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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Where do doctor’s prescriptions end and pharmacists dispensing begin?

An article in news.com.au on Tuesday ( the 24th) has brought up an interesting question in my mind, where does the line exist between pharmacy dispensing of medications and requiring a doctor’s prescription?

The article describes the debate over restricting medications containing codeine to prescription-only, requiring patients wanting these medications to see their doctor’s first before obtaining the drug. The Thearputic Goods Administration was indicating a change in codeine-related products from pharmacy-dispensed to prescription in 2016, although debate over the issue is heading up as the deadline for the change is February next year.

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Pharmacy representatives state this would affect the quality of analgesic care for patients by requiring them to see their doctor first. Physician groups are stating that low-dose codeine found in these medications show on therapeutic benefit, and the restriction would prevent misuse. Politicians are stuck in the middle in wanting to satisfy both sides.

So what is the issue with codeine? It is addictive and potentially harmful in high doses. Codeine is an opiate, an analgesic similar to Morphine. Therefore, its properties of pain relief can lead to addiction if misused. The Sydney Morning Herald stated that 12% of Australians surveyed exceeded the recommended daily dose of analgesic medications containing codeine. While the codeine dose is quite small the issue with this worrying fact is the potential for overdosing on paracetamol and ibuprofen; both have potentially toxic effects if too much is in the human body. An article by NPS Medwise has shown that when codeine has been consumed to lethal levels, although being accidental in nature, the number of deaths are double that of deaths related to stronger prescription medication such as morphine.

So why take it away from pharmacists hands? Simply control and monitoring. Even in my role within a public hospital I see frequently patients who travel from one hospital to another asking for pain relief, sometimes discharging and presenting to multiple hospitals in the course of a day. I am sure that most pharmacists are very conscientious and ethically-responsible people. However, a patient could approach one pharmacy let’s say in the morning and buy a codeine-related product, and then travel to a completely different area in the afternoon approach another for more product. This individual may not even intend to do this, instead they may work in the city and travel from home in a completely different area by public transport. The second pharmacist would not have knowledge of the previous purchase and therefore would not question the transaction.

A doctor’s prescription requires individuals to physically see a doctor. A record of the prescriptions would exist and could be tracked. Additionally, higher consumption could trigger the doctor to investigate the reasons for the increased usage and try to eliminate the cause of pain in the first place.

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 While I have no issue with pharmacists as I think they are very competent and ethical practitioners I do support the moving the responsibility of codeine release from pharmacists to doctors.  Codeine is an opiate, and most opiates (along with other analgesics of similar strength) are classified as schedule eight restricted due to their addictive properties. The low doses of codeine and the toxic properties of the main ingredients (paracetamol and ibuprofen) mean that overdosing on these over-the-counter medications can lead to serious health consequences. Finally, as I stated above requiring a prescription can then lead a doctor to investigate, and hopefully treat, the source of pain rather than continuing to mask it through analgesics.

What do you think of codeine-related products requiring a prescription? Does it even matter to you?

Until next time,

Ray

News.com.au- MPs push to water down ban on codeine sales without prescription

New Scientist- Australia bans non-prescription codeine to fight opioid crisis

Therapeutic Goods Administration- Update on the proposal for the rescheduling of codeine products

Sydney Morning Herald- More than 2 million Australians exceeding recommended medicine dosage, worrying doctors

NPS Medwise- Codeine-related deaths: a cause for concern

Another wake-up call to revamp the aged care sector

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The Australian newspaper has reported that federal aged care minister Ken Wyatt has released several recommendations from an independent review into aged care facilities which, if implemented, may lead to changes within the Residential Aged Care Facilities (RACF) community.

In a side note from minister Wyatt he stated in a speech to the National Press Club that up to 40% of aged care residents never receive visitors. While I cannot say I agree with that high figure I will agree that there are a significant number of residents who do not receive any visits from friends or family. This may be simply due to family and friends dying out, as does happen with age, or to family dynamics. But it does create a lonely environment for those residents. The advantage of aged care facilities for these residents is the social atmosphere of other residents and staff. In all of the aged care homes I have worked in and visited I can say emphatically that the care staff do interact and provide social connection with the residents.

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While all of the recommendations from minister Wyatt were not laid out in the article one particular recommendation was worthy of note to prompt me in writing this post. Minister Wyatt has called for annual re-accreditation to be conducted spontaneously without prior notice given to aged care facilities or their parent companies. To me if this is done effectively it could serve to lead to increased compliance and overall adherence to the governing federal policies for RACFs.

Currently, when a facility is nearing the end of their accreditation period the governing agency, the Australian Aged Care Quality Agency, will usually notify the RACF of the date of their re-accreditation visit with several weeks notice. This starts a chain of events where numerous corporate representatives invade the facility and start pouring through the documentation and policies ensuring that the facility meets the four standards required for re-accreditation. Oftentimes this process sees months and sometimes years of inaction or bending of rules suddenly become corrected. Resources are brought in to ensure compliance. Documentation is mulled over and errors corrected. On the day everything is perfect. The accreditors are treated like royalty for their two or three day visits, and once passed the same routine resumes.

But an unannounced visit would change this. Facilities would not be aware in advance of a visit, as the current unannounced visits are conducted. But unlike unannounced visits the re-accreditation looks closely at all standards. Facilities would need to enact processes and procedures which would require ongoing compliance, not just rushing in and fixing everything up just before they show up at the door. While it may not fix all of the issues and solve all of the complaints in RACFs it would at least serve as a start to ensuring that facilities RUN as they should, not to just look good on paper once every three years.

Until next time.

Ray

The Australian- Crisis in aged-care industry prompts wave of reform

The Aged Care Quality Agency website

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

Should Australia adopt a national Dementia plan?

 

Anyone who works in healthcare, particularly those in aged care, can attest to the fact that dementia is one of the largest problems facing our aged population. Here are a few Australian facts courtesy of Alzheimer’s Australia:

  • There are more than 413,106 individuals in Australia living with dementia
  • Currently 244 new individuals will be considered has having dementia every day
  • Dementia is the second leading cause of death of Australians
  • In 2017 the cost of caring for those with dementia in Australia is estimated to be 14.67billion
  • Dementia is the single biggest factor leading to disability of adults over the age of 65
  • Dementia accounts for 52% of those residing in aged care facilities (RACF)

It is a huge problem! In an article on the 2nd of June in Australian Ageing Agenda Maree McCabe of Alzheimer’s Australia has strongly encouraged Australia to join the international community in developing and funding a national Australian dementia policy. In the article it states that the World Health Organization (WHO) has adopted a Global Plan of Action on Dementia, and that Australia should join other countries in adopting it.

What is Australia doing about it?

The government’s response has not been favorable to Alzheimer’s Australia’s (AA) request. Dr Margot McCarthy told a Senate estimates committee that, although she was aware of AA’s request there was no national strategy but a series of increased funding for research and new dementia-specific programs. Dr. McCarthy also in her statement referred to the National Framework on Action on Dementia, but said the government had to decide on how to follow-through with the framework.

The National Framework on Action for Dementia 2015-2019 was developed by the  Australian Health Ministers Advisory Council (AHMAC) through a consultative process and merely serves to

The purpose of the Framework is to guide the development and implementation of actions, plans and policies to reduce the risk of dementia and improve outcomes for people with dementia and their carers. It does this by drawing on current evidence to promote dementia friendly societies and delivery of consumer-focused care.

The keywords here is ‘guide’ and ‘development and implementation’. This is NOT a national framework, but merely a fact-finding paper with the results of interviews and consultations on the problem. While the national framework policy does not give any direct action to the problems of dementia, there have been some attempts by the government to tackle dementia issues.

In June of 2016 the government began a commitment to tackle the issue of dementia in the community by the initiation of the Severe Behviour Response Teams (SBRT), a partnership between the government and Hammond Care. The SBRT is meant to be an assessment and management team designed to visit the individual and work to identify and create strategies to handle adults who suffer from dementia-related behaviours. The government also acknowledged at the time that specific dementia facilities for those with behaviours would be needed. Dr. Judd, then chief executive of Hammond Care, indicated that accreditation standards for aged care facilities had led to those facilities increasing in size and therefore “as nursing homes get bigger and bigger, it becomes harder not to have institutional buildings which are less homelike and more regimented… Today, the public areas of some aged care ‘facilities’ look more like airport lounges than lounge rooms” (quote by Dr. Judd taken from this article).

A year later and the Ageing Australian Agenda article confirmed that the special dementia units promised in 2016 were largely not developed. Therefore, the bulk of dementia-specific management of older adults rests squarely on the shoulders of current residential aged care staff and caregivers when dementia-sufferers are at home. But what about the WHO’s Global Action on Dementia? Wouldn’t that give some indication on where Australia should go?

The World Health Organization and Dementia

I have looked through the WHO’s website and cannot see any agreed final document on the global action on dementia. According to the WHO dementia has been labeled as a public health priority in 2012 and a Ministerial Conference on Global Action on Dementia did occur in 2015, resulting in a draft document of the same name. In the push for WHO development of information a site entitled The Global Dementia Observatory was meant to be a sharing house for information relating to statistics on global dementia and development of strategies to treat and handle those with dementia. However, in my research neither has the Global Action on Dementia been finalized nor has the Global Dementia Observatory been created and implemented despite statements made by Alzheimer’s Australia.

So from my perspective after looking at all of the information the WHO is no further in looking for a unified dementia strategy than Australia is. We continue to develop reactionary stop-gap measures to modify behaviours and reduce pressure on caregivers. But that does not help identify and treat the root cause. Non-government organizations like Alzheimer’s Australia and Hammond Care are doing great things to try and help this looming national (and international) epidemic.

We in healthcare are at the front-line of this issue. Of the patients I see a vast majority are over the age of 65, as they take up more acute healthcare beds. And while I do not have specifics of those with dementia I can say with my experience that many who enter our beds do. Dementia causes quite a few issues that can lead to life-shortening situations.

My thoughts

Those who follow this blog know that I have talked twice about the concept of ‘premature deaths’ a topic surrounding why individuals in aged care facilities are dying from un-natural causes. Falls was listed as the greatest cause of these premature deaths. I wonder if Mr. Ibrahim’s proposed study would look to identify of those falls how many patients have a diagnosis of dementia? Being reasonable and looking at common sense, if I do not have dementia and have all of my faculties would I not use the vast range of mobility aids and ask for help to prevent falling when I look to walk or even stand? Those with dementia do not have the for-sight to realize that they are no longer able to mobilize without help, and therefore are at higher-risk of falling.

Interestingly Dr. Judd in his address in 2016 also talked of aged care facilities becoming larger. This is another troubling point. Larger facilities mean more residents for staff to monitor in a larger space. Another interesting study could look at the amount of time each staff is given per resident. I think it would find that staff have difficulty in adequately supervising residents, particularly those with dementia who are prone to stand and walk- and therefore fall.

Unifying Australia’s stance on dementia and the associated research and programs would give clarity and focus within all aspects of the aged care community. Let’s face it, the aged care population is faced to grow over the next few years. And with it those with dementia is also most likely going to grow. It is a debilitating condition that we need to know more about to effectively care for and treat. I agree with Mrs. McCabe, Mr. Judd and the WHO that we need to put more focus on a unified and strategic plan to deal with this growing epidemic.

References

Australian Ageing Agenda: Australia behind as global dementia plan endorsed

Alzheimer’s Australia: KEY FACTS AND STATISTICS FOR MEDIA – NSW

Australian National Framework for Action on Dementia 2015-2019

Australian Ageing Agenda: Coalition to fund special dementia care units for severe behaviours

Dementia Behaviour Advisory Service

Hammond Care: Severe Behavoiour Response Team

World Health Organization: Dementia