Putting the Brake on E-Cigarettes

The FDA has launched strong regulatory and enforcement moves against the industry, branding the use of e-cigarettes among teens and ‘epidemic.’

In a pronouncement, Food and Drug Administration Commissioner Scott Gottlieb on Sept. 12 declared e-cigarette use "epidemic" among teens, signaled a possible ban on flavored e-cigarette liquids and launched sweeping enforcement efforts against retailers who sell e-cigarettes to minors.

"I use the word epidemic with great care," Gottlieb said in a statement. "The FDA won't tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products."

The enforcement action against nearly 1,300 retailers is the largest organized crackdown of its kind in FDA history, Gottlieb said. The agency issued warning letters and imposed fines ranging from $279 to $11,182 on 130 repeat offenders. A ban on flavorings could put the brakes on a fast-growing market. Average monthly sales grew 132 percent between 2012 and 2016, according to a study published in August by the Centers for Disease Control and Prevention.

Joanna Cohen is the Bloomberg professor of disease prevention and director of the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health.


Gottlieb hinted at preliminary FDA data, not yet published, indicating that e-cigarette use is soaring among high school students. In August, the CDC reported that e-cigarette use increased 900 percent among U.S. high schoolers from 2011 to 2015, making them the most commonly used source of nicotine in this group, driven by aggressive marketing and appealing flavors.

Officials say that e-cigarettes may be a safer way to deliver nicotine and may help smokers reduce their risk of smoking-related illnesses and death, but they worry about the rapid rise of e-cigarettes among teens and young adults.

The Vapor Technology Association, a trade group representing more than 600 members, accused the FDA in a statement of "kowtowing to hysterical public health groups," taking a "giant step backwards" in smoking prevention and reinvigorating "Big Tobacco."

Joanna Cohen, the Bloomberg professor of disease prevention at the Johns Hopkins Bloomberg School of Public Health and director of the Institute for Global Tobacco Control, spoke to U.S. News about the FDA's growing authority to rein in e-cigarette manufacturers and...

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Testosterone Replacement Therapy Can Slow Men’s COPD, Study Finds

Testosterone replacement therapy can help slow the progression of chronic obstructive pulmonary disease (COPD) in men, a new study shows.

Men with COPD tend to experience shortness of breath, leading physicians to prescribe them long-term steroid-based medications. While these medications help treat pulmonary symptoms, they are also associated with testosterone dysfunction.

Accordingly, previous studies have shown that men with COPD have low testosterone levels, which could lead to a worsening of the condition.

“Previous studies have suggested that testosterone replacement therapy may have a positive effect on lung function in men with COPD,” Jacques Baillargeon, the study’s author and a professor in preventive medicine and community health at University of Texas Medical Branch at Galveston, said in a press release.

The study, set to be published in the journal Chronic Respiratory Disease, was designed to determine whether testosterone replacement therapy (in which patients are prescribed testosterone) could help reduce the risk of hospitalization due to respiratory disease in middle-aged and older men with COPD.

Baillargeon noted that “we are the first to conduct a large-scale, nationally representative study on this association.”

Baillargeon and his colleagues used the Clinformatics Data Mart dataset, which comprises one of the largest commercially insured populations in the United States. They examined data from 450 men ages 40-63 with COPD who began testosterone replacement therapy between 2005 and 2014.

Researchers also used the national Medicare database to study data from 253 men age 66 and up with COPD, and who initiated testosterone replacement therapy between 2008 and 2013.

Researchers found that patients who underwent testosterone replacement therapy had a greater reduction in respiratory hospitalizations when compared to patients who did not receive the therapy.

“Specifically, middle-aged testosterone replacement therapy users had a 4.2 percent greater decrease in respiratory hospitalizations compared with non-users,” Baillargeon said. “Older testosterone replacement therapy users had a 9.1 percent greater decrease in respiratory hospitalizations compared with non-users.”


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Research Suggests New Mechanism at Play in Some Severe Asthma Cases

A newly published study offers a better understanding of the mechanisms at play in a subset of patients with severe asthma. Scientists hope the new insights will help direct the development of more tailored approaches to asthma therapy.

For the study, a team of investigators from several US academic research hospitals set out to better understand the pathogenesis of severe asthma, which does not respond to treatment with corticosteroids and which affects about 10% of the 24 million Americans with asthma.

Some of those patients with severe asthma have substantial neutrophilia, and the investigators hypothesized that the presence of neutrophilia is indicative of mechanisms distinct from other types of inflammation.

To test their hypothesis, the team mimicked allergic lung inflammation by exposing a mouse model to house dust mites and endotoxin. When exposed to both the allergen and endotoxin, the mice showed an increase in lung neutrophils and neutrophil extracellular traps (NETs). NETs help defend a host by immobilizing invading microorganisms; however, they can also cause inflammation and injure organs. NETs are activated and released through NETosis. During vital NETosis, neutrophils eject their nuclear material to form NETs, then re-seal themselves, forming cytoplasts.

The animal model findings suggest NETosis and cytoplasts play an important role in sparking and amplifying the allergen-initiated neutrophilic immune responses in lung inflammation. To confirm the insights, the investigators analyzed fluid samples from the lungs of human patients with severe asthma. Indeed, a group of those patients also had high neutrophil counts as well as NETs and cytoplasts.

Lead author Bruce Levy, MD, chief of the division of pulmonary and critical care medicine at Brigham and Women’s Hospital, told MD Magazine® that the findings suggest potential therapeutic pathways for investigators working on asthma.

“There are many reasons why patients can develop an increased neutrophil count,” he said. “If a patient has severe asthma with an increased lung neutrophil count, our findings have uncovered a new immunological mechanism for this type of inflammation that we hope will inform new (yet-to-be-developed) treatment.”

The findings are important because current clinical trials for new moderate and severe asthma therapies don’t distinguish between patients with high neutrophil counts.

Levy said these findings might also pave the way...

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Smoking Banned in Public Housing Nationwide

Smokers can no longer light up in or near public housing facilities in the U.S. due to a new rule that went into effect July 31. The nationwide ban on smoking in public housing was implemented nearly two years after the rule was passed by the Obama administration in 2016.

The Department of Housing and Urban Development (HUD) now prohibits the use of cigarettes, cigars and pipes in all public housing units and common areas, as well as any outdoor areas up to 25 feet from public housing and administrative office buildings. The ban does not apply to e-cigarettes, snuff and chewing tobacco, although there may be restrictions on those in some areas.

HUD says about 228,000 public housing units under more than 600 local agencies were already smoke-free, and the new rule wipes out smoking in more than 940,000 other units. The ban is expected to save government housing agencies $153 million a year in repairs and health care costs, including $16 million for costs tied to smoking-related fires, the Centers for Disease Control and Prevention estimated in 2014.

HUD said the new policy would reduce health hazards from secondhand smoke and encourage residents to quit smoking

The ban on smoking products must be included in public housing tenants' leases, HUD says. Tenants will not be evicted for a single instance of smoking but could face eviction after several smoking violations.

Reach out to MD Spiro for information on Smoking Cessation and the products we offer to help your patients QUIT once and for all!

Additionally, for more information to quit smoking, officials recommend calling 1-800-QUIT-NOW (1-800-784-8669) toll-free to talk to a trained coach or go to


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Unraveling the Relationship Between COPD and Stroke

Emerging evidence suggests that chronic obstructive pulmonary disease (COPD) could be a risk factor for stroke.1,2 COPD is the fourth leading cause of death worldwide, and up to 80% of patients with the disease have at least one comorbidity.2 Many of the commonalities between COPD and stroke portend poor outcomes for patients with both diseases: age, indoor and outdoor pollution exposure, tobacco smoke, asthma and airway hyper-reactivity, and lower socioeconomic status.2

One of the preventable confounders for COPD and stroke risk is smoking, which contributes to fatal events and stroke.2 Indeed, in a systematic review of 30 studies, Ann D. Morgan, MSc, of the National Heart and Lung Institute at the Imperial College London, and colleagues, found that COPD increased the prevalence and incidence of stroke. Even when the researchers adjusted for smoking, COPD was still a risk factor for stroke.1

In a recent interview with Pulmonology Advisor, coauthor Jennifer Quint, MD, clinical senior lecturer in respiratory epidemiology at the National Heart and Lung Institute in London, United Kingdom, explained, “Independently of COPD, smoking increases the risk of having a stroke. There is something about having COPD, too, though, that also increases the risk. This may be linked to inflammation that occurs as a result of having COPD.”

“Tobacco smoking is a risk factor both for ischemic stroke and COPD. Patients who are hospitalized for either condition should receive intensive tobacco cessation education and support both during the hospital and as they make the transition to their post-discharge residence,” neurologist Dawn M. Bravata, MD, of Indiana University School of Medicine and the Richard L. Roudebush VA Medical Center in Indianapolis, told Pulmonology Advisor.

Exacerbations and Comorbidities That Increase Stroke Risk

Current and former smokers with a 10-pack-year history were included in a cohort study of 16,485 patients with COPD (age range, 40-80 years) with cardiovascular disease (CVD) or multiple CVD risk factors to determine whether acute exacerbations of COPD (AECOPD) increased the risk for CV events.3 Kunisaki and colleagues found that when people with COPD needed additional antibiotics or corticosteroids, they were at higher risk of having a CV event, including CV death, myocardial infarction (MI), unstable angina, transient ischemic attack, or stroke 30 days after the exacerbation (hazard ratio, 3.8; 95% CI, 2.7-5.5). For those...

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Causes of Shortness of Breath During Pregnancy

According to a 2015 study, an estimated 60 to 70 percent of women experience shortness of breath during pregnancy.

Doctors often attribute this to the growing uterus pushing upward on the lungs and making it difficult to breathe.

This article will explore this and other possible reasons for shortness of breath during pregnancy. We also cover coping strategies and when to see a doctor.


Shortness of breath is a common symptom during pregnancy.

While shortness of breath is a common symptom of pregnancy, it is not always possible for a doctor to pinpoint one single cause.

Shortness of breath during pregnancy appears to be due to a variety of factors, ranging from the growing uterus to changes in the demands on the heart.

Some women may notice changes in their breathing almost immediately, while others see differences during the second and third trimesters.

First trimester

A fetus does not have to be very large to cause breathing changes in a pregnant woman.

The diaphragm, a muscular band of tissue that separates the heart and lungs from the belly, rises by as much as 4 centimeters during the first trimester of pregnancy.

The diaphragm's movement helps the lungs fill up with air. While some women may not be aware of changes in how deeply they can breathe in, others may notice they cannot take full, deep breaths.

As well as changes in the diaphragm, pregnant women often breathe faster due to increases in the hormone progesterone.

Progesterone plays an essential role in the fetus's development. It is also a respiratory stimulant, meaning it causes a person's breathing to quicken.

The amount of progesterone in a woman's body will increase throughout pregnancy.

While breathing faster does not necessarily cause shortness of breath, some women may notice changes in breathing patterns.

Second trimester


The heart working harder during pregnancy may cause shortness of breath.

Pregnant women may experience more noticeable shortness of breath in the second trimester.

The growing uterus commonly contributes to shortness of breath in the second trimester. However, some changes in the way the heart functions can also cause breathlessness.

The amount of blood in a woman's body increases significantly during pregnancy. The heart has to pump harder to move this blood through the body and to the placenta.

The increased workload on the heart can make a pregnant woman feel short of breath.

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A Chronic, Rare Lung Disease Causes More Than Just Irreversible Scarring of the Lungs

The American Lung Association offers resources and support for this serious, life-threatening lung disease

Pulmonary fibrosis is a rare lung disease that causes irreversible scarring of the lungs, which can cause shortness of breath and a persistent cough, and progressively gets worse over time. And because there is no cure, a diagnosis of pulmonary fibrosis can bring up a lot of emotions for both patients and caregivers. 

American Lung Association Better Breathers Clubs are in-person adult support groups that provide respiratory health information and resources. Close to 500 nationwide have primarily served individuals living with chronic obstructive pulmonary disease (COPD) – a lung disease that also gets worse over time and has no cure.  We've now taken steps, with support from Three Lakes Partners, to better equip this program to serve those living with pulmonary fibrosis and their caregivers that face similar issues as those facing COPD and other chronic lung diseases.  

Better Breathers Clubs meet regularly and are led by trained facilitators that provide group discussions on topics ranging from oxygen therapy and breathing techniques to home healthcare and lung transplants, as well as how to live a full and engaging life with a chronic lung disease.

"The most important part of a Better Breathers Club is not always the educational component but the relationships that form within the groups," said Deb Brown, Chief Mission Officer of the American Lung Association. "Being able to open up these Clubs to pulmonary fibrosis patients and caregivers is an obvious extension of the goal of these groups – which is to help individuals better connect to others in similar situations."

Pulmonary fibrosis is a challenging and unpredictable disease, and symptoms can progress quickly or stay stable for many years, but most succumb to the disease three to five years after diagnosis. There are ways to make living with pulmonary fibrosis easier, including oxygen therapy, pulmonary rehabilitation and medications to help slow disease progression. Additional factors include nutrition, exercise, and stress management, all of which have an impact on quality of life for those living with pulmonary fibrosis.

In order to accommodate new members with pulmonary fibrosis, American Lung Association health educators have been working with Club facilitators to expand educational components to include information specific to pulmonary fibrosis and learn how to...

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Lung Cancer Risk Drops Within 5 Years of Quitting Smoking

Smokers who quit have a substantially lower risk for lung cancer than current smokers even within 5 years of stopping smoking, new research shows.

"If you smoke, now is a great time to quit," says lead author Hilary Tindle, MD, MPH, the William Anderson Spickard Jr. professor of medicine, Vanderbilt University School of Medicine in Nashville, Tennessee.

"The fact that lung cancer risk drops relatively quickly after quitting smoking, compared to continuing smoking, gives new motivation," she said in a statement.

On the other hand, former heavy smokers still have over a threefold greater risk for lung cancer than those who never smoked for several decades after giving up the habit, the same research shows.

"Former heavy smokers need to realize that the risk of lung cancer remains elevated for decades after they smoke their last cigarette, underscoring the importance of lung cancer screening," said senior author Matthew Freiberg, MD, professor of medicine, Vanderbilt Center for Clinical Cardiovascular Outcomes Research and Trials Evaluation, Nashville, Tennessee.

The study was published online May 16 in the Journal of the National Cancer Institute.

Data from the Framingham Heart Study (FHS) Original as well as the FHS Offspring cohort were analyzed for lifetime smoking and lung cancer incidence from 1954 to 1958 for the Original cohort and between 1971 and 1975 for the Offspring cohort. Lung cancer rates were tracked through 2013.

Information on smoking habits was collected and participants were categorized as current, former, or never smokers. Some 3905 participants from the FHS Original cohort and 5002 participants from the FHS Offspring cohort were included in the analysis.

"Most people (89.5%) who were smoking at baseline quit during follow-up and never relapsed," the authors point out.

However, during a median follow-up of 25.1 years for the FHS Original cohort and 33.6 years for the FHS Offspring cohort, investigators documented 284 diagnoses of lung cancer.

"Among ever smokers, the majority of lung cancers (92.7%) occurred among heavy smokers, with 21.3 or more cumulative pack-years of smoking," researchers note.

In this subgroup of participants with 21.3 or more cumulative pack-years of smoking, the unadjusted lung cancer risk was greater than 10-fold higher compared with those who had never smoked.

Are you running a solid smoking cessation program in your practice? It’s time to with MD Spiro.


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