicotine content, has only about 20% of the nicotine of a puff from a cigarette. However, recent research has demonstrated that experienced users can achieve the same amount of nicotine intake as regular cigarettes by increasing the number of puffs taken (Bolivarian, 2014; Fernandez, 2014; Grana et al., 2014). The use of e-cigarettes, where cigarettes are routinely not permitted, can result in dual usage, which equates to an even higher intake of nicotine (Grana et al., 2014). From a wound-healing perspective, nicotine is a vasoconstrictor that reduces nutritional blood flow to the skin, resulting in tissue ischemia and impaired healing of injured tissue. Nicotine also increases platelet adhesiveness, raising the risk of thrombotic microvascular occlusion and tissue ischemia. In addition, proliferation of red blood cells, fibroblasts, and macrophages is reduced by nicotine (Silverstein, 1992). Although secondary smoke is not a concern with e-cigarettes, those in the vicinity of the user can be exposed to the aerosol containing nicotine and toxins such as formaldehyde, acetaldehyde, acetic acid, and others in reduced levels as compared with cigarette smoke (Fernandez, 2014). The nicotine in a propylene glycol or glycerin carrier is vaporized by a battery powered heating element that delivers the aerosol using ultrafine particles. There are also several different flavorings and preservatives that are also being delivered, and there are no long-term studies on the safety of these particles and substances being deposited on the lungs. Some e-cigarettes deliver more particles than regular cigarettes. The amount of nicotine delivered can vary from product to product. Heating elements contain heavy metals, which can deposit in the alveoli in the lungs, and propylene glycol in its heated and vaporized form can result in the formation of a potential carcinogen. Research has shown that the use of e-cigarette constricts peripheral airways, which could be www.psnjournalonline.com
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significant in patients with chronic lung disease such as asthma, emphysema, or chronic bronchitis. Other adverse effects include throat and mouth irritation, cough, nausea, and vomiting (Grana et al., 2014). From 2011 to 2012, the use of e-cigarettes in adolescents doubled from 3.3% to 6.8% (Fernandez, 2014). In many states, there are no restrictions of sales of e-cigarettes to minors. The flavorings, resembling candy in some instances (grape, chocolate, bubble gum, and gummy bear), are used to target the younger population. Also of concern is the potential for young children to access concentrated liquid nicotine stored in the home, which can be lethal for their body weight (Bassett, 2014; ChathamStephens et al., 2014).
CONCLUSIONS The scientific community agrees that there is a need for further research to determine the long-term effects of e-cigarettes on health. The known adverse effects of nicotine for adults and adolescents make this a less than healthy option when compared with not smoking at all. As the popularity of this modality is increasing, vaping/ the use of e-cigarettes should be included in the health history along with smoking, to help ensure a complete preoperative assessment. Health care providers concerned with optimizing surgical outcomes should consider if recommendations regarding cessation of smoking
166
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and nicotine containing products should include vaping as well. REFERENCES
Bassett, R. (2014). E-cigs: a big threat for the littlest kids. Retrieved July 8, 2014, from http://www.medscape.com/ viewarticle/825199?src = wnl_edit_specol&uac = 2957AG Bolivarian, S., (2014). E-cigarettes: what to tell patients, Medscape Nurses. Retrieved July 8, 2014, from http://www.medscape. com/viewarticle/827440?src = wnl_edit_specol&uac = 2957AG Chatham-Stephens, K, Law, R, Taylor, E, Melstrom, P., Bunnell, P., & Wang, B., et al., et al. (2014). Centers for Disease Control and Prevention (CDC). Notes from the field: calls to poison centers for exposures to electronic cigarettes—United States, September 2010–February 2014. Morbidity and Mortality Weekly Report, 63, 292–293. Retrieved July 8, 2014, from http://www.cdc. gov/mmwr/preview/mmwrhtml/mm6313a4.htm Fernandez, E. (2014). E-cigarettes expose people to more than “harmless” water vapor—first comprehensive analysis shows that industry health claims are unsupported by data. Retrieved July 8, 2014, from http://www.ucsf.edu/news/2014/05/114301/e-cigarettes-expose-people-more-%E2%80%98harmless%E2%80%99water-vapor-and-should-be-regulated Food and Drug Administration. (2014). Recognize tobacco in its many forms. Retrieved July 8, 2014, from http://www.fda.gov/ ForConsumers/ConsumerUpdates/ucm392735.htm#e-cigarettes Grana, R., Benowitz, N., & Glantz, S. (2014). E-cigarettes a scientific review. Circulation, 129, 1972–1986. Retrieved July 8, 2014, from http://circ.ahajournals.org/content/129/19/1972.full Silverstein, P. (1992). Smoking and wound healing. American Journal of Medicine, 93(1A), 22S–24S. Retrieved July 8, 2014, from http://www.ncbi.nlm.nih.gov/pubmed/1323208 VUSE (2014). Retrieved July 8, 2014, from https://vusevapor.com/ modules/Security/Landing.aspx
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P
er the Food and Drug Administration (FDA), “Electronic cigarettes (E-Cigarettes, also referred to as: Vape Pens, e-Hookahs, Hookah Pens) often resemble traditional cigarettes but they use a heat source, usually powered by a battery, to turn ‘e-liquid’, a liquid that usually contains nicotine from tobacco and flavorings, into an aerosol that is inhaled by the user. The amount of nicotine in the aerosol may vary by brand. Little information about the safety of electronic cigarettes exists” (FDA, 2014). E-cigarettes have been available in the United States since 2008, and they currently generate approximately $2 billion in sales annually. It is expected that they will bypass cigarettes in sales by 2024. In June 2014, R. J. Reynolds launched a national campaign to promote the first American made digital vapor cigarette (Bolivarian, 2014; VUSE, 2014). E-cigarettes have the appearance of real cigarettes, but, instead of smoking them, the user “vapes” them. Popularity has increased as there is no tax on e-cigarettes in most states, and they are promoted as healthier. In addition, the users can vape indoors in many places where cigarettes are banned. Up to 20% of smokers have tried e-cigarettes, and they have been promoted as a smoking cessation tool (Bolivarian, 2014; Grana, Benowitz, & Glantz, 2014).
HEALTH SAFETY ISSUES Until recently, the majority of e-cigarettes came from one Chinese manufacturer with variable manufacturing and quality standards (Grana et al., 2014). E-cigarettes are not yet regulated by the FDA (although at the time of the writing of this article the FDA is considering extending
Rachelle Springer, MS, ARNP, CS, CPSN, LHRM, is president of RCS Consulting Group, Inc., and serves as a consultant to office-based surgical facilities for accreditation preparation nationwide. She is a licensed health care risk manager in Florida, where she works with office surgical facilities in preparation for state inspection or accreditation by state-approved accreditation agencies. She also works for the Florida Department of Health as an office surgical inspector. She has served as Director of Education for ASPSN and as a member of the editorial board of Plastic Surgical Nursing. The author report no conflicts of interest. The author has not received any funding for this work. Address correspondence to Rachelle Springer, MS, ARNP, CS, CPSN, LHRM, 2685 NW 48th St, Boca Raton, FL 53454 (e-mail: RCSConsult@ outlook.com). DOI: 10.1097/PSN.0000000000000067
Plastic Surgical Nursing
its authority to cover additional products that meet the definition of a tobacco product), and they are heavily promoted in print, on television and on the Internet. The advertising content for e-cigarettes resembles that used in the 1950s and 1960s to promote cigarettes before that promotion was banned in the 1970s (Fernandez, 2014). In terms of using e-cigarettes as part of a smoking cessation program, there is no data to support their therapeutic use for this purpose (Grana et al., 2014). Each e-cigarette puff, with the highest nicotine content, has only about 20% of the nicotine of a puff from a cigarette. However, recent research has demonstrated that experienced users can achieve the same amount of nicotine intake as regular cigarettes by increasing the number of puffs taken (Bolivarian, 2014; Fernandez, 2014; Grana et al., 2014). The use of e-cigarettes, where cigarettes are routinely not permitted, can result in dual usage, which equates to an even higher intake of nicotine (Grana et al., 2014). From a wound-healing perspective, nicotine is a vasoconstrictor that reduces nutritional blood flow to the skin, resulting in tissue ischemia and impaired healing of injured tissue. Nicotine also increases platelet adhesiveness, raising the risk of thrombotic microvascular occlusion and tissue ischemia. In addition, proliferation of red blood cells, fibroblasts, and macrophages is reduced by nicotine (Silverstein, 1992). Although secondary smoke is not a concern with e-cigarettes, those in the vicinity of the user can be exposed to the aerosol containing nicotine and toxins such as formaldehyde, acetaldehyde, acetic acid, and others in reduced levels as compared with cigarette smoke (Fernandez, 2014). The nicotine in a propylene glycol or glycerin carrier is vaporized by a battery powered heating element that delivers the aerosol using ultrafine particles. There are also several different flavorings and preservatives that are also being delivered, and there are no long-term studies on the safety of these particles and substances being deposited on the lungs. Some e-cigarettes deliver more particles than regular cigarettes. The amount of nicotine delivered can vary from product to product. Heating elements contain heavy metals, which can deposit in the alveoli in the lungs, and propylene glycol in its heated and vaporized form can result in the formation of a potential carcinogen. Research has shown that the use of e-cigarette constricts peripheral airways, which could be www.psnjournalonline.com
165
Copyright © 2014 American Society of Plastic Surgical Nurses. Unauthorized reproduction of this article is prohibited.
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significant in patients with chronic lung disease such as asthma, emphysema, or chronic bronchitis. Other adverse effects include throat and mouth irritation, cough, nausea, and vomiting (Grana et al., 2014). From 2011 to 2012, the use of e-cigarettes in adolescents doubled from 3.3% to 6.8% (Fernandez, 2014). In many states, there are no restrictions of sales of e-cigarettes to minors. The flavorings, resembling candy in some instances (grape, chocolate, bubble gum, and gummy bear), are used to target the younger population. Also of concern is the potential for young children to access concentrated liquid nicotine stored in the home, which can be lethal for their body weight (Bassett, 2014; ChathamStephens et al., 2014).
CONCLUSIONS The scientific community agrees that there is a need for further research to determine the long-term effects of e-cigarettes on health. The known adverse effects of nicotine for adults and adolescents make this a less than healthy option when compared with not smoking at all. As the popularity of this modality is increasing, vaping/ the use of e-cigarettes should be included in the health history along with smoking, to help ensure a complete preoperative assessment. Health care providers concerned with optimizing surgical outcomes should consider if recommendations regarding cessation of smoking
166
www.psnjournalonline.com
and nicotine containing products should include vaping as well. REFERENCES
Bassett, R. (2014). E-cigs: a big threat for the littlest kids. Retrieved July 8, 2014, from http://www.medscape.com/ viewarticle/825199?src = wnl_edit_specol&uac = 2957AG Bolivarian, S., (2014). E-cigarettes: what to tell patients, Medscape Nurses. Retrieved July 8, 2014, from http://www.medscape. com/viewarticle/827440?src = wnl_edit_specol&uac = 2957AG Chatham-Stephens, K, Law, R, Taylor, E, Melstrom, P., Bunnell, P., & Wang, B., et al., et al. (2014). Centers for Disease Control and Prevention (CDC). Notes from the field: calls to poison centers for exposures to electronic cigarettes—United States, September 2010–February 2014. Morbidity and Mortality Weekly Report, 63, 292–293. Retrieved July 8, 2014, from http://www.cdc. gov/mmwr/preview/mmwrhtml/mm6313a4.htm Fernandez, E. (2014). E-cigarettes expose people to more than “harmless” water vapor—first comprehensive analysis shows that industry health claims are unsupported by data. Retrieved July 8, 2014, from http://www.ucsf.edu/news/2014/05/114301/e-cigarettes-expose-people-more-%E2%80%98harmless%E2%80%99water-vapor-and-should-be-regulated Food and Drug Administration. (2014). Recognize tobacco in its many forms. Retrieved July 8, 2014, from http://www.fda.gov/ ForConsumers/ConsumerUpdates/ucm392735.htm#e-cigarettes Grana, R., Benowitz, N., & Glantz, S. (2014). E-cigarettes a scientific review. Circulation, 129, 1972–1986. Retrieved July 8, 2014, from http://circ.ahajournals.org/content/129/19/1972.full Silverstein, P. (1992). Smoking and wound healing. American Journal of Medicine, 93(1A), 22S–24S. Retrieved July 8, 2014, from http://www.ncbi.nlm.nih.gov/pubmed/1323208 VUSE (2014). Retrieved July 8, 2014, from https://vusevapor.com/ modules/Security/Landing.aspx
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Copyright © 2014 American Society of Plastic Surgical Nurses. Unauthorized reproduction of this article is prohibited.
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