E-cigarettes, Asherman's syndrome, Rugby

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INSIDE HEALTH

Programme 6. – E-cigarettes, Asherman's syndrome, Rugby

TX:  16.02.16  2100-2130

PRESENTER:  MARK PORTER

PRODUCER:  ERIKA WRIGHT

Porter

Coming up today:  Rugby – are parents having the wool pulled over their eyes when it comes to the risks of serious injury?

Clip

If you were to send your children up into the hills on a school trip and they came back with the same number of fractures and head injuries and concussions there would be a major inquiry every single week.  So the question is why are we not having a major inquiry every single week into the injuries that are taking place on the rugby pitches?

Porter

And Asherman’s syndrome – a little known, often missed complication of miscarriage and gynaecological surgery that can leave women infertile.

But we start with the licensing of the UK’s first electronic cigarette. The approval by the Medicine and Healthcare Products Regulatory Agency, the MHRA, means British American Tobacco’s e-Voke e-cig is now classed as a medicine, paving the way for its prescription on the NHS to help smokers quit.

But is it a step forward in the ongoing battle against tobacco, or a step back? I hit the streets in London to gauge opinion among vapers:

First vaper

I just started vaping really because it’s quite pleasant, it still feels like smoking.

Porter

And do you still smoke or do you just vape?

First vaper

I don’t smoke at all no.

Porter

If your e-cig was prescribable on the NHS, you could get it from your doctor, would you go to your doctor to get it?

First vaper

Probably not, I get it online, it’s all cheaper than a prescription anyway.

Second vaper

Well I did smoke heavily for about 25 years, so I think it was time to give it up.  But it doesn’t really feel like I’ve given up cigarettes at all, vaping was a way of smoking while not smoking.

Porter

And what’s the plan with the vaping now – to carry on in the medium term or are you hoping to give that up too?

Second vaper

No I quite like vaping.

Porter

If you e-cig was prescribable on the NHS would you have gone to your doctor to get it?

Second vaper

Err probably not, when I did give up smoking in the past I did it by myself.

Porter

How do you feel about the UK’s first licensed e-cig actually being made by a tobacco manufacturers, one of the biggest tobacco companies in the world?

Second vaper

I think they’ve probably seen the future and seen it’s in vaping.

First vaper

I know speaking to other people that they’re slightly worried that effectively what will happen is that you get big tobacco firms who can afford the R & D and getting everything licensed and properly put through and then the price of these goes up.

Third vaper

I was kind of on about 30, 40 a day and I think one of the reasons why I kind of ended up doing the vaping thing was – I guess it’s my mental picture of myself, I see myself as a smoker and when I vape I still feel and look as if I smoke.

Porter

When was the last time you had a cigarette?

Third vaper

June last year.

Porter

What would you say if I, as a GP, could prescribe a licensed version of this, part of a move to get you to give up the nicotine altogether, is that something that would put you off or is that something that’s attractive?

Third vaper

No, maybe attractive, maybe I’m just a bit self-reliant because I’m kind of self-managing my way down the nicotine strength level.

Porter

So you’re weaning yourself?

Third vaper

So I’m weaning myself off, yeah.  I think if I’d felt that I needed help on that I may well have been attracted by going to talk to my GP about it.

Porter

A sample of what some vapers think, but what about healthcare professionals? Robert West is Professor of Psychology at University College London and one of the world’s foremost experts on smoking cessation. And Dr Margaret McCartney is our resident sceptical GP. Margaret, the UK’s first licensed e-cig - good move, or bad move?

McCartney

Yeah, it’s not one that feels particularly comfortable for me as a prescriber.  I mean I think we do lack a fair bit of data, trial evidence really, about the best ways to use these products.  In particular how long for.  And one of the big concerns I have I suppose is that we are seeing so many shops opening up, we’ve got this really sort of freewheeling market that’s opening up.  We’ve got a lot of young people that are very interested in it as well.  We seem to – at one end – be sort of saying well we’re doing quite well overall, smoking rates are coming down in the UK, but on the other hand we’ve got this big market opening up.  Where is that leading to?

Porter

Robert, if you look at the vaping forums and there are plenty out there, there’s a lot of concern that big tobacco are going to take over these devices and well make them less enjoyable.

West

Yeah I think we have to be in no doubt whatsoever the tobacco industry’s job is to sell tobacco and so they are incredibly incentivised to keep people smoking.  The fact that they’ve put a toe in the water or more than a toe in the water of the vaping market I think we must view with considerable suspicion.  And I would say when it comes to using taxpayers’ money, for example, to pay for a licensed nicotine product owned by a tobacco company I would say well why would you do that?  There are already products out there that we can be giving people that have a stronger evidence base than the new product that’s produced by the tobacco industry.

Porter

So looking specifically at Evoke, this licensed product, I mean is there good evidence to support its use or are they extrapolating data from existing nicotine replacement studies?

West

That’s exactly what they’re doing, they’re extrapolating data from bioequivalent studies, they’re not showing that these products are significantly better than existing products.  And until and unless they do I can’t see any particular reason why you’d want to use them.

Porter

Over and above a patch or something like that for instance?

West

No.

McCartney

I do think we should be quite keen to know what the evidence base is for this particular product because I think we do lack data about it and I think there’s lots of other products on the market that we know work, so really are we pushing something that just sounds a bit more modern, when actually we’ve got better solutions out there?

Porter

So given that there’s no new evidence Robert, why have we suddenly got a licensed version?

West

The MHRA have to basically under their rules.  If the tobacco industry can show a product which satisfies the criteria for safety and efficacy in this case, in terms of efficacy, it’s based on bioequivalence, they assume because we’ve got lots of data from other products, that if you give nicotine to people in a form that’s different from a cigarette it’ll help them stop smoking.

Porter

Doesn’t matter which – how you give that?

West

It doesn’t appear to make much difference.

McCartney

However, just because something is licensed by the NHRA doesn’t mean to say that NHS doctors have to prescribe it.

West

Quite right.

McCartney

So that’s a second tier it has to go through and then you have to get cost effectiveness analysis and that’s where I think we are really lacking in research about how effective these particular products are.

Porter

And there are lots of GPs particularly out there who are worried about the prospect of patients coming in saying can I have my e-cigarettes on the NHS please.  How do you feel about that?

West

Troubled actually, I think that the tobacco industry must be feeling quite pleased with themselves.

McCartney

Well I think that smoking cessation is best done in specialist clinics with trained staff who can offer people the best behavioural therapy and support while they’re giving up.  And we have better products, I feel, available.  I certainly don’t feel very comfortable about prescribing a drug that’s made by British American Tobacco.

West

If I were being mischievous I might suspect that the tobacco industry were trying to wind us all up by creating these kind of divisions that in fact their activities are within the public health community.  I think probably the way to view e-cigarettes at the moment anyway is it’s a consumer driven phenomenon for people who don’t want to go to the NHS services.  If we could get everyone to go to the NHS services we would solve the tobacco problem fairly quickly.

Porter

Can you put e-cig use in context?  I mean what proportion of people who use nicotine type products, I’m including tobacco, does it make up?

West

It’s the largest proportion of non-tobacco nicotine use.  So e-cigarettes are, by some margin now, the most popular method of stopping smoking.  They’re also more popular than the licensed nicotine products in terms of smokers who are using them to cut down.  Now that raises an interesting question for us:  If they were this game changer, if they were going to be – have this massive effect on everyone switching to e-cigarettes and stopping smoking we might have expected to see a bigger effect than we have seen so far which has actually been relatively small.

Porter

But is there research going on in this area to try and answer this question?

West

Yes there is.  There’s actually quite a lot of research but of course research takes time, so there are randomised control trials now in the field looking at whether you can enhance success rates using an e-cigarette compared with, for example, the traditional licensed nicotine products.  Unfortunately we won’t be hearing from those anytime particularly soon, it’s going to be months even years possibly before we know the results.

Porter

What about the other widely held concern that this can be a gateway to smoking, what’s the latest thinking on that?

West

The latest thinking is different from the latest evidence, I’m afraid to say, because there’s a lot of confusion out there.  The evidence remains that the proportion of never smokers who use an e-cigarette and continue to use it is extremely low.  So the opportunity for it to act as a gateway is very limited because the vast majority of youngsters who use an e-cigarette are already smoking or have tried smoking.  Now if you look at population figures of the rates of smoking over time as there’s been a growth in e-cigarette use what you see is that the rate of decline in new smoking has continued at the same rate or slightly higher in the United States than previously.  So there really isn’t evidence at a population level of a gateway effect, although you’ll see a lot of claims that there is.

McCartney

Although there have been studies that have suggested that even a minority, a small minority, I think one of them in the northwest of England was 15.8% of teenagers who had access to e-cigarettes had never smoked conventional cigarettes.  So I’m not saying it’s a big problem or necessarily a gateway drug but I do think there is an issue with so many of these shops being on the high street, you know people are going to try them and I think it would be wrong to ignore the possibility that these may end up doing more harm than good in a population who would never have smoked otherwise.  And I think it’s really important that the research continues to be done to see what’s happening and to whom.

West

Can I completely agree with that?  I think you’re absolutely right.  But there is a big difference between trying an e-cigarette and continuing to use it obviously.

McCartney

Oh absolutely, I mean I think we’re all guilty of trying things once.  But this is just such a new big and shifting market and almost as soon as the research has been done it’s out of date.  And I think in general when it comes to looking at addictive products in the community we’ve got a fairly poor record of doing well by people, we seemed to have failed at every turn historically and it would be a real shame if we didn’t get the best out of e-cigarettes while getting rid of the worst.

Porter

What about this sort of rather nebulous concept, because it covers a multitude of sins, when we talk about harm reduction, this is where smokers perhaps are not giving up but are substituting vaping for tobacco – what do we know about that?

West

We know that most people who use e-cigarettes are continuing to smoke and when you ask them they’ll tell you that they’re mostly doing that to try to cut down the amount they smoke.  But we also know that if you look at how much they’re smoking it’s not really that much different from what they would have been doing if they weren’t using an e-cigarette.  So I think as far as using an e-cigarette to reduce your harm while continuing to smoke is concerned there really isn’t good evidence that it has any benefit.

Porter

Professor Robert West and Dr Margaret McCartney. And you will find useful links on the subject on the Inside Health page of the Radio 4 website.

Baby noises

Now to the part of the programme where you set the agenda and a listener’s question.

Fran

My name is Fran and this is Lawrence my miracle baby.  It’s been a long journey to have him as a result of getting a diagnosis of Asherman’s, a condition that not many people know about it, it’s frequently misdiagnosed and it would be great if the programme could look into it.

Baby noises

Beckett

My name is Virginia Beckett and I’m a consultant obstetrician and gynaecologist specialising in infertility.  Asherman’s syndrome is where there are adhesions or scar tissue within the cavity of the womb.  And in general the most common time when we see that is when people have had an operation inside their womb.  So perhaps they’ve had a miscarriage and they require surgery to remove what we call the products of conception or they might have a placenta that’s become stuck after delivery.  We also see it after termination and after operations for fibroids.  Very occasionally we’ll see it as a result of significant infection, most commonly with tuberculosis.  So the way I describe it to my patients it’s a little bit like when you graze your knee, perhaps when you were a child, the tissue that’s exposed is quite sticky and so if you were to put cotton wool on it, for example, you’d find that bits of the cotton wool were getting stuck on that raw area.  So with the womb the two walls are very closely opposed and so they can very easily become stuck together.

Porter

If you get Asherman’s syndrome what sort of problems can it cause?

Beckett

Well some women might notice that they get quite light periods, so if the damage is fairly extensive then the lining of the womb doesn’t build up when your hormones change through your cycle and so you would have quite light periods.  Some people get painful periods, so if the scar tissue’s limited to around the area of the cervix, so the lining of the womb is building up but it can’t be shed, then that will cause pain.  Or it might be that women just find that they’re not getting pregnant.  And of course there are many causes for those three symptoms and that perhaps explains why sometimes it can take a while for people to be diagnosed.

Porter

Lawrence is Fran’s third child and when his older brother was born things didn’t go smoothly.

Fran

It was a very traumatic difficult delivery and as a result two weeks later I haemorrhaged, had to come back into hospital and unfortunately had a retained placenta.  And was told I needed surgery, literally the next day which was a D & C, which I had.  Kind of got back into normal life as such and then stopped breast feeding and my periods didn’t come back and at the same time I was noticing that each month I was having quite extreme pain, I mean literally two weeks of agonising pain.  So I decided to go and see my GP and I was told well you’ve stopped breast feeding, it can take 12-18 months for the periods to resume, go away a couple of months and then come back and toing and froing.  And I ended up going away, just feeling like something really wasn’t right.  So I looked online and went on the international Asherman’s Association website and I kind of ticked all the boxes.  So went back to see my GP and she said well Asherman’s is extremely rare, very unlikely that you’ve got it but I’ll refer you off to see a general gynaecologist. 

Beckett

There are some studies that suggest the risk is as high as one in a 100 to one in a 150 with the highest risk perhaps being in women who require an operation in the first couple of weeks after a full term pregnancy.  But I think because not everyone will then want another pregnancy after that procedure I think perhaps we underestimate the incidence.  But I think you know I run a very busy fertility practice and I probably only see one or two cases a year.

Porter

What can we do to help women who have Asherman’s?

Beckett

The gold star investigation would be to have a camera put inside the womb and then that you have someone who’s experienced at dealing with the scar tissue to carry out a procedure to remove them.  You can make things much, much worse if you’re not very experienced at doing this procedure.  So the procedure is again done down a camera and involves cutting the scar tissue, they’re like strands, we call them synechiae.  And afterwards you need to be managed incredibly carefully, so we would tend to put something in that will hold the walls of the womb apart, so that they can’t become stuck together again, and then we’d use some oestrogen treatment to help the lining of the womb to build up.  But I would also say that I think it’s really important that people understand that we try to avoid Asherman’s in the first place.  And although sometimes patients I see they don’t feel particularly happy to consider medical management of their miscarriage for example or their termination, so that’s using tablets instead of an operation to empty the uterus, the reason we encourage that is because we want to retain fertility for the future and avoid these kind of problems and risks.

Porter

Because the worry is that if the pregnancy’s ended and there’s still contents in the womb if it’s left that can get infected and that can cause a lot of problems can’t it?

Beckett

There are absolutely certain circumstances where our strong advice would be to have an operation.  So if the womb is unable to remove what it sees then as a foreign body essentially then it will bleed very significantly and that could endanger the woman’s life and also it can act as a focus of infection, which can be very serious – sepsis has been in the news very recently – and we see young women developing very significant sepsis for this reason.  So it’s a fine line, there’s a risk whatever management option you take and it’s about being well informed, so I’d encourage patients to ask questions and make sure that they’re really at the centre of the decision making in respect of their case.

Fran

When we had the diagnosis of Asherman’s and my case was severe my uterus was totally scarred shut, I had to have two procedures, very invasive, and I just thought do you know what we’re not going to have any more children.  So Lawrence is our little miracle and if people out there are struggling really fight for it and make sure you see the right people.

Porter

The delectable sounding Lawrence with his mother Fran. And thanks too to specialist Virginia Beckett. There is more information on Asherman’s syndrome on our website.

Rugby practice

Rugby’s in the news with the Six Nations Championship now into the third round, both England and Wales having had a good start – Scotland and Ireland well less so.

The sport is growing in popularity, particularly among children, with 1.2 million of them now playing rugby at schools and clubs in England alone. But at what cost?

Sport is good for young people for myriad reasons, but rugby is rough and injuries more common than most parents think.

Allyson Pollock is Professor of Public Health Research and Policy at Queen Mary, University of London. Her son was injured repeatedly playing rugby and his experience, plus the number of other children Professor Pollock knew who’d been similarly hurt, prompted her to take a closer look.

Pollock

Well I started by going to the rugby unions and asking them for the data on injuries in schoolchildren and I also went to the Health and Safety Executive.  And to my surprise they couldn’t provide me with any of the injury data and yet there is a reporting requirement – at the same time I went to the schools and I found that the schools were also not gathering and collecting the data.  So this was a great concern to me and I did a number of things.  First of all I started to put together all the literature on injuries in schoolchild rugby and also I conducted two studies, one was a study of six Scottish schools over half a season to look at the injury rates and the types and causes of injury and I also did a telephone survey of sixth formers in one school.

Porter

And what did you find?

Pollock

My findings were very alarming and deeply concerning.  The academic literature and my own studies show that there were very high rates of injuries, as much as one in six of a chance of being injured in a season but actually in some studies it could be a 90% chance.  We’re talking about fractures – fractured legs, collarbones, dislocated shoulders, ligamentous tears and concussion.  And also that most injuries were occurring during contact because collision is built into the game.  And more than 80% of all the injuries are occurring during contact especially during the tackle, scrum and ruck and maul.

Porter

And from the research that you’ve done did concussion make up a significant proportion of those injuries?

Pollock

Yes in the community game we know that concussion is now leading the way as the top cause of injury and certainly in schoolchild rugby as well we’re seeing it as one of the major causes of injury.  But I’d like to also say that if you were to send your children up into the hills on a school trip and they came back with the same number of fractures and head injuries and concussions there would be a major inquiry, every single week.  So the question is why are we not having a major inquiry every single week into the injuries that are taking place on the rugby pitches?

Porter

Have the authorities taken your message on board, is there any sign of any change in attitude?

Pollock

Not nearly enough.  For at least 40 years we’ve had the studies to show that rugby is a collision sport and the studies are there to show that this is a very dangerous game.  And one of the things that’s happened since professionalisation is that the injury rates have doubled in the adult game and tripled in the children’s game.  Now the studies have always been there, it’s just that the rugby unions have chosen not to respond.  So I would argue actually that the rugby unions should not be in charge of creating the laws for the children’s game.  The governance of the sport for the professional game should be entirely separate from the governance of the sport for the children’s game and it needs to be a very different sort of game.

Porter

The traditional argument is that we all know that rugby can be a very dangerous game and as a young player myself I knew of someone who’d broken their neck, those sorts of stories haunt the game, but they’re regarded as being exceptionally rare.  It’s a tough sport, you’re going to get some injuries.  Are you blowing this out of proportion and what would you say to people who’d say that?

Pollock

We’re looking at very high risks of injuries in a season.  In our study two-thirds of injuries resulted in more than three weeks off school, that’s not acceptable.  I mean what the rugby unions are doing is they’re doing secondary prevention, they’re doing all this concussion recognition at the moment.  But what we really need is a primary prevention, we need to prevent the injuries happening in the first place.  And the way in which we prevent it is by removing the contact from the children’s game because most of the injuries are occurring during contact, during collision, which is the tackle.  The government is busy rolling out five key sports in schools which include rugby.  The government needs to put in place proper injury monitoring and prevention strategies and second it needs to take heed of the evidence and remove contact from the game of rugby in the under-18 game.  If they don’t it’s more than likely we’re going to see a lot of litigation as the evidence becomes available of the harms of the game.

Porter

Professor Allyson Pollock. Well listening to that was Rugby Football Union’s community medical director Dr Mike England.

So Mike should it be a non-contact sport for children – with under 18s effectively playing touch rugby only?

England

In England actually our only offer for state schools is tag rugby, which is non-contact.  The phases of the game that you see sort of in the televised game with the scrum, the line out, don’t come in till much later on into secondary school.  In rugby clubs and independent schools we’ve introduced Kids First rugby and the philosophy behind this is to use rugby to develop children physically and socially through rugby based games.  And these are principally small sided, they’re not the 15-a-side game you see on television, they’re small sided games and specifically the contact elements are only introduced very gradually.

Porter

So to be clear Mike – contact in state schools typically doesn’t start until the age of 14, although elements may be introduced earlier in some clubs and private schools.  But how does that fit with Allyson Pollock’s claim that injury rates in children have tripled since the ‘90s?  Surely if schools and clubs are delaying contact you’d have expected injury rates to fall.

England

I suppose the challenge here is how injury is defined.  And one of the issues is that that definition has changed over the years.  In a lot of the studies we do now we’ve tried to standardised the definition, along with World Rugby, so you can actually compare data.  There are very few studies that compare injury rates across sports using exactly the same methodology.  And actually within Allyson’s meta-analysis one of the few studies that did that in New Zealand compared rugby league with rugby union and netball and what’s interesting what comes out of that is using the same definition of injury and the same methodology for the study, rugby league came out as a significantly higher risk for injury and rugby union and netball actually came out on a very similar level.

Porter

Is there a conflict of interest for somebody like the RFU, who’s looking at the big prize of the professional game, do you think the RFU’s the right person to be looking after both the professional game and the game at primary school and secondary school?

England

I think they are best placed to govern their own sports and they understand their sport, they have the expertise on how to develop players and athletes.  We recognise that as a contact sport there are risks involved and all elements of the RFU, that’s across coaching, referring, player development and medical, we work together to continuously review and improve what we do in this area.

Porter

One of the obvious changes that’s occurred since the professionalisation is the size of the players, they are huge today compared to where they were just 20 or 30 years ago, and that’s percolating down into schools as well, does that concern you?

England

With professional players the size of the players did increase and the biggest increase actually took place in the early ‘90s as the Rugby World Cup was introduced and professionalisation came in.  Actually in recent years there hasn’t been an increase in size in professional players and what you’re seeing now is actually some of the players are starting to get smaller, people have realised that the large physical players aren’t necessarily the most skilful and don’t create the enjoyable game that people want to watch.

Porter

Dr Mike England from the RFU speaking to me from our Gloucester studio. As ever links to more information, including Allyson Pollock’s research, are on the website.

Just time to tell you about next week when I discover more about Charles Bonnet syndrome – a common cause of vivid visual hallucinations in people with poor eyesight, but one that few people –  including doctors and optometrists – seem to know much about. Join me next week to find out more.

ENDS