July 26, 2024 • 30 mins
In this episode of the Dr Journal Club podcast, we reveal the alarming statistic that one in five children are still exposed to secondhand smoke despite declining smoking rates. We dive into the differences between mainstream and sidestream smoke, explore vaping's unique mechanisms that retain 99% of nicotine, and analyze a study on nicotine absorption in children.
We also discuss the reliability of observational studies on smoking and vaping habits, highlighting the biases that can affect results, such as social desirability bias. Measuring genuine exposure levels, especially when parents smoke indoors, presents complex challenges that we scrutinize in depth.
Join us for critical insights and ethical considerations on this pressing issue. Connect with us on social media at DrJournalClub to share your thoughts and questions. Be part of our mission to explore evidence-based integrative medicine and improve public health.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2821086
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Introducer (00:02):
Welcome to the Dr Journal Club podcast, the show
that goes under the hood ofevidence-based integrative
medicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
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(00:23):
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com.
Dr. Joshua Goldenberg (00:31):
Please bear in mind that this is for
educational and entertainmentpurposes only.
Talk to your doctor beforemaking any medical decisions,
changes, etc.
Everything we're talking aboutthat's to teach you guys stuff
and have fun.
We are not your doctors.
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You can post questions andcomments for specific videos,
(00:55):
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com.
Send us your listener questionsand we will discuss it on our
pod.
Hello everyone and welcome toanother Dr Journal Club podcast.
Dr. Adam Sadowski (01:15):
Yes, sir.
Dr. Joshua Goldenberg (01:15):
I'm feeling.
I don't know what am I feeling.
I'm feeling.
Dr. Adam Sadowski (01:19):
Why are you sitting on the couch
chain-smoking cigarettes whileeating a TV dinner there, Josh?
Dr. Joshua Goldenberg (01:24):
I'm feeling that I'm tired of doing
smoking studies and when yousent this one to me, I was like
not another one?
Are we really doing it?
Nobody smokes anymore.
And then, like heartbreakingly,it said that one fifth of all
kids have exposure to secondhandsmoke.
I couldn't believe it.
To secondhand, smith, Icouldn't believe it, and it just
(01:47):
underlines what you always sayabout me, which is I'm
completely not in touch withreal life.
So it's like, oh my gosh, thatis just totally heartbreaking.
And, yeah, this is still aproblem, this is still an issue.
People still smoke.
People still smoke inside.
People still smoke insidearound kids.
It's insane one in five kidsare exposed to this.
So, yeah, this is a superimportant issue.
(02:07):
I'm glad you brought it up withone of your favorite jam and
network journals.
Uh, so shall we?
Shall we jump in?
Let's go okay, let's do it,let's do it, let's do it okay.
So, um, we'll, probably.
It's a pretty straightforwardpaper.
I thought I think maybe, uh, isthere anything in the
introduction you wanted to talkabout, or should we kind of jump
(02:28):
into methods?
What were you thinking?
I think really the main thing isthere is definition now for
like a mainstream, versus what'sknown as sidestream, secondhand
exposure to smoking Rightno-transcript you've got and it
(03:08):
was surprising to me that thiswould be so different, but I
guess it makes sense becauseyou're absorbing some of the the
substances, but yeah, so, likeyou, you take a drag, you blow
it out.
That's mainstream.
But meanwhile, while you'relike pontificating about
philosophy or why you think youlook like james dean, the
cigarette's still burning and Ithink my read this is the first
I heard that phrase too thatthat was this, that was the
(03:29):
smoke from, that was the sidestream, uh, exposure type of
thing.
And then this was interestingand so, like they, they say that
, in contrast to vaping, right,so, where you don't have an
aerosol between puffs.
So there's there, there arethese unique differences between
vaping and smoking that mayhave direct impacts on
(03:52):
secondhand smoke, and that'skind of sets us up for this
conversation and this study of.
Okay, if we're talking aboutkids and we're interested in
kiddos and their exposure tosecondhand smoke, you know what
kind of exposure are theygetting if the people smoking
inside are vaping versus smokingcigarettes?
Because there's all these youknow differences, mechanistic
(04:13):
differences, between thechemicals produced.
Dr. Adam Sadowski (04:17):
Right and and the reality is that the
prevalence well, I guess bothincidents and prevalence of
vaping is increasing, increasingespecially amongst our younger
population, and there is someinteresting background data
that's suggestive of the ofvaping being a quote-unquote
cleaner product, where there'sless, um you know, chemicals
(04:39):
that are that are being uhreleased through through the
vaping, and that has to do withits uh mechanism.
Uh, and, shockingly, here'ssomewhere where I am in favor,
where mechanism seems to matter.
Dr. Joshua Goldenberg (04:51):
Yeah, I couldn't believe.
I mean the introduction Ithought was quite interesting
because I didn't know any ofthis stuff.
So, first of all, that sidestream, mainstream, and then,
like you said, so 99% of thenicotine is retained when you
inhale from vaping versus Idon't know what it is for
cigarettes, but much less.
So essentially you just havevery efficient, I guess,
(05:12):
absorption with vaping, and soless is then breathed out to be
secondarily breathed in by bykiddos.
So again you have, like yousaid, all these different
mechanistic differences betweenthem.
And of course it's not just thenicotine.
We're not really that worriedabout nicotine per se.
We're more worried aboutcarcinogens and other toxicants
that are associated with withthat, and of course that also is
(05:34):
lower in vaping than in regularcigarette smoking.
Dr. Adam Sadowski (05:38):
Exactly.
And so what these authorswanted to do was look at um
nicotine absorption amongstchildren, who are being exposed
to secondhand smoke only, rightto secondhand vape use only, or
to those who are exposed toneither.
And that makes sense.
You don't want, you don't wantto expose, have one group be
(06:00):
exposed to both, because thenyou don't know if it's coming
from the tobacco use or if it'scoming from the, from the, you
know, e-cigarette use, so thatoff the back doesn't make any
sense.
And it also makes sense thatthis was a cross-sectional study
, because, one, they have datathat's regularly available and
then, two, you can't really likerandomize participants into a
(06:23):
smoking non-smoking or vapingnon-vaping group, because that
would be unethical, at least inthis country.
Dr. Joshua Goldenberg (06:29):
Yeah, here you go, little six-year-old
kid, why don't we randomize youto go sit in this house where
people are smoking all day?
No, can't do that.
Yeah, so, yeah.
So I agree.
Appropriate, appropriate studydesign.
Um, and it's from the NHANES uhstudy.
Do you want to?
Should we talk a little bitabout what that is, just so
people have a sense?
It's super famous continuouscohort.
Dr. Adam Sadowski (06:50):
Yeah, so it's a continuous cohort, but for
this particular study it's usingcross-sectional data, right?
So this is a cohort that'sconstantly being evaluated and
constantly being studied.
But what we're doing is we'resaying, hey, we're actually just
going to look at this specifictime point and try to come up
(07:10):
with an association or see ifthere is an association or not
between an exposure and anoutcome that we're interested in
.
So we're not like continuouslymonitoring them, we've kind of
like monitored them within aspecific, very specific period
and we're just kind of taking asnapshot of this ongoing cohort.
And so this is a US-basedcohort and it's nationally
(07:32):
representative.
They're taking data basicallyacross the country and
specifically in this cohort theyactually oversample minority
populations because they knowthat this way they'll get a
little bit more data withinthose participant groups,
because minorities are sooftentimes underrepresented in
(07:54):
medicine and in science, and sothis is one way of actually
getting a more true UnitedStates participation
representation.
And NHANES stands for theNational Health and Nutrition
Examination Survey, and whatthey used specifically in this
study was looking at childrenwithin this cohort.
(08:18):
But really, because if you're athree-year-old you're unlikely
to actually be able tounderstand what's going on they
used what they refer to as proxyparticipants.
Basically, they asked the legalguardian of the house, or
someone in the house who isconstantly around the children,
(08:39):
to provide the answers to thequestionnaires that were asked.
And so, within this cohort,basically, they're they're
constantly asking all sorts ofquestions what are you eating?
How much are you exercising?
What are you exposed to?
Do you do this, do you do that?
Um, and continuously askingthem on a I don't know if it's a
yearly basis or every two years, or how frequently they're
(08:59):
asking them, but, um, it's.
They're just constantly gettingyou know a data from, from,
from people.
Dr. Joshua Goldenberg (09:05):
Yeah, and it's a super high quality study
going on over many, many, many,many years.
And an additional benefit tothat besides, like you said,
oversampling minority groups andbeing a truly representative
national sample is that it alsogets objective data.
So, like they go in and getthese high quality, you know
(09:25):
survey results, but then they'llgo in their, their clinical
unit will go in and draw likelots of blood and in this case
there's a blood marker fornicotine exposure that they were
looking at.
So they're basically trying tosay, okay, let's get a sense of
all these kiddos, how many areexposed to smoke?
If so, what type vaping orcigarettes they threw out?
(09:45):
I think you said anyone thatwas exposed to both, because
it'd be too confusingmethodologically, and then
people who are not exposed toeither and then also looked at
biomarkers of that nicotineexposure, to say, okay, what
levels are we actually seeing inthe blood of these kiddos
Exactly?
Dr. Adam Sadowski (10:02):
The only issue with that was you know a
lot of the participants onlyafter answering the survey.
It wasn't like they answeredthe survey and then had blood
drawn the same day.
There was about a.
There was a gap in time and itwas kind of you know, it was
over a couple of days, so theywould, let's say, monday you
(10:25):
answer the question.
It was like, okay, come in onFriday.
And one of the biases that weneed to be aware of within this
is the fact that one you'realready asking a question that's
viewed as unhealthy, soparticipants may not want to be
as truthful in their answeringand then from there you're going
(10:49):
to be getting a blood sample acouple days after answering that
.
You know, potentially, um, it'snot a loaded question, but but
participants may feel likethey're being judged by
answering truthfully and so thatmay change their behavior at
the time that they're gettingthat objective marker.
So yeah you know they, they maybe falsely lowering the amount
(11:10):
that they're, that the levels ofnicotine in their blood if
they've decided to stop smokingor stop vaping.
And it's what's referred to asthe social desirability bias.
You're going to be answeringquestions based off of what
current social norms are andhaving a more socially desirable
answer.
You may feel ashamed orembarrassed of being like, yeah,
(11:31):
I smoke inside the house withchildren.
I know it's not good for them,but I do it type of thing, and
so that may stoke some emotionsin these participants who are
like, actually, you know what Ianswered that question, I'm
going to stop smoking, and thenthey just so happen to get those
labs that you know in a coupleof days.
So that's one thing that we dohave to be aware of.
Dr. Joshua Goldenbe (11:52):
Interesting in a couple of days.
So that's one thing that we dohave to be aware of.
Interesting, yeah, that's aneat, that's interesting.
I mean I thought I thought Iwas thinking about the first
part, but not the second part.
That's very interesting.
So not only could peopleuntruthfully answer the question
basically say, oh no, no, no,there's, there's no exposure to
the to smoke in this household.
So that would be one thingbecause the social desirability,
but the other is they mighteven change their behavior just
(12:14):
by being asked that Interesting,and then the blood marker a few
days later will be artificiallylowered.
That's very interesting, okay.
So if that's true, and thenwhat you would really have a
problem with because here we'retrying to compare vaping versus
no smoke exposure, versusregular cigarettes is if people
who are smoking cigarettes inthe house versus vaping in the
(12:37):
house, if they feel differentguilt or different judgments in
that way and maybe they do maybevaping is more socially
acceptable.
So the cigarette smokinghouseholds are more likely to
maybe answer less honestly andor change behavior.
Huh, that is interesting.
So not only is there apotential mechanism for that,
but you can make an argumentthat it would be differentially
(12:59):
affected, the different groups.
Yeah, really good point, man.
Yeah, really really good point.
I don't know how you get aroundthat.
I mean besides immediatelysampling right away for that
latter point.
But that just may not bepragmatic.
Dr. Adam Sadowski (13:11):
Yeah, I think it's just also, you know, this
is the one of the problems thatyou just have to accept.
Uh, when it comes toobservational studies,
especially cross, uh,cross-sectional studies, is you
just?
Hey, this is a reality, youknow, interpret with caution and
this is something that we justis unavoidable.
Yeah, and to clarify when, whenthey looked at participants in
the study, when, when they theyasked them, do you smoke inside
(13:32):
the house?
It wasn't like, hey, do you gooutside on the porch to smoke,
to go away from your children,or do you go into an unattached
garage or do you step outsideand close the door and then come
back in.
This was do you like smoke onthe couch with children in the
house, or like smoke in thekitchen?
(13:53):
Like very much like what wasnormal, I guess, in the 70s and
80s, um, and, and that's kind oflike what they were looking at,
because and that makes sensetoo, because if you think about,
like, comparing that to vaping,people aren't excusing
themselves to go outside to vapethey're just puffing like right
then and there, and so I thinkthat that that actually kind of
is a strength in how they're andhow they're questioning.
(14:16):
So, although it may notnecessarily be 100 pragmatic and
totally how, like what I'veseen most people do for those
who are smokers like most peoplewho I know that are smokers and
smoke at home do excusethemselves and go outside or or
only smoke in a basement orthat's unattached um, or will
smoke on the porch and then comeback inside.
(14:36):
So you are limiting thatexposure to a certain extent, um
, but in this, in this instance,they're they're doing like very
much old school, like hey, areyou smoking on the couch
actually in inside the house,without excusing yourself.
Dr. Joshua Goldenberg (14:50):
Yeah, really good points.
First of all, it's justshocking that even that level is
still a one fifth of kids areexposed to.
That is it's mind blowing.
But yeah, really excellentpoint, because that word we're
not asking people do you smokeor vape it's?
Are you doing that in the house?
And you're right, because folksthat they are maybe more likely
perhaps do that in the houseand so you're still comparing
like to like.
Yeah, really really good points.
(15:11):
I love all of that.
I think that's definitely astrength and also kind of
shocking and, to your point,still very, very relevant
unfortunately in our society,and I think it may even be worse
in a lot of other countries.
Look, the thing is we don't dothis for money.
This is pro bono and, quitehonestly, the mothership kind of
(15:38):
ekes it out every month or so,right?
So we do this because we careabout this, we think it's
important, we think thatintegrating, evidence-based
medicine and integrativemedicine is essential and there
just aren't other resources outthere.
The moment we find somethingthat does it better, we'll
probably drop it.
We're busy folks, but right nowthis is what's out there,
unfortunately.
That's it, and so we're goingto keep on fighting that good
fight and if you believe in that, if you believe in intellectual
honesty in the profession andintegrative medicine and being
(15:59):
an integrative provider andbringing that into the
integrative space, please helpus, and you can help us by
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Interact with us on socialmedia, listen to the podcast,
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(16:20):
These are all ways that you cansort of help support the cause.
Okay, cool, so I think we talkedabout that.
Covariates, I think, yeah goahead.
Dr. Adam Sadowski (16:31):
Another thing that was important, too, was
what'd you think of the responserates?
Dr. Joshua Goldenberg (16:35):
Yeah, that was kind of interesting
pretty darn low.
So we have response rates of63% for one to five year olds
and 59% for six to 11 year olds.
So I mean, you're like that'shorrific, right?
So normally when you do a riskof bias assessment for surveys,
(16:56):
for survey data, for prevalencedata which is essentially what
this is anything any responserate less than like 80% is
usually right away marked as ahigh risk of bias.
And so you're, you're missinglike 40% of respondents here,
and so, especially with such aloaded although they were
sitting it wasn't just this onequestion, right?
(17:17):
I'm assuming this is a responserate for the entire NHANES
questionnaire, and so you knowyou could make an argument.
Yeah, it's less strong of anargument as far as like oh, I
don't want to answer about thesmoking situation, because it's
just a general survey in generalthat they're being asked to
fill out.
Right, that was my read anyway.
Dr. Adam Sadowski (17:36):
Um, I don't.
I don't know one way or theother of that, but I also
thought it was interesting that,although those response rates
were low, the participationwithin the mobile um, like lab
draw sites, was high right so ofthose 63% and 59%, it was 92%
and 89% who got their labs drawn.
Dr. Joshua Goldenberg (17:56):
Yeah, so if you answered the survey, you
pretty much also got all thatclinical data.
But just very few people evensigned up to do that.
But it is nice that it's kindof it tracks together.
The people that were in wereall in, if you will.
Yeah, and I am concerned.
It's a good point.
It's a very, very low responserate and I think that, yeah, I
(18:17):
mean I don't know what you'resupposed to do about that.
Like this is extremelyrepresentative US sample,
extremely well conducted, and Ithink it's just hard to get
people to answer these likereally onerous surveys, and
especially when you're likeasking about kids, I guess.
So from a quality of studyperspective, like it's hard to
judge the scientists, right, butfrom a risk of bias perspective
(18:37):
, it's like how could you notview that as a high risk of bias
just off the bat, right?
Just the fact that we'remissing so much data.
Dr. Adam Sadowski (18:44):
Right, right.
And then the reason why theyuse children between three to 11
years is because they justdidn't have any sort of it looks
like they didn't have contininelabs for, like a reference
range for those who are betweenbirth and two years old.
Dr. Joshua Goldenberg (19:00):
Yeah, so that's what they use.
So this, that was a newsubstance to me.
What did you call it?
Continine?
Continine, yeah, uh, so that's.
It is a nicotine marker, butapparently a better choice for
secondhand smoke exposure, whichI found interesting.
I was not familiar with thatbiomarker before, but
specifically to kind of measurethe secondhand exposure.
And then another cool thingabout that is, um, if they saw
(19:23):
levels were so high that itcould could only be explained by
actually smoking like, let'ssay, a 10 year old was sneaking
out to get a cigarette theywould throw that data out, right
, so they could tell that it wasonly secondhand smoke, that
they were measuring there.
And then they would basicallysay we're you know, obviously
this would be confounded ifyou're actually smoking, so
we're going to throw thatinformation out.
Yeah, exactly, cool.
(19:44):
Okay, well, that I'm good withthat.
Should we jump into the results?
Anything else for methods youwant to chat about?
Dr. Adam Sadowski (19:49):
When they did their analyses they adjusted
for age, sex, ethnicity, income,body weight and height.
And yeah, let's jump into theresults.
So basically, 1,827 childrenwere surveyed and then they
ended up with an actual analysissample of 1,777.
And then dropouts were due toconstant exposure just being too
(20:11):
high to be actually realistic.
And then dropouts were due toconstant exposures just being
too high to be actually likerealistic.
And then some people wereexposed to both secondhand smoke
and secondhand vapor.
And then there were 12 children, which was just less than 1% of
those included in the study,had missing body weight or
height, and so they justexcluded them from that.
(20:33):
So of the 1,827 who wereincluded, just about 15% were
exposed to secondhand tobaccosmoke only, and then 2.5% to
secondhand e-cigarette only andthen the rest, so just a little
bit over 80% were exposed toneither tobacco or vaping use.
Dr. Joshua Goldenberg (20:57):
Yeah, interesting, yeah, so there you
go.
So 20% one in five kiddosexposed pretty insanely high
levels.
Okay, so let's jump into I wantto jump into the actual results
here, if that's okay.
Dr. Adam Sadowski (21:12):
Yeah, before we get into that, the mean age
was 7 1⁄2 plus or minus 2 1⁄2.
It was basically 50-50 betweenmale and female.
30% were below the federalpoverty line, which is a pretty
high amount, and then it waspretty evenly distributed
amongst Hispanic, non-hispanicBlack and non-Hispanic Whites,
(21:35):
and then 18% were reported asmultiracial.
And I think it was prettyinteresting to see, when we look
at table one, looking at thatdemographic table, the number of
participants or the proportionof participants who were exposed
to smoke only seem to be of ofa greater minority background.
(22:00):
Um, more were below the povertyline.
So when we look at those who areexposed to smoke only,
cigarette smoke only 46 percentwere yeah, oh, I see what you're
saying vapor versus smoke,gotcha, yeah, 46 percent were
below poverty, whereas those whowere exposed to vapor, only 16
(22:20):
percent were below poverty.
Um, so I thought that waspretty interesting.
Um, when we look at, uh, likethe, the race and ethnicity,
basically everything is doublerelative to those who are
exposed to to vapor only, and Ijust thought that you know that
it was interesting.
That that's kind of how it wasbroken down, but, um, in the
(22:40):
analyses they did adjust forthis, so right yeah, yeah, yeah,
yeah, no, interesting indeed.
Dr. Joshua Goldenberg (22:46):
And again , I feel, methodologically I'm
okay with it.
Um and so probably for the, youknow, let's just look at the
actual.
So the actual numbers probablyaren't going to mean much to you
, unless you're very used toseeing these um, these
particular biomarkers, but let'sjust kind of talk them through
so.
So the highest exposure werefor kiddos that were exposed to
(23:09):
secondhand smoke only, which was0.494 micrograms per liter.
Okay, so that's our, that's ouractual smoke.
So cigarette smoke, we're at0.494.
Dr. Adam Sadowski (23:20):
That's also the unadjusted.
When we look at the adjusted umit's, it is reduced a little
bit, but the point remains thesame.
Dr. Joshua Goldenberg (23:29):
Yeah, so okay.
So maybe we'll just talkrelative numbers then, because
maybe that makes more sense.
But essentially you have adramatic, dramatic difference
between only smoke versus onlyvapor, like 80% reduction, like
absolutely dramatic difference.
If you look in the, if you'refollowing with us in the paper,
we're in figure.
(23:50):
I think that's figure one.
It's just you just see thisvery, very dramatic drop from
only smoke to only vapor ofabout 80%.
Now that is a 90% drop if youcompare it to neither.
So people that are not exposedthey're still going to pick
stuff up in the environment, ormaybe this it's measurement
error or something like that.
So there's still a little bitin the blood.
And you obviously see adramatic difference between no
(24:14):
smoke or vapor exposure and onlysmoke.
But the difference betweenvapor and only smoke is, just to
me anyway, mind-blowinglydifferent.
However, the vapor itself,compared to no exposure, is also
statistically significantlydifferent.
So it's not like it's withoutrisk.
It's definitely better to nothave vapor exposure.
(24:34):
But when you're looking at,okay, should we expose the
kiddos to cigarette, smoke orvapor?
It is just.
It seems to me like this, justa no, it's a no brainer.
If you're replacing one for theother, right, obviously nothing
is better, but if you'rereplacing one for the other,
like 80% difference there.
Dr. Adam Sadowski (24:51):
Yeah, I think there's a real conversation to
be had that if you're someonewho is a current smoker and you
are smoking in the house and youhave children, I you know, I
don't think it's unreasonable tohave that conversation of you
know, is it healthier to switchfrom tobacco smoke to then
vaping, even if you're tradingone for the other and if you're
(25:11):
kind of looking for like what'sthe lesser evil?
It seems to be based on theliterature that that's out there
, that switching from fromsmoking cigarettes to
e-cigarette products may perhapsbe better, even if it may not
change sort of like thatnicotine addiction, because
you're being exposed to fewercarcinogens and not by, like,
(25:35):
just a little bit amount.
It seems to be a dramaticreduction, and then those around
you are also getting asignificantly reduced exposure
as well.
Dr. Joshua Goldenberg (25:44):
Yeah, I mean this.
This kind of is in line withthe overall theme, I would say,
of like all the smoking andvaping papers we've done, which
is, when you compare it tocigarette smoke, it is seems to
be a better choice.
But obviously if on the tableis not smoking or not vaping,
that is better.
However, if that is not on thetable, it seems to me anyway
(26:06):
like a pretty clear choice.
And actually this dramaticdifference really underscores
the benefits, right, becausethis is looking just at the
nicotine exposure and using thatas a proxy for the really
harmful toxicants that we'reactually worried about.
Again, we're less worried aboutnicotine exposure per se, it's
more everything else that comeswith it.
(26:28):
So they're using that as aproxy for exposure for
everything else in the smoke orin the in the vapor.
However, to your point, vaporitself has less of those
chemicals, right?
So it's even going to be lessharmful exposure than what it
seems like on this graph.
So we're probably going to haveeven more than an 80%
difference in exposure there.
(26:49):
So, again, we know secondhandexposure is dangerous, but just
a dramatic difference.
And if you're not willing tostep outside or to a detached
garage or something like this,then switching to vapor just
would have a dramatic impact onthe exposure to those kiddos.
Dr. Adam Sadowski (27:06):
Yeah, no, I thought, I thought, I know, I
thought it was an interestingstudy.
Dr. Joshua Goldenberg (27:09):
Yeah, you know, I really I have this bias
of this.
You know, you know the phraselike don't make the perfect the
enemy of the good, like I reallybelieve in that pretty strongly
.
And I hear the argument thatsome people make that with
addiction it's you need to beall in or all out, right, I've
heard that argument before andcertainly that was true for me
with cigarettes.
But I think I don't know ifyou're not going to quit.
(27:31):
You know it feels weird saying,okay, it's okay to vape, but
actually maybe it is rightCompared to the alternative, and
we don't want to make theperfect the enemy of the good.
And if just like beratingpeople to just be like, well, go
outside, why aren't you goingoutside?
Or just quit, why aren't youquitting?
I don't know that that works,but maybe it does.
But if that's not working, thenat least getting them to switch
(27:52):
to vaping can have a dramaticimpact at least on the kids and
I'm sure on them as well.
Dr. Adam Sadowski (27:58):
Yeah, yeah.
No, I thought it was aninteresting paper.
It's open access, free foranyone to go look at, you don't
need a paywall.
And it was not funded by anysort of industry.
It was all through grantfunding, so this is publicly
funded paper.
Dr. Joshua Goldenberg (28:12):
Very nice , very nice.
I will send Michelle the linkand thanks.
Sort of a short and sweet papertoday, very straightforward,
good paper, besides thatresponse rate, which I think you
were very wise to point out,and I think that's all I got for
you guys today.
Very wise to point out, and Ithink that's all I got for you
guys today.
How about you, adam, anythingelse you wanted?
Dr. Adam Sadowski (28:27):
to end on Nope, that's it.
If anyone wants more of avisual or a deeper dive, I do
expect to see this one on the DrJournal Club website.
There will be graphs and alittle bit more attention to
data visualization there, ifyou're interested.
Dr. Joshua Goldenberg (28:41):
Beautiful .
All right, thank you, Adam, andI will see you next week.
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(29:03):
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Thank you.
Hey hey .
y'all.
This is Josh.
You know we talked about somereally interesting stuff today.
I think one of the things we'regoing to do that's relevant.
There is a course we have on DrJournal Club called the EBM
Boot Camp.
That's really meant forclinicians to sort of help them
understand how to criticallyevaluate the literature, etc.
(29:24):
Etc.
Some of the things that we'vebeen talking about today.
.
Go ahead and check out the shownotes link.
We're going to link to itdirectly.
I think it might be of interest.
Don't forget towwwdrjournalclub.
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Etc.
So please reach out to us.
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(29:46):
If you have any specificquestions you like to ask us
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Don't hesitate to ask.
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for listening to the doctorjournal club podcast, the show
that goes under the hood ofevidence-based integrative
(30:09):
medicine.
Introducer (30:10):
We review recent research articles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Be sure to visitwwwdoctorjournalclubcom to learn
more.
Welcome to the Dr Journal Club podcast, the show
that goes under the hood ofevidence-based integrative
medicine.
We review recent researcharticles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Continue your learning afterthe show at www.
(00:23):
d rjournalclub.
com.
Dr. Joshua Goldenberg (00:31):
Please bear in mind that this is for
educational and entertainmentpurposes only.
Talk to your doctor beforemaking any medical decisions,
changes, etc.
Everything we're talking aboutthat's to teach you guys stuff
and have fun.
We are not your doctors.
Also, we would love to answeryour specific questions on
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com.
You can post questions andcomments for specific videos,
(00:55):
but go ahead and email usdirectly at josh at
drjournalclubcom.
That's josh at drjournalclub.
com.
Send us your listener questionsand we will discuss it on our
pod.
Hello everyone and welcome toanother Dr Journal Club podcast.
Dr. Adam Sadowski (01:15):
Yes, sir.
Dr. Joshua Goldenberg (01:15):
I'm feeling.
I don't know what am I feeling.
I'm feeling.
Dr. Adam Sadowski (01:19):
Why are you sitting on the couch
chain-smoking cigarettes whileeating a TV dinner there, Josh?
Dr. Joshua Goldenberg (01:24):
I'm feeling that I'm tired of doing
smoking studies and when yousent this one to me, I was like
not another one?
Are we really doing it?
Nobody smokes anymore.
And then, like heartbreakingly,it said that one fifth of all
kids have exposure to secondhandsmoke.
I couldn't believe it.
To secondhand, smith, Icouldn't believe it, and it just
(01:47):
underlines what you always sayabout me, which is I'm
completely not in touch withreal life.
So it's like, oh my gosh, thatis just totally heartbreaking.
And, yeah, this is still aproblem, this is still an issue.
People still smoke.
People still smoke inside.
People still smoke insidearound kids.
It's insane one in five kidsare exposed to this.
So, yeah, this is a superimportant issue.
(02:07):
I'm glad you brought it up withone of your favorite jam and
network journals.
Uh, so shall we?
Shall we jump in?
Let's go okay, let's do it,let's do it, let's do it okay.
So, um, we'll, probably.
It's a pretty straightforwardpaper.
I thought I think maybe, uh, isthere anything in the
introduction you wanted to talkabout, or should we kind of jump
(02:28):
into methods?
What were you thinking?
I think really the main thing isthere is definition now for
like a mainstream, versus what'sknown as sidestream, secondhand
exposure to smoking Rightno-transcript you've got and it
(03:08):
was surprising to me that thiswould be so different, but I
guess it makes sense becauseyou're absorbing some of the the
substances, but yeah, so, likeyou, you take a drag, you blow
it out.
That's mainstream.
But meanwhile, while you'relike pontificating about
philosophy or why you think youlook like james dean, the
cigarette's still burning and Ithink my read this is the first
I heard that phrase too thatthat was this, that was the
(03:29):
smoke from, that was the sidestream, uh, exposure type of
thing.
And then this was interestingand so, like they, they say that
, in contrast to vaping, right,so, where you don't have an
aerosol between puffs.
So there's there, there arethese unique differences between
vaping and smoking that mayhave direct impacts on
(03:52):
secondhand smoke, and that'skind of sets us up for this
conversation and this study of.
Okay, if we're talking aboutkids and we're interested in
kiddos and their exposure tosecondhand smoke, you know what
kind of exposure are theygetting if the people smoking
inside are vaping versus smokingcigarettes?
Because there's all these youknow differences, mechanistic
(04:13):
differences, between thechemicals produced.
Dr. Adam Sadowski (04:17):
Right and and the reality is that the
prevalence well, I guess bothincidents and prevalence of
vaping is increasing, increasingespecially amongst our younger
population, and there is someinteresting background data
that's suggestive of the ofvaping being a quote-unquote
cleaner product, where there'sless, um you know, chemicals
(04:39):
that are that are being uhreleased through through the
vaping, and that has to do withits uh mechanism.
Uh, and, shockingly, here'ssomewhere where I am in favor,
where mechanism seems to matter.
Dr. Joshua Goldenberg (04:51):
Yeah, I couldn't believe.
I mean the introduction Ithought was quite interesting
because I didn't know any ofthis stuff.
So, first of all, that sidestream, mainstream, and then,
like you said, so 99% of thenicotine is retained when you
inhale from vaping versus Idon't know what it is for
cigarettes, but much less.
So essentially you just havevery efficient, I guess,
(05:12):
absorption with vaping, and soless is then breathed out to be
secondarily breathed in by bykiddos.
So again you have, like yousaid, all these different
mechanistic differences betweenthem.
And of course it's not just thenicotine.
We're not really that worriedabout nicotine per se.
We're more worried aboutcarcinogens and other toxicants
that are associated with withthat, and of course that also is
(05:34):
lower in vaping than in regularcigarette smoking.
Dr. Adam Sadowski (05:38):
Exactly.
And so what these authorswanted to do was look at um
nicotine absorption amongstchildren, who are being exposed
to secondhand smoke only, rightto secondhand vape use only, or
to those who are exposed toneither.
And that makes sense.
You don't want, you don't wantto expose, have one group be
(06:00):
exposed to both, because thenyou don't know if it's coming
from the tobacco use or if it'scoming from the, from the, you
know, e-cigarette use, so thatoff the back doesn't make any
sense.
And it also makes sense thatthis was a cross-sectional study
, because, one, they have datathat's regularly available and
then, two, you can't really likerandomize participants into a
(06:23):
smoking non-smoking or vapingnon-vaping group, because that
would be unethical, at least inthis country.
Dr. Joshua Goldenberg (06:29):
Yeah, here you go, little six-year-old
kid, why don't we randomize youto go sit in this house where
people are smoking all day?
No, can't do that.
Yeah, so, yeah.
So I agree.
Appropriate, appropriate studydesign.
Um, and it's from the NHANES uhstudy.
Do you want to?
Should we talk a little bitabout what that is, just so
people have a sense?
It's super famous continuouscohort.
Dr. Adam Sadowski (06:50):
Yeah, so it's a continuous cohort, but for
this particular study it's usingcross-sectional data, right?
So this is a cohort that'sconstantly being evaluated and
constantly being studied.
But what we're doing is we'resaying, hey, we're actually just
going to look at this specifictime point and try to come up
(07:10):
with an association or see ifthere is an association or not
between an exposure and anoutcome that we're interested in
.
So we're not like continuouslymonitoring them, we've kind of
like monitored them within aspecific, very specific period
and we're just kind of taking asnapshot of this ongoing cohort.
And so this is a US-basedcohort and it's nationally
(07:32):
representative.
They're taking data basicallyacross the country and
specifically in this cohort theyactually oversample minority
populations because they knowthat this way they'll get a
little bit more data withinthose participant groups,
because minorities are sooftentimes underrepresented in
(07:54):
medicine and in science, and sothis is one way of actually
getting a more true UnitedStates participation
representation.
And NHANES stands for theNational Health and Nutrition
Examination Survey, and whatthey used specifically in this
study was looking at childrenwithin this cohort.
(08:18):
But really, because if you're athree-year-old you're unlikely
to actually be able tounderstand what's going on they
used what they refer to as proxyparticipants.
Basically, they asked the legalguardian of the house, or
someone in the house who isconstantly around the children,
(08:39):
to provide the answers to thequestionnaires that were asked.
And so, within this cohort,basically, they're they're
constantly asking all sorts ofquestions what are you eating?
How much are you exercising?
What are you exposed to?
Do you do this, do you do that?
Um, and continuously askingthem on a I don't know if it's a
yearly basis or every two years, or how frequently they're
(08:59):
asking them, but, um, it's.
They're just constantly gettingyou know a data from, from,
from people.
Dr. Joshua Goldenberg (09:05):
Yeah, and it's a super high quality study
going on over many, many, many,many years.
And an additional benefit tothat besides, like you said,
oversampling minority groups andbeing a truly representative
national sample is that it alsogets objective data.
So, like they go in and getthese high quality, you know
(09:25):
survey results, but then they'llgo in their, their clinical
unit will go in and draw likelots of blood and in this case
there's a blood marker fornicotine exposure that they were
looking at.
So they're basically trying tosay, okay, let's get a sense of
all these kiddos, how many areexposed to smoke?
If so, what type vaping orcigarettes they threw out?
(09:45):
I think you said anyone thatwas exposed to both, because
it'd be too confusingmethodologically, and then
people who are not exposed toeither and then also looked at
biomarkers of that nicotineexposure, to say, okay, what
levels are we actually seeing inthe blood of these kiddos
Exactly?
Dr. Adam Sadowski (10:02):
The only issue with that was you know a
lot of the participants onlyafter answering the survey.
It wasn't like they answeredthe survey and then had blood
drawn the same day.
There was about a.
There was a gap in time and itwas kind of you know, it was
over a couple of days, so theywould, let's say, monday you
(10:25):
answer the question.
It was like, okay, come in onFriday.
And one of the biases that weneed to be aware of within this
is the fact that one you'realready asking a question that's
viewed as unhealthy, soparticipants may not want to be
as truthful in their answeringand then from there you're going
(10:49):
to be getting a blood sample acouple days after answering that
.
You know, potentially, um, it'snot a loaded question, but but
participants may feel likethey're being judged by
answering truthfully and so thatmay change their behavior at
the time that they're gettingthat objective marker.
So yeah you know they, they maybe falsely lowering the amount
(11:10):
that they're, that the levels ofnicotine in their blood if
they've decided to stop smokingor stop vaping.
And it's what's referred to asthe social desirability bias.
You're going to be answeringquestions based off of what
current social norms are andhaving a more socially desirable
answer.
You may feel ashamed orembarrassed of being like, yeah,
(11:31):
I smoke inside the house withchildren.
I know it's not good for them,but I do it type of thing, and
so that may stoke some emotionsin these participants who are
like, actually, you know what Ianswered that question, I'm
going to stop smoking, and thenthey just so happen to get those
labs that you know in a coupleof days.
So that's one thing that we dohave to be aware of.
Dr. Joshua Goldenbe (11:52):
Interesting in a couple of days.
So that's one thing that we dohave to be aware of.
Interesting, yeah, that's aneat, that's interesting.
I mean I thought I thought Iwas thinking about the first
part, but not the second part.
That's very interesting.
So not only could peopleuntruthfully answer the question
basically say, oh no, no, no,there's, there's no exposure to
the to smoke in this household.
So that would be one thingbecause the social desirability,
but the other is they mighteven change their behavior just
(12:14):
by being asked that Interesting,and then the blood marker a few
days later will be artificiallylowered.
That's very interesting, okay.
So if that's true, and thenwhat you would really have a
problem with because here we'retrying to compare vaping versus
no smoke exposure, versusregular cigarettes is if people
who are smoking cigarettes inthe house versus vaping in the
(12:37):
house, if they feel differentguilt or different judgments in
that way and maybe they do maybevaping is more socially
acceptable.
So the cigarette smokinghouseholds are more likely to
maybe answer less honestly andor change behavior.
Huh, that is interesting.
So not only is there apotential mechanism for that,
but you can make an argumentthat it would be differentially
(12:59):
affected, the different groups.
Yeah, really good point, man.
Yeah, really really good point.
I don't know how you get aroundthat.
I mean besides immediatelysampling right away for that
latter point.
But that just may not bepragmatic.
Dr. Adam Sadowski (13:11):
Yeah, I think it's just also, you know, this
is the one of the problems thatyou just have to accept.
Uh, when it comes toobservational studies,
especially cross, uh,cross-sectional studies, is you
just?
Hey, this is a reality, youknow, interpret with caution and
this is something that we justis unavoidable.
Yeah, and to clarify when, whenthey looked at participants in
the study, when, when they theyasked them, do you smoke inside
(13:32):
the house?
It wasn't like, hey, do you gooutside on the porch to smoke,
to go away from your children,or do you go into an unattached
garage or do you step outsideand close the door and then come
back in.
This was do you like smoke onthe couch with children in the
house, or like smoke in thekitchen?
(13:53):
Like very much like what wasnormal, I guess, in the 70s and
80s, um, and, and that's kind oflike what they were looking at,
because and that makes sensetoo, because if you think about,
like, comparing that to vaping,people aren't excusing
themselves to go outside to vapethey're just puffing like right
then and there, and so I thinkthat that that actually kind of
is a strength in how they're andhow they're questioning.
(14:16):
So, although it may notnecessarily be 100 pragmatic and
totally how, like what I'veseen most people do for those
who are smokers like most peoplewho I know that are smokers and
smoke at home do excusethemselves and go outside or or
only smoke in a basement orthat's unattached um, or will
smoke on the porch and then comeback inside.
(14:36):
So you are limiting thatexposure to a certain extent, um
, but in this, in this instance,they're they're doing like very
much old school, like hey, areyou smoking on the couch
actually in inside the house,without excusing yourself.
Dr. Joshua Goldenberg (14:50):
Yeah, really good points.
First of all, it's justshocking that even that level is
still a one fifth of kids areexposed to.
That is it's mind blowing.
But yeah, really excellentpoint, because that word we're
not asking people do you smokeor vape it's?
Are you doing that in the house?
And you're right, because folksthat they are maybe more likely
perhaps do that in the houseand so you're still comparing
like to like.
Yeah, really really good points.
(15:11):
I love all of that.
I think that's definitely astrength and also kind of
shocking and, to your point,still very, very relevant
unfortunately in our society,and I think it may even be worse
in a lot of other countries.
Look, the thing is we don't dothis for money.
This is pro bono and, quitehonestly, the mothership kind of
(15:38):
ekes it out every month or so,right?
So we do this because we careabout this, we think it's
important, we think thatintegrating, evidence-based
medicine and integrativemedicine is essential and there
just aren't other resources outthere.
The moment we find somethingthat does it better, we'll
probably drop it.
We're busy folks, but right nowthis is what's out there,
unfortunately.
That's it, and so we're goingto keep on fighting that good
fight and if you believe in that, if you believe in intellectual
honesty in the profession andintegrative medicine and being
(15:59):
an integrative provider andbringing that into the
integrative space, please helpus, and you can help us by
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If you're in need of continuingeducation credits, take our
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We have ethics courses,pharmacy courses, general
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Interact with us on socialmedia, listen to the podcast,
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(16:20):
These are all ways that you cansort of help support the cause.
Okay, cool, so I think we talkedabout that.
Covariates, I think, yeah goahead.
Dr. Adam Sadowski (16:31):
Another thing that was important, too, was
what'd you think of the responserates?
Dr. Joshua Goldenberg (16:35):
Yeah, that was kind of interesting
pretty darn low.
So we have response rates of63% for one to five year olds
and 59% for six to 11 year olds.
So I mean, you're like that'shorrific, right?
So normally when you do a riskof bias assessment for surveys,
(16:56):
for survey data, for prevalencedata which is essentially what
this is anything any responserate less than like 80% is
usually right away marked as ahigh risk of bias.
And so you're, you're missinglike 40% of respondents here,
and so, especially with such aloaded although they were
sitting it wasn't just this onequestion, right?
(17:17):
I'm assuming this is a responserate for the entire NHANES
questionnaire, and so you knowyou could make an argument.
Yeah, it's less strong of anargument as far as like oh, I
don't want to answer about thesmoking situation, because it's
just a general survey in generalthat they're being asked to
fill out.
Right, that was my read anyway.
Dr. Adam Sadowski (17:36):
Um, I don't.
I don't know one way or theother of that, but I also
thought it was interesting that,although those response rates
were low, the participationwithin the mobile um, like lab
draw sites, was high right so ofthose 63% and 59%, it was 92%
and 89% who got their labs drawn.
Dr. Joshua Goldenberg (17:56):
Yeah, so if you answered the survey, you
pretty much also got all thatclinical data.
But just very few people evensigned up to do that.
But it is nice that it's kindof it tracks together.
The people that were in wereall in, if you will.
Yeah, and I am concerned.
It's a good point.
It's a very, very low responserate and I think that, yeah, I
(18:17):
mean I don't know what you'resupposed to do about that.
Like this is extremelyrepresentative US sample,
extremely well conducted, and Ithink it's just hard to get
people to answer these likereally onerous surveys, and
especially when you're likeasking about kids, I guess.
So from a quality of studyperspective, like it's hard to
judge the scientists, right, butfrom a risk of bias perspective
(18:37):
, it's like how could you notview that as a high risk of bias
just off the bat, right?
Just the fact that we'remissing so much data.
Dr. Adam Sadowski (18:44):
Right, right.
And then the reason why theyuse children between three to 11
years is because they justdidn't have any sort of it looks
like they didn't have contininelabs for, like a reference
range for those who are betweenbirth and two years old.
Dr. Joshua Goldenberg (19:00):
Yeah, so that's what they use.
So this, that was a newsubstance to me.
What did you call it?
Continine?
Continine, yeah, uh, so that's.
It is a nicotine marker, butapparently a better choice for
secondhand smoke exposure, whichI found interesting.
I was not familiar with thatbiomarker before, but
specifically to kind of measurethe secondhand exposure.
And then another cool thingabout that is, um, if they saw
(19:23):
levels were so high that itcould could only be explained by
actually smoking like, let'ssay, a 10 year old was sneaking
out to get a cigarette theywould throw that data out, right
, so they could tell that it wasonly secondhand smoke, that
they were measuring there.
And then they would basicallysay we're you know, obviously
this would be confounded ifyou're actually smoking, so
we're going to throw thatinformation out.
Yeah, exactly, cool.
(19:44):
Okay, well, that I'm good withthat.
Should we jump into the results?
Anything else for methods youwant to chat about?
Dr. Adam Sadowski (19:49):
When they did their analyses they adjusted
for age, sex, ethnicity, income,body weight and height.
And yeah, let's jump into theresults.
So basically, 1,827 childrenwere surveyed and then they
ended up with an actual analysissample of 1,777.
And then dropouts were due toconstant exposure just being too
(20:11):
high to be actually realistic.
And then dropouts were due toconstant exposures just being
too high to be actually likerealistic.
And then some people wereexposed to both secondhand smoke
and secondhand vapor.
And then there were 12 children, which was just less than 1% of
those included in the study,had missing body weight or
height, and so they justexcluded them from that.
(20:33):
So of the 1,827 who wereincluded, just about 15% were
exposed to secondhand tobaccosmoke only, and then 2.5% to
secondhand e-cigarette only andthen the rest, so just a little
bit over 80% were exposed toneither tobacco or vaping use.
Dr. Joshua Goldenberg (20:57):
Yeah, interesting, yeah, so there you
go.
So 20% one in five kiddosexposed pretty insanely high
levels.
Okay, so let's jump into I wantto jump into the actual results
here, if that's okay.
Dr. Adam Sadowski (21:12):
Yeah, before we get into that, the mean age
was 7 1⁄2 plus or minus 2 1⁄2.
It was basically 50-50 betweenmale and female.
30% were below the federalpoverty line, which is a pretty
high amount, and then it waspretty evenly distributed
amongst Hispanic, non-hispanicBlack and non-Hispanic Whites,
(21:35):
and then 18% were reported asmultiracial.
And I think it was prettyinteresting to see, when we look
at table one, looking at thatdemographic table, the number of
participants or the proportionof participants who were exposed
to smoke only seem to be of ofa greater minority background.
(22:00):
Um, more were below the povertyline.
So when we look at those who areexposed to smoke only,
cigarette smoke only 46 percentwere yeah, oh, I see what you're
saying vapor versus smoke,gotcha, yeah, 46 percent were
below poverty, whereas those whowere exposed to vapor, only 16
(22:20):
percent were below poverty.
Um, so I thought that waspretty interesting.
Um, when we look at, uh, likethe, the race and ethnicity,
basically everything is doublerelative to those who are
exposed to to vapor only, and Ijust thought that you know that
it was interesting.
That that's kind of how it wasbroken down, but, um, in the
(22:40):
analyses they did adjust forthis, so right yeah, yeah, yeah,
yeah, no, interesting indeed.
Dr. Joshua Goldenberg (22:46):
And again , I feel, methodologically I'm
okay with it.
Um and so probably for the, youknow, let's just look at the
actual.
So the actual numbers probablyaren't going to mean much to you
, unless you're very used toseeing these um, these
particular biomarkers, but let'sjust kind of talk them through
so.
So the highest exposure werefor kiddos that were exposed to
(23:09):
secondhand smoke only, which was0.494 micrograms per liter.
Okay, so that's our, that's ouractual smoke.
So cigarette smoke, we're at0.494.
Dr. Adam Sadowski (23:20):
That's also the unadjusted.
When we look at the adjusted umit's, it is reduced a little
bit, but the point remains thesame.
Dr. Joshua Goldenberg (23:29):
Yeah, so okay.
So maybe we'll just talkrelative numbers then, because
maybe that makes more sense.
But essentially you have adramatic, dramatic difference
between only smoke versus onlyvapor, like 80% reduction, like
absolutely dramatic difference.
If you look in the, if you'refollowing with us in the paper,
we're in figure.
(23:50):
I think that's figure one.
It's just you just see thisvery, very dramatic drop from
only smoke to only vapor ofabout 80%.
Now that is a 90% drop if youcompare it to neither.
So people that are not exposedthey're still going to pick
stuff up in the environment, ormaybe this it's measurement
error or something like that.
So there's still a little bitin the blood.
And you obviously see adramatic difference between no
(24:14):
smoke or vapor exposure and onlysmoke.
But the difference betweenvapor and only smoke is, just to
me anyway, mind-blowinglydifferent.
However, the vapor itself,compared to no exposure, is also
statistically significantlydifferent.
So it's not like it's withoutrisk.
It's definitely better to nothave vapor exposure.
(24:34):
But when you're looking at,okay, should we expose the
kiddos to cigarette, smoke orvapor?
It is just.
It seems to me like this, justa no, it's a no brainer.
If you're replacing one for theother, right, obviously nothing
is better, but if you'rereplacing one for the other,
like 80% difference there.
Dr. Adam Sadowski (24:51):
Yeah, I think there's a real conversation to
be had that if you're someonewho is a current smoker and you
are smoking in the house and youhave children, I you know, I
don't think it's unreasonable tohave that conversation of you
know, is it healthier to switchfrom tobacco smoke to then
vaping, even if you're tradingone for the other and if you're
(25:11):
kind of looking for like what'sthe lesser evil?
It seems to be based on theliterature that that's out there
, that switching from fromsmoking cigarettes to
e-cigarette products may perhapsbe better, even if it may not
change sort of like thatnicotine addiction, because
you're being exposed to fewercarcinogens and not by, like,
(25:35):
just a little bit amount.
It seems to be a dramaticreduction, and then those around
you are also getting asignificantly reduced exposure
as well.
Dr. Joshua Goldenberg (25:44):
Yeah, I mean this.
This kind of is in line withthe overall theme, I would say,
of like all the smoking andvaping papers we've done, which
is, when you compare it tocigarette smoke, it is seems to
be a better choice.
But obviously if on the tableis not smoking or not vaping,
that is better.
However, if that is not on thetable, it seems to me anyway
(26:06):
like a pretty clear choice.
And actually this dramaticdifference really underscores
the benefits, right, becausethis is looking just at the
nicotine exposure and using thatas a proxy for the really
harmful toxicants that we'reactually worried about.
Again, we're less worried aboutnicotine exposure per se, it's
more everything else that comeswith it.
(26:28):
So they're using that as aproxy for exposure for
everything else in the smoke orin the in the vapor.
However, to your point, vaporitself has less of those
chemicals, right?
So it's even going to be lessharmful exposure than what it
seems like on this graph.
So we're probably going to haveeven more than an 80%
difference in exposure there.
(26:49):
So, again, we know secondhandexposure is dangerous, but just
a dramatic difference.
And if you're not willing tostep outside or to a detached
garage or something like this,then switching to vapor just
would have a dramatic impact onthe exposure to those kiddos.
Dr. Adam Sadowski (27:06):
Yeah, no, I thought, I thought, I know, I
thought it was an interestingstudy.
Dr. Joshua Goldenberg (27:09):
Yeah, you know, I really I have this bias
of this.
You know, you know the phraselike don't make the perfect the
enemy of the good, like I reallybelieve in that pretty strongly
.
And I hear the argument thatsome people make that with
addiction it's you need to beall in or all out, right, I've
heard that argument before andcertainly that was true for me
with cigarettes.
But I think I don't know ifyou're not going to quit.
(27:31):
You know it feels weird saying,okay, it's okay to vape, but
actually maybe it is rightCompared to the alternative, and
we don't want to make theperfect the enemy of the good.
And if just like beratingpeople to just be like, well, go
outside, why aren't you goingoutside?
Or just quit, why aren't youquitting?
I don't know that that works,but maybe it does.
But if that's not working, thenat least getting them to switch
(27:52):
to vaping can have a dramaticimpact at least on the kids and
I'm sure on them as well.
Dr. Adam Sadowski (27:58):
Yeah, yeah.
No, I thought it was aninteresting paper.
It's open access, free foranyone to go look at, you don't
need a paywall.
And it was not funded by anysort of industry.
It was all through grantfunding, so this is publicly
funded paper.
Dr. Joshua Goldenberg (28:12):
Very nice , very nice.
I will send Michelle the linkand thanks.
Sort of a short and sweet papertoday, very straightforward,
good paper, besides thatresponse rate, which I think you
were very wise to point out,and I think that's all I got for
you guys today.
Very wise to point out, and Ithink that's all I got for you
guys today.
How about you, adam, anythingelse you wanted?
Dr. Adam Sadowski (28:27):
to end on Nope, that's it.
If anyone wants more of avisual or a deeper dive, I do
expect to see this one on the DrJournal Club website.
There will be graphs and alittle bit more attention to
data visualization there, ifyou're interested.
Dr. Joshua Goldenberg (28:41):
Beautiful .
All right, thank you, Adam, andI will see you next week.
If you enjoy this podcast,chances are that one of your
colleagues and friends probablywould as well.
Please do us a favor and letthem know about the podcast and,
if you have a little bit ofextra time, even just a few
seconds, if you could rate usand review us on Apple Podcast
or any other distributor, itwould be greatly appreciated.
(29:03):
It would mean a lot to us andhelp get the word out to other
people that would really enjoyour content.
Thank you.
Hey hey .
y'all.
This is Josh.
You know we talked about somereally interesting stuff today.
I think one of the things we'regoing to do that's relevant.
There is a course we have on DrJournal Club called the EBM
Boot Camp.
That's really meant forclinicians to sort of help them
understand how to criticallyevaluate the literature, etc.
(29:24):
Etc.
Some of the things that we'vebeen talking about today.
.
Go ahead and check out the shownotes link.
We're going to link to itdirectly.
I think it might be of interest.
Don't forget towwwdrjournalclub.
com follow us on social andinteract with us on social media
at DrJournalClub DrJournalClubon Twitter.
We're on Facebook, we're onLinkedIn, etc.
Etc.
So please reach out to us.
We always love to talk to ourfans and our listeners.
(29:46):
If you have any specificquestions you like to ask us
about research evidence, being aclinician, etc.
Don't hesitate to ask.
And then, of course, if youhave any topics that you'd like
us to cover on the pod, pleaselet us know as well thank you
for listening to the doctorjournal club podcast, the show
that goes under the hood ofevidence-based integrative
(30:09):
medicine.
Introducer (30:10):
We review recent research articles, interview
evidence-based medicine thoughtleaders and discuss the
challenges and opportunities ofintegrating evidence-based and
integrative medicine.
Be sure to visitwwwdoctorjournalclubcom to learn
more.
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