Ask the Flight Surgeon / By MAJ Jacob Mathew, Jr., DO, FACOI: Q: I’m a 24-year-old crew chief, who took up smoking during a deployment and now I want to quit. I have seen soldiers in my unit “vaping” and I was wondering if it is an effective method to quit smoking. Are there any risks to e-cigarettes? Will this affect my flight status?
FS: Tobacco smoking is the single largest preventable cause of many chronic diseases and deaths, claiming the lives of more than 5 million people worldwide each year. In 2014, the U.S. Surgeon General released a report stating that cigarettes and combustible tobacco products “overwhelmingly” cause loss of life. Quitting at any age is beneficial to the individual, but most people struggle to achieve long-term smoking cessation. Relapse is common due to the highly addictive main ingredient, nicotine. Many researchers believe that the ignition of the cigarette (combustion) may be the source of much of its toxicity. Theoretically then, if we can eliminate the combustion we will have a product that may be less harmful than cigarettes, cigars and pipe tobacco, while still satisfying the nicotine cravings.
Enter the electronic cigarette (e-cigarette); a battery-operated nicotine delivery device without the typical cigarette combustion. With the introduction of e-cigarettes in 2004, there has been an unprecedented shift from cigarettes to electronic cigarettes, especially as they continue to be marketed as a smoking cessation tool.
Due to its marketing, public perception is that e-cigarettes are safer than traditional tobacco. Their actual “safety” profile remains to be seen, however, and a growing body of research suggests that vaping may not be as safe as previously advertised. The U.S. Surgeon General has warned the public that e-cigarettes expose users to multiple dangerous compounds other than nicotine to include formaldehyde (the chemical used to preserve tissue samples in the lab), lead, the main ingredients in anti-freeze, and known cancer-causing agents. These compounds can not only lead to cancer, but irreversible lung damage, and exposure of bystanders to possible harm. Furthermore, e-cigarettes can often administer doses of nicotine that are considerably higher than traditional tobacco products. This not only poses a risk to your health (and a possible derailment of your quitting strategy), but can be a flight safety concern.
The Federal Drug Administration (FDA) has not formally approved any e-cigarette as an effective method for smoking cessation and their current nicotine levels remain unregulated. There are, however, more heavily studied nicotine replacement therapies (NRT) on the market that are FDA approved. These include: varenicline, nicotine patches, gum, lozenges, and Wellbutrin. Varenicline, or Chantix®, is one of the most popular choices we see in the aviation clinic. Patients should be grounded during the duration of treatment as well as for one week after completing therapy.
Another option is a combination of short and long acting therapies. This can be done with a combination of nicotine gum or lozenges with a nicotine patch. This option is popular during deployments as they are more readily available. However, be aware that with hot weather, increased sweating may make the patch difficult to use. Upon initiating treatment with the patch specifically, no flying activities can be performed for 48 hours (after first patch). If no adverse symptoms are reported, flying duties can be resumed after flight surgeon evaluation. When using the gum, if no adverse reactions are noted, then no grounding is required. Duration of treatment for the patch and gum is advised not to exceed 3 months while concurrently performing flight duties. Wellbutrin, though less effective in studies compared to Chantix, is still a viable option if other options are not effective. It may also help to limit the amount of post nicotine cessation weight gain that patients can experience as well as treat any concurrent depression that may be present. Similar to Chantix, grounding is required while on the medication but also for 2 weeks after completing treatment.
There are established aeromedical policy letters dedicated specifically to these cessation options. Contact your local aeromedical provider for more details. Always remember to make your command team aware of plans that may ground you to limit the effects on the mission profile. No formal aeromedical policy letter (APL) exists regarding the use of e-cigarettes and flying. As a result, a discussion between the crew member and your aeromedical provider is recommended to include potential risks of using them. The use of e-cigarettes in or around the aircraft is strictly prohibited.
Although e-cigarettes have been touted as an effective and safe method for smoking cessation, further research is required to fully understand the risks they pose to the user. They should not be considered healthy, and patients should understand the risks posed by their use. Patients are strongly encouraged to quit using tobacco products and should reach out to their provider regarding the flight approved options and how those options may affect their flight duties.
Stay safe! Dr. Mathew
MAJ (Dr.) Jacob Mathew is a flight surgeon at the U.S. Army School of Aviation Medicine, Fort Rucker, AL.