Dissolving Tobacco: ‘Candy’ to feed nicotine addiction

Who ever thought that tobacco companies would come up with a way to market a tobacco product that does not light up or need to be spit out? Camel Orbs and other forms (sticks or strips) are being marketed now. It is interesting, a dissolving product that delivers from 0.6 to 3.1mg of nicotine (depending on form vs. 1mg per usual smoked cigarette). It is made from ground tobacco, and flavored. You would think given the dose of nicotine delivered that it is considered at least an over the counter agent?

I learned of this from a recent newsletter for clinicians (Here is the link where the article is posted: http://www.smartbrief.com/servlet/wireless?issueid=41F0A8DB-0D52-4644-A460-C671DA25785E&sid=4424389f-4968-420d-b19a-428ead999285 ). I think they missed the boat on the focus to report: that babies or children might accidentally put the small tic-tac size ‘candies’ in their mouth and ingest toxic doses of nicotine. This report follows a study from Connelly et al.( 2010) in Pediatrics (http://pediatrics.aappublications.org/papbyrecent.dtl). This is a concern to be sure. Adults might shake out a few from their childproof container and leave them where a child could find them. In addition, the ‘candies’ are flavored, so they taste good and encourage eating more than one? An important point and users should beware.

A bigger concern, is that tweens and teens might be interested in trying this substance for the effects of nicotine without smoking! It even tastes good. Let’s see if we can hook a whole new generation on tobacco and call it candy this time. Not a good idea. There are enough other substances in the world to get hooked on. Do we really need a new one? I can see the rationalizing already, it isn’t smoked so won’t cause lung cancer, secondary smoke, etc…

When a product delivers a pharmacologically active agent like nicotine, shouldn’t it require strong regulation? More than that of a tic tac? Particularly when we have reams of data about how addictive the substance is? I don’t think this is much different than other nicotine products, which pharma created and I’m sure went through many hoops to get approved. Shouldn’t this product be treated the same way?

The New York Times coverage of this story yesterday, (here is the link: http://www.nytimes.com/2010/04/19/business/19smoke.html) identifies that in fact the FDA does regulate tobacco now… R.J. Reynolds did submit documents showing research and other material about this new ‘candy’, but the FDA still has 2 years to determine the safety of the product. I guess they can begin marketing it before we know its safety?

From what I can find, they are also available as ‘sticks’ (like a toothpick that dissolves) and ‘strips’ (like a breath mint strip). Here is a picture of the product, in case you are interested:

My thoughts on 'Anti-Energy' Drinks

Let me be perfectly clear: I am not an expert on nutrition, nor do I research these agents or drinks. I do have an opinion though, which I shared on my blogs Wednesday and I will share today.

I was asked by someone if I knew anything about the effects of anti-energy drinks such as Drank, which just recently started being sold in Connecticut. The product contains three main ingredients: valerian root, rose hips and melatonin. Part of the question was if there was evidence of an effect of these ingredients on stress relief and/or relaxation. In addition I was asked if I know anything about the three main ingredients. I do not have special knowledge to answer these questions with, they are not my areas of study. They are excellent questions!

I do think this is an interesting twist on the use of nutrients and other agents in beverages. In fact I have not researched energy drinks to any great degree, except to look up some of the ingredients. I just have a long standing concern: people think just because something is a ‘natural’ substance (herb or vitamin or mineral) it is ok to take it however they wish. I also don’t think people understand the lack of protections we have, given the lack of required evidence of safety to put products like these on the market. People may also think because it is on the store shelf it must be safe.

Unfortunately the websites available about drinks of these kinds do not have specifics about the amounts of each ingredient. They do not identify specifically the labelling with nutritional information (at least that I could find on the website for Drank). I'll have to go to the store and see what the label says. Despite the ingredients mystery, they are very direct in suggesting this is a fun new way to relax though.

I do not know off-hand of the safety of the ‘anti-energy’ drinks. My concerns about safety would be similar to those of all energy or 'nutritional' drinks. Whenever we begin to use agents in food or beverage that are commonly consumed at meals or other times, we have to wonder about the effects of exposure (i.e. how many of these drinks might you drink in a day? What is the dose of the substance you get over the day?). Is it like water and you can drink as much as you want?. Over long periods of time and with penetration of these products in the marketplace there is increased population exposure. Because they are foods/drinks they are differently regulated. How many people do you know that would take 3 pills a day (valerian, rose hips and melatonin) without considering the safety? Drinking them seems to make them appear safe to people. That is my concern. What if they are on other medication? Could they interact and cause negative effects? Do they check with their health practitioner to be sure it won’t cause a problem?

The other concern is we may have studies of a substance like melatonin for example and consider it safe for some use in some dose, but are there potential interactions between the three substances in this particular drink? Also where is the long term evidence of safety of these substances (individually and combined) in such a common food/drink source? An absence of evidence does not equal an absence of negative effect. It just means we haven’t studied it in this way.

I suspect ‘anti-energy’ drinks will be popular in the marketplace… It makes you wonder whether people will be pumping up on energy drinks all day and then trying to settle down with the anti-energy drinks in the evening. I am sure the beverage industry is very excited about all this… It is like they are the new but unregulated pharma – without having to shoulder the costs of safety research and clinical trials.

I am sure I told you more than you are really interested in. I am not the ‘expert’ on these ingredients. There are many people I am sure who have much more knowledge than I do about these ingredients. (actually you might look at the medline plus search info for supplements from the national library of medicine, if you haven’t already found it). Here is the link to info about melatonin:
http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-melatonin.html I would consider medline plus a trustworthy source of data on ingredients like this.

‘Healthy Drinks’ Mask High Caffeine Content

I decided to cross-post this piece here as well... I find this topic quite disturbing.

I was glad to see the Journal for Nurse Practitioners take up an important issue to our health and well-being: Energy Drinks. Pohler, H. (2010). Caffeine intoxication and addiction. Journal for Nurse Practitioners. 2010;6(1):49-52. http://www.medscape.com/viewarticle/714855

These drinks are marketed as a healthy alternative to other choices like soda and coffee, but in my view they potentially have many negative implications. For the past two years, I have observed a 7th grade boy purchase two cans of Red Bull each morning when I purchase my cup of coffee. 2 cans of highly potent, caffeinated Red Bull, which is advertised to “revitalize body and mind”. Some days he buys Full Throttle (which CNN tells me ( http://www.cnn.com/HEALTH/library/AN/01211.html) nearly doubles the dose of caffeine per can (cans are bigger)).

How commonly do children buy these drinks? I wonder a bit about the groups that are the highest consumers of energy drinks like Red Bull or Red Star or Liquid Cocaine? Are we (and our children) unwittingly getting hooked on high doses of stimulants in ‘healthy’ energy drinks? Let’s not forget the little ‘shots’ available for purchase too, so you can quickly get your stimulant without a lot of drinking… Also, check the label of your vitamins, as often vitamin supplements have caffeine in them as well. I had that experience a while back. It isn’t pretty to see me after a cup of coffee and a vitamin with caffeine. We need to look at the labels of the products we buy!!!

Caffeine is one issue, each 8.3oz can of Red Bull contains 75mg of caffeine. The other ingredients have potential effects as well. Here are the ingredients of Red Bull: Carbonated water, sucrose, glucose, sodium citrate, taurine, glucuronolactone, caffeine, inositol, niacinamide, calcium-pantothenate, pyridoxine HCl, vitamin B12, artificial flavors, colors.

I appreciate Pohler telling us that ingredients like guarana and cola nut are synonyms for caffeine in an ingredients list. She also details the physiologic metabolism of caffeine into byproducts theobromine and theophylline (which can be found on labels of nutraceuticals).

Consumers need to be aware of what they are ingesting. I found in the store some vitamin labels might list the name of a stimulant (like guarana or caffeine) and on the external package not print the amount (mg) in each tablet (which made me think at the time of purchase there was no caffeine in there). I didn’t recheck the bottle label inside the packaging until a few days later when I realized I was jittery and overstimulated and knew I hadn’t increased my coffee consumption. My One-A-Day multi-vit actually gave me as much caffeine as my morning coffee. Time to change vitamins, and be careful about reading those labels!

While I readily admit a ‘habit’ (do I really have to call it an addiction?) of a 16oz hazelnut coffee each day, I haven’t moved to even try a product like Red Bull. I am also reticent to drink Vitamin Water and other ‘nutritious’ drinks because the additives that make them ‘healthy’ are not familiar to me. What is taurine? (ok, I looked it up, it is an amino acid) And Glucuronolactone? (an artificially produced stimulant – so adds to the load of stimulant in Red Bull). I recognize some of the nutritional ingredients like niacinamide, pyridoxine and vitamin B-12, which worry me a little less. However it goes back to my argument about using nutraceuticals in general: where is the evidence to tell us the use of ingredients in this way is really healthy? In addition the labels don’t tell us how much of each ingredient we are ingesting, and we all know that many vitamins, minerals and nutritional products can have toxic effects if we ingest too much.

Health professionals are well aware that drugs interact with one another. In addition, at times substances that are seemingly ‘good’ for us have negative effects. This is the reason I don’t drink beverages like that. Nor would I allow my child to drink them! Particularly on a daily basis in high amounts. Do we have long term data on children's brain development to tell us this is not harmful? Do we have any long term data that tells us that these ingredients together won’t harm our kidney function in the future? Or other body systems? What happens 10 years out with daily high dose stimulant, taurine, glucuronolactone and other ingestion? (actually caffeine seems better to me given our lack of knowledge of these other ingredients and the high prevalence and long term use of caffeine in our culture… unless of course some of the common chronic illnesses are fed by caffeine – which of course hypertension is one).

Am I the only one who is worried about the marketing and unwitting consumption of ‘healthy’ beverages like this? I am pleased to see Nurse Practitioners considering the implications of stimulant beverage consumption by their clients. As mental health clinicians we can be no less vigilant...

Should Heart Disease in Women Have a Different Name?

Well an interesting article about the differences in heart disease by gender was published in the Journal of the American College of Cardiology. The authors suggest that in women heart disease should be called ‘Ischemic Heart Disease’ vs. Coronary Artery Disease or Coronary Heart Disease in men. This is based on evidence suggesting the pathology most common in women is different than that in men. I like the idea of that.

However doing this also has implications for measurement and research in heart disease epidemiology. It is not clear whether this will add to ambiguity in the field or whether it will be a more specific way to identify the disease. Offhand I think that there would need to be very specific criteria by which the actual pathology of the disease is diagnosed, regardless of gender. It is fine if IHD is more often diagnosed in women because it is what actually happens physiologically. On the other hand, I disagree with the different diagnosis being applied simply because it is a woman with symptoms.

I think I need to more carefully review that article to understand what is really being suggested!

See the article, “Women and Ischemic Heart Disease” by Shaw, Bugiardini, & Bairey Merz: http://content.onlinejacc.org/cgi/content/abstract/54/17/1561
[J Am Coll Cardiol, 2009; 54:1561-1575, doi:10.1016/j.jacc.2009.04.098]

How can we be prepared for emergencies?

I read with interest the article in the NY Times magazine about decision making at Memorial Hospital during Hurricane Katrina. See the link at the bottom to the article. It describes the long series of events that occurred after Hurricane Katrina that led to the deaths of a large number of patients, many of whom were not expected to die.

Who and what else is involved in the wrongful deaths? We might consider:
-prior administrators had decided not to pay for the cost of improving the electrical system so that flood waters would not cut power completely
-officials who allowed the circumstances that lead to the floods occurring in New Orleans (including our overall lack of foresight in building anything below sea level!).
-lack of coordination between the hospital and the LifeCare unit; why would this subunit in the hospital come second to the hospital at large? What was the coordinated disaster plan and evacuation plan for this unit of critically ill people? How had communication ensued that LifeCare could not independently evacuate their patients?
-A lack of knowledge or training related to principles that should be used to carefully allocate resources in the midst of an emergency that is long term. When should such principles be used? Are the most ill evacuated first or last? When would people not be evacuated? What is abandonment in a situation like this? How can workers in the midst of such a great crisis be expected to think logically and make the best decisions? Was this a group think situation, with individuals only seeing one way out of an extremely difficult situation?
-How were decisions made about who was a priority to rescue and evacuate? Why wasn’t more help available to move or transport patients when the hospital staff was exhausted? What was the rationale to send away the helicopters at that point? How could this be better planned for in the future?
There is also a more general consideration, for a different blog... How comfortable are we that every day lethal combinations of drugs are given to people who are at the end of life? Generally this is done to ‘comfort’ the seriously ill in their last moments. Comments by the physicians and nurses do indicate a knowledge that death is hastened in these circumstances. Does this comfort with hastening death make it easier to decide to hasten death in a person not otherwise expected to die immediately yet who is seriously ill?

There was a disaster plan...
-The person in charge, a nursing administrator knew that disaster plan… had authored it, managed work groups to develop it, and implemented that plan during the Hurricane. This is a good example of how difficult emergency planning is. Particularly for large entities. How can we envision every emergency that we would be faced with? How can we know exactly what our deficiencies in planning are, until we are faced with the reality? In this case it could be argued that it is easy to imagine the emergency and sequelae of a hurricane in New Orleans. This is true, but think of all the expected and random events that could occur in such a situation. Generally disaster planning is rather linear. You assume a particular situation and its parameters and decide upon how we can best be prepared for all aspects of that situation and its ramifications. Should the emergency plan have figured out details for evacuation if the streets were flooded? Should the plan have identified what to do if there was a ‘complete’ power failure (and for how many hours or days)?

A problem is that planning probably did not ever imagine the conditions that continued for days in this situation. In the midst of a crisis situation, best decisions cannot be made. Decisions are made based on the information and resources available. It seems to me that in the midst of this terrible, terrible situation, many of the caregivers experienced cognitive constriction. Cognitive constriction is the inability to imagine any other means out of or to resolve a situation. It is a common symptom experienced by those who are suicidal, and is described by Edwin Schneidman (1996) in his book, The Suicidal Mind. It sounds like elements of 'Group Think' are also present.

Now it is easy to see that in the midst of this incredible crisis, that there were many alternatives available. Unfortunately in crisis situations problem solving abilities may not be at their best. Which of course is the reason we plan for disasters.

The article does not tell us how communication or decision making were handled after the initial implementation of the plan. It appears that many were working based on limited or varied information. It is unclear what information offered by individuals involved and reported in the article is presented to protect the providers involved.

Should providers be called into question about decisions made during those long and terrible hours following the floods of Katrina? Absolutely.

Should there be protections for health care providers who do provide care? Absolutely.

I believe there is a middle ground here. Without questions we will never learn from a situation so that we might respond better the next time. We do need providers to feel able to respond without personal risk during a crisis. We also need to learn how to prevent a similar situation from occurring within a disaster.

A harder question is what we as a society expect in the midst of such a crisis or disaster? Most people expect that somehow normal functions of all kinds will resume quickly after a crisis.

What is reasonable in situations of 'chronic' disaster functioning like this?

Here is the link to the NYT Magazine story: http://www.nytimes.com/2009/08/30/magazine/30doctors.html?pagewanted=16&th&emc=th

Latest Greed package from Wall Street: Profiting from your sick family member’s insurance policy?

When the banks and real estate market were plummeting, I believe much of the credit goes to the ‘credit default swaps’ falling apart. I was marveling that it could be ok to take out what was basically an insurance policy on someone else’s risk. Yet again, Wall Street is coming up with another way to profit on individual misfortune, by investing in individual’s life insurance policies. Check out this link to the article describing the brilliant ‘new idea’ in Saturday’s New York Times:
http://www.nytimes.com/2009/09/06/business/06insurance.html?th&emc=th

How could this be good for the economy or the individuals involved? The basic idea is, the banks will bundle up and sell our insurance policies as an investment instrument, so that when we die they can collect the money! Imagine that?! Is that what insurance was developed for? For bankers to make profit from? I don’t understand it. Insurance is a regulated industry, how can this be possible to do? I am sure it will be marketed as a public service: When you or I are most needing money, the banks will be happy to cash in that life insurance policy you have been paying on for years. Then they will hold it, and it appears hope that you die young so they will get a bigger payout!

I know someone who still smokes, maybe he smokes at night, gets sleepy and is at risk for burning his house down… let’s buy his insurance policy rights! Maybe we can also take out a policy on his house when it burns down!

How can we go so wrong? By the way what happens when a lethal pandemic does hit and all those chronically ill people cannot survive it? Or a natural disaster? Will we again need to bail out Wall Street or the insurance companies having to pay out all those policies at once? Hopefully the higher risk of death from other events in ill people is a consideration of the computer model they are running. On the other hand, regardless of computer models, there is always the risk of the worst happening all at once… didn’t we just live through that in the past year?

Greeting others and the H1N1 flu… What makes sense?

Here is an article to read… kind of interesting. http://www.nytimes.com/2009/09/04/health/views/04greet.html?th&emc=th

Chan suggests we re-examine our cultural behaviors in greeting, given that the H1N1 flu continues to circulate this year. Interpreting the article in this way offers some interesting considerations of how we greet others, and of how this is done in a variety of cultures. I actually do like the idea of considering these common behaviors and how other cultures handle things like greetings and showing respect. Some of the comments are interesting. I do find our culture continues to become more casual and less formal over time. I enjoy many of the effects of that, but having and showing respect for others is also very important to me.

Unfortunately some of the comments take this to a more disturbing level… which to me moves towards a bit of misophobia (fear of germs, thank you phobialist.com!). Of course you might expect individuals with anxiety related to germs to be more apt to comment on an article like this. The rate of confirmed cases of H1N1 in the US is not among the top 10 in the world (see Wikipedia link to data below). Does the rate of H1N1 we see in that table relate to cultural practices and greetings (i.e. Brunei, Australia, and New Zealand have the highest rates)?

I suggest we take a common sense approach to preventing illness…
• Cough or sneeze into your elbow or shoulder, or use a tissue/handkerchief to not disperse your germs
• Wash your hands frequently and particularly at mealtime
• Stay at home if you are sick or have cold/flu symptoms (which of course is a problem for workers if absences are not tolerated)

Stay aware of the ‘facts’ of the flu…
• How prevalent is it in your area at this time?
• What are the symptoms?
• What is the severity?

Try not to get caught up in the media frenzy! This article reports the swine flu has killed about 2000 people worldwide this year, but does not tell us any comparative information. This compares to approximately 36,000 influenza deaths annually and over 226,000 influenza related hospitalizations annually in the US alone! (reference: August 2008 ACIP Recommendations on Prevention and Control of Influenza, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5707a1.htm ). Always check out the facts…

Actually Wikipedia nicely presents what looks like excellent validated data on the H1N1 flu and reports approximately 3,300 deaths have been confirmed worldwide. Check it out: http://en.wikipedia.org/wiki/2009_flu_pandemic_by_country and thank you to whoever is keeping that Wikipedia page going with some good data! The references used here look very good!