Flavored E-cigarettes and Vapes are “Sucking ” Kids In

Electronic cigarettes and vaping have become the most popular form of tobacco and nicotine exposure among American youth.  Many e-cigarette liquids have flavors and packaging that are targeted specifically to adolescents and young adults.  Over 95% of vaping liquids contain nicotine and since 2014, e-cigarettes have been the most common form of tobacco and nicotine exposure for teens in America.  Tobacco use in adolescents is a strong predictor of continued tobacco and nicotine use as an adult.  By luring kids into using e-cigarettes as children, companies are developing addictions that may last a lifetime.

Wang TW, Gentzke A, Sharapova S, Cullen KA, Ambrose BK, Jamal A. Tobacco Product Use Among Middle and High School Students — United States, 2011–2017. MMWR Morb Mortal Wkly Rep 2018;67:629–633. DOI: http://dx.doi.org/10.15585/mmwr.mm6722a3.

In 2009 the FDA banned flavored cigarettes specifically to reduce the use of tobacco products by youth.  A that time, e-cigarette use and vaping was not very common.

The FDA has the authority and the ability to ban flavored e-cigarette and vaping fluids and should avail itself of that authority to immediately ban flavored liquids for e-cigarettes.

Multiple leading health and parental organizations are opposed to the use of e-cigarettes by adolescents and youth and many have developed and published position statements and resources aimed at keeping kids away from these products.

• The American Academy of Pediatrics is opposed to the use of any tobacco product by children, including e-cigarettes.
  • American Academy of Pediatrics resources on e-cigarettes
• The National Parent Teacher Association (PTA) has developed a resolution opposing the use of e-cigarettes by American Youth.
  • National PTA opposes e-cigarette use by children
• And the American Cancer Society advocates maximal regulation of e-cigarettes and every effort to keep youth from using them.
  • American Cancer Society advocates against e-cigarette use by youth

As a parent and as a physician, I encourage each and every one of us to contact the FDA and to contact your elected representatives to take the common sense position of banning flavored e-cigarette and vaping liquids.

 

Aboriginal Youth in Northern Canada facing a Suicide Crisis

Authors: Cameron Carlock, Olivia Roanhorse, Avita Sooknanan

Source: https://commons.wikimedia.org/w/index.php?curid=46895498

In October 2015, the former Prime Minister of Nunavut (one of the northernmost Territories in Canada) Peter Taptuna announced a suicide crisis. Aboriginal people in Canada comprise First Nations, Metis, and Inuit. According to Statistics Canada, Inuits comprise 27,070 of the 27,360 people living in Nunavut. Furthermore, 57% of the Inuits are under the age of 25 in comparison to 19% in the non-Aboriginal population. The Centre for Suicide Prevention in Canada reports that the suicide rate in male youth ages 15-24 is more than 5 times the rate (126 per 100,000) when compared to non aboriginal male youth (24 per 100,000). In females the suicide rate is seven times more (35 per 100,000) compared to non aboriginal females (5 per 100,000). One of numerous studies by Kral et al. in 2016 points to the widespread mental health issues in aboriginal communities including but not limited to depression, alcohol, and drug abuse. The article also points to colonization as a root cause of historical trauma, deculturalization, and isolation in the aboriginal population in Canada which further predisposes the group to suicide.

Local non profit agencies in Nunavut like Embrace Life have created culturally specific helplines for youth contemplating suicide. Collaborations like Connected North between the renowned Hospital for Sick Children in Toronto, Royal Bank Canada, and Cisco Canada (a computer agency) are working to launch tele-psychiatry programs in order for adolescents to access health care services related to mental health and addictions. The government of Nunavut has made addressing the suicide crisis a priority. Having created a website, specific strategies have been elucidated by the government of Nunavut to help curb suicide rates. One creative strategy includes YouTube videos for individuals to break their silence on suicidality.

Source: https://www.gov.nu.ca/health/information/suicide-prevention

However, the government of Nunavut and local public and private agencies cannot eliminate suicide on their own. It is necessary that the Federal Government of Canada provide funding to the territory of Nunavut to create a culturally specific crisis centre for Inuit youth with information in their native language and access to elders to provide social, spiritual, and cultural support. The crisis centre would be a hub for the Nunavut community to train staff, work closely with researchers, and promote strength based programming to ultimately reduce rates of youth suicide and improve the mental health of the Inuit and aboriginal youth population in Nunavut.

Healthy Diné Nation Act: Impacts on Addressing Type 2 Diabetes on Navajo Nation

 

SOURCE: PARTNERS IN HEALTH

The Navajo Nation spans across Arizona, New Mexico and Utah, and has ~300,000 enrolled tribal members. The Indian Health Service estimates that 1/3 of Navajo tribal members are Type 2 diabetic or are pre-diabetic, and over half are overweight or obese. In an effort to combat these rates of obesity and diabetes, the Navajo Nation government enacted the Healthy Diné Nation Act in 2014. This policy mandates a 2% tax on “unhealthy” (processed/junk foods) with the ultimate goal of disincentivizing the purchase of these foods. The money collected is redistributed to the local tribal government chapter houses to implement community health initiatives.

SOURCE: PARTNERS IN HEALTH

While the idea of taxing junk food and putting those funds towards community health initiatives seems like a step in the right direction, the potential unintended consequences should be considered. 1/3 of Navajo people do not have electricity or running water, and the vast majority qualify as “food insecure” and have to drive an average of 1 hour (60+ miles) to get to a grocery store. 80 percent of the Navajo grocery stores’ inventory qualified as junk food. It could be argued that a junk food tax on a population that is both food insecure and predominately living at or below the poverty line could perpetuate the cycle of poverty. The larger, structural issue at hand is the food system on Navajo Nation. There are only 13 grocery stores across 27,000 square miles of land, limited access to electricity (to store fresh fruits and vegetables) and a harsh high desert climate (with short growing seasons). These limit the ability of tribal members to access health foods and practice food sovereignty, thus perpetuating the dependence on processed foods. Enacting policies upon groceries stores who wish to sell on tribal land that limit the amount of junk food they sell and set standard pricing for fresh fruits and vegetables would be a better option for addressing high obesity and diabetes rates. This puts the responsibility back onto the food industry (which establishes the food environment) rather on the individual (who is a product of the environment), and enables the Navajo Nation government to enforce autonomy within their food system.

The worst drug lag in Japan “Acceptance of medical use of cannabis”

In Japan, we can’t use marijuana for medical use at all.  Even so, there are many people who do not believe, confusing cannabis and opioids, “Even opioids can use if there is a prescription of a physician.” But it is, unfortunately, true.  Our “Cannabis Control Law” stipulates that by using medicines manufactured from hemp, both physicians and patients are punished by imprisonment etc.  There is no movement to review it, and none can reasonably explain it.  This is the problem of medical cannabis in Japan.  In other countries, it has been recognized that “cannabinoid” which is a medicinal ingredient of cannabis is useful for treatment of diseases, and it has become available for medical use.

Cannabis legality status around the world in 2018

As a physician, I support the development of a national medical cannabis use policy in Japan.  It is said to be useful for the treatment of a wide range of intractable diseases such as cancer, rheumatism, epilepsy, hypertension, Alzheimer, glaucoma, cataract, diabetes, multiple sclerosis, PTSD, depression, drug addiction.  In Japan, especially in a super aging society, expectations for prevention of dementia are increasing.  Overseas, clinical trials have also progressed, and the number of countries in which cannabis medical use is publicly admitted is increasing. 　However, in Japan, owing to the regulation of the law, possession of marijuana is prohibited even if the purpose of use is medical research.  For patients with intractable diseases it is necessary to break through the present situation.

Patients have the right to be saved, and laws are not allowed to interfere with their rights.  We must prepare to proceed with research to demonstrate scientific data.  There is no solution except to change the law or to apply specific district to a country and obtain special permission.  First, Japanese Clinical Association of Cannabinoid (JCAC) has been established to disseminate knowledge to citizens and stakeholders including Health Labor Welfare Ministry of Japan, and Drug Abuse Prevention Center of Japan.　Next, we must recreate rules based on scientific research data.  I hope this problem is widely acknowledged and discussed in the National Legislature and that medical care in our country will proceed better.

 

The US Department of Health and Human Services Title X Program Funds Family Planning Services – What if the Trump Administration Changes That?

The abortion “debate” is a political hotbed. Regardless of where you stand, preventive health services provided by the national Title X grant program are undeniably good for public health. According to ACOG, “Four million Americans rely on Title X to access contraception and other essential care, such as cancer screenings, STI testing and treatment, and well-woman exams… After years of progress reducing unintended pregnancy rates—bringing our nation to its lowest rate of teen pregnancy—(the proposed) changes are shortsighted and hazardous. Our message to HHS is clear: keep politics out of the exam room.” https://www.acog.org/About-ACOG/News-Room/Statements/2018/Changes-to-the-Title-X-Program-Reject-Science-and-Endanger-Comprehensive-Care

Planned Parenthood supporters demonstrate on Capitol Hill in July 2017. (Astrid Riecken for The Washington Post), retrieved August 18, 2018 from: https://www.washingtonpost.com/news/to-your-health/wp/2018/05/23/is-it-a-gag-rule-what-changes-to-family-planning-funds-and-abortion-referrals-might-mean/?noredirect=on&utm_term=.bad1e39bca3b

The changes, recently proposed by the Trump administration in an appeal to voters that oppose abortion, would do the following: 1) withhold funding from health centers that perform abortions or are affiliated with those that do and 2) prohibit health care providers from discussing pregnancy termination, providing materials that mention abortion, or referring patients to abortion providers.

The restriction to counsel a patient on pregnancy options automatically limits the ability to follow the evidence-based clinical guidelines recommended by the American College of Obstetrics and Gynecology, known as three option counseling—continue pregnancy and parent, continue pregnancy and seek adoption services for the child, or terminate the pregnancy.

In my home city of Baltimore, almost 1 in 3 women rely on Title X for family planning services. Thanks to this funding, unplanned pregnancy rates have fallen by 61% between 2010 and 2016. Many of the 23 sites in Baltimore that receive Title X funding would be at risk for closing their doors if the proposed rules were adopted. https://www.wmar2news.com/news/state/proposed-title-x-changes-could-affect-health-services-funding-in-baltimore-city-delegation-warns

The Baltimore City Health Department officials who have denounced these proposed changes have encouraged those of us who care for patients, or otherwise have a stake in women’s health care, to make our voices heard, to hopefully stop legislative action on the proposed changes. Comment here: https://action.aclu.org/petition/no-gag-rule

 

 

Better Beverage Choices for Northern Mariana Islands Residents

CNMI college students educate children and their parents on sugar content in commonly purchased beverages at a community event in 2016. Credit: Kaitlyn Neises-Mocanu

Factors which determine our health include the environments in which we live, work and play: these factors exist outside the clinic walls and beyond the range of our public health services. Improving the health of our population in the Commonwealth of the Northern Mariana Islands (CNMI) requires an environment which supports healthy choices.

Consuming sugar-sweetened beverages is not only strongly associated with obesity, but there is a body of evidence showing an association between the consumption of sugary drinks and chronic conditions such as type 2 diabetes, cardiovascular problems, gout, and liver, and dental diseases. The diabetes epidemic is affecting generations of CNMI residents and eroding the quality of life for those afflicted with the disease along with those who love them, and sugary drinks have had a role in creating the problem.

Inflatable Coca-Cola advertisement at the same community event photographed above. Credit: Kaitlyn Neises-Mocanu

We are inundated by a “culture” of sugary drinks created by the beverage industry, promoting the over-consumption of sugary drinks. According to the 2016 CNMI Non-Communicable Disease and Risk Factor survey, nearly three out of four (74.1%) CNMI adults drink at least one sugar-sweetened beverage every day.

 

If we expect our neighbors to make healthy lifestyle choices, the healthy choice needs to be the easy choice. When unhealthy beverages are cheap, deceptively marketed, and dominate beverage coolers at every mom and pop store,  we make drink choices at the cost of our own health. A tax on sugar-sweetened beverages brings down consumption levels, incentivizes distributors and retailers to stock healthier beverage options, and has the potential to change beliefs, attitudes and norms about sugary drink consumption. 

Source: 2016 CNMI NCD Risk Factor and Behavior Survey

As an added benefit, a tax on sugary drinks raises much-needed revenue for diabetes prevention and management programs, opens up a funding resource for local groups who want to improve health in their communities, and supports the CNMI’s only hospital.

Our government is responsible for protecting the health of the public, and when products which detriment our health, like sugary drinks, are heavily marketed and sold cheaply in our community, action must be taken. Encourage CNMI Legislators to send the message that the health of our people is a priority, and urge them to take action to increase the tax on sugary drink distribution.

Time to Decrease Gun Injuries and Deaths in Canada

Despite substantial decreases in deaths and injuries caused by firearms over the past few decades in Canada, many other countries still observe better health outcomes in this area.  Throughout Canada, firearm-related deaths are mainly due to suicides, with non-restricted firearms being involved.
These deaths are not primarily related to criminal activity. Although less prevalent, high profile homicides, sometimes targeting multiple individuals, is what is often reported in the news. Sadly, the men and women who are mandated to protect us, our community police officers, are often the victims of these types of criminal acts.

When there are fewer guns, there are fewer injuries, and deaths, caused by them. States that have taken measures to regulate and monitor the sales of firearms have fewer people killing themselves, or others, with guns. Although restricted and prohibited firearms are tracked as part of a federal registry in Canada, people in distress are still using non-restricted firearms to take their own lives, or kill others. The province of Quebec responded to this reality by establishing their own registry for non-restricted firearms owned within their territory.

Currently, Bill C-71 is in second reading in the House of Commons, and it proposes increased background checks and better record keeping for these non-restricted weapons. After multiple changes in firearm legislation from past governments, some groups point out that monitoring is less robust than it was decades ago.

In the interest public safety and injury prevention, the federal government should consider reintroduction of a registry for non-restricted firearms to keep them out of the hands of those at risk of harming themselves and others. Although gun ownership in Canada has always been a privilege, and not a right, such measures do not prevent the Canadian sports enthusiast, or indigenous community member pursuing traditional harvesting, from accessing a non-restricted firearm.

A reintroduction of a non-restricted firearms registry should be seen as one part of a multi-pronged effort at suicide prevention that keeps guns out of the hands of distressed members of our communities.

Gastric cancer screening program in Japan

 

Gastric cancer in the third leading cause of cancer deaths and the prevalence of gastric cancer is the highest among all cancers. The 5-year survival rate of gastric cancer is more than 90 percent if gastric cancer is detected and treated at an early stage.

Japan cancer society recommends upper gastrointestinal series (UGIS) or esophagogastroduodenoscopy (EGD) as the screening modalities biannually. The Japanese society of Gastrointestinal Cancer Screening published the manual of gastric cancer screening using EGD in which it is recommended to receive EGD biannually.
Helicobacter pylori (H. pylori) is the important risk factor for gastric cancer. The cohort study performed in Japan demonstrated that gastric cancer developed in populations infected with H. pylori but not in uninfected populations.

Japan Research Foundation of Prediction, Diagnosis and Therapy for Gastric Cancer proposed the gastric cancer screening using serum anti-H. pylori IgG antibody and serum pepsinogen levels, “ABC method”.

Although the risk of gastric cancer is quite different between H.pylori positive and H. pylori negative populations and the proportion of H.pylori infection in the Japanese population is gradually decreasing, H.pylori infection status is not considered in UGIS and EGD programs and all people are supposed to receive these modalities.

Although implementation of gastric cancer screening program is in charge of local governments and many stakeholders including organizations, cancer screening hospitals, and companies are involved in gastric cancer screening program, the limited resources should be used effectively considering public health.

We support H.pylori-based gastric cancer screening. Because it is not cost-effective that all people receive UGIS or EGD regardless of H.pylori infection status, H.pylori is the most important risk factor for gastric cancer. Sensitivity and specificity for the detection of gastric cancer are high in EGD, and positive predictive value is associated with disease prevalence and specificity used.

We suggest that H.pylori-based screening program is firstly performed for all the people at the age of 50 and EGD is applied only to H.pylori-positive subjects for the early detection of gastric cancer. The Japanese government should set the law for this mandatory screening.

Increased Opioid Overdoses Need Increased Access to Reversal Drug Naloxone

More than 72,000 Americans died from a drug overdose in 2017, a ten percent increase from 2016.  Opioids, including synthetic opioids such as fentanyl, are the leading cause of these overdose deaths and it can be expected that this number would be larger if naloxone was not utilized to reverse opioid overdoses.  Naloxone, an FDA approved medication that prevents an opioid overdose by blocking opioid receptor sites, is available by prescription in all 50 states.  The US Substance Abuse and Mental Health Services Administration notes that “However, many individuals who are most at risk for an opioid overdose do not have regular contact with health professionals and would benefit from alternative means of obtaining naloxone.”  Individuals with high risk substance use disorders are unlikely to engaged with medical staff because of insurance status and stigma of their addiction.

Nebraska is the only state in the country that does not allow non-patient-specific prescriptions, or authorization for individuals and organizations to obtain naloxone without a prescriber meeting.  This authority is essential in ensuring that naloxone is readily available for individuals who are at an elevated risk of opioid overdose but do not interface with a medical provider.  While Nebraska maintains a relatively low opioid overdose rate (2.4 deaths per 100,000 people in 2016), local first responders have been busier than ever responding to drug overdoses.

(Image source)

The Bellevue (Nebraska) Fire Department has been administering naloxone since 2001, but has seen an uptick in emergency calls that require naloxone.  Emergency Medical Services supervisor Shari Lentsch notes “the department used the drug on 48 calls in 2017….. naloxone is likely to be used on at least 80 calls [in 2018].”

Making naloxone, a drug with no negative side effects, more accessible will reduce the reliance on local emergency responders when an overdose occurs and will save Nebraskan lives.  The 2017 legislative package, championed by state Senator Sarah Howard who lost her sister in a fatal drug overdose, shows this state is ready to address the national addiction crisis. We encourage the nonpartisan state legislature to introduce legislation that puts this lifesaving drug in more hands during the 2019 legislative session.

Urgent Action Needed to Reduce E-cigarette Influence Among Middle School and High School Students

Although the Centers for Disease Control and Prevention (CDC) has said that smoking is the leading cause of preventable disease, millions of middle and high schools students are still attracted to tobacco products. From 2011 to 2017, the traditional cigarette smoking has decreased among both middle school students, and high school students. However, during the same time the use of electronic cigarettes has increased 2.7% in middle school students, and 10.2% in high school students. Within the past 10 years, e-cigarettes have emerged as the most commonly used tobacco product among middle and high school students, with 11.3% of high school and 4.3% of middle school students currently using in 2016.

Multiple factors contribute to the increasing e-cigarettes use among youth. According to the 2016 National Youth Tobacco Survey, the three reasons for middle and high school students use e-cigarettes were, 1) friend or family use; 2) variety choices of flavors; 3) celebrity influences from media. The advertising expenditure of e-cigarette companies increases the influence of youth smoking as well. Many students believe e-cigarette may be less harmful than traditional cigarette smoking. However, most e-cigarettes contain nicotine, which is addictive, toxic and harmful to brain development from adolescent to the early mid-20s.

In order to eliminate smoking-related diseases and create a healthy environment for the future generation, the Food and Drug Administration (FDA) began enforcing the Tobacco Control Act in September 2009 to ban cigarettes containing certain characterizing flavors. American Lung Association (ALA) issued a statement against the sale of e-cigarettes too. In addition to these decries to tobacco use, an immediate stringent and enforceable law to eliminate all advertisements of e-cigarettes and flavored tobacco products are necessary to reduce the influence on American youth. This elimination of advertisements will span across social media, TV advertisements, print and in store advertisement placements. This law would be championed by the FDA and the ALA in an attempt to extend the safeguards that are already legally in place to prevent tobacco use among middle school and high school students in the United States.