5/16/2018 1 Comment E-Cig's and AMDby Paul Batson, O.D. Center Director VisionAmerica of Birmingham It doesn't take much to see Vaping shops popping up all around. According to Business Service News, "The global e-cigarette market size is estimated to be around $15 billion in 2017, will grow at a CAGR of 27.3% during 2018-2023 and is forecasted to attain a value of $70 billion by 2023." [1] I had a call a few months ago from a referring doctor asking about the recommendation of E-Cigarettes and Macular Degeneration. To be honest, I hadn't thought about it very much and started asking around. I even posted a poll on our Facebook page to gauge what people are recommending. We seem to be all over the place and it's hard to find a solid recommendation. So... I (along with Dr. Rod Nowakowski) started doing some research and this is a quick summary. So what exactly is vaping or electronic cigarettes or ENDS? E-cigarettes are battery-powered devices that have cartridges or refillable tanks containing a liquid mixture composed primarily of propylene glycol and/or glycerol and nicotine, as well as flavorings and other chemicals. During use, inhalation activates a pressure-sensitive circuit that heats the atomizer and turns the liquid into an aerosol that is inhaled by the user through the mouthpiece and exhaled as a fine mist. Some e-cigarettes have buttons that allow the user to manually activate the heating element. The exhaled aerosol does not contain smoke, tar, or carbon monoxide.[2] As a result, you remove many of the carcinogens from the cigarette and are left with glycerin and nicotine plus any desired flavor. Assuming the glycerin, flavors and other components are benign (which is still very questionable), then one of the main questions becomes whether the nicotine is damaging to the eye. This becomes a difficult question and one that has not been clearly defined yet. What impact, if any, does nicotine have on the eye? Nicotine promotes pathologic angiogenesis and retinal neovascularization in murine models. It causes age-related macular degeneration in mice. In a clinical study, the most virulent form of age-related maculopathy was associated with retinal neovascularization that contributed to visual deterioration.[3] Nicotine was also shown to increase the risks of progression of wet AMD in passive smokers due to its effect on human retinal pigment epithelium (RPE) cells and in rats. Although this link has not yet been firmly established in human eyes, it is strongly suspected to have an adverse effect.[4] What are some of the systemic effects of nicotine? Nicotine poses several health hazards. There is an increased risk of cardiovascular, respiratory, gastrointestinal disorders. There is decreased immune response and it also poses ill impacts on the reproductive health. It affects the cell proliferation, oxidative stress, apoptosis and DNA mutation by various mechanisms which lead to cancer. Nicotine also affects the tumor proliferation and metastasis and causes resistance to chemo and radio therapeutic agents.[5] What are some of the known Public Health consequences of E-Cigarettes? In January of this year, the National Academies of Sciences, Engineering, and Medicine released a paper with the goal to provide a comprehensive and systematic review of the literature evaluating E-cigarettes and health. To review this full report, click here . They divided their results into various levels of evidence. Those findings which were labeled as "Conclusive" provided the highest level of certainty. Below is a list of these conclusions: · Conclusion 3-1. There is conclusive evidence that e-cigarette use increases airborne concentrations of particulate matter and nicotine in indoor environments compared with background levels. · Conclusion 4-1. There is conclusive evidence that exposure to nicotine from e-cigarettes is highly variable and depends on product characteristics (including device and e-liquid characteristics) and how the device is operated. · Conclusion 5-1. There is conclusive evidence that in addition to nicotine, most e-cigarette products contain and emit numerous potentially toxic substances. · Conclusion 5-2. There is conclusive evidence that other than nicotine, the number, quantity, and characteristics of potentially toxic substances emitted from e-cigarettes is highly variable and depends on product characteristics (including device and e-liquid characteristics) and how the device is operated. · Conclusion 14-1. There is conclusive evidence that e-cigarette devices can explode and cause burns and projectile injuries. Such risk is significantly increased when batteries are of poor quality, stored improperly or are being modified by users. · Conclusion 14-2. There is conclusive evidence that intentional or accidental exposure to e-liquids (from drinking, eye contact, or dermal contact) can result in adverse health effects including, but not limited to, seizures, anoxic brain injury, vomiting, and lactic acidosis. · Conclusion 14-3. There is conclusive evidence that intentionally or unintentionally drinking or injecting e-liquids can be fatal. · Conclusion 18-1. There is conclusive evidence that completely substituting e-cigarettes for combustible tobacco cigarettes reduces users' exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes. Summary While we don't have conclusive human studies associating nicotine with an increased risk of AMD, there are certainly animal models supporting this association. In addition, there are numerous adverse systemic side effects of nicotine and electronic cigarettes. There is not a formal recommendation of e-cigarettes and its impact on eyes. Until then, it is our job to help educate patients on what we do know and allow them to make an informed decision. We hope this helps. [1]https://businessservices24.com/702332/e-cigarette-market-size-share-trends-distribution-channel-market-demand-and-growth-by-2023/ [2]Bhatnagar A, Whitsel LP, Ribisl KM, Bullen C, Chaloupka F, Piano MR, Robertson RM, McAuley T, Goff D, Benowitz N; on behalf of the American Heart Association Advocacy Coordinating Committee, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Electronic cigarettes: a policy statement from the American Heart Association. Circulation. 2014;130:1418-1436. [3]Mishra A, Chaturvedi P, Datta S, Sinukumar S, Joshi P, Garg A. Harmful effects of nicotine. Indian Journal of Medical and Paediatric Oncology: Official Journal of Indian Society of Medical & Paediatric Oncology. 2015;36(1):24-31. doi:10.4103/0971-5851.151771. [4]http://www.ecoo.info/2013/12/12/european-coalition-for-vision-statement-on-damaging-effects-of-smoking-on-eye-health/ [5]Mishra A, Chaturvedi P, Datta S, Sinukumar S, Joshi P, Garg A. Harmful effects of nicotine. Indian Journal of Medical and Paediatric Oncology: Official Journal of Indian Society of Medical & Paediatric Oncology. 2015;36(1):24-31. doi:10.4103/0971-5851.151771
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