Should E-Cigarette Use Be A Co-morbidity in Workers’ Comp?

| | Evidence Based Medicine

Dr Cortes E Cigaretts Article June 2017
While cigarette smoking has decreased substantially over the past several decades, particularly in the youth and young adults, the use of electronic cigarettes (or e-cigarettes) has exploded. For example, the 2016 Surgeon General E-Cigarette Report shows that e-cigarette use has grown 900 percent among high school students from 2011 to 2015. These products are now the most commonly used form of tobacco among youth in the U.S.

Smoking cigarettes has been well accepted to be a risk factor and co-morbidity for developing numerous pulmonary conditions. The American Lung Association lists lung cancer, chronic obstructive pulmonary disease (COPD), heart disease, stroke, premature births and low birth weight babies, diabetes, cataracts and other cancers among the 10 worst diseases caused by smoking cigarettes. Tobacco smoke has been found to be loaded with numerous chemicals, of which nicotine is only one key element. This is why smoking is listed as a co-morbidity in workers’ comp.

Although e-cigarettes do not utilize tobacco, they have variable amounts of nicotine and other known and unknown chemicals. The most common type of e-cigarette is a battery powered heating element that atomizes a liquid mixture of propylene glycol, glycerin, nicotine and various flavorings. Studies have shown a lack of consistency in the amount of nicotine in e-cigarettes. The studies also suggest that experienced users learn how to manipulate their devices to deliver nicotine in higher concentrations. One of the more disturbing chemicals is formaldehyde, which is not only a carcinogen but also a risk factor for developing asthma and COPD when inhaled. There is still much to learn about the health risks associated with all of the chemicals commonly found in the liquid nicotine solution.

From my perspective as an orthopedic surgeon, both cigarette smoking and e-cigarette use are detrimental to wound healing, primarily due to nicotine. This is because nicotine is a vasoconstrictor that reduces blood flow to soft tissues, including muscle, tendon and skin. This affects the healing capacity after injury and surgical treatments. Slower and incomplete healing has been observed clinically in smokers with wounds resulting from trauma, disease, or surgery. This results in a higher incidence of failure after surgical treatments and the need for costly revision surgeries or salvage procedures.

While smoking has long been recognized as a co-morbidity in workers’ comp, thus far the use of e-cigarettes has not. So in answering the question of whether the use of e-cigarettes should be obtained in the medical history of an occupational patient, as traditional tobacco use is, I tend to think that it should. This strikes me as particularly appropriate when a patient is claiming an industrial injury.

The American Lung Association supports prohibiting the use of e‐cigarettes in worksites, including e-cigarettes with tobacco products under smokefree laws. Currently, nine states and the District of Columbia have prohibited e-cigarette use in the same places where smoking is already prohibited. If I had to guess, I would say that by the end of this decade e-cigarette use will be considered a co-morbidity in workers’ comp.  Looking at all of the evidence surrounding e-cigarette use, I tend to think this is a good idea.

Zenia Cortes, MD, Orthopedic Surgeon

Dr. Zenia Cortes brings her combined expertise in sports and orthopaedic medicine to UniMed Direct, along with insights from her experience in peer and utilization review.