Page 8 Complete Your CE Test Online - Click Here Electronic nicotine delivery devices are often marketed as a safer alternative to cigarettes, or as a way to cut down or quit smoking. Proponents and distributors like to point out that the main ingredients are “generally recognized as safe” by the FDA. However, most health care workers know that the FDA’s “safe” list refers to food ingredients, not components to be inhaled, which is quite different. Oils, for example, are safe to eat, but not generally safe to inhale. In addition, manufacturers do not usually list all of the ingredients in the liquids, which vary greatly by maker and flavor. Finally, while the companies typically list the amount of nicotine the product is supposed to deliver, surveys have found that this labeled amount is not always accurate: some labeled no nicotine contained fairly large amounts, and others had much less than labeled. The refill liquids are made in a number of countries, including the U.S. and China as well as European countries [303]. There are serious concerns that the flavors in the liquids – more than 7,000 have been catalogued, ranging from bacon to peanut butter chocolate – are attractive to teens, making the products a potential gateway to traditional tobacco products. There are data that suggest this is occurring. A 2013 study from the U.S. Centers for Disease Control and Prevention (CDC) found that youths who have used e-cigarettes are twice as likely to say that they might or would probably smoke conventional cigarettes than those who have never used e-cigarettes [67]. There is also a wide degree of quality in the manufacture of electronic vapor devices, a majority of which are made in China. Many Chinese manufacturing companies are not as closely regulated as their counterparts in the U.S., and brands are sometimes counterfeited [47]. There are anecdotal reports of people who have used the devices to quit smoking. However, there are much purer forms of nicotine in carefully controlled doses and safer delivery systems that can be used by people who want to quit smoking. There is even an inhalable form of nicotine available by prescription for those who want to quit smoking safely. Given all this, and the fact that they have only been around a few years, research on anything beyond short-term effects is still pending. This will be the case until these products have been in use long enough for longitudinal studies. Again, as it is known that nicotine is addictive, these are another route for people to become chronic users of nicotine. Helping your patient quit People who use tobacco should be urged to quit; even those who already have cancer can benefit from quitting. There are many forms of nicotine replacement and other drugs that have been proven to help with the physical part of quitting tobacco [194]. Individual or group counseling, telephone “quitlines” like the CDC’s 1-800-QUIT-NOW, and groups such as Nicotine Anonymous (NicA) are some of the methods that can be used to help with the emotional and mental components of quitting. There is even an online group dedicated to quitting smokeless, at http:// Many of these methods are cost-free or partly covered by insurance. Nursing consideration: Offer your patients specific resources to quit smoking before cancer treatment starts. Advise patients that evidence shows a higher risk of complications and recurrence in people who continue to smoke during cancer treatment [194]. Alcohol Drinking alcohol can increase the risk of cancer of the mouth, throat, esophagus, larynx (voice box), liver, and breast. This fact is rarely mentioned in media reports on carcinogens, and many people seem unaware of it. The more a person drinks, the higher their cancer risk. The risk of cancer is much higher for those who drink alcohol and also use tobacco [138]. The International Agency for Research on Cancer (IARC) classifies the ethanol in alcoholic beverages as a ‘Group 1 Carcinogen’, meaning that it is known to be carcinogenic to humans. The IARC further notes that acetaldehyde, which is produced in the body after consuming alcohol, is known to be carcinogenic as well [106]. The U.S. National Toxicology Program also lists alcoholic beverages as known carcinogens, although acetaldehyde is still on its list of “reasonably anticipated to be human carcinogens [228].” The American Cancer Society recommends that people who drink should do so in moderate amounts. Their intake maximums agree with the U.S. Federal government’s Dietary Guidelines for Americans, which defines moderate alcohol drinking as up to one drink per day for women and up to two drinks per day for men [10,138]. They further define a standard drink as 12 ounces of beer, five ounces of wine, or 1.5 ounces of 80-proof liquor. All of these serving sizes contain about 0.6 of an ounce of pure ethanol [10]. Researchers have identified multiple ways that alcohol may increase the risk of cancer, including: ● ● Metabolizing ethanol acetaldehyde, which is a toxic chemical; acetaldehyde can damage both DNA and proteins. ● ● Generating reactive oxygen species (chemically reactive molecules that contain oxygen), which can damage DNA, proteins, and lipids through a process called oxidation. ● ● Impairing the body’s ability to break down and absorb a variety of nutrients that may be associated with cancer risk, including: vitamin A; nutrients in the vitamin B complex, such as folate; vitamin C; vitamin D; vitamin E; and carotenoids. ● ● Increasing blood levels of estrogen, a sex hormone linked to the risk of breast cancer. Some alcoholic beverages may also contain a variety of carcinogenic contaminants that are introduced during fermentation and production, such as nitrosamines, asbestos fibers, phenols, and hydrocarbons [139]. It has been suggested that certain substances in red wine, such as resveratrol, have anticancer properties. However, there is no evidence that drinking red wine reduces the risk of cancer [138]. What happens to cancer risk after a person ceases drinking alcohol? Most of the studies that have examined whether cancer risk declines after a person ceases drinking alcohol have focused on head and neck cancers and on esophageal cancer. In general, these studies have found that stopping alcohol consumption is not associated with immediate reductions in cancer risk; instead, it may take years for the risks of cancer to return to those of never-drinkers [139]. For example, a pooled analysis of 13 case-control studies of cancer of the oral cavity and pharynx combined found that alcohol-associated cancer risk did not begin to decrease until at least ten years after stopping alcohol drinking. Even 16 years after they stopped drinking alcohol, the risk of cancer was still higher for ex-drinkers than for never drinkers [248]. In several studies, the risk of esophageal cancer was also found to decrease slowly with increasing time since alcohol drinking cessation. A pooled analysis of five case–control studies found that the risk of esophageal cancer did not approach that of never drinkers for at least 15 years after alcohol drinking cessation [248]. Drugs Exogenous hormones Estrogens, a group of female sex hormones, are known human carcinogens. Although these hormones have essential physiological roles in both females and males, they have also been associated with an increased risk of certain cancers. For instance, taking combined hormone therapy to reduce menopause symptoms (estrogen plus progestin, a synthetic version of the female hormone progesterone) can increase a woman’s risk of breast cancer. Menopausal hormone therapy with estrogen alone increases the risk of endometrial cancer and is used only in women who have had a hysterectomy [169]. A woman who is thinking about menopausal hormone therapy should understand the possible risks and benefits before she starts taking it [169]. After the cancer connection was identified, doctors began to prescribe it only for bothersome menopausal symptoms in low doses and for the shortest possible lengths of time. Studies have also shown that a woman’s risk of breast cancer is related to the estrogen and progesterone made by her ovaries (endogenous estrogen and progesterone). Being exposed for a long time and/or to high levels of these hormones has been linked to an increased risk of breast cancer. Increases in exposure can be caused by early menarche, late menopause, being older at first pregnancy, and never having given birth. Conversely, having given birth is a protective factor for breast cancer [169]. On the other hand, the risk of ovarian cancer decreases with longer years of having taken oral contraceptives [182].