NSW looking to ban e-cigarettes from smoke-free areas. What’s the big deal?

Once touted as a traditional cigarette replacement on the road to quitting the nicotine habit ‘electronic cigarettes’ or e-cigarettes as they are more commonly known has developed  a bad reputation.  ABC news reported on Thursday that support is growing for New South Wales to join five other Australian states (ACT, Queensland, Victoria, Tasmania and South Australia) in banning the use of e-cigarettes in smoke-free public areas where currently only traditional burned cigarettes are outlawed. So what are e-cigarettes and are they as harmful to the user and bystanders as traditional cigarettes?

What are e-cigarettes

Both traditional cigarettes and e-cigarettes do share one very common trait, the heating of the consumed material to make either smoke or vapor. E-cigarettes, instead of using smoldering or fire to burn the solid material implement an electronic heating element within  the device to vaporize a liquid thereby allowing that liquid to enter the user’s lungs much the same as traditional tobacco smoke. Proponents say that e-cigarettes are less harmful to both the user by eliminating the secondary chemicals normally found in traditional cigarettes and to those affected by traditionally passive smoke as the e-cigarette is less likely to transmit harmful chemicals throughout a space. The latter fact is what is being debated regarding the smoke-free e-cigarette ban.

Traditional cigarette risks versus e-cigarettes

Traditionally burned cigarettes have been widely studied and their harmful health effects well known. The American Cancer Society warns that there could be as many as 70 harmful chemicals in cigarettes which could lead to cancer when burned and inhaled. The same site does state that there are chemicals known to be contained in e-cigarettes which could contribute to cancer formation, however the biggest risk in e-cigarettes is the current lack of regulation and control on the ingredients, both type and quantity, which means that it is difficult to quantify their effects. A publication by New South Wales Health agrees with the American Cancer Society that there are a wide variety of levels of harmful chemicals, including nicotine, in unregulated levels within various e-cigarettes without accurate labeling. Additionally, e-cigarettes could also contain other by-products such as heavy metals which are used in the heating elements of the device. The take-home message for users of e-cigarettes is that there is an inherent danger as the e-cigarette market is mostly unregulated allowing for a range of chemicals, both listed and unlisted, to be included in the liquid active ingredients. This range of chemicals could lead to both short and long-term health effects.

The New South Wales Health fact sheet also state that there is a risk of exposure for people in the immediate vicinity of users of e-cigarettes, known as exposure to second-hand smoke. Again research into second-hand smoke with traditional cigarettes have been widely studied; and this has led to the smoke-free bans seen here in Australia and world-wide to protect non-smokers from the effects. The study into second-hand smoke amongst e-cigarettes and the effect on those around smokers is not as clear cut.

Second-hand e-cigarette smoke research and opinion

A systematic review of the effects of second-hand smoke from e-cigarettes was published by the Public Health Research and Practice group in 2016. The review looked at scholarly articles published between 1996 and 2015 regarding the study of this subject. The results showed that there were particles of nicotine, harmful chemicals similar to traditional cigarettes and heavy metals found within the vicinity of the e-cigarettes. However, the levels of these chemicals were much less. Additionally, the spread of these chemicals was overall less as the authors concluded the exhalation of traditional cigarette smoke could spread the airborne chemicals further than e-cigarettes. However, this study concluded similar results to those listed above that regulation of e-cigarette ingredients and concentrations of those ingredients have led to poor research outcomes.

The ‘vaping’ community has weighed in on this topic. The website “Vaped: by Totally Wicked” has stated:

Though studies are still ongoing on this topic, those that have been done so far strongly indicate that passive vaping poses little danger, if any. In fact, what they have managed to show thus far is that passive vaping is a non-existent problem, with ‘no apparent risk to human health from e-cigarette emissions based on the compounds analysed.’

The study linked to this statement was published in 2012 by the journal Inhaled Toxicology. While I did not have access to the article the synopsis did state that

For all byproducts measured, electronic cigarettes produce very small exposures relative to tobacco cigarettes. The study indicates no apparent risk to human health from e-cigarette emissions based on the compounds analyzed.

The issue is that the study used four e-cigarette liquids and compared to traditionally burned cigarettes. As the discussion has indicated previously there is widespread variation in chemical inclusions and concentrations as well as a lack of clear labelling which makes any comparison impossible. Therefore, research into the effects of passive smoke cannot be generalized at this point.

Another blog site, Vaping 360, lists a 2016 report prepared by the Royal College of Physicians entitled “Nicotine without smoke Tobacco harm reduction” which discussed the use of e-cigarettes as nicotine-replacement- alternatives and how traditional tobacco companies were attempting to gain ground in this market within the UK. The Vaping 360 cite quoted:

Users of e-cigarettes exhale the vapour, which may therefore be inhaled by others, leading to passive exposure to nicotine. There is, so far, no direct evidence that such passive exposure is likely to cause significant harm, although one study has reported levels of polycyclic aromatic hydrocarbons that were outside defined safe-exposure limits. It is clear that passive exposure will vary according to fluid, device and the manner in which it is used. Nicotine from exhaled vapour can be deposited on surfaces, but at such low levels that there is no plausible mechanism by which such deposits could enter the body at doses that would cause physical harm.

Nicotine-replacement legislation in Australia

But the debate over second-hand smoke and e-cigarettes could be moot here in Australia. According to the Royal Australian College of General Practitioners (RACGP) the use of e-cigarettes for nicotine-replacement are illegal.

In all Australian states and territories, it is an offence to manufacture, sell or supply nicotine as an S7 poison without a licence or specific authorisation. This means e-cigarettes containing nicotine cannot be sold in any Australian state or territory. There are several reported instances where individuals have been charged with the illegal supply of liquid nicotine for use in e-cigarettes in Queensland.16,17

A recent clarification from the Federal Department of Health has advised that nicotine can be imported by an individual for use as an unapproved therapeutic good (eg a smoking cessation aid), but the importer must hold a prescription from an Australian registered medical practitioner and only import 3 months’ supply at any one time. The total quantity imported in 12 months cannot exceed 15 months’ supply of the product at the maximum dose recommended by the manufacturer.18 Most current consumers are unlikely to visit medical practitioners for a prescription of products that are readily available over the internet. The purchase and possession of nicotine by individuals are not regulated by Commonwealth legislation except for importation as allowed under Commonwealth law.

Non-nicotine e-cigarettes are not regulated, according to the RACGP site, however if they are not specifically for nicotine-replacement therapy then their use is purely recreational and should be subject to concerns raised by state governments and health authorities as to the additive chemicals and the effects of those chemicals on non-users within the immediate vicinity. Therefore, with no specific medical need for e-cigarettes the health concerns of second-hand smoke should outweigh the desire to have a cigarette-substitute in public and should be banned.

What does all of this mean for e-cigarette use in public?

So what does this mean for Australia, and specifically New South Wales, in the debate over e-cigarettes? The debate, to me, is quite simple. E-cigarettes in Australia at this point cannot contain nicotine as per Commonwealth law. Therefore, they cannot be considered as a replacement to traditional cigarettes as has been touted elsewhere in the world. That also means they have no medical necessity to users. Non-nicotine e-cigarettes at this point are legal, however there are a number of chemicals used in various e-cigarettes which can be as harmful as in traditional cigarettes to individuals standing within close proximity to the user. Additionally, chemicals used in e-cigarettes are not regulated so the quantities and types of chemicals contained do not need to be listed. While e-cigarettes are less harmful than traditional cigarettes there is still a risk of passive second-hand exposure. So there seems to be no reason why the state government should not join the five other states in outlawing e-cigarette use in smoke-free locations throughout the state.

Your thoughts? Until next time,

Ray

 

 

References

ABC News- E-cigarette ban in smoke-free areas of NSW attracts Government support

http://www.abc.net.au/news/2017-11-02/fight-to-ban-e-cigarettes-in-smoke-free-areas-of-nsw/9109858?pfmredir=sm

Web MD- The Vape Debate: What You Need to Know

https://www.webmd.com/smoking-cessation/features/vape-debate-electronic-cigarettes#2

American Cancer Society- Harmful Chemicals in Tobacco Products

https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/carcinogens-found-in-tobacco-products.html

New South Wales- Are electronic cigarettes and e-liquids safe?http://www.health.nsw.gov.au/tobacco/Factsheets/e-cigs-are-they-safe.pdf

Centers for Disease Control- Secondhand Smoke (SHS) Facts

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/index.htm

Public Health Research and Practice- A systematic review of the health risks from passive exposure to electronic cigarette vapour

http://www.phrp.com.au/issues/april-2016-volume-26-issue-2/a-systematic-review-of-the-health-risks-from-passive-exposure-to-electronic-cigarette-vapour/

Vaped: by Totally Wicked- SHOULD YOU WORRY ABOUT PASSIVE VAPING?http://www.totallywicked-eliquid.co.uk/vaped/passive-vaping/

Inhaled Toxicology- Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality.

https://www.ncbi.nlm.nih.gov/pubmed/23033998

Vaping 360- Is second hand vapor harmful?

http://vaping360.com/is-second-hand-vapor-harmful/

Royal College of Physicians- Nicotine without smoke: Tobacco harm reduction

https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0

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Support for voluntarily assisted suicide coming from the AMSA

As reported in Sky News, and validated by myself from the Australian Medical Students’ Association (AMSA), that the AMSA members have voted to endorse a policy which supports Voluntarily Assisted Suicide (VAS) should it become legal in Australia.

The press release (which can be accessed here) details that the association recognizes that VAS is not yet legal in Australia, and can only be implemented once legalized. Additionally, VAS should not be a replacement for a quality palliative care program; nor should it be implemented unless all other treatment options have been exhausted.

The press release by the AMSA is a measured and logical approach to the idea of physician assisted euthanasia. There has been discussion recently in the media regarding this issue, with quite far-flung statements being made both ways. Here is my opinion on the matter which has come from work as a palliative care social worker, aged care manager, aged care nurse and emergency department nurse:

  1. Reasonable and sound-minded individuals do not want to end their life.
  2. Certain illnesses and chronic conditions can cause such pain and suffering that NO palliative treatment can mitigate the debilitating symptoms and lead to a good quality existence.
  3. All treatment options, assisted suicide amongst them, need to be measured against that quality of life test.
  4. In this country, as in many others, when the family pet has become too sick to lead such a quality existence their owners are given the choice to end the animal’s life with dignity and without suffering. However, because we are human and not a domesticated animal some are meant to suffer a painful and meaningless existence while their body deteriorates to the point of failure. If our beloved pets are given such an option why not our human family members?
  5. Voluntarily assisted suicide (or physician assisted suicide) does not mean the doctor or health professional is condoning people ending their life. Neither is it (as I heard on the radio yesterday) a violation of the Hippocratic Oath. It is a trained health professional allowing a person-centered care plan which details how they wish to proceed with their medical care. This, to me, is similar to how we now implement not-for-resuscitation orders.

The Australian Medical Association’s code of ethics expands on the Hippocratic Oath, and point 1.4 section c I think says it succinctly

Respect the right of a severely and terminally ill patient to receive treatment for pain and suffering, even when such therapy may shorten a patient’s life.

For those in the medical community I can hear you already saying “but Ray, that’s not what this statement is intended for.” I know that. But what it does is highlight the need for ALL health professionals to recognize that there comes a point where we must pull back and allow patients to shorten their life; if that shortening comes with dignity, control and comfort.

I have been, and always will be a supporter of a balanced and reasonable assisted dying policy. Let us make sure there are safeguards in place to prevent misuse. Let us make sure there are processes in place to ensure death is peaceful and quick. But most of all let us allow an individual with no hope of recovery and only staring at a prolonged existence of suffering and decay to choose when they decide to end their life.

I would very much like to hear your opinions.

Until next time,

Ray

Sky News- Doctors in training support assisted dying

Australian Medical Student Association- press release

Australian Medical Association- code of ethics

Healthy one day, sick the next- the issue of Diagnosis Creep

 

An article by Hugo Wilcken in the Medical Journal of Australia InSight page turned me onto the discussion over ‘Diagnosis Creep’. Essentially this is coined as a negative term for the change in definitions of diseases which causes an increase in those diagnosed with that disease which prior to the change would be otherwise considered as not having it. An example would be osteoporosis where in 2008 a new definition was adopted and instantly changed the affected population of women from 21% to 72%! Similarly changes to definitions have created ‘pre-‘ conditions in the diseases of diabetes and hypertension. Wilcken contends that what makes these changes diagnosis creep is that they do not offer health benefits as the treatments do not successfully aid to overall health or well-being.

Some factors have been forwarded to explain diagnosis creep. One such idea is that of the ‘pre’ classification of diseases. Therefore, you may not clinically have the disease, but you are at risk of contracting it. Another theory is that the expert panels who decide on what clinical factors are needed to lead to a diagnosis are made up of clinicians who specialize in their field. These experts, in order to be able to treat effectively, tend to be more inclusive than exclusive when re-examining factors and therefore lessen the threshold for diseases.

Then there is the nasty side of diagnosis creep. There seems to be a pervasive concern that pharmaceutical companies have a wayward hand in expanding the population with certain diseases in order to increase sales of medications for that disease. The MJA InSight article discusses this as ‘Big Phrama’ and contends that some ‘expert panel’ members are sponsored by pharmaceutical companies- leading to potential conflicts of interest. A similar argument was made in an article in The Conversation in 2016.

No matter what the reasons diseases are being re-defined to include more patients an article in the Australian Prescriber magazine sums up the reason for this post:

Health professionals should be more aware, and patients and the public better informed, about the controversy surrounding many contemporary definitions of disease. Diagnostic criteria are not set in stone – they are regularly changed, often with the best of intentions, but are also often rigorously challenged because of the potential for unintended harms.

In Australia the issue has been seen as serious enough that the NPS group has developed an entire campaign entitled “Choose Wisely” to inform and attempt to tackle the need for certain tests, treatments and procedures. Readers of this blog can also follow the Choose Wisely campaign on Twitter at @ChooseWiselyAU.

Before the MJA article I had not known about diagnosis creep, nor the controversy surrounding it. However, the issue does make sense. All healthcare professionals should be conscious of how and why patients are being diagnosed with diseases and what treatments are being given. While I do recognize the need for disease management and appropriate medications I also recognize that we can easily over-medicate and the elimination of any unneeded treatment would be valuable, particularly in the elderly. I applaud the works of Wilcken and the NPS at serving as a checks-and-balance system in this most important area.

References

MJA InSight: Diagnosis creep: the new problem in medicine

The Conversation: Resisting expanding disease empires: why we shouldn’t label healthy people as sick

Australian Prescriber: Caution! Diagnosis creep

NPS Medwise: Choosing Wisely Australia

Telehealth to combat Australia’s growing demand for healthcare?

An article in IT Brief tackles the topic of how Australia is going to tackle the increased need for healthcare moving forward. According to a report in the Newcastle Herald Australian men are ranked in the top three countries worldwide in life expectancy, while women are in the top fourth. This is great news for Australians, and can cause sleepless nights for policy makers. The World Health Organization reports that currently Australia as of 2014 spends 9.4% of Gross Domestic Product on healthcare, that equates to approximately $4,357 per person. With the baby boomers expected to reach their senior age this figure is surely going to rise.

The IT Brief discussed several

items relating to IT and healthcare. One such discussion was over the My Health Record program by the federal government. I have previously discussed the My Health Record in another post. I believe it is a vital and important forward step in advancing the Australian healthcare system.

Another item discussed was the use of smartphone apps and other personal IT devices to aid in chronic disease management. This is a field that is sure to improve as our tech-savy population ages.

But the item discussed that interested me was that of individuals being able to visit with a doctor via an online medium. This was described in the article as a potential way for people to access medical care without needing to wait in a doctor’s office and would allow access in rural areas. In Australia we have a similar system in place in rural areas. However, looking to rely on this as a measure to markedly decrease the reliance on in-person healthcare is suspect.

While visual clues and interviews are important in assessing health concerns palpation, auscultation and the ability to have the patient in front of you make up much of both doctors’ and nurses’ assessments. Additionally, many presentations we see in hospital that have come from GPs requires further acute assessment not available in a doctor’s surgery: ultrasounds, CT scans, and urgent blood tests. These items would not be available to a patient sitting in their lounge room speaking with a doctor over the internet.

If there are chronic and stable conditions which only call for simple follow-up then online medical consultation would be fine. However, I wonder if that is not being done already? My concern is that moving forward the need for acute in-person healthcare will only increase. And with that increase will be the need for more acute beds in hospitals and more healthcare facilities to deal with demand.

Your thoughts?

References

IT Brief: Digital tech – the answer to Aussie healthcare’s biggest ailments?

Newcastle Herald: Australia about to lose top spot in this world health ranking

WHO: Australia

Australia, better healthcare than America- absolutely!

stethoscope-840125_1280

 

I came across this article and had to write about it. Marie Shieh, a doctor trained in America and now practices in Australia, has written a piece for the The Telegraph. In it she states emphatically that Australia’s health care is better than Americas. Full stop, no qualifiers. And as a former consumer and provider of America’s healthcare system I can agree.

Confession: my road to becoming a registered nurse started because of poor quality healthcare that my father received before his death. We were poor, not living on the streets poor, but we did not have a lot of money. My parents owned a printing business, and we did not have health insurance. When I was young my father was diagnosed with diabetes, then cancer and finally a heart condition. Because we did not have health insurance all of these medical conditions were treated very conservatively and without extensive examination. I believe, as a consequence of that, he suffered a major heart attack and died prematurely.

Now I know that he contributed to his condition with smoking and being overweight. But a lack of medical care significantly contributed to his death. From that moment on I was destined to be in healthcare, despite my attempts to move away from it. I have worked in palliative (hospice in America) care in the U.S. and now work in the Australian hospital system.

We have an amazing healthcare system. Yes, it is over-budget. Yes, there is over-crowding and never enough beds in our hospitals. Yes, people do (at times) come into emergency departments for things that could just as well be handled at their own doctors. But our system allows for every Australian the chance to have optimal health and to be free of medical issues, or at least have them treated to the best that our medical and nursing care can offer without fear of being unable to pay for such treatment.

I have always said that the Australian healthcare system would not work in America. The current push to repeal ‘Obamacare’ as it is called exemplifies this. Americans feel that they should be self-sufficient. And that is not necessarily a bad thing. Health insurance plans are out there to assist with costs. However, the American attitude of “if you can’t afford it we won’t pay for it” still leads to a class-based healthcare system. If you have money then you have health. As a nurse and believer in healthcare that is not right. Health is part of Maslow’s basic needs, and I feel it should be offered as a right just as security in the form of police and safety with firefighters.

maslow-pyramid

Maslow’s heirachy of needs- image source

Alas I do not feel that America will change their ways. The core beliefs of self-sufficiency go all the way back to revolutionary times. I am proud to say I am an Australian registered nurse. I am proud to say that the healthcare I and the thousands of other dedicated workers allows everyday Australians peace of mind and can allow us to continue to prosper.

 

The Telegraph: Trump is right about Australian health care, an American doctor in Australia says

Privacy concern or valuable tool: all Aussies can have an e-health record, would you?


The ABC network has written that with a new surge in federal funding the My Health Record project looks to provide all Australians with the ability to have an electronic health summary. This is a follow-on from other E-health projects trying to establish similar results. While I can understand the apprehension noted by some with regards to privacy and sharing of health information from a healthcare worker’s perspective it is a great leap forward.



In my history as a registered nurse I remember the days before electronic health records. The nature of our health system in Australia means that an individual can present at numerous public and private health institutions without any ability of those institutions knowing prior medical treatment. This is a safety concern for the patient at worst and could potentially prolong the time for effective treatment in the least.


With the implementation of the local electronic health record if I am looking after a patient who has visited another health facility within the same area, state, or even nationally connected the doctor and I can see previous treatments and tests, allowing for more accurate diagnosis and treatment. Expanding this nationally would allow those visiting or recently moved to the area to have better quality care by allowing information sharing.


It is also better for the GP. Now general practitioners must rely on discharge summaries for information about hospital treatment. However, with the electronic record the GP could access more complete information from hospital visits, aiding in their continuation of care at home. A GP could also review and place information for patients on the record in case they travel or are too sick to speak for themselves, vital information which could save their life.


There is always a potential for abuse of the system. However, I would trust that the powers-at-be would design safeguards to prevent unauthorized information sharing of electronic health records. I, for one, will be happy to welcome this advancement in Australian healthcare. According to the ABC report individuals would be allowed to ‘opt out’ of the program.

ABC news: Everyone to have a digital health record

The tragedy of Manchester brings out the true colours of emergency services

As a relatively short-lived member of an emergency department I can say I have never been through a horrific event like that which occurred in Manchester, UK. But the spirit behind all of the nurses in the six hospitals lives within all of us.

By default emergency nurses and doctors are trained to take a patient with little background and through systematic assessment treat the priorities to bring about the best possible outcome.

Nurses learn to act selflessly and tirelessly to get the job done. I am proud to consider myself a member of an elite fraternity called emergency room nurses. Absolute praise and respect to all those who helped in the aftermath.