Wednesday, 30 November 2016 22:24

By Dr Farsalinos

I feel sorry but I have to admit that today was one of the rare instances where I could not believe my eyes reading a “study” published in the journal of the American Society of Plastic Surgeons (Plastic and Reconstructive Surgery). To make matters worse, the “study” was accompanied by a press statement. I must say, this is the first time I am witnessing a respected journal literally risking their reputation (or, I could say, getting ridiculed) in their effort to get some publicity for a ”hot topic” such as e-cigarettes. Not only is this paper a sad attempt to “criminalize” e-cigarettes based on NOTHING, it is also one of the most irrelevant and worst-written papers you will ever find.

To start, the paper and the press statement reached to the conclusion that: “Patients should stop using e-cigarettes before plastic surgery”. I precisely counted the number of studies cited that e-cigarettes have adverse effects in humans postoperatively, after plastic surgery or any kind of surgical procedure. I managed to find exactly ZERO studies addressing this issue.

But this is the least of the problems. The paper is a meaningless review of laboratory studies on nicotine, in many cases irrelevant to plastic surgery, with a total confusion between nicotine and smoking. For example, there is a section titled: “MECHANISM OF ACTION OF NICOTINE”. At the end of the 3rd paragraph of this section they mention: “In humans, the ameliorating effects of cessation are supported by Level I evidence suggesting that the optimal duration of preoperative cessation is 4 weeks or longer.27”. In case you missed it, they do not refer to cessation of nicotine but to cessation of smoking! Further on, it gets even worse. In the same section, I quote: “Numerous complications following surgery have been related to nicotine.54 The cause is thought to be the presence of reactive oxygen species in cigarette smoke” (my emphasis). Does this make sense to anyone? In case you don’t believe that a respected journal could ever allow such statements pass the peer-review process, get published and be accompanied by a press statement, please go to page 1063e of the pdf file to read it yourself.

Unfortunately, this is not the end. In the above-mentioned quote about the effects of nicotine on surgical complications, they cite a study with reference number 54. Reference 54 is the study: “Farsalinos KE, Romagna G, Tsiapras D, Kyrzopoulos S, Voudris V. Evaluation of electronic cigarette use (vaping) topography and estimation of liquid consumption: Implications for research protocol standards definition and for public health authorities’ regulation. Int J Environ Res Public Health 2013;10:2500–2514”. I can reassure you, neither this nor any other of my studies present complications following surgery that are related to nicotine (or e-cigarettes).

Another amazing statement is: “A meta-analysis of 177 articles that addressed smoking and wound healing was performed.55 … These effects are likely related to the combination of nicotine and any additional harmful products in cigarette smoke”. This is unbelievable for 2 reasons. First, reference 55 is: “Kosmider L, Sobczak A, Fik M, et al. Carbonyl compounds in electronic cigarette vapors: Effects of nicotine solvent and battery output voltage. Nicotine Tob Res. 2014;16:1319–1326”. Again, a completely wrong reference (this is happening many times throughout the text). Second, the last sentence about the contribution of nicotine is an arbitrary and unsubstantiated conclusion of the authors. They provide no reference. On the contrary, in a review about smoking and plastic surgery, the authors (not the same as this paper) mentioned some very interesting things about nicotine: “Few studies have reported on the effects of NRTs with regard to wound healing. Experimental studies on animals have employed nicotine doses markedly higher than those caused by in vivo NRTs in humans. A study on humans carried out in 1998 by Fulcher et al. [85] did not detect any negative effect of NRTs on peripheral microcirculation. Moreover, Sorensen et al. did not bring to light any negative effects of transdermal patches on infection rates or wound healing [46,54]”. Another metanalysis on smoking cessation and postoperative complications found that quitting smoking with NRT was associated with fewer complications compared to continuous smoking. The authors mentioned that: “There is no suggestion that NRT has any adverse effect on wound healing”. I want to thank Amelia Ruby Howard for the tip on these 2 studies.

In fact, in a response to a letter about the detrimental effects on e-cigarettes on surgical patients, published in BMJ in 2014, I clearly presented that the authors of the letter confused nicotine with smoke: “Some of the studies they cite make it clear that nicotine has minimal, if any, adverse effects on wound healing compared with those of smoking.2,3 One study noted raised tissue oxygen tension after nicotine infusion, in contrast to the reduction seen after smoking.2 Another study by the same group found that smoking cessation improved wound healing irrespective of whether a nicotine or placebo patch was used as a smoking cessation aid.3”.

It is sad to see a well-respected journal with 50 years of history jeopardizing their reputation and discrediting themselves in an attempt to create media headlines. I also feel sorry for journalists, who have once again fallen to the trap of irresponsible communication of “evidence” (in this case there is no evidence at all for the conclusion mentioned in the press release). I doubt if any serious journalist would ever reproduce this knowing the content of the paper and the basis for the recommendation.