Antidepressants in Pregnancy

This morning BBC News are running with this rather terrifying looking story about the dangers of antidepressants in pregnancy. This is an area that I deal with pretty commonly, so I thought you may be interested in my assessment of the situation.

First thing to note: things can go wrong in even a normal, healthy pregnancy. There is always a risk of malformations or miscarriage, and unfortunately these things can happen for reasons that we dont understand. The risks are usually low, but are increased by things like increased age, obesity, illnesses etc.

One of those illnesses can be uncontrolled depression. "But how can feeling a bit sad harm an unborn baby?" I hear you ask. Well firstly, depression can be a very serious illness which should be taken seriously. It may even be terminal. Pregnancy is a time of massive changes, and as a consequence is a high risk time where someone's mental health can destabilise. If you have depression, you may not be looking after yourself properly: you might not be eating well, you might be avoiding exercise etc. In the worst, most tragic cases, suicide attempts might happen. We don't have enough data to put figures on how much of an increase in risk this all adds up to, but we do know that it can increase risks in a pregnancy if not sufficiently controlled.

Of course, this doesn't even take into account the more nebulous risks to both the child and mother- how will having a depressed mum impact psychologically on the child, how will the bond be affected, and what are the long term effects of this? 

So what of the SSRIs, the most commonly used type of antidepressants in pregnancy? Looking at the risk of cardiac malformations,, the BBC article claims that:

"Currently, prescription guidelines for doctors only warn specifically against taking the SSRI, paroxetine, in early pregnancy."

 It used to be the case that we were aware of the possibility of a cardiac malformation risk with paroxetine. Up until, oh, about 2010, when a large review was published which suggested that the increase in risk, if it exists, may be a class effect. The UK Teratology Information Service's Guidance was changed accordingly to be more practical, to remove a heirachy of one particular SSRI, and to make the drug of choice that which is the best for the individual patient (please note that UKTIS are a service for healthcare professionals only, and pateints should not ring them directly). The fact that NICE guidelines haven't yet been updated probably says more about NICE's workload and update schedule than any evil big pharma cover up.

As an aside, you will notice that there are a lot of words in this post which suggest uncertainty. That is because there is a lot of uncertainty in teratology: because we cant do large robust trials on pregnant women because of ethical concerns, we have to scrape together what we can and make the best of it. There are few certainties in this area.

Strange then, that the BBC are quoting a Prof Pilling from NICE:

"He says the risk of any baby being born with a heart defect is around two in 100; but the evidence suggests if the mother took an SSRI in early pregnancy that risk increases to around four in 100."

I'd love to know where these figures came from. The current status of data on the risks of SSRIs is pregnancy is as follows:

• There is lots of data, which has had various statistical analysis methods applied to it. 
• Some of this data suggests no increase in risk
• Some of it suggests a small increase in risk.

So, with some data saying there isn't an increase and with some saying there is, it is virtually impossible to say for certain if there is an increase. The only thing we can say for certain at this point is that we can't say anything for certain. But given that we have lots of data, and SSRIs are commonly taken in pregnancy, I think we can say that if there is a large increase in risk, we would have known about it by now. So any increase in risk, if it is there, will be low.

Of course the BBC are reporting the relative risk, which sounds more impressive: a doubled risk sounds much more sensational than a small absolute risk. But I'm not even sure where this figure has come from, given the conflicting state of the evidence at the moment. Needless to say, research is oretty much constantly ongoing.

All of this is a very long winded way of saying: we dont know at the moment. But the fact that we don't know, in the face of how commonly used these drugs are in pregnancy, could be seen as reassuring.

As with all things in healthcare, this is a balance. A balance between the risks of uncontrolled depression and destabilising a mother's mental health during pregnancy, compared with the -as yet unknown but likely to be small- risks of SSRI antidepressants. Of course some women with minor depression might be taking antidepressants unnecessarily, but in cases where it is required, we need to look at the bigger picture. Just focusing on a drug's teratogenic potential is not enough: we need to consider the teratogenic potential of the illness itself, and the impact on everyone's lives that might happen if treatment is withheld.


The bottom line is, if women are thinking of becoming pregnant or are already pregnant whilst taking an SSRI, and they are worried, they shouldn't stop it of their own accord, but should make an appointment with their GP to have a discussion about their concerns.

Hxxx

UPDATE: I've been thinking about this 4 in 100 figure for cardiac malformations, and last night tried to find the reference source from it.

I've tweeted @bbcpanorama asking to know where this figure has come from, as have a few others. I've also tweeted @shelleyjofre, the journalist who has mad ethe programme, and have been met with a stony silence. This is really unfortunate, given that to be able to deal effectively with any enquiries from patients relating to this programme, I -and all the other health care professionals dealing with worried mums to be- need to be able to see and appraise the evidence for ourselves.

I have managed to find this document from the MHRA, which does mention a 4 in 100 figure. However, I sincerely hope that this isn't the source in question, given that:

• The document refers to paroxetine alone, not the whole class of SSRIs
• There is no date on the document, meaning we have no way of knowing how up to date these figures are.
• the 4 in 100 figure cited refers to the risk of ALL malformations, not just cardiac ones.
• the risk cited for cardiac malformations is 2 in 100. Half that which the BBC and Professor Pilling are quoting.
• The background risk of all malformations cited is 3 in 100, and the background rate of cardiac malformations is 1 in 100. So yes, the relative risk is doubled, but the overal risk remains very low. 

As I say, I really do hope that this isn't the source, and that @bbpanorama or @shelleyjofre are able to provide me with the reference soon. 

In which the title of "Pharmacist" makes a real difference.

Here is a little story of something that made me proud to be a pharmacist. It works as a sort of counterpoint to all the talk of pharmacy as a quack profession, the sort of bad experiences I have recently had as a customer in a pharmacy, and the Which? Report.

It happened now behind a pharmacy counter, or in my office, but instead at one of my last phototherapy sessions. Because they were three times a week for 10 weeks, you sort of start to get to know the other folk who go there, and of course I got chatting with a few. I had mentioned offhand to one of them during a bout of small talk that I was a pharmacist.

The next time I saw her, she was eager to talk to me "I've been thinking, and I have a question for you, although I hope you don't mind me asking." She had had very severe psoriasis for many years, and it was having a real, tangible impact on her life. It had been suggested to her that she could try methotrexate, but she had been resistant to this treatment strategy "Because I'm just so terrified of all the side effects"

Her question to me was simple: Would I, as a pharmacist myself, take methotrexate if I was in her position? What a great question. And how amazing that someone I don't know at all thinks enough about my opinion, simply because of my job description, to ask me it.  And so, shivering slightly in our hospital gowns in the clinical white of the dermatology changing rooms, we had a really good chat about the benefits and risks of all drug treatments, about how methotrexate works ("someone told me its like chemotherapy!"), about her fears of the medicine ("I've had a look on the internet and the side effects are terrifying") and her fears of the psoriasis ("I sometimes think other people think psoriasis is something that isn't serious enough to warrant a drug like methotrexate, when it's also used to treat cancer and things. But it really is ruining my life."), about the sort of monitoring she could expect. and some of the things to look out for if she did decide to take it.

My bottom line answer was that yes, I would take it if my psoriasis was as severe as hers, and having the impacts on her life that she was experiencing. I explained that I too would be scared of the side effects, but not everyone gets them, and because you're quite closely monitored whilst you're on it, the most serious side effects should be pretty easily picked up and with some careful dosing, along with folic acid, could hopefully be minimized.

"Eeee, well thank you. You've really put my mind at rest." she said, and off she padded to receive her few minutes on the NHS sunbed whilst I attempted to put my clothes on the right way round for the second time that day- no mean feat when you're me and you haven't yet had your first cup of tea or coffee yet. I don't know whether or not she was definitely going to start taking the methotrexate, but I get the feeling that I had given her a few things to consider that she hadn't thought about, and that I had provided some reassurance that the horror stories on the internet are not the full story.

This just goes to show the sort of esteem we pharmacists have the privilege of in the eyes of some. Its a privilege we should honour by doing all we can to ensure our advice is good quality and evidence-based. Being a Good Pharmacist doesn't stop the moment we extract ourselves from behind the counter, or out of our office or wards. Our words are more trusted, more weighted than many of us probably realise, because to some (but not enough) people "Pharmacist" really does mean "expert in medicine", and we need to ensure that we don't take advantage of that to sell products that don't have a good evidence-base just for profit. Our integrity as medicines experts can and should shine through, even when you're standing in a cubicle failing to rock the hospital chic look, bleary eyed and in need of caffeine.

Hxxx

The Godless Matinee

A while ago I- with the help of all of you lovely lot- collected together a little playlist of songs with an atheist theme. It was a great post to write, and what I love about it is that I still get suggestions now, or will be absentmindedly listening to something and will think "ooh, I must add that to the list". I love very much that many of you now have atheist playlists on your MP3 playing devices, and that I've had a tiny part to play in that.

Its been at the back of my mind for a while that a similar list for films should be in existence, then I was kicked into action by the same suggestion from the lovely Alom Shaha. Great minds and all that, eh? So here we have it, a humble list of films with an atheist or godless theme.

Some House Rules first. Be warned that I am the sort of person who will get up halfway through a film to tell someone off for talking, or having their phone on during a film. Even minor rustling of food packaging drives me crazy. So may I politely request that you follow this Code of Conduct, and we'll all get along fine.

So, phones off? Right, well settle in, get comfy, and lets watch some films.

Remember guys, let me know if you want anything added. email me at healthydoseofskepticism@gmail.com, tweet me @SparkleWildfire, or leave a comment. I'd love to include your reasoning for choosing the films too.

Miracle on 34th Street (1947) as suggested by @krypto: "All about the goodness of people. Polar opposite of religious remake"

Winter Light (1963) as suggested by @eyeswideshut75: "Bergman was tormented by atheism all his life.  i wouldn't say he was a one who celebrated it - to him one of the great pains in life was the silence of God, and this is never more evident than in Winter Light, Bergman's most unflinching and searing portrayal of personal, emotional and spiritual suffering.  the main character is a country priest who has lost his faith, but continues the rituals and tasks of his religion out of servitude, fear, a lack of anything else to do, out of service to his (ever dwindling and hopeless) congregation, and out of any cowardice to actually face up to this.  that Bergman's father was a strict Lutheran pastor adds whole new dimensions to the film." There you go, Ian, I did use more than two sentences after all.

The Wicker Man (1973) I recently rewatched this as part of an all-nighter at my beautiful local cinema, and it struck me how differently I viewed it now, as a more self-aware atheist than the first time I saw it. It seems like an odd choice at first glance, given it is entirely about belief of one form or another. But from an outside observer's perspective, its really interesting. Staunch catholic Sergeant Howie seems utterly repressed by his Catholic faith, whereas the paganism of the Summerisle residents initally seems full of freedom, but soon becomes a clear example of cargo cult science. In the end, all parties end up looking daft- the residents useless singing  in the face of failing crops whilst Sergeant Howie cries out in vain to Jesus, who can't save him from a fiery death. Oh, and sorry for the spoiler, but lets be honest here- the title is a spoiler anyway.

Carrie (1976) I only watched Carrie for the first time a couple of weeks ago. Not the most flattering depiction of religious families really, is it?

Life of Brian (1979) "He's not the Messiah. He's a very naughty boy!"

Star Trek V (1989) as suggested by @_TheGeoff.

Chocolat (2000). i add this on a Friday night of what has been an exhausting week. I've just watched Mother, a Korean film which is not what one would call a laugh riot, so I figured I had earned a sugary sweet, mindless film. (Mindless films are actually quite rare for me, with the exception of zombie films. I tend to shy away from anything that even vaguely resembles a rom com.) Its been over ten years since I saw this, so I had completely forgotten how atheist it is. And you can't beat a bit of Binoche.

Touching The Void (2003) as suggested by @damonayoung

Kingdom of Heaven (2005), as suggested by @JPSargeant78

Conversations with my Gardener Dialogue Avec Mon Jardinier (2007). This film has been chosen by North East Humanists as one for their film night next year. I haven't seen it yet, but am happy to take their word for it that it contains many of the sorts of values held by humanists.

Religulous (2008), as suggested by @epparry. Im watching this as we speak, and crying laughing at the Holy Land Experience bit.

The Invention of Lying (2009) As mentioned in Alom's book.

A Serious Man (2009) as suggested by @Buster_Bear

Whatever Works (2009) I'm sure I saw somebody suggesting this but I can't find who it is, so my apologies

The Infidel (2010) in which a lapsed British Muslim finds out he is actually Jewish. Its not godless as such, but it does call into question the ridiculousness of hatred between the different factions of religion.

Four Lions (2010) because one if the only ways we have of dealing with the horrors of terrorism and religious freedom extremism is to make black comedies and laugh at it. When I saw it at the cinema I was left uncomfortable at the riotous laughter going on around me: its a film of hilarity mixed with deep sadness, but many appeared to be missing the sadness bit. Through the humour, the dangerous ridiculousness of violence based on religion is addressed, along with the manipulation it involves. In the end, you're left feeling that when it comes down to it, a belief in god is about as valid as a belief in rubber dinghy rapids.

The Ledge (2011) as suggested by Alom Shaha

Paul (2011) as suggested by @Alex250175. "beautiful moment of revelation"

Side Effects (2013) as suggested by @Dilip_Modhvadia. In his words "a good film apart from Jude Law's nauseating perfomance".

Philomena (2013) as suggested by the ever wonderful @obsolesence

Anything by Michael Bay. Because any merciful god would surely not allow such atrocities to exist.

Hxxx

The Not-So-Wise Owls

You might have noticed that Holland and Barrett, the high street's most proliferative purveyor of pointless supplements, homeopathic, and herbal medicines are in the midst of a rather odd marketing campaign, called #AskOurOwls.

*Gratuitous Fluffy Animal Pic* Meet Willow. Willow is a fully grown, 10 year old south African Owl who lives in Kielder Forest. Willow does not purport to be an expert in complementary and alternative medicines, but he does have very soft feathers. Willow would like to make it known that he does not condone the actions of Holland and Barrett owls.

#AskOurOwls means you can ask any question about a Holland and Barrett product, and if their staff can't answer your question, you get 20% off in store. This is accompanied by a kawaii cute animated advert featuring bunnies, hedgehog, and other adorable woodland creatures. Because natural remedies are always totally cute, safe and innocuous, right? And presumably because everyone who works there is in actual fact a shape-shifting owl cavorting as a human. Its like David Icke stuff, but with more feathers.

In the words of the ad agency who designed it:

"The campaign aims to demonstrate Holland & Barrett’s USP of considerable staff expertise, endorsing the fact that every Holland & Barrett store within the UK has had an officially qualified associate to give advice on all own label supplements, vitamins, healthy foods and weight management products"

Now, I've lost count of the number of enquiries I've dealt with because of Holland and Barrett. These enquiries are usually along the lines of "My patient has bought <insert Holland and Barrett product> and wants to know if they're safe to use with their other medicines." In some of these cases, patients have presented with over £40 worth of herbal medicines etc, and have then been told that no, they can't take it, either because it will interact with their medicines, or because it isn't suitable to be taken by someone with their medical problems.

I have no idea what the Holland and Barrett in-house staff training consists of, but I'm not sure what part of it would allow someone to buy multiple, expensive remedies before they know if they are safe for them to use. Its not only a dangerous strategy, but its really very poor customer service, and doesn't do much to 'demonstrate considerable staff expertise'.

Anecdotally, I have heard that in some areas, Holland and Barrett employees have been known to send patients to a nearby pharmacy to ask if they are able to take a product. Whilst this at least demonstrates an awareness of their knowledge limitations, its also pretty inconvenient for the customer to have to traipse in and out of different shops, and i should imagine pretty irritating for the pharmacist, who is having to do H&B's work for them. And believe me, these sorts of enquiries aren't always easy to do, and can be very time consuming.


So that's not all that encouraging for their #AskOurOwls scheme, is it? And it is a really quite bizarre strategy. If I ask a question about whether a product is safe for me to take, and they can't answer it, I can't really see how offering me a discount on something that I don't know is safe or not would help.

Of course the skeptical community understandably used this opportunity to Ask Some Owls some reasonable questions about where the evidence is for many of the products they sell, why they sell homeopathy when there is literally nothing in it, why they promote detox products when there is no scientific evidence for detox, why they sell high dose vitamins when there is some evidence that they may increase cancer risk etc. And no answers flowed in at all. I ask three questions, and got no response, then sent a Tweet about how I had gotten no response. This did attract a -very curt and actually pretty damn rude- reply from Holland and Barrett demanding to know if it was a question or not.

Funnily enough, after being bombarded with questions about their selling of quackery, the terms and conditions now read that the offer does not apply to questions asked via Facebook or Twitter. I have no idea at all whether these terms were the same at the start of the campaign (do let me know if you know), but it would seem very strange indeed if they have launched a campaign centred around a hashtag but which is not for use on social media. It would sort of suggest that they was actually being rather misleading, or just very careless in the original advertising campaign. Or, of course, that they hadn't quite thought through the consequences of encouraging people to ask questions about remedies that have no basis in science or evidence. Presumably they think that us mean skeptic-types will be so overwhelmed by their wondrous array of snake oil remedies that we will turn to mush and be unable to think of a question in store.

Let's see what that ad agency says again, shall we?

"The brand strategy extends to social media, where customers can engage with Holland& Barrett staff via Twitter to answer relevant health questions. By using the hashtag, #askourowls, customers are directed back to the brand."

Suspicious, non? And lets just think about this strategy for a moment. They are encouraging people to ask them health questions in less than 140 characters. Given that people are complex, and may have multiple health issues and be on many different medicines, this seems a somewhat cavalier strategy.

Then again, Holland and Barrett are home to some other really quite bizarre offers as well. What on earth is going on with that buy one, get the other for 1p thing? Save everyone the bother of having to faff about with change and just do a plain old BOGOF, for goodness sake. Or, even better, how about not encouraging pointless polypharmacy with multi-buy offers in an area where they are clinically inappropriate and potentially even dangerous? 

So, next time you're passing a Holland and Barrett store, take a moment or two to drop in, and ask them for the evidence. If they can't provide you with any, then enjoy your 20% off- you should be able to find something to buy there- they do sell Bombay mix after all, which is approximately 50% more baked than their #AskOurOwls campaign ever was. Do let me know how you got on, if you do get a chance to ask a question.


You can read some more about how the #AskOurOwls campaign went wrong for H&B but right for skeptics here, and the sort of non-answer Slipp Digby got here. 

Hxxx

UPDATE: interestingly, a mere few hours after I published this post, I got an @reply from Holland and Barrett on Twitter, promising me that someone was looking into my enquiry about acai and i would hear from a nutritionist soon. At the same time, they were merrily sending out requests for follows so that they could DM answers to many other people who had asked similar questions. However, I've never heard anything since, or been asked to follow them to get a DM response-this is now 3 days after they told me someone would contact me.

Putting aside all the other problems with this campaign, this is just utterly terrible customer service. My job involves me dealing with often very complex enquiries, and it would maybe take me three days maximum to do a complex enquiry involving a full research strategy, medical literature searches, critical appraisal of multiple papers, and to compose an answer. I would, of course, acknowledge the enquiry immediately and let the enquirer know of any delays- its common courtesy.

I can't help but notice that on their Twitter feed they do appear to be answering other questions about their products using their Timeline. So why are they using DMs to answer any which question the efficacy of their products? 

I've decided to give them another chance, however, and have just asked them another, very specific question, which would take a pharmacist maybe 30mins-1 hour to answer fully:

We'll see how long that takes to get a response, shall we?

Making Clinical Trials Sexy

If you're buying a new TV, how do you go about it? My guess is that you probably have a look around the shops or internet, find a model you like, then get online to find some reviews of it and decide whether or not to buy based on what you've read. You may well scroll down to the reviews if you're buying something on Amazon, before you click the "Buy" button. If you book a holiday, you're probably straight on Trip Advisor to see what other people- humans just like yourself- have got to say about the hotel.

It is perfectly reasonable behaviour. We understand and respond to the personal experiences of other people- its part of our nature, stitched into our being. Each review is a little story, and humans love stories, especially when they are about other humans.

Its therefore a hugely unfortunate problem that, when it comes to healthcare, stories just aren't good enough. When peoples' lives are hanging in the balance, reviews and testimonials just aren't up to scratch. Here's why:

I have guttate psoriasis. Imagine I go on holiday (alas this is merely a pipedream this year, thanks to what feels like millions of large unexpected bills that seem to keep turning up in my life) and lo and behold, when I return, my psoriasis has cleared up. I conclude that it is definitely the sunshine that has cured it, and proceed to proclaim that I have found the ultimate 100% effective cure for psoriasis.

Is it reasonable that I have come to that conclusion, based only on my own experience? No, not at all. Why have I focused on the sunshine aspect alone? Maybe a week spent relaxing is what has actually cured it. Maybe its because I've changed my diet on holiday and have been eating lots of lovely fresh fruit and vegetables and fish?  Maybe it is because there is a magic ingredient in Sangria which miraculously beats rogue skin cells into submission. What if chlorine in swimming pool water is my skin superhero? Maybe-just maybe- its because guttate psoriasis can be self-limiting, and it has just faded away of its own accord. With just my experience to go on, there is no way I will ever be able to know what it is that has made my condition improve.

What I would need to do to be able to decide is to scale things up. Get as many people as possible with guttate psoriasis, and divide them into at least two groups- one exposed to sunlight, one not. I'd have to try to control the peoples' behaviour as best as I could for the other factors like diet, chlorine exposure, sangria intake, stress etc. Whilst I could never completely control for everything, if the group exposed to sunshine experience a significantly better improvement in their psoriasis, then I could say with more certainty that it is the sunshine that did it rather than anything else.

This is the beauty and elegance of a clinical trial. They are simply the best, slickest, most reliable way we have of teasing out whether a treatment actually does make a difference. They're like an anthology of stories, carefully selected and analysed by researchers in a bid to start finding an answer to a treatment question. Whilst they're not 100% perfect, they're certainly the best sort of information we have at the moment on which to base any decisions about which treatment to choose for which disease, and for which patient.

This is, however, very easy to forget when you actually have to read one. I do not have a mathematically inclined brain, and when faced with tables full of numbers, p values, confidence intervals, hazard ratios, relative and absolute risks etc, my grey matter is usually to be found quivering and wimpering in the corner of my skull. I have to really try hard to focus on the stats and results when reading a clinical trial- its a constant fight to wrench my thoughts back onto the page, when they keep merrily skipping away to think about kittens or bunnies or *that* picture of a minipig wearing red wellies. And I say this as a geeky pharmacist who has undertaken a decent amount of training in how to read a clinical trial. What hope then, does an individual patient or regular joe have of understanding trial data?

A quick glance at pretty much any website selling an 'alternative medicine' and you'll notice there is usually a "Testimonials" page on there. Many other types of healthcare sites also use testimonials to prove their treatment works. They're easy to read, often full of personality, and can really seem to speak to you as a reader. They may seem convincing, but as you've (hopefully) seen from my example above, they simply can't be used to decide if a product works or not. A glossy celebrity story endorsing a product in a magazine is infinitely more sexy than ten pages full of stats and graphs in a medical journal.

Testimonials and reviews are, at first glance, more attractive and more seductive than the more dowdy clinical trial. So what can we do to help the clinical trial apply a bit of lippy, spray some perfume on itself, and don its heels to get out on the town and make people weak at the knees? My short answer is I don't know. Campaigns like International Clinical Trials Day help of course, but at the moment it feels like we're swimming against the tide somewhat. My ultimate dream would be a primetime TV series, fronted by a hunky Brian Cox type. If he can make physics sexy enough to be at the forefront of our entertainment, surely there is some way that we can do the same for one of the best inventions in healthcare? I'd like to get to a place were it's second nature for everyone, whether they be a patients, pharmacist, healthcare professional or general geek, instinctively bypasses testimonials to look for clinical trial evidence instead.

Do you have any ideas? Have you had any really good experiences of explaining clinical trials to patients? Are there any techniques we can use to simplify the stats and make trials more accessible to all? My friend Nancy had a great idea of including a Plain English summary as part of an abstract for every trial. Is there anything else we could do? Let me know, however outlandish your idea, either by commenting, tweeting me (@SparkleWildfire), or dropping me an e-mail at my new shiny sparkly e-mail address healthydoseofskepticism@gmail.com

Hxxx

The Vaper Verdict

I seem to have gotten myself a bit of a reputation as a Vaper-hater. In truth, I'm actually really not.

I even once owned a disposable e-cigar. It was a good few years back now. Although I consider myself a non-smoker, I do smoke the odd cigar, but about one a week and only when the weather is nice (so about 4 days a year then) and only when someone has brought me some back from their holidays probably does not constitute a habit, or would be considered the world's most pathetic addiction. I would never dream of smoking indoors, and somebody thought it would make a nice stocking filler for me one year.

I used it a few times, and it was alright, in the same way that a Pot Noodle is mildly enjoyable in its own right, but bears no resemblance to a steaming hot bowl of freshly cooked spicy Szechuan chicken in udon noodles (no 69. on the menu at Nudo, my favourite restaurant in Newcastle. Its always giggle-worthy ordering it). E-cigarettes are the Smash mashed potato of the smoking world, a Cup-A-Soup to a home-made broth.

I can see how it would be good to have something vaguely resembling a cigarette if you're trying to give up smoking, and I can certainly see how a nicotine delivery method that avoids all the tar, chemicals and other gunk that smoking dumps in your lungs is more healthy.

My reservations are thus:

1. If they're unregulated, you have no idea what's in them. It might say on the pack that it contains x mg of nicotine and chemicals y and z but there is no guarantee of this. Some have been found to contain toxic chemicals like ethylene glycol, for example. Its undoubtedly likely that they still contain less dangerous chemicals that cigarettes, but it would be very nice to have that guaranteed.
2. There's no long term safety data. We literally don't know what the long term effects of these things are. For all we know, the seemingly safe-at-first ingredients could actually prove to be carcinogenic, say, when inhaled in this way in the long term. Admittedly its unlikely the products would be as bad or worse than smoking, but without the studies we just don't know. Theoretically they may seem like they're going to be harmless, but without the data there to back it up we just cannot make that assumption- its that sort of reasoning that lead to the thalidomide disaster, for instance. Unknown does not mean safe.
3. There's evidence that products are often do not contain what it says on the label (if they even have a label at all). A study in the BMJ's Tobacco Control found that products contained variable and potentially dangerous amounts of nicotine- most often the product contained less than was stated. Now, if I'm paying for a product that says it contains 72mg/ml of nicotine, I expect that product to contain 72mg/ml of nicotine, just as I would expect a 500mg paracetamol tablet to contain 500mg paracetamol. If it contains less than this, I'm essentially being ripped off. The other available nicotine replacement products- patches, gums, inhalators etc- all have a license, and I don't really see why these electronic cigarettes should be any different.
4. In smoking cessation, using a product which looks like a cigarette might be helpful in the short term, but it doesn't help to address the habits of smoking rituals, and in my experience of helping people quit, that's half the battle.
5. The risk of serious accidental nicotine poisoning in both adults and children. 
6. There is a risk that the ease of use of the products and ability to use them indoors might actually increase nicotine intake in some people.
7. Even if nicotine itself were entirely safe (which it isn't), its still an addictive substance. Any addiction can lead to harmful effects in a person. For evidence of this, try speaking to me on a day when I have not had any caffeine. If I added up all the time and money I have spent in my life engaging in drug-seeking behaviour to feed my addiction (mainly desperately trying to find the nearest kettle or coffee shop), I suspect it would be very upsetting.

Today there has been, in my opinion, some good news. The MHRA have decided to start regulating nicotine containing products as medicines. This decision essentially eliminates concerns number 1, 3 and 5 and starts us on the road to also ruling out concerns 2,4 and 6. The BMA have responded enthusiastically to the news, stating:

“We can now build on this and press for good research which looks at the efficacy and health implications of e-cigarettes. It’s really important that we find out if the hand to mouth use of e-cigarettes either breaks or reinforces smoking behaviours. We need to know if e-cigarettes actually help smokers quit."

I'm also enthusiastic about this step. Whilst it may lead to decreased availability and choice of these products, it will hopefully lead to a smaller number of better quality products being legitimized and incorporated more formally into smoking cessation or harm reduction schemes- if they are proven to work in robust clinical trials. This is yet another case where, instead of waiting until we have good, robust data that a product works and is safe, it has been widely sold and adopted by users in lieu of risk or efficacy information. There will no doubt be an outcry from users and manufacturers, and wails that the MHRA have banned e-cigarette sales, that its a Big Pharma conspiracy to give everyone cancer so they can sell more drugs, that big evil corporations are trying to trample the little guys down, when all they are trying to do is save some lives. But none of this regulation means that.

All a manufacturer of e-cigarettes would need to do to continue selling their product is to prove its safety, efficacy and quality. It will take money and time, but if they have been already producing their wares safely and in accordance with Good Manufacturing Practice guidelines, they're already some of the way there. Gaining a license will of course cost time and money, but if these manufacturers are genuinely interested in saving lives- and not just unscrupulously making profit- they would see the value in the licensing process, and the opportunities available for a licensed product in the long run.

So here's to what could be start of a new dawn of smoking cessation or harm reduction. I really hope so, but will reserve judgement until the evidence starts piling in.

Hxxx

Book Review- Which Way To The Nearest Wilderness?

“I left the woods for as good a reason as I went there. Perhaps it seemed to me that I had several more lives to live, and could not spare any more time for that one. It is remarkable how easily and insensibly we fall into a particular route, and make a beaten track for ourselves.” -Henry David Thoreau

I was a pretty proficient reader as a child, and I have a vague memory of winning this book for some reason or another from school. I had completely forgotten about it, then for some reason, the title just popped uninvited into my head the other night, and I knew I had to read it again. I managed to find a secondhand copy, which, when delivered, turns out to be an ex-school library copy, still nestled in its plastic cover, and with a label stuck neatly into the front declaring it a gift to the school from the P.T.A. It has that beautiful, musty smell of old books and appears to have been last taken out of the library in 1991. I can't help but wonder by who, and what they thought of it. 

I remember reading this book over and over as a child. I really loved it, although I do remember not quite relating to the situations the main character, Eunice, finds herself in. She has a brother and a sister, and parents who are teetering on the brink of divorce, with a stormy home life characterized by constant arguing. I remember struggling with some of the words, but caring enough about the story to get out a dictionary and find out what they meant.

On reading it now, as an adult, I’m amazed by it. It’s a wonderful, forgotten book, and one of the best portrayals of girls and friendships as I’ve ever seen in either a children’s book, or even adult literature (although I will make an exception for Margaret Atwood’s Cat’s Eye, which I’m also reading again at the moment and which is like the perfect counterpoint to this book.) I wouldn’t say its feminist as such, but it is about girls who are not defined by their looks or even their talents, but by their friendships, personalities, morals, and philosophies.

It doesn’t, like most children’s literature, shy away from difficult topics like divorce, bitterness, or mental health issues. It’s ostensibly aimed at girls, but isn’t shrouded in pink or ponies or candy-floss. Nor is it  faux-darkly serious- There isn’t a vampire in sight. It’s a Ken Loach-esque naturalistic, social realist sort of YA, I suppose. The language is actually quite challenging: on the first page, words like philosophy, hobgoblin, façade abound.

It centres around Eunice’s decision to go into the wilderness, build herself a cabin, and live as a hermit, prompted by reading Walden. In the meantime, her sister suffers-and survives- heartbreak, her parents separate and precariously reunite, her quiet, sensitive brother requires- and survives- counselling, Eunice and her best friend set up a business, fall out, and make up again. Where a lot of YA for girls is all about boys, reinforcing the belief that a girl can’t be fully whole without a relationship, this book shows Millie stepping away her boyfriend when he declares he loves her, and eventually embracing her independence, even within the context of a relationship.

Reading this now, as an adult, I’m amazed by how many important life lessons are in there. I suspect they may have seeped into me without my knowledge as a read and re-read it as a child. Is this where my love of peanut butter sandwiches comes from? My ability to deploy sarcasm liberally? My-previously unsuspected, and completely surprising to myself- ability to bounce back from my own divorce? My love of my own company and need to retreat, coupled with an overwhelming love for my friends? Although I must admit, the idea of living in the countryside on my own fills me with absolute dread.

I finished reading it in three days, and I’m slightly stunned that one hardly-known little book could have that much packed inside it. I suspect they don’t make children’s books like that anymore.  

Hxxx