M. May Zhang, PharmD Candidate

Use of electronic cigarettes (e-cigarettes), or vaping, has drastically increased in recent years, primarily among young adults. About 1 in 5 young adults use e-cigarettes regularly, and 1 in 4 believe that e-cigarettes are harmless and nonaddictive.

E-cigarettes aerosolize nicotine mixed with flavoring and preservative agents. Though combustible tobacco products, such as cigarettes and cigars, are widely recognized as causes of respiratory disease, e-cigarettes are often promoted as safe alternatives. However, studies show that vaping leads to chronic pulmonary inflammation, tissue damage, oxidative stress, and mucus hypersecretion.

 shows the first population-based, longitudinal analysis of the relationship between e-cigarettes and respiratory disease. The researchers used data from 32,320 participants in the Population Assessment of Tobacco and Health (PATH) study, a national population-based study led by the NIH and FDA.

 At baseline and over 2 years, researchers noted whether respondents had respiratory disease, used e-cigarettes, and/or used combustible tobacco products.

A number of subjects reported both respiratory disease and e-cigarette use at baseline. Even after controlling for confounding factors that included age, BMI, poverty level, and combustible tobacco smoking, there was a significant association between former or current e-cigarette use and the risk of respiratory disease.

The researchers then studied the incidence of respiratory disease that occurred throughout the study in initially disease-free subjects. Again, even after controlling for confounding factors, former or current e-cigarette use was shown as an independent risk factor. Notably, current e-cigarette use increased the odds of incident respiratory disease by a factor of 1.29.

The data also revealed a pattern of reverse causality—subjects who had respiratory disease at baseline were significantly more likely to participate in future e-cigarette use. Patients may be unaware of the risk e-cigarettes pose, viewing them as safe alternatives that will not further exacerbate respiratory conditions.

More than 90% of e-cigarette users in the study also reported using combustible tobacco. This usage pattern may be explained by patients who are aware of traditional smoking’s risks and, though not entirely quitting, are smoking less and vaping instead. However, since both activities are independent risk factors, a dual user has 3.3 increased odds of respiratory disease—higher odds than either smoking or vaping alone.

This study highlights the respiratory risks of e-cigarette use and reveals alarming patterns in dual usage of e-cigarettes and combustible tobacco. As vaping continues to grow in popularity, it becomes increasingly critical to correct misconceptions about its safety and long-term effects. Health care providers should counsel patients accordingly, and should not recommend e-cigarettes for smoking cessation.

 is a 2022 PharmD Candidate at the University of Connecticut in Storrs.

Tallent A. National Survey Reveals One in Five Young Adults Regularly Uses E-Cigarettes and Believes They are Harmless, Not Addictive. American Society of Clinical Oncology. https://www.asco.org/about-asco/press-center/news-releases/national-survey-reveals-one-five-young-adults-regularly-uses-e. Published September 26, 2019. Accessed January 10, 2020.

Bhatta DN, Glantz SA. Association of E-Cigarette Use With Respiratory Disease Among Adults: A Longitudinal Analysis. 

. December 2019. doi:10.1016/j.amepre.2019.07.028.

Population Assessment of Tobacco and Health (PATH) - Home. National Institutes of Health. https://pathstudyinfo.nih.gov/UI/HomeMobile.aspx. Accessed January 10, 2020.

Articles

As vaping continues to grow in popularity, it becomes increasingly critical to correct misconceptions about its safety and long-term effects.

New Study Shows that E-Cigarette Use Is an Independent Risk Factor for Respiratory Disease

Obesity is a well-known risk factor for type 2 diabetes, so much so that the 2 are considered ‘twin epidemics.’ More than 90% of people with type 2 diabetes are overweight or obese, and the recent rise in diabetes diagnoses is correlated with increasing obesity rates.

However, weight is a dynamic measure, and trajectories vary over time. Little is known about how onset time or cumulative exposure to obesity impact diabetes risk. Now, a recent study published in 

 shows that diabetes risk is associated with younger age at onset of obesity, and longer exposure to obesity.

Researchers used data from the Australian Longitudinal Study on Women’s Health, a population-based analysis of Australian women studying the effect of various factors on health. Over 19 years, they gathered data from 11,192 initially diabetes-free women aged 18-23 years, focusing on BMI and incidence of type 2 diabetes.

The researchers identified 6 BMI trajectories, which varied by baseline BMI and rate of increase. Women who were initially overweight or obese, or became so over the course of the study, had a significantly increased risk of developing diabetes.

However, the data also showed that cumulative exposure to obesity increased diabetes risk. The researchers measured exposure using obese-years, which account for both duration and magnitude of obesity. A higher number of obese-years, indicating more cumulative exposure, was positively associated with diabetes. Women with less than 10 obese years were 2.18 times more likely to develop diabetes, while women with 30 or more years were 5.88 times more likely.

Researchers also found a negative association between age at onset of obesity and diabetes risk. This may be because women with early-onset obesity are likely to have a longer duration of obesity, thus increasing cumulative exposure. Additionally, obesity at a young age may have more impact on insulin resistance.

Women with rapidly increasing BMIs were more at risk than women with stable trajectories. Normal weight subjects classified as rapid increasers were more likely to develop diabetes than their stable weight counterparts. Likewise, overweight and obese rapid increasers were more at risk than the baseline-only overweight and obese groups.

This study sheds new light on the importance of obesity timing and exposure in young women. Early-onset obesity should be considered an independent risk factor for type 2 diabetes. Over half of the cohort experienced a rapid BMI increase in young adulthood, highlighting this age group as a population that should be routinely counseled about weight management.

Health care providers should encourage these patients to monitor their weight and weight change over time to prevent early-onset and rapid-increase obesity. Not only preventing obesity, but even delaying age at onset and reducing exposure, may significantly decrease diabetes incidence.

Type 2 Diabetes and Obesity: Twin Epidemics. American Society for Metabolic and Bariatric Surgery. https://asmbs.org/resources/weight-and-type-2-diabetes-after-bariatric-surgery-fact-sheet. Published December 30, 2014. Accessed January 8, 2020.

Luo J, Hodge A, Hendryx M, Byles JE. Age of obesity onset, cumulative obesity exposure over early adulthood and risk of type 2 diabetes. 

. December 2019. doi:10.1007/s00125-019-05058-7.

A recent study shows that diabetes risk is associated with younger age at onset of obesity, and longer exposure to obesity.

Increased Diabetes Risk Due to Age at Onset of Obesity and Cumulative Exposure

Chronic diseases account for 70% of health care expenditures, and pulmonary diseases are the most expensive of the lot. Chronic obstructive pulmonary disease (COPD) leads in hospital costs, physician services, and prescription drugs.

COPD patients suffer from dyspnea, cough, sputum production, and airflow obstruction. Coupled with a complex treatment regimen, this leads to a progressive decline in quality of life, and functional capacity.

COPD is marked by frequent exacerbation episodes that often lead to hospitalization. Despite supportive inpatient care, post-discharge patients show lower functionality, and higher symptomatic burden. The current standard of care is insufficient.

Shared decision-making is a process in which health care providers and patients make joint decisions about patient care. This engages patients in an active role, empowering them as agents of their own health. This is especially valuable in chronic, complex diseases such as COPD.

has published a study analyzing the effectiveness of an inpatient COPD shared-decision making and patient engagement (SDM-PE) program. The control group received a standard treatment of systemic steroids, antibiotics, inhaled bronchodilators, and oxygen therapy. In addition to the standard treatment, the intervention group received an individualized SDM-PE program. Each program was tailored to the patient, who collaborated with the health care team to identify goals and strategies based on his or her own priorities.

​​​All patients were assessed at admission, discharge, and at a 3-month followup. The researchers measured variables such as symptoms, physical activity, pain, perceived health status, COPD knowledge, and adherence.

At discharge, both groups had improved in all variables, with the exception of a decrease in physical activity while inpatient. The SDM-PE group had superior improvements in pain, perceived health status, and COPD knowledge. General functionality improved in both groups, and there was no significant difference between groups.

After 3 months, the control group had worsened in all variables, while the SDM-PE group maintained or improved all measures compared to discharge values. All values were superior in the SDM-PE group, with significant between-group differences in physical measures including dyspnea, pain, functionality, and physical activity.

Moreover, SDM-PE patients had significant between-group differences in COPD knowledge, adherence, and perceived health status. These non-physical measures may be more indicative of how the intervention affected holistic health, motivation, and lifestyle.

Due to the chronic, complex nature of COPD, burdened patients may lose motivation, leading to declines in overall health and adherence. SDM-PE programs give patients an active role in tailoring their own treatments, leading to sustainable improvements in physical functionality, adherence, and holistic health. Both inpatient and outpatient practitioners should integrate aspects of shared decision-making and patient engagement.

Granados-Santiago M, Valenza MC, López-López L, Prados-Román E, Rodríguez-Torres J, Cabrera-Martos I. Shared decision-making and patient engagement program during acute exacerbation of COPD hospitalization: A randomized control trial. 

. December 2019. doi:10.1016/j.pec.2019.12.004.

Chronic obstructive pulmonary disease (COPD) leads in hospital costs, physician services, and prescription drugs.

Shared Decision-Making and Patient Engagement Significantly Improve Long-Term COPD Outcomes

Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common psychiatric disorder worldwide, and the rate of diagnosis has increased significantly over the past decade. As of 2016, an estimated 6.1 million American children had been diagnosed with ADHD.

ADHD is correlated with lower health-related quality of life that starts in childhood and can persist into adulthood. Previous studies associate ADHD with decreased academic performance and physical activity, and increased odds of screen time, overeating, and obesity. Effective treatment requires a combination of pharmacological and nonpharmacological approaches.

The existing literature shows that regular physical activity is a beneficial adjunct treatment. Previous studies have demonstrated many benefits of exercise in children with ADHD, including improvement in core symptoms, test scores, sleep, mood, and social disorders.

 recently published a study that analyzed the relationship between ADHD diagnosis and engagement in physical activity. The researchers studied data from the 2016 National Survey of Children’s Health (NSCH), a caregiver-reported survey conducted by the US Census Bureau. The final study population included 34,675 children ranging in age from 6 years to 17 years.

The study found that children diagnosed with ADHD had 21% lower odds of engaging in daily physical activity than nondiagnosed children, confirming the inverse association shown by previous studies. The researchers further qualified the relationship by studying the association between ADHD and different degrees of activity. Diagnosed children were increasingly less likely to participate in 1-3 days, 4-6 days, and 7 days per week of exercise, respectively.

The survey also analyzed several covariable factors, including the caregiver’s highest level of education, and the child’s sex, age, race, and digital media exposure. Female gender, ages 12-17 years, and increased digital media exposure were all independent risk factors for decreased physical activity.

Low levels of education, and non-English speaking households were negatively associated with physical activity. Additionally, Spanish-speaking households reported a lower rate of ADHD diagnosis than English-speaking households. This confirms existing health disparity research, which has shown that minority families are less likely to receive an ADHD diagnosis, and may therefore receive less support and resources.

This study validates the inverse relationship between ADHD diagnosis and physical activity, and emphasizes the complex societal factors at play. In addition to educating ADHD families about the importance and benefits of regular physical activity, health care providers should work with families to facilitate exercise in their home environments. Clinicians may also mitigate other risk factors for inactivity by counseling to set limits on screen time, connecting caregivers to adult education resources, and ensuring interpreter services.

Data and Statistics About ADHD. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/adhd/data.html. Published October 15, 2019. Accessed January 8, 2020.

Mercurio LY, Amanullah S, Gill N, Gjelsvik A. Children With ADHD Engage in Less Physical Activity. 

 December 2019. doi:10.1177/1087054719887789.

ADHD is correlated with lower health-related quality of life that starts in childhood and can persist into adulthood.

Study Finds Children with ADHD are Less Physically Active

Transgender and gender nonconforming (TGNC) people have a significantly increased risk of HIV infection. In 2015, the number of transgender people diagnosed with HIV was 3 times the national average. Transgender women have 49 times the odds of having HIV compared with the general population, and transgender men also have notably higher infection rates.

Antiretroviral therapy (ART) decreases morbidity, mortality, and transmission; therefore, ART adherence is critical to the health of TGNC patients with HIV. Understanding adherence patterns is the first step to combat the HIV epidemic in this population.

 analyzed TGNC ART adherence based on the US Trans Survey (USTS), the largest survey of TGNC people in the United States. This large-scale evaluation, which reached TGNC people from many backgrounds, may provide more representative data than previous studies focusing on HIV patients connected to health care.

The researchers studied data from the 2015 USTS, in which 162 respondents reported an HIV diagnosis and ART prescription. Within this group, 66% of respondents were classified as adherent, and 34% were considered nonadherent. The researchers then studied how other factors—including race, living arrangements, sex work history, and substance use&mdash;differed in adherent vs. nonadherent populations.

A higher proportion of whites and Hispanics were adherent compared to black individuals. Adherent individuals reported higher rates of home ownership, while nonadherent individuals were more likely to report “other” living conditions, such as roommate situations, and homelessness. Additionally, nonadherent participants reported higher rates of verbal harassment, sex work, and illegal/illicit drug use in the past year, and lower rates of seeing a doctor due to cost in the past year.

These findings support previous data that social determinants of health play a critical role in ART adherence and HIV outcomes. One particularly high-priority population may be black TGNC individuals, who report both higher HIV rates, and lower adherence rates. Vulnerable TGNC populations in unstable sociostructural conditions, such as homelessness, sex work, and drug use, are more prone to nonadherence.

As accessible, approachable health care workers, community pharmacists have both opportunity and responsibility to counsel at-risk patients regarding ART adherence. This may prove to be a critical step to improve health outcomes, and decrease health disparities in this vulnerable population.

is a 2022 PharmD Candidate at the University of Connecticut in Storrs.

Teti M, Bauerband LA, Altman C. Adherence to Antiretroviral Therapy Among Transgender and Gender Nonconforming People Living with HIV: Findings from the 2015 U.S. Trans Survey. 

. 2019;4(1):262—269. Published 2019 Oct 25. doi:10.1089/trgh.2019.0050

Understanding adherence patterns is the first step to combat the HIV epidemic in this population.