16:14 PM

493 - E-Cigs for Smoking Cessation?, Sunscreen 2023, A Healing Poem

Take 3 – Practical Practice Pointers©

From the Cochrane Collaboration

1)  Should Electronic Cigarettes be Used for Smoking Cessation?


It is important to frame this question the right way. We know that substantial risk from cigarette smoking comes from the constituents in cigarettes other than nicotine (tar, pesticides, etc.). However, nicotine itself is not benign and does contribute to some level of cardiovascular risk, addiction, impaired cognitive development in children, etc.

Electronic cigarettes are not just nicotine replacement. They have chemical flavorings of uncertain toxicity, and the doses of nicotine are relatively unregulated and often higher than those found in cigarettes, potentially leading to greater nicotine addiction. There is some fluidity of use between electronic cigarettes (e-cigs) and traditional cigarettes, and the potential for more severe addiction due to greater nicotine levels in e-cigs can cause users to seek out greater levels of traditional tobacco (more packs per day, hookah, etc.) when they switch back.

However, e-cigs are being studied for smoking cessation, and a Cochrane review has an update to a “living systematic review” on this question. The authors searched for controlled or crossover trials of e-cigs vs. a control condition or single cohort studies of just e-cigs. The included studies had to have abstinence for greater than six months with biochemical validation and/or safety data beyond 1 week as an outcome. Secondary outcomes looked at persistence of use of e-cigs or other therapies, and a set of clinical measures (carbon monoxide levels, blood pressure, etc.). Seventy-eight studies were included (N = 22,052 adults, 40 randomized controlled trials (RCTs)). Only ten were of low risk of bias.

The review found high-certainty evidence from six studies that e-cigs achieved greater quit rates than nicotine replacement therapy (NRT, RR 1.63, 95% CI 1.30 to 2.04, number needed to treat (NNT) for cessation at 6-12 months ~ 25). Moderate certainty evidence revealed no difference in adverse events (AEs, mostly throat/mouth irritation,

headache, cough, and nausea). Serious adverse events (SAEs) were too rare to analyze confidently, but there were no differences seen. Five studies showed that nicotine-containing e-cigs worked better than non-nicotine e-cigs (RR 1.94, 95% CI 1.21 to 3.13, NNT ~ 14). Once again, there was no difference in AEs, and too few SAEs to draw conclusions. Very low certainty evidence showed that nicotine-containing e-cigs worked better than either behavioral support or no treatment (RR 2.66, 95% CI 1.52 to 4.65, NNT ~ 50) with a small increase in AEs. There was, again, insufficient evidence on SAEs. The secondary outcome data was either supportive of the primary outcomes or was insufficient.

John’s Comments:

There is still much unanswered and worrisome about these unregulated products, but the authors note that the principle of “harm reduction” is most applicable in this case – e-cigs may not be good for you, but they’re probably better than cigarettes. The National Academy of Medicine’s last position in 2018 (covered in Take 3 #388) is similar. At that time, I concluded that behavioral approaches were still preferred for children/teens. For adults, this evidence suggests that a harm reduction approach is reasonable. Educating our patients about the potential for long-term toxicity and addiction to higher nicotine doses (and possibly returning to higher tobacco smoking rates) is important.


·       Hartmann-Boyce J, Lindson N, Butler AR, et al. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews. 2022;(11). Link


From Consumer Reports, the AAD, and in Preparation for Summer

2)  Sunscreen 2023:  Let the Wearer Beware


According to the American Academy of Dermatology (AAD), it is estimated that one in five Americans will develop skin cancer in their lifetime.  Sun protection is the most effective way to prevent skin cancer.  For sunscreen, the sun protection factor (SPF) is a relative measure of how long a sunscreen will protect from UVB rays, which are the chief cause of sunburn and a contributor to skin cancer.  Usually the number is explained as the amount of time it takes an individual’s skin to burn when it’s covered in sunscreen compared with when it’s not. For example, assuming you apply—and reapply—the sunscreen correctly (recommended every 2 hours), if you’d normally burn after 20 minutes it would take 10 hours with the application of SPF 30 sunscreen.

SPF calculations do not apply to UVA rays, which can tan and age skin and cause skin cancer. That’s why it is necessary to use a broad-spectrum sunscreen that provides protection against both types of UV rays.  However, no sunscreen blocks 100 percent of UVA or UVB rays. The breakdown: SPF 30 blocks 97 percent of UVB rays, SPF 50 blocks 98 percent, and SPF 100 blocks 99 percent.  The AAD recommends everyone use water resistant sunscreen that offers broad-spectrum protection against UVA and UVB rays at a SPF 30 or higher.

It is also important to note that sun protection may be required indoors if much time is spent sitting near a sunny window. Glass blocks UVB rays, but it can let through some  UVA rays.  Automobile windshields do a good job for both UVA and UVB light (particularly newer models), but automobile side windows don’t provide as effective protection for UVA light. 

The Consumer Reports company has recently published its 2023 sunscreen ratings.  In the past few years, the company has consistently noted that many tested products perform at less than half their labeled SPF number and many are inconsistent in their protection across product batches and various products from the same company.  They’ve also found that cost and brand name do not necessarily correlate with quality.  Since the AAD recommends using a product with an SPF of 30 or higher, this means that many cases, users are not adequately protected, even with listed SPF ratings of 50.  This also means that most products with an SPF rating of 30 are not sufficient.   

Additionally, testing has consistently found that so-called natural or mineral sunscreens (those that contain only titanium dioxide, zinc oxide, or both as active ingredients) have tended to perform less well.  This does not include products labeled sunblock, such as higher concentration zinc oxide products (think white noses on lifeguards).

According to the FDA, there are no chemical sunscreens that are generally regarded as safe and effective (GRASE) because additional data needed.  Note, this does not mean they are unsafe (comparable to an “I” recommendation from the USPSTF).

The Top Rated/Recommended Sunscreens per Consumer Reports for 2023:

·       Lotion:    - La Roche-Posay Anthelios Melt-In Milk Lotion SPF 60 (quite expensive)

                - Equate (Walmart) Ultra Lotion SPF 50 (best value)

                     - Kiehl’s Activated Sun Proector Lotion SPF 30 (quite expensive)

                     - Equate (Walmart) Sport Lotion SPF 50 (affordable)

·       Spray:     - Trader Joe’s SPF Spray 50+ (highest rated of any product)

- Sun Bum Spray SPF 50

- Australian Gold Ultimate Hydration Continuous Spray SPF 30

- Equate (Walmart) Sport Spray SFP 50 (best spray value)

- Up and Up (Target) Sport Spray SPF 50

- Banana Boat Sport Ultra Spray SPF 100

Some additional tips regarding sunscreen from Consumer Reports include:

·       Check the expiration date (formulated to remain effective for 3 years)

·       Shake the product well before applying

·       Apply generously at least 15 minutes before going into the sunlight or water

·       Don’t forget commonly missed spots, including lips, backs of hands, tops of feet, back of the neck, scalp, and ears.

·       Reapply every 2 hours and immediately after swimming or sweating

·       Use spray screens appropriately by holding the nozzle 4 to 6 inches away from the  skin, spraying until the skin glistens, then rubbing it in, even if it is labeled “no rub.”

Mark’s Comments: 

What makes the Consumer Reports evaluation compelling is that the same process was used on all products under the same conditions (less potential bias than a company testing their own product).  They also buy the product off the shelf.  The Equate products have been consistent best values for multiple years now, as has the Trader Joe’s as the highest rated product.  And don’t forget to wear a sun protection hat.  Baseball caps may be fashionable but they’re really not particularly effective for comprehensive protection from the neck up.


·       Consumer Reports Sunscreen Ratings:  April 2023 (by subscription): Link

·       American Academy of Dermatology Sunscreen FAQs:  Link

From PeerARTx ( www.PeerRxMed.org )

3)  The Healing Power of a Poem


“Poetry is a life-cherishing force …. For poems are not words, after all, but fires for the cold, ropes let down to the lost, and something as necessary as bread in the pockets of the hungry.”   Mary Oliver, poet:  A Poetry Handbook

One of the places where I, paradoxically, feel most grounded, interconnected, and “at home” is when I am standup paddleboarding, even (or perhaps especially) when I am paddling alone.  That time on the water surrounded by the sights, sounds, scents and rhythms of the natural world awakens and enlivens my spirit and speaks to my soul. 

While paddling, I have become quite enamored by the semi-annual migration ritual of Canadian geese.  There is something quite mystical about having geese flying over me in formation while on the water, and as I muse from where they come and to where they are going, I am left wondering the same about myself.  Such has been the case for me recently during their annual spring migration. 

Another “place” that can powerfully ground, connect, and awaken me is when I immerse myself in a poem that speaks to something deep inside.   When that occurs, poems can become a form of “healing art” – medicine for my soul.      

These two aspects merge for me in the poem “Wild Geese” by the poet Mary Oliver, which is shared below.   As you read it, consider the following questions:

·       What are some words, phrases, or images that speak to you and “where” do they speak to you?

·       Are there any emotions that bubble up for you?  If so, give them a name.  Any memories?

·       What are some places that feel like “home” to you?

Wild Geese

You do not have to be good.
You do not have to walk on your knees
for a hundred miles through the desert, repenting.
You only have to let the soft animal of your body
love what it loves.
Tell me about your despair, yours, and I will tell you mine.
Meanwhile the world goes on.
Meanwhile the sun and the clear pebbles of the rain
are moving across the landscapes,
over the prairies and the deep trees,
the mountains and the rivers.
Meanwhile the wild geese, high in the clean blue air,
are heading home again.
Whoever you are, no matter how lonely,
the world offers itself to your imagination,
calls to you like the wild geese, harsh and exciting --
over and over announcing your place
in the family of things.

This week, consider a poem that has spoken to you over the years, and share it as well as what it has meant to you with your PeerRxMed partner.  Afterall, tapping into some “life-cherishing force” is something we could all use more of and sharing that force becomes a double bonus!


Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org