Charleskiy
Initiate
- Joined
- May 19, 2017
- Messages
- 21
I thought people might be interested to see what sort of education doctors are exposed to when it comes to e-cigarettes, and Stanford's release of an online CME course provides an interesting glimpse.
The course can be found here:
https://med.stanford.edu/cme/courses/online/e-cig.html
It's aimed at doctors, but is free to all (they won't ask to see your medical degree) and takes at most an hour and a half.
The meat of the course consists of three patient interviews, offering branching flows where you can choose what sort of advice to give, and then concluding with short discussions from three 'experts' outlining what they'd say.
Fair warning: the course is directed by Robert Jackler, a man who is notorious for his biased, irresponsible and alarmist attitude toward e-cigarettes, so we know in advance that the material may not represent best practice. Even so, it's useful to see the sort of training that doctors are being given these days. Although this is clearly aimed at US physicians, you can be sure that UK doctors will use it as well.
The first case is pretty easy: a young student who's a very light smoker has come to ask about the safety of using 'e-hookahs' (a basic clearomiser pen) at parties. The right advice is simple: if you don't smoke, or smoke very little, then just stop. Chances are you won't need any sort of nicotine replacement if you only have one or two cigarettes a week. The experts mostly get this one right: if you don't smoke, then don't start, and don't go taking nicotine. While she's vaping a low dose of nicotine (6mg), puffing on a acquaintance's stick at parties may lead to being exposed to much higher doses, which will certainly give a buzz and can easily lead to addiction. Rather than adopt a sensible approach, Jackler discourses at length about the few incidents of exploding batteries, which just leaves you rolling your eyes and wondering if he avoids using a cell phone, since it's likely to blow his ear off. The other two discussions (from Judith Prochaska and Suzaynn F. Schick) are far more sensible.
The second case involves an older heavy smoker who's been bought a heavy-duty (probably sub-ohm) device and complains it's irritating his throat. I'm sure everyone here will instantly recognise the problem: he's getting a reaction to propylene glycol and needs to use a high-VG liquid with less nicotine that's better suited to the delivery system he has. None of the 'experts' recognise this issue, and apart from some vague advice from Jackler to 'try a different product' none of them provide the concrete recommendation he needs. Jackler tries to recommend the gum/patch/drug methods that have already failed the patient, but does eventually come around to a grudging acceptance that ecigs offer an effective means to stop smoking. Schick, on the other hand, offers nothing but waffle about the theoretical dangers and completely omits to address the very real health problem that continued smoking poses to this patient, and earns a failing grade.
After a break (apparently two patients constitutes a busy morning ...) the third case concerns a relatively young patient who's had breast cancer and is preparing for reconstructive surgery. She's a light smoker but clearly needs encouragement to quit completely and hasn't tried any therapy apart from cutting down. Again, there are some strange responses in the discussion. Jackler correctly identifies the negative impact that nicotine has on the regrowth of the smallest blood vessels (microvasculature) in the presence of nicotine, something that can impair healing after surgery. But he then goes on to recommend nicotine patches or gum, which may have an equally deleterious effect. Schick offers nothing but nagging: she needs to get off cigarettes, and should really be off nicotine as well for the surgery, but she provides no advice as to how this outcome may be attained. Prochaska probably comes closest to a sensible response that she should try as-needed (ad libitum in the jargon used) gum or lozenges as a way to wean off the cigarettes completely, though needs to be clearer that this should happen in the context of a flexible strategy that's ready to switch to ensure that she stays off the fags. None of them mention what must be the first concern for anyone undergoing a general anaesthetic: what's the impact on the lungs? While ecig vapour definitely contains a large amount of ultrafine particulates, there's evidence (Flouris et al. 2013) that it doesn't impair lung function (maybe this doesn't fit the agenda). Even so, I would probably err on the side of caution and advise starting with more conventional methods of cessation in such a case, with the proviso that she needs to find something that works for her, and if gum and patch don't work then ecigs are an important option.
Overall it's a bit shocking to see the below-average quality of the advice given. They flounder particularly in the case of the older heavy smoker, who needs to stop as a matter of urgency and has already been failed by conventional remedies. This is a course coming from one of the top medical schools in the US, and will be taken as gospel by many doctors who don't know better. Those who navigate all the options will notice that the course material contains many inaccuracies: they perpetuate the myth about formaldehyde and are grossly out-of-date concerning diacetyl exposure. The final 'Health Policy Forum' contains some reasonable discussion from David Abrams, but gets sidetracked by the other two into an unsubstantiated discussion about flavours and children. The poor quality of discourse on this topic in the US certainly does provide a stark contrast to the generally more balanced and informed level found here in the UK, even if we do have to suffer the TPD.
I've obviously rambled on far too long, sorry about that.
The course can be found here:
https://med.stanford.edu/cme/courses/online/e-cig.html
It's aimed at doctors, but is free to all (they won't ask to see your medical degree) and takes at most an hour and a half.
The meat of the course consists of three patient interviews, offering branching flows where you can choose what sort of advice to give, and then concluding with short discussions from three 'experts' outlining what they'd say.
Fair warning: the course is directed by Robert Jackler, a man who is notorious for his biased, irresponsible and alarmist attitude toward e-cigarettes, so we know in advance that the material may not represent best practice. Even so, it's useful to see the sort of training that doctors are being given these days. Although this is clearly aimed at US physicians, you can be sure that UK doctors will use it as well.
The first case is pretty easy: a young student who's a very light smoker has come to ask about the safety of using 'e-hookahs' (a basic clearomiser pen) at parties. The right advice is simple: if you don't smoke, or smoke very little, then just stop. Chances are you won't need any sort of nicotine replacement if you only have one or two cigarettes a week. The experts mostly get this one right: if you don't smoke, then don't start, and don't go taking nicotine. While she's vaping a low dose of nicotine (6mg), puffing on a acquaintance's stick at parties may lead to being exposed to much higher doses, which will certainly give a buzz and can easily lead to addiction. Rather than adopt a sensible approach, Jackler discourses at length about the few incidents of exploding batteries, which just leaves you rolling your eyes and wondering if he avoids using a cell phone, since it's likely to blow his ear off. The other two discussions (from Judith Prochaska and Suzaynn F. Schick) are far more sensible.
The second case involves an older heavy smoker who's been bought a heavy-duty (probably sub-ohm) device and complains it's irritating his throat. I'm sure everyone here will instantly recognise the problem: he's getting a reaction to propylene glycol and needs to use a high-VG liquid with less nicotine that's better suited to the delivery system he has. None of the 'experts' recognise this issue, and apart from some vague advice from Jackler to 'try a different product' none of them provide the concrete recommendation he needs. Jackler tries to recommend the gum/patch/drug methods that have already failed the patient, but does eventually come around to a grudging acceptance that ecigs offer an effective means to stop smoking. Schick, on the other hand, offers nothing but waffle about the theoretical dangers and completely omits to address the very real health problem that continued smoking poses to this patient, and earns a failing grade.
After a break (apparently two patients constitutes a busy morning ...) the third case concerns a relatively young patient who's had breast cancer and is preparing for reconstructive surgery. She's a light smoker but clearly needs encouragement to quit completely and hasn't tried any therapy apart from cutting down. Again, there are some strange responses in the discussion. Jackler correctly identifies the negative impact that nicotine has on the regrowth of the smallest blood vessels (microvasculature) in the presence of nicotine, something that can impair healing after surgery. But he then goes on to recommend nicotine patches or gum, which may have an equally deleterious effect. Schick offers nothing but nagging: she needs to get off cigarettes, and should really be off nicotine as well for the surgery, but she provides no advice as to how this outcome may be attained. Prochaska probably comes closest to a sensible response that she should try as-needed (ad libitum in the jargon used) gum or lozenges as a way to wean off the cigarettes completely, though needs to be clearer that this should happen in the context of a flexible strategy that's ready to switch to ensure that she stays off the fags. None of them mention what must be the first concern for anyone undergoing a general anaesthetic: what's the impact on the lungs? While ecig vapour definitely contains a large amount of ultrafine particulates, there's evidence (Flouris et al. 2013) that it doesn't impair lung function (maybe this doesn't fit the agenda). Even so, I would probably err on the side of caution and advise starting with more conventional methods of cessation in such a case, with the proviso that she needs to find something that works for her, and if gum and patch don't work then ecigs are an important option.
Overall it's a bit shocking to see the below-average quality of the advice given. They flounder particularly in the case of the older heavy smoker, who needs to stop as a matter of urgency and has already been failed by conventional remedies. This is a course coming from one of the top medical schools in the US, and will be taken as gospel by many doctors who don't know better. Those who navigate all the options will notice that the course material contains many inaccuracies: they perpetuate the myth about formaldehyde and are grossly out-of-date concerning diacetyl exposure. The final 'Health Policy Forum' contains some reasonable discussion from David Abrams, but gets sidetracked by the other two into an unsubstantiated discussion about flavours and children. The poor quality of discourse on this topic in the US certainly does provide a stark contrast to the generally more balanced and informed level found here in the UK, even if we do have to suffer the TPD.
I've obviously rambled on far too long, sorry about that.
