In the lastest of our series of e-cigarette interviews, Paul Bergen interviews Dr Farsalinos about an intriguing case study and a huge new survey of vapers.
This interview takes place just prior to the publication of Dr. Farsalinos’ case study of a patient who dramatically improved after switching from smoking to vaping. Later in the article we also discuss his launch of the most comprehensive survey of vapers to date.
PLB: You are about to publish an intriguing case study in which a patient suffering from chronic idiopathic neutrophilia (elevated white blood cells) has normalized after switching from smoking to vaping. According to your report the patient suffered from this for over 7 years and had unsuccessfully tried to quit smoking (including approved cessation medications) but was finally able to quit with e-cigarettes.
First of all, could you explain in layman’s terms why elevated white blood cells would be a problem for someone?
Answ. This patient, now age 35, suffered from a condition called chronic idiopathic neutrophilia. It is a condition where elevated white blood cells are found on routine laboratory exams that cannot be explained by any underlying disease. This means that we cannot find a specific cause for this (like for example, infection, inflammation etc). Indeed, after an extensive diagnostic work-up, we could not find any specific condition causing the elevation of white blood cells. Additionally, he had persistently mildly elevated C-reactive protein, a marker of low-grade chronic inflammation. He was a smoker since the age of 18, and he also had elevated blood cholesterol levels, treating with medications (statins). Overall, his profile was considered high-risk for future cardiovascular disease.
PLB: So just to be clear – do elevated white blood cells predispose one to heart disease? I know that while most people think of cancer as the great risk associated with smoking, cardiovascular complications are much more common.
Answ: Cardiovascular disease is the second most common condition caused by smoking. However, it should be taken into account that while lung disease is mainly caused by smoking alone, cardiac disease is multifactorial and smoking multiplies the already elevated risk associated with other conditions (like high cholesterol and blood pressure). Now, it should be understood that atherosclerosis (and therefore cardiovascular disease) is basically an inflammatory process, and markers of inflammation like elevated C-reactive protein and white blood cells (both elevated in our patients) indicate a high-risk profile for the patient. Taking into account that the patient also had hyperlipidemia, he had a high-risk profile for future cardiovascular disease despite his young age.
PLB: I understand that both smoking and obesity are considered common causes of this condition. Any idea why?
Answ: Yes, smoking and obesity have been considered as predisposing factors for this condition. Overall, we know that smokers have approximately a 25% elevation in white blood cell count; however, our patient had levels 40%-100% higher than normal, which is quite uncommon. And this was a consistent finding over a 7-year period of follow-up. There are some mechanisms by which smoking directly acts on the bone marrow, promoting the release of white blood cells. Moreover, we know that smoking induces a low-grade inflammation to the organism, and this is an independent predictor of future cardiovascular disease.
PLB: Other than vaping I imagine the literature already recommends quitting smoking for those with the condition?
Answ: In fact, the condition is relatively rare and no guidelines have been formally published. Although we know that smoking is a cause for this condition, we could not find in the literature any other case reporting such a decline in white blood cell count few months after smoking cessation. However, since we do not find any other cause for this condition, we advised our patient to try to quit smoking as soon as possible. He had two unsuccessful attempts to quit smoking (one self-assisted and one by using varenicline together with NRT).
PLB: Given that vaping seems to be the easiest way to quit smoking it might be the one worth promoting as the best recommendation for those with this condition.
Answ: I wouldn’t confine such a suggestion to this population alone. I think physicians are currently facing an important ethical dilemma, which I also addressed in the published paper. Given the fact that almost all scientific organizations state that e-cigarettes should not be used, how should I advice my patient when he told me that he managed to quit smoking by the use of electronic cigarette? Should I have told him to stop using them, taking the risk that he would (almost certainly) go back to smoking? What about now, that chronic idiopathic neutrophilia has resolved despite the daily use of e-cigarette? Should I tell him to avoid using them, according to scientific guidelines? And even before that, what is scientifically and ethically correct for a patient that has failed to quit smoking by currently approved methods? To tell him not to ever try electronic cigarette and let him keep smoking without providing any less harmful alternatives? These are major issues, and I think it is time to deal with them in a responsible way.
PLB: This is just one study but considering the number of smokers in the world, and the link of smoking with the condition, this could suggest a fruitful avenue of further studies. I also imagine that there must be quite a bit of hidden data of quitters (functionally equivalent to vapers) who have shared the same pattern with your one patient. We should always be cautious with just one case: do you have reason to think that this is not an isolated case?
Answ. We can never be sure when we report just one case. However, many times new ideas come from such an isolated case; that is why we wanted to publish it. This particular patient has been followed up rigorously since 2005. We can never absolutely exclude that it was just a chance finding; at the same time, we cannot exclude that the electronic cigarette itself might have a beneficial effect and might be the cause for the condition to be relieved. Most probably however, it was smoking cessation that caused the reversal of the condition. Still, the finding is very important because we have shown that, at least in this patient, the daily use of the electronic cigarette did not hinder the beneficial effects of smoking cessation.
PB: Given that there seems to be a strong link between smoking and the condition, that is many with the condition smoke, what about the reverse. How common would you say, or is it possible to estimate, how many smokers suffer from this condition?
Answ: Although we know that smoking triples the risk of having this condition, the population of sufferers is quite small. However, it is very important to see what happens in those who have mild elevations in white blood cell counts. As a general population, smokers have 25% higher white blood cells compared to non-smokers, and it is very important to see what happens in those who quit smoking by the use of electronic cigarettes. We should test the hypothesis that white blood cells (and C-reactive protein levels) might fall in this group.
PLB: So would you say that this higher cell count for smokers predisposes them or makes them more vulnerable to something worth being concerned about?
Ans: Higher white blood cell count means that there may be an ongoing inflammatory process. However, for most of smokers, white blood cell counts remain within normal limits therefore it cannot be widely used as a marker for elevated risk. In our patient, the levels were significantly higher than normal, to a level that could be interpreted as a marker of inflammation and elevated risk. For someone who has levels similar to our patient’s, our study has shown that it should alert him to quit smoking, and the daily use of electronic cigarette will not hinder any beneficial effect derived from smoking cessation.
PLB: As you conclude yourself, switching to vaping alleviates this condition. It seems that there is yet another reason to switch to vaping.
Answ: I can say with confidence that this patient had a huge, pragmatic and evident benefit from smoking cessation. And electronic cigarette was the only method that allowed him to succeed. Taking into consideration the limitations inherent to a single case-report, I think that we should observe and study the whole spectrum of diseases caused by smoking and evaluate the effects of electronic cigarettes on these conditions. And we should open the discussion of what we can and must do for the majority of smokers that cannot quit with currently approved methods.
PLB: Now onto what might be more exciting news for anybody interested in learning more about vaping and health effects, you are on the brink of launching a very large international internet survey of vapers.
Ans: Yes. It will take the form of a questionnaire of 60 questions translated to English, Greek, Italian, German, French and Spanish. It has been prepared over the past 6 months by me, my colleague Dr Giorgio Romagna from Italy and colleagues from the Onassis Cardiac Surgery Centre. Our goal is to have a participation of over 10,000 people, and why not get close to 20,000. This will be by far the biggest survey ever performed on electronic cigarette use. Our goal is to publish all results to medical journals. The questionnaire was designed based on our personal experience and contact with several electronic cigarette users that have participated in our research projects. We will address all major aspects of electronic cigarette use, including data on dependence relative to smoking dependence, common misinformation spread by those against e-cigarettes and many other aspects. We think (and hope) that it will have a major impact on the public health community and authorities.
We ask everyone’s help considering participation (we will release all questionnaires to Survey Monkey) so that we will reach our goal of 10,000+ participants.
Additionally, we want to trigger the interest of vendors, because we have no funds for this study. Just for publishing the questionnaire we will need 1800 euros (300 euros per survey on Survey Monkey). We will publish the English questionnaire over the next few days and we have to fund it ourselves. Additionally, we will need funding for data analysis and interpretation, after the survey has ended. Having 10,000+ participants answering a 60-question survey is tremendous data. Several colleagues must work for a long time in order to transform them to a published manuscript. We will probably need several thousand euros for this work, depending on participation. So, I am taking the opportunity of this interview firstly to urge electronic cigarette community and users to participate in this study and secondarily to raise the issue of funding. Since the study is scientist-initiated and driven, we raise the funds rather than having the industry directly fund this project.
PLB: And finally, you mentioned you had written a response to a paper out of Singapore and published in Tobacco Control: (analyzing e-cigarettes and concluding that “Based on samples tested in this study, many contain misleading information on product ingredients. The results show poor consistency between actual nicotine content analysed on ENDS cartridges and the amount labelled. These findings raise safety and efficacy concerns for current and would-be recreational users or those trying to quit smoking.” Your response is at http://tobaccocontrol.bmj.com/content/early/2012/11/30/tobaccocontrol-2012-050483.short/reply#tobaccocontrol_el_12237 . It is a well considered rebuttal to some of the statements by the authors such as propylene glycol being characterized as a known irritant. I have to say I would have been a little more caustic in my response. You point out that the range of inconsistencies in nicotine levels etc being delivered is no different than the variation when a person is smoking. I would have added that it is almost criminal to use the variation and some concerns about labelling to dismiss a product so much safer than smoking. It is a common tactic in tobacco control to use absolute safety (that is how much safer is the product than using nothing at all) to divert the attention from relative safety (how much safer is this product than smoking). At any rate, combining tobacco control and Singapore never results in anything but calling for abstinence from all nicotine.
PLB: Did you have any further thoughts in regard to this article?
Ans: My biggest surprise was that they devoted only one sentence in the whole article mentioning that no nitrosamines or polycyclic aromatic hydrocarbons were found. They even said that it was an expected finding. Although I could agree to this concerning aromatic hydrocarbons, since they are mostly produced by the burning process, we know that this is not the case for nitrosamines. Another surprise is that they compared electronic cigarettes with electrically–heated cigarettes, a product developed by tobacco companies that involves heating instead of burning tobacco. Electronic cigarettes are in no way similar to these products. Finally, concerning your comment about a more caustic response, although I agree with you I must say that in general it is quite difficult to have medical journals accept any manuscript or comments that are favourable towards electronic cigarettes. Therefore, we must be more cautious and mild in our expressions; otherwise we will never have the opportunity to express our opinion (and our findings) in medical journals.
PLB: Unfortunately, you are right about that, I thank you for your time and perhaps soon we will be discussing the findings of your survey.
Also see our previous interview with Dr Farsalinos here.
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