From the Editor

How to help him quit?

We often speak to our patients about the dangers of smoking – with middling success, especially with those who aren’t interested in cessation. Are e-cigarettes part of the solution? In a new JAMA Network Open paper, Karin A. Kasza (of the Roswell Park Comprehensive Cancer Center) and her co-authors report on a cohort study focused on this refractory population. “In this US nationally representative cohort study of 1600 adult daily cigarette smokers who did not initially use e-cigarettes and had no plans to ever quit smoking, subsequent daily e-cigarette use was significantly associated with an 8-fold greater odds of cigarette discontinuation compared with no e-cigarette use.”

In the second selection, we consider a new Canadian Journal of Psychiatry research letter. Dr. Martin Rotenberg (of the University of Toronto) and his co-authors look at green space and schizophrenia. A connection? They find one. “We found that residing in an area with the lowest amount of green space was associated with an increased risk of developing schizophrenia, independent of other sociodemographic and socioenvironmental factors.”

Finally, in the third selection, Dr. Jessica Gregg (of the Oregon Health and Science University) writes about her experiences as a physician and as a patient. In this New England of Journal paper, she talks personally about sudden illness and unsatisfactory health care. “I knew – and know – that our system of not-care for the sick and scared is broken. I knew – and know – that our system of un-care for people affected by addiction or poverty, for those who make bad choices and those who were never offered fair choices in the first place, is even more fractured.”


Selection 1: “Association of e-Cigarette Use With Discontinuation of Cigarette Smoking Among Adult Smokers Who Were Initially Never Planning to Quit”

Karin A. Kasza, Kathryn C. Edwards, Heather L. Kimmel, et al

JAMA Network Open, 28 December 2021  Online First

“Most published studies that investigate whether use of electronic nicotine delivery products (e-cigarettes) can help cigarette smokers quit smoking have been restricted to smokers who are planning to quit, or they have not considered smokers’ quit intentions. However, a recent study using data from the US nationally representative Population Assessment of Tobacco and Health (PATH) Study looked at daily cigarette smokers who were not planning to ever quit smoking and found that subsequent daily use of e-cigarettes was positively associated with change in intentions to quit cigarette use. A long-standing theory suggests that taking even a first step toward contemplating quitting smoking can have a positive impact on net cigarette cessation rates; thus, evaluation of factors associated with cigarette discontinuation among smokers not planning to quit is important to understanding the range of potential impacts of e-cigarette use on net cigarette cessation.”

So begins a paper by Kasra et al.

Here’s what they did:

  • The authors analyzed a cohort study drawing on US nationally representative data (four waves of the Population Assessment of Tobacco and Health Study). 
  • Those included: adult daily cigarette smokers with no plans to ever quit smoking for good.
  • The main outcome: discontinuation of cigarette smoking. 

Here’s what they found:

  • Demographics. Participants tended to be male (56.1%), about a third were aged 55 to 69 years (29.3%), and many had incomes less than $25 000 (55.2%).
  • Use. 37.6% smoked 20 to 29 cigarettes per day; 12.7% smoked 30 or more cigarettes.
  • “Overall, 6.2% of the population discontinued cigarette smoking.”
  • “Discontinuation rates were higher among those who used e-cigarettes daily (28.0%…) compared with not at all (5.8%… adjusted odds ratio [aOR], 8.11).”
  • “Furthermore, 10.7% discontinued daily cigarette smoking, with higher rates of discontinuation observed among those who used e-cigarettes daily (45.5%) compared with not at all (9.9%; aOR, 9.67).”

This is a good and interesting paper.

Clearly, this population – smokers who have no intention of quitting – are particularly challenging to engage in smoking cessation. Yet, they did well with e-cigarettes; the real numbers are small but significant. The authors see potential and offer a reasonable conclusion: “These findings call for consideration of smokers who are not planning to quit when evaluating the risk-benefit potential of e-cigarettes for smoking cessation in the population.”

Of course, we don’t know about smoking intentions and the exact role of e-cigarettes (as opposed to other factors), nor about the device used. The clinical take-away: if someone has started to switch, give them time to switch completely and don’t discourage them from vaping. 

From a public policy perspective, e-cigarettes have been controversial. Can we find the regulatory sweet spot, keeping adolescents away from e-cigarettes but providing access to adult smokers?

And a quick thanks to addiction physician Dr. Peter Selby (of the University of Toronto) for his insights.

The full JAMA Network Open paper can be found here:

Selection 2: “Green Space and the Incidence of Schizophrenia in Toronto, Canada”

Martin Rotenberg, Andrew Tuck, Kelly K. Anderson, Kwame McKenzie

The Canadian Journal of Psychiatry, 4 February 2022  Online First

“The association between urbanicity and an increased risk of developing schizophrenia has been replicated in many jurisdictions; however, the mechanisms underlying this association are not clear. There has been increasing interest in the study of novel environmental risk factors. A recent population-based study in Denmark found that cumulative childhood exposure to green space is a protective factor that reduces the risk of developing schizophrenia during adolescence and adulthood. These findings have yet to be replicated, nor have they been assessed solely in the context of an urban environment. This study explores the association between green space and the incidence of schizophrenia in a large Canadian urban center, while adjusting for known socioenvironmental risk factors.”

So begins a paper by Rotenberg et al.

Here’s what they did:

  • Drawing on administrative data, they looked at the incident cases of schizophrenia and schizoaffective disorder for 140 Toronto neighbourhoods, and compared that to the amount of green space (using Urban HEART measure of neighbourhood-level green space). 
  • “We calculated adjusted incidence rate ratio (IRR) estimates using multilevel Poisson regression models adjusting for age, sex, neighbourhood-level marginalization, and neighbourhood-level green space.”

Here’s what they found:

“We identified 4,841 cases in a cohort of 649,020 people… Exposure to the lowest amounts of green space was associated with a higher risk of developing schizophrenia independent of age, sex, and neighbourhood-level marginalization. People residing in neighbourhoods with the lowest amount of green space had a 24% higher risk of developing schizophrenia (Q1 adjusted IRR  =  1.24…), compared to people residing in neighbourhoods with the highest amount of green space (Q5), after adjusting for age, sex, and neighbourhood-level marginalization. The risk of developing schizophrenia was not elevated in areas with intermediate levels of green space (Q2–Q4).”

How reproducible are these results? The authors note: “These findings are consistent with a study from Denmark that examined this association across the entire country, finding a 52% higher risk of psychotic disorder among people exposed to the lowest amounts of green space during childhood.”

They write about the significance: “The current study builds on this international work, as we found a similar albeit modest association to be present in a diverse urban city in Canada. These findings contribute to a growing evidence base that environmental factors may play a role in the etiology of schizophrenia.”

The full CJP research letter can be found here:

Selection 3: “The Care I Needed”

Jessica Gregg

The New England Journal of Medicine, 3 February 2022

“One afternoon last winter, I caught myself massaging aches in my wrists and hands, aches that hadn’t been there the day before. A few hours later, I was rolling away pain in my shoulders, then in my neck. The next morning, my knees hurt too, and my stiff paws fumbled as I tried to turn the doorknob.

“I was worried, but not terrified; I’ve been healthy my whole life, and I have excellent insurance through a large HMO. Also, I’m a doctor; I would get the care I needed. I scheduled an urgent telehealth visit for the following day through my HMO’s elegant app. So easy! Then I took extra-strength Tylenol, chased it with ibuprofen, and went to work.”

So begins a paper by Dr. Gregg.

She describes the nightmare scenario that we all dread: from good health to sudden illness. She writes about the difficulty of trying to reach a doctor: “My phone pinged, buzzed, and exclaimed with each result, but no one called. I worried and ached and went to bed at 7:00 and then the next night at 6:00. Finally, I contacted the clinic through the online portal, as the website instructed. My first message asked if someone would please call. A few hours later, my second message urged them to call immediately – I was worried and I hurt. My third message felt like a journal entry, or a note to a lover who was no longer interested. I was scared, I said, and didn’t understand their silence.”

She fantasizes about a physician encounter: “I imagined unburdening myself to a white-coated colleague, someone about my age, maybe a little older. She would lean forward, asking concerned questions. Did I have any rashes? What about fevers? Did it feel safe to drive? Then she would think aloud about possible causes of my symptoms while reassuring me that we’d get to the root of it all. My imaginary doctor was unrushed, had no other thoughts but of my problems, and sort of loved me.”

Instead, she describes an “efficient” physician visit. “He nodded, tippity-tapping on his computer. ‘Let’s check a few labs.’ Then he gave the camera a quick smile, ‘It was very nice to meet you.’”

The essay is short, well written, and thoughtful. Her health care experience is high tech (apps, an online portal, notifications of test results) and yet unsatisfying. The “doctor as patient” isn’t a new theme, of course, but Dr. Gregg describes well that the convenience and dazzle of technology is no substitute for proper care.

She explores the challenges of navigating the health care system even though she is a physician. What would her experience have been like if she had three part-time jobs and no medical knowledge?

The full NEJM paper can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.