Electronic Cigarettes: Means for Smoking Cessation, or New Appealing Disguise for an Age Old Problem?

Between January 2000 and December 2007 the United States implemented comprehensive IMG_4650smoke-free laws that prohibited smoking in workplaces, restaurants and bars. The Missouri Clean Indoor Air Law (2000) was Missouri’s response to this movement.1 The law mandated that no public place may have more than 30% of its entire establishment dedicated to smoking and clear signs must be in place to distinguish between smoking and non-smoking sections. Since 2011, Jefferson City, along with other major cities in Missouri, has gone a step further to completely ban smoking in public facilities. Smoking sections are becoming a thing of the past and lit cigarettes can only be spotted on sidewalks, patios, and within private establishments.

Why do we care? According to the Centers for Disease Control and Prevention (CDC), “exposure to second-hand smoke from burning tobacco products causes disease and premature death among non-smokers. There is no risk free level of second-hand smoke and even brief exposure can cause immediate harm.” Since the implementation of smoke-free laws nationwide, there has been a noticeable decrease in the amount of hospital admissions and deaths associated with coronary events, along with respiratory and heart disease.2 The push to eradicate cigarette smoke was an attempt to improve population health, decrease the pervasion of cigarette smoking in the community, and to protect non-smokers from the potentially harmful effects of second-hand smoke. With public smoking becoming more taboo, the need for a more sociably acceptable alternative arose. The answer presented itself on the market in 2007with the electronic cigarette.

Let’s begin with the basics. An electronic cigarette(EC) is a battery-powered device that contains a liquid that is composed of a combination of propylene glycol, vegetable glycerin, flavor concentrates, and varying concentrations of nicotine. During use, the liquid is vaporized, allowing inhalation without combustion or smoke. ECs have been used as a form of smoking cessation and potentially address the chemical (cravings) and behavioral components of tobacco addiction. ECs have been praised as a new and safer alternative to cigarette smoking, but how much do we really know about these new “saviors” that have taken the market by storm? Have they helped decrease the prevalence of cigarette smoking in the community or have the cigarette companies found a new way to appeal to a more diverse and perhaps even younger audience?

A scientific report which monitored nicotine absorption from electronic cigarettes compared to combustible cigarettes (CC) has shown that the use of ECs causes an increase in plasma nicotine levels higher than in people using cigarettes alone.3 New generation electronic cigarette or “vapor” devices are associated with a faster nicotine absorption rate and higher plasma nicotine concentration levels. These rates were higher in experienced vapor users when compared to vapor naïve users. This suggests that nicotine absorption and plasma levels increase after sustained use and adjustment to the electronic delivery device. This faster nicotine delivery may explain the increased effectiveness of electronic cigarettes as a smoking cessation tool, but may potentially increase dependence.

While we have always been concerned with the health risks associated with second-hand-smoke, electronic cigarettes also have a potential to cause harm from nicotine exposure. EC refill bottles and cartridges contain concentrated, toxic amounts of nicotine. This proposes a severe problem for children who may be attracted by the cartridges sweet smells or flavorings. To an unsuspecting youth, the total nicotine content from consumption could prove to be life threatening and since e-cigarettes have no regulations in force, the safety and quality of e-liquids is not guaranteed. Additionally, nicotine from the aerosol or liquid cartridges can remain on surfaces long after exhalation and the aerosol has cleared the room. This residual nicotine left on public surfaces leads to a risk of third-hand exposure through the skin, inhalation and ingestion. Nicotine exposure can lead to adverse effects that may include: irritation, nausea/vomiting, heartburn, dizziness or headache.

Do the benefits of ECs outweigh the risks? Are these devices replacing the other nicotine replacement therapies already on the market for smoking cessation? A 5-year prospective cohort study began in November 2013 with the goal of observing the efficacy and safety of e-cigarettes long term.6 The study is predicted to be completed in 2019; however, preliminary findings presented at a 12 month follow up so far show no significant adverse effects from e cigarette use. Patients enrolled in this study were smokers of ECs only, CCs only or using both interchangeably. After surveying these groups after one year, it was found that nearly a third of all of the patients smoking e-cigarettes only, relapsed to tobacco smoking (n=236) with 10% reverting to using both e-cigarettes and tobacco smoke. For those who were only tobacco smokers at the beginning of the study, nearly 78% of all participants continued this trend, with only 7% quitting tobacco smoke in favor of e-cigarettes (n=491). When looking at the final group who smoked both CCs and ECs, over 50% of participants reverted to tobacco smoking only, 25% continued smoking both forms, and 10% quit tobacco smoking and continued using ECs (n=232). These early findings suggest that e-cigarettes may not be as effective as a tool for smoking cessation or reduction.

The truth of the matter is that electronic cigarettes are targeting a larger consumer base than solely current smokers. According to Dr. Pisinger, in correspondence with BMC medicine, the prevalence of smoking has increased from 24-38% in the past 3 years.7 As ECs become more popular, they have transitioned from being purchased by smokers only, and spread to use by ex-smokers and those who had never smoked at all. ECs come in all shapes and sizes, colors and models that are appealing to all ages. Adolescents between the ages of 12-14 have begun experimenting with ECs and their numbers have doubled in the past couple years.7 The range in flavors available for nicotine vapor come in a wide variety that can appease nearly any taste. The sweet candy-like flavors also seem to appeal to the young in a way cigarettes never could.

I would argue that combustible cigarettes are the most dangerous, legal product on the market and that when comparing to this formidable contender, anything would seem like a safer alternative. The truth is that there are currently no completed clinical trials that show the long term effects of electronic cigarette use. We still do not know what potential health risks these devices present with extended exposure. However, if an EC can convert a lifetime smoker or decrease cigarette consumption, then the health benefits are substantial. I feel, as the World Health Organization (WHO) stated in 2014, “it is an evolving frontier filled with promise and threat for tobacco control.”

Kenna Marx

UMKC School of Pharmacy in Columbia

Pharm.D. Candidate 2016


  1. Bureau of Health and Wellness Comprehensive Tobacco Control Program. FAQs About the Missouri State Clean Indoor Air Law. Accessed August 5,2015. http://health.mo.gov/living/wellness/tobacco/smokingandtobacco/pdf/FAQ_CIA.pdf
  1. Centers for Disease Control and Prevention. Smoke Free Policies Improve Health. Accessed August 5, 2015. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/protection/improve_health/. Accessed August 6, 2015.
  1. Farsalinos KE, Spyrou A, Stefopoulos C, et al. Nicotine absorption from electronic cigarette use: comparison between experienced consumers (vapers) and naïve users (smokers). Sci Rep. 2015;5:11269.
  1. Polosa R. Electronic cigarette use and harm reversal: emerging evidence in the lung. BMC Med. 2015;13:54.
  1. Beard E, Brown J, Mcneill A, Michie S, West R. Has growth in electronic cigarette use by smokers been responsible for the decline in use of licensed nicotine products? Findings from repeated cross-sectional surveys. Thorax. 2015
  1. Manzoli L, Flacco ME, Fiore M, et al. Electronic Cigarettes Efficacy and Safety at 12 Months: Cohort Study. PLoS ONE. 2015;10(6):e0129443
  1. Pisinger C. Why public health people are more worried than excited over e-cigarettes. BMC Med. 2014;12:226.

The Birth and Evolution of Modern Day Third Party Payer Healthcare

The 1920s marked a decade full of economic prosperity, seeing dramatic industrial and social changes. The “Roaring Twenties”, as it is often referred, is when many of our modern day luxuries were born. Nearly 40% of Americans owned a radio and national IMG_4314radio broadcasting began. Cars were assembled in mass production, becoming an asset to the working class, and by “1929 there was one car on the road for every five Americans” [1]. The film industry evolved to include color and synchronized sound, women gained the right to vote, and birth control became widely available. The poor enjoyed some of the same indulgences as the rich, and individuals of all ages admired and idolized the fashions and talents coming out of Hollywood. Unfortunately, this era ended as dramatically as it played out with the stock market crash in 1929 leading to the most notable economic collapse of all time – the Great Depression.

It has been nearly a century, and a lot has changed in society and medicine. Take a moment to let it sink in that health insurance has not always existed… There was once a time when there were no limits on pricing for physician services and many practitioners would charge more for care than the average American could afford. A select few would even commit malpractice (some which led to death) to ensure their own salary at the expense of their patients. A farmer could lose his land and his livelihood from an unexpected surgery and individuals typically only received care in an acute setting – when they were sick, injured, or pregnant.

Throughout the twenties, as big business was burgeoning, physicians and hospitals started to realize there was a huge market in healthcare. In 1929 – to protect patients and physicians alike – a few innovative practitioners and health care groups around the country pioneered pre-paid medical plans. These trailblazers included Dr. Michael Shadid of Elk City, OK, Ross-Loos Medical Group in Los Angeles, CA and Baylor Medical Center in Dallas, TX. These plans ensured constant, steady revenue for health care professionals while covering a range of acute, preventative, and specialized services for their members. They were predicted to reduce long-term medical costs for members. This concept was known as managed care – a coordination, organization, and rationalization of the health care delivery in such a way that improve service access and quality while optimizing expenditures. The plans were eventually known as Health Maintenance Organizations, and they flourished during the Great Depression – and thus began health care’s evolution into modern day third party payer healthcare.[2]

In 1929, a number of great minds were thinking alike all across the country. Dr. Michael Shadid began selling shares for $50 per member to build an independent hospital – the Community Hospital. Once construction was complete in 1931, members received discounted medical services for about a year, and then paid an annual premium of $12 per individual or $25 per family of four. Hospitalization cost an extra $1 per day, and surgery was an additional 20 dollars. Even during the hard times of the Great Depression, these prices were reasonable (going rates: $150 for an appendectomy and $50 for a tonsillectomy). By 1936, the hospital was serving over 2,400 families and thriving with the support of local farmers and political backing. [3]

During the same year halfway across the country, a duo of physicians, Donald E. Ross and H. Clifford Loos, formed Ross-Loos Medical Group to provide prepaid healthcare services to over 2,000 employees of Los Angeles County and the Department of Water and Power and their families. The plan focused on quality and prevention, and included such services as prenatal and well-baby visits and immunizations. Members paid $1.50 per month for this plan, which eventually became CIGNA. In the south, Justin Ford Kimball was also developing a prepaid healthcare plan for Baylor Hospital in Dallas, Texas to provide hospital services to nearly 1,500 teachers at the university. This plan eventually evolved into Blue Cross hospital services and within 10 years Blue Shield plans were developed to cover physician services. Combined these plans provided coverage to over 10 million individuals nationwide.3,[4]

As competing physicians and medical societies caught wind of these innovative plans, there was outcry in the medical community. The American Medical Association (AMA) adopted a strong opposition to prepaid group plans. They evoked fear in many health care professionals, threatening to suspend licenses of those who joined group practices. Local medical societies pushed to expel associated practitioners from their professional groups and prevent them from practicing at local hospitals. Competing physicians feared they would be forced to compete by providing services below cost. Many were deterred from participation, but not the reformers. Physicians brave enough to join group practices longed to see equal medical care for all Americans.

According to research published in 1932 by the Committee on the Costs of Medical Care (CMCC) – a group of 49 respected leaders in healthcare, including physicians, dentists, pharmacists, nurses, public health administrators, experts in medical economics, etc. – every dollar spent in health care broke down as 30% to physicians, 23% to hospitals, and 18% to medicines; there was misdistribution of health care – lower incomes equated to less medical care; and due to only a small percent of the public able to afford services, the average general practitioner had a low income. They recommended the expansion of prepaid group practice, encouraged continuing education and training, and emphasized a focus on patient-provider relationships, preventative care, and quality assurance. They took the stance that health care should be the “right” of every American, and if individuals could not afford monthly premiums, the government should provide subsidies.[5] In 1947, the U.S. Supreme Court upheld a ruling against AMA for violating the Sherman Antitrust Acts, by ostracizing physicians who participated in group plans, eventually leading way to increased participation of physicians in group plans and expansion of third party payer plans.[6]

By 1955, their dreams were becoming reality with nearly 70% of the U.S. population enrolled in health insurance plans. In 1965, Medicaid was established to further increase access to care for low-income families, and over the next several years expanded to incorporate new plans for children under the age of 21, elderly, and physically and developmentally disabled populations. The Healthcare Maintenance Organization (HMO) Act of 1973 was specifically designed to increase market competition and reduce healthcare costs while also increasing access and coverage. Amendments over the next 20+ years increased emphasis on quality care and accountability. By 1982, every state offered Medicaid services, patients gained more freedom in healthcare choices, and hospitals providing care to impoverished populations received state compensation. By 1990, Medicaid continued to grow, providing eligible women with prenatal care, covering certain health emergencies for illegal immigrants, and including dental benefits for many members.[7]

The development of Preferred Provider Organizations (PPOs) and Point-of-Service (POS) care in the 1990s, increased choices of healthcare providers and cost management for members. With the implementation of the Omnibus Reconciliation Act of 1990, Medicaid created a drug rebate program to help cut medication expenses. By the turn of the century, privacy laws were enacted as the Health Insurance Portability and Accountability Act (HIPAA) was enforced nationwide, Children’s Health Insurance Program (CHIP) was established to include children in families with higher income brackets, and the federal government was mandating that care be provided to all uninsured women diagnosed with breast or cervical cancer, regardless of income.6

In March of 2010, President Barack Obama signed the Affordable Care Act into law, which includes two legislative acts – Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010. This legislation encourages health insurance reform to expand coverage and quality while increasing accountability, controlling costs, and ensuring increased choices for consumers. It organized the Health Insurance Marketplace to provide a streamlined application process for affordable government approved insurance programs with eligibility determined through this single process. There is a strong focus on preventative care and an increase in program transparency and integrity. In 2011, state grants were approved to increase access to long-term care services and supports within a member’s local community. In 2014, new policies were released to extend funding in order to increase eligibility for CHIP through 2015 and increase federal matching rates until 2019. Centers for Medicaid and Medicare Services enacted new laws to upgrade existing CHIP eligibility.[8]



Western Clinic in Tacoma, WA offered medical services through select providers, for $0.50 per month for lumber mill owners and their employees, to ensure steady revenues for the clinic. (First example of managed care)


First medical co-op: Michael Shadid organized the Rural Farmers Cooperative in Elk City, OK

First Health Maintenance Organization (HMO): Ross-Loos Medical Group was formed to provide prepaid healthcare services to over 2,000 employees of Los Angeles County and the Department of Water and Power and their families

Baylor Hospital in Dallas, Texas develop a group health plan to provide hospital services to nearly 1,500 teachers at the university


American Medical Association adopted strong opposition to prepaid group plans

The Committee on the Cost of Medical Care (CCMC) published findings on the benefits of HMOs, recommending the expansion of prepaid group practice


The Kaiser Foundation Health Care Plans were initiated to finance medical care for the Kaiser construction company employees

The Home Owner’s Loan Corporation organized Group Health Association (GHA) in Washington D.C. to assist families with medical expenses in order to decrease the number of foreclosures


During World War II, several new HMOs were established by employers to provide employee health benefits in order to increase employment rates

A number of state medical societies develop Blue Shield plans, as adjunct to Blue Cross plans, to cover physician services


Health Insurance coverage is less than 10% nationally


The Health Insurance Plan (HIP) was founded to provide coverage for New York City’s city workers.


The Group Health Cooperative of Puget Sound was organized by 400 families in Seattle (First consumer-founded prepaid medical co-op)

AMA convicted of violating the Sherman Antitrust Acts by ostracizing physicians who participated in group plans – upheld by the U.S. Supreme Court


San Joaquin Medical Foundation was established to compete with the Kaiser Foundation Health Care Plans. They were the first independent fee-for-service model licensed by the state of California to receive capitation payments.


Health Insurance coverage is nearly 70% nationally


Medicaid was established under the Social Security Act of 1965


Amendments were made to the Public Health Service Act to promote and assist in the extension and improvement of comprehensive health planning and public health services, to provide for a more effective use of available Federal funds for such planning and services, and for other purposes.[9]


The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Plan was developed by Medicaid for children under the age of 21


Medicaid started to cover intermediate care for patients with intellectual disabilities

Supplemental Security Income (SSI) Benefits were established to provide assistance to elderly and disabled


The Healthcare Maintenance Organization (HMO) Act of 1973 was specifically designed to reduce healthcare costs by increasing market competition, increasing access to care and focusing on preventative care. Amendments over the next 20+ years increased emphasis on quality and accountability


Medicaid increased flexibility and freedom for patients to select their own health care team

Each state was required to pay hospitals that provided services to low-income patients


Arizona became the last state to provide Medicaid services


Eligible pregnant women covered for medical services associated with pregnancy


Medicaid covered emergency medical care for illegal immigrants (situational)


Dental services were added to benefits provided by Medicaid (not all states provide this benefit)


The development of Preferred Provider Organizations (PPOs) and Point-Of-Service (POS) products increases choices of healthcare providers and flexibility to manage costs for members

Omnibus Reconciliation Act of 1990 passed to help control prescription drug costs


January 1st, Medicaid Drug Rebate Program goes into effect in response to Omnibus Reconciliation Act of 1990


The Health Insurance Portability and Accountability Act (HIPPA) guarantees insurance portability and personal privacy for all Americans


Children’s Health Insurance Program (CHIP): by the US Department of Health and Human Services, develop benefit solutions to bridge the gap that left millions of American children uninsured in families with incomes that are modest but too high to qualify for Medicaid


2000 Breast and Cervical Cancer Treatment and Prevention Act provides coverage opportunity to any uninsured woman, regardless of income, upon diagnosis of breast or cervical cancer


Consumer Directed Health Plans (CDHP) begin to develop, enabling Blue Cross and Blue Shield members to have more personal control over the amount they spend on their own healthcare. This starts a movement towards empowering individuals to be more actively involved in their healthcare decision-making


President Barack Obama signed the Affordable Care Act (PPACA) into law. Companies partner with doctors, nurses, hospitals and others to rein in costs, improve quality, help people stay well and better manage their care


State grants were approved to increase access to long-term care services and supports within a member’s local community


New policies released to extend federal funding in order to increase CHIP eligibility through 2015 and increase federal matching rates until 2019


Medicaid Managed Care in Missouri expands to statewide coverage

Blue Cross and Blue Shield companies cover nearly one-in-three Americans, in every zip code in every state and Federal Territory.

[1] The Roaring Twenties. History.com. Accessed July 20, 2015. http://www.history.com/topics/roaring-twenties

[2] Kongstvedt, Peter R. Managed Care: What it is and how it Works. 3rd ed. Sudbury, Mass.: Jones and Bartlett, 2009. Web. https://books.google.com/books?id=nuZ5oUgIkRQC&printsec=frontcover&dq=managed+care+what+it+is+and+how+it+work+2nd+edition&hl=en&sa=X&ved=0CEUQ6AEwBWoVChMI5KCso_TsxgIV05yICh0xDwC0#v=onepage&q&f=false.

[3] Dr. Shadid’s Maverick Medicine. World History Group. Accessed July 21, 2015. http://www.historynet.com/dr-shadids-maverick-medicine.htm

[4] Ross-Loos Medical Group. World Heritage Encyclopedia. 2014. Accessed July 21, 2015. http://www.worldheritage.org/articles/Ross-Loos_Medical_Group.

[5] Smith, Charles C. The Committee on the Cost of Medical Care – Presented to the Innominate Society for the Study of Medical History on April 10, 1984. Accessed July 22, 2015. http://www.innominatesociety.com/Articles/The%20Committee%20%20On%20The%20Costs%20Of%20Medical%20Care.htm.

[6] Mullner, Ross M. Encyclopedia of Health Services Research. Accessed July 25, 2015. https://books.google.com/books?id=MUItoTour5oC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false.

[7] Medicaid History. Centers for Medicare and Medicaid Services. Accessed July 23, 2015. http://www.gomedicare.com/medicare-information/medicaid-history.html.

[8] Affordable Care Act. U.S. Department of Health and Human Services. Accessed July 24, 2015. http://www.medicaid.gov/AffordableCareAct/Affordable-Care-Act.html

Melanoma Risk and Prevention

It’s Saturday afternoon and the sunlight beats down on your face, warming your skin. You are so relaxed, you close your eyes and soak in the moment. You hear kids playing in the background, laughing and splashing in the water. The grill is lit, and the food smells absolutely amazing. As you sip your refreshing drink, you enjoy these moments IMG_4307surrounded by family and friends, wishing they would never end. Summer is in full swing and millions of families all across America, just like you, are enjoying hours upon hours soaking up the sunshine. So often we forget – hiding in those comforting rays is a silent threat – melanoma.

Skin cancer is not really the topic people want to discuss when making plans for their summer. However, it is the most commonly diagnosed cancer in the United States, so it is a discussion we need to have. One out of every 50 Americans will develop invasive melanoma – the deadliest form of skin cancer – during their lifetime, with many suffering lasting physical damage and nearly 10,000 each year paying the ultimate price, their life. The American Cancer Society estimates there will be 73,870 new melanoma of the skin cases in 2015. As pharmacists, we are in a prime health care position to educate the public on the risks of sun exposure and melanoma prevention.

The primary cause of melanoma is exposure to ultraviolet (UV) radiation, UVA and UVB rays, which cause irreversible DNA damage. UVA rays are commonly associated with tanning beds, and play a role in wrinkles and overall aging of the skin. UVB rays are more potent than UVA rays, causing direct damage to the DNA; they are more often associated with sunburns. DNA damage is cumulative over the years of UV exposure. Research has demonstrated that regular use of sunscreen decreases the amount of damage caused by sun exposure, leading to a reduction in the risk of melanoma.

To help us better understand UV risk in relation to location, the National Weather Service and the Environmental Protection Agency have developed the UV index, a calculated risk on a scale from 1 to 11+, provided per zip code – the greater the number the greater the risk. The UV index considers factors such as the time of year, time of day, location in reference to the equator, and altitude. UV radiation is at its strongest in spring and summer months, from 10 am to 4 pm each day, as you move closer towards the equator, and/or towards higher elevations. A UV index is often given in the local forecasts, newspaper and weather apps.

UV Index




People of all backgrounds and skin colors are susceptible to skin cancer. In order to ensure proper education on skin cancer prevention, it is important to know what traits put some individuals at higher risk than others. Below is a list of risk indicators most commonly associated with skin cancer:

  • Personal history of skin cancer or family history of melanoma
  • Fairer traits and sensitivity to the sun – including lighter natural skin color that freckles or burns easily, natural red or blonde hair, and blue or green eyes
  • History of excessive sun exposure, including sunburns – on average, a person’s risk for melanoma doubles if they have had more than 5 sunburns
  • History of tanning, including tanning beds or a lot of time spent outdoors for work or play
  • Immunosuppressant therapy or an innate decreased immunity
  • Presence of atypical, large, or numerous (more than 50) moles


Symptoms of sunburn, including red tender skin, blistering, and fatigue, can take nearly 4 hours after sun exposure to appear. These symptoms typically worsen over the first 24-36 hours and may take 3 to 5 days to resolve. Symptoms of skin cancer may take decades to appear. Therefore education and prevention is key, starting at a young age. The table below offers tips to follow to provide protection from the sun and reduce chances of getting melanoma in the future.


Use sunscreen – SPF-15 or higher* with “Broad Spectrum” on the label Apply liberally, 1 oz. (one shot glass full) or more, 30 minutes prior to sun exposure and then every two hours or immediately after swimming or excessive sweating – regular daily use of an SPF 15 or higher sunscreen reduces the risk of developing melanoma by 50%*Using sunscreen with a SPF over 30
Seek the shade Stay out of the direct sun as much as possible, especially during the hours of 10 am – 4 pm, when UV radiation is at its strongest
Avoid tanning Both indoor tanning booths and laying out in the direct sun cause similar amounts of damage to skin and eyes
Dress to protect Wear clothing that will cover as much skin as possible, preferably clothing made from a tightly woven fabricDark colors typically provide more protection than lightSome clothing has a UV Protection Factor – the higher the UPF, the better the protection from UV rays
Cover your head, neck and face Nearly 80% of skin cancers occur on the head, neck, and face – Wearing a hat, with at least a 2- to 3-inch brim all the way around can provide invaluable protection
Protect your eyes Sunglasses not only protect the delicate skin around the eyes, they also reduce the risk of developing cataracts – look for ones that protect against both UVA and UVB rays
Know your local UV index The local UV index can typically be found in a local forecast, newspaper, or weather apps.


Sun protection factor (SPF) is a measurement of how well a sunscreen blocks UVB rays from damaging the skin. The amount of protection it provides can be described two different ways, how long skin is protected from UVB radiation, or the percent of UVB rays blocked. How long a person is protected from a sunburn can be determined by multiplying the SPF by the amount of time it would normally take to sunburn if unprotected; so if it normally takes 30 minutes to burn and SPF-15 is applied, then theoretically, one would be protected for 450 minutes (7.5 hours). However, it is important that sunscreen be applied every two hours to ensure maximum protection.

SPF may also be represented in terms of the percent of UVB rays filtered: SPF 15 prevents 93% of UVB rays from damaging the skin, SPF 30 shields from 97%, SPF 50 blocks 98%, and SPF 100 blocks 99%. As you can see, as SPFs increase over 30 they provide very minimal added protection. Therefore, many health professionals do not recommend using a sunscreen above SPF-30. On the other hand, they do recommend using sunscreens labelled as “broad spectrum”. Broad-spectrum protection indicates there is an added component to the sunscreen that also provides protection against UVA radiation. The CDC recommends applying sunscreen SPF-15 or higher – with broad spectrum coverage – liberally, 30 minutes prior to sun exposure and then reapplying it every two hours during sun exposure.

As you enjoy the rest of the summer, remember to advocate for the skin health of the patients you serve. Skin cancer is a very preventable disease, and as a pharmacist, you have the tools to provide the public with invaluable knowledge to know their risk and protect themselves from the most commonly diagnosed cancer in America. Take time out to promote sunscreen and educate on its proper use. Take the steps to ensure your patients are provided with the power to prevent. And remember, sunscreen saves lives, so let’s start saving lives, one blocked ray at a time.

Dea S. Deuser

University of Missouri-Kansas City

Doctorate of Pharmacy Class of 2016

Operation Heart Co-Chair


  1. Cancer Facts & Figures 2015. http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf. American Cancer Society. Accessed July 7, 2015.
  2. Skin Cancer Facts. http://www.skincancer.org/skin-cancer-information/skin-cancer-facts. The Skin Cancer Foundation. Accessed July 7, 2015.
  3. Skin Cancer Prevention and Early Detection. http://www.cancer.org/cancer/cancercauses/sunanduvexposure/skincancerpreventionandearlydetection/skin-cancer-prevention-and-early-detection-what-is-u-v-radiation. American Cancer Society. Accessed July 8, 2015.
  4. Sunscreens Explained. http://www.skincancer.org/prevention/sun-protection/sunscreen/sunscreens-explained. The Skin Cancer Foundation. Accessed July 17, 2015.
  5. UV Index. http://www2.epa.gov/sunwise/uv-index. United States Environmental Protection Agency. Accessed July 9, 2015.


My Rotation Experience

After sitting in a classroom for 5-years, it was finally time for me to start my Advance Pharmacy Practice Experience (APPE) rotations. Finishing up my last semester of classes, then immediately starting rotations sent me through a roller coaster of emotions; excited, scared, nervous, and so IMG_3644many more. I remember early in this last semester choosing my preferences and thinking that the Missouri Pharmacy Association (MPA) would be a unique experience I probably wouldn’t get anywhere else, so it went to the top of my list. After waiting, what felt like years, I got my final rotation schedule, and there it was; MPA was listed as my first rotation. I had only heard good things about this rotation site from students going through the program last year, but I still had the first day jitters when that start date came. What I didn’t know before coming to this rotation was that I was going to get two rotation experiences in one. I not only spent time in the MPA office, but I also got the opportunity to spend time with Dr. George Oestreich and Dr. Jennifer Kemp-Cornelius at G.L.O. & Associates. While there is a connection between the two different sites, the experiences associated with each were unique.

Missouri Pharmacy Association (MPA)

The Missouri Pharmacy Association (MPA) gave me a perspective on the pharmacy career I had never seen before. They work behind the scenes on legislative matters, such as granting pharmacists provider status and fighting to implement an electronic health record (EHR) between pharmacies throughout the state. While on this rotation I got the opportunity to write blogs for the MPA website and even get published in the Missouri Pharmacists Magazine. I attended meetings with Ron Fitzwater, the CEO of MPA, including those with the Missouri Board of Pharmacy and Missouri Pharmacists Care Network discussing new and exciting events coming up in the next year. I even got the chance to take a tour of the State Capitol, which surprisingly I had never done before considering I’m from a small town just outside of Jefferson City. Touring the Capitol gave me insight on what really happens with the government and how the history of our country is so important. I give huge thanks to the staff at the MPA for making me feel so welcome and taking the time to help me learn. Upon graduation I will definitely keep my membership with the MPA.

G.L.O. & Associates

It was a pleasure to work under Dr. George Oestreich and Dr. Jennifer Kemp-Cornelius at G.L.O. & Associates and see what else pharmacists can do besides work in a retail or hospital pharmacy. I was able to observe several Show Me ECHO pain clinics, the Missouri Medicaid Prior Authorization Committee meeting, participate in a Missouri Primary Care Association (MPCA) workshop for their FQHC pharmacies, and get insight on Xerox, which is more than just a printer brand.

At the Show Me Echo Clinic Dr. Oestreich would participate along with Dr. Haake who specializes in pain management, and Dr. Lillard a psychologist from LifeSong, to provide recommendations to other primary care physicians all over the state through telecommunication. It was interesting to see how doctors, pharmacists, and psychologists could work together as a team and develop recommendations for physicians to handle their hard to treat patients. When Dr. Haake would have questions for the pharmacist, I was able to help with the research and provided feedback.

The Missouri Medicaid Prior Authorization Committee meeting took place in Jefferson City, Missouri where I was able to attend with Dr. Kemp-Cornelius. This is an open meeting to the public that happens four times a year and discusses which medications should be on the preferred medication list of MO Medicaid. It was a great experience to see behind the scenes of how medications are put on this list and how some fail to make it. I witnessed how representatives of drug companies pleaded their cases as to why their medication should be added to the preferred list. To my surprise one of my professors, Dr. Patrick Bryant, was one of the pharmacists participating on the board, which I assume is because he’s a wizard at evidence-based medicine! It was great to see his work in action.

Like I said before, Xerox is much more than just a brand of printer. I was able to sit down with the project manager at the Jefferson City location and see how their whole corporation contributes to the pharmacy world. Xerox in basically the middleman between all MoHealthNet claims that are billed daily. Having a retail pharmacy background I was able to relate and see that Xerox was a part of my everyday work routine of sending claims for medications to insurance companies. It only takes a few seconds for the server to respond, which is simply amazing, since so much happens in that little amount of time.

I would highly recommend this rotation to any student pharmacist in the process of choosing their APPE’s. I definitely got more out of it than I expected, and appreciate all those who contributed to me be able to receive all of these experiences.

Olivia Schwaller

Pharm.D. Candidate 2016

UMKC – School of Pharmacy

Technology Seeks to Make Finger Sticks a Thing of the Past

Diabetes is a medical condition we are all familiar with. In 2012, the American Diabetes IMG_4034Association reported that 29.1 million Americans had diabetes. This alarmingly high number can only be expected to increase as the incidence of diabetes continues to rise. In 2012, 1.7 million new diagnoses for diabetes were made. Diabetes goes hand-in-hand with daily blood sugar monitoring. Some patients require vigorous monitoring which may result in more than 3 finger sticks a day. Blood sugar monitoring helps physicians determine how effective the patient’s insulin and medication regimen are in the maintenance of diabetes. Certain patients may choose not to regularly monitor their blood sugar or feel it is tedious for the monitoring to be so frequent. This may lead to poor blood sugar control which can lead to further complications of the disease including, but not limited to, hypoglycemia, peripheral neuropathy, retinopathy and diabetic foot ulcers. In 2011, it was reported that a total of 282,000 emergency room visits were due to hypoglycemia.1 The disease was listed as the 7th leading cause of death in the United States in 2010. As a result of these striking statistics, the medical field has responded by working to develop better ways to accurately and effectively monitor blood sugar over a period of time, instead of at a single point in time.

Continuous glucose monitors are medical devices that first entered the market approximately ten years ago. They were met with reluctance from consumers due to being non-user friendly and having unreliable accuracy. DexCom, a San Diego based company, released a new and improved version of the continuous glucose monitor in 2012 which was reported to have improved accuracy. The monitor is composed of three parts; a small radio transmitter, a wire that is inserted under the skin and a handheld receiver. The thin wire goes underneath the skin which allows it to assess the body’s glucose levels in the interstitial fluid (fluid surrounding cells). The device is set to perform a blood sugar reading every five minutes. The wire connects to the small transmitter usually attached at the patient’s waist. After each reading the transmitter sends the information to the handheld receiver allowing the readings to be viewed by the patient. The patient has the option of syncing the receiver up to their smartphone to have all readings sent there instead. In order to improve its convenience, DexCom is in the process of seeking approval from the FDA for a continuous glucose monitor that would use a wireless connection from the sensor to the patient’s smartphone, eliminating the handheld receiver. Upon receiving the continuous glucose monitor for the first time, the user sets a threshold for what blood sugar levels are to be considered low and high. This establishes a range of blood sugars considered safe for the patient, any blood sugar level detected outside of this range will cause the machine to set off an alarm.2 The alarm may also sound if the blood sugar increases or decreases too quickly. Having blood sugar readings at five minute intervals allows for the possibility of being able to identify glucose trends which may lead to more efficient overall glucose control.

While these continuous monitors provide more blood sugar data and are less of a hassle than constant finger sticks, they do have flaws. Each monitor requires that two finger sticks be performed daily in order to calibrate the machine’s effectiveness.2 From a cost perspective, charges can add up quickly when using one of these monitors. The sensor wire requires replacement every 1-2 weeks which adds up to roughly $3,900 annually. The initial expense for the machine is $850. DexCom’s Executive Vice President Steven Pacelli reports that patients with insurance are usually responsible for paying twenty percent of the device’s total costs out of pocket.3 The sensitivity of the alarm function may also be seen as another downfall. It may be an interference with the patient’s daily activities or result in the patient feeling anxious over their blood sugar.

Other manufacturers saw these flaws as an opportunity for their advancement. Abbott Laboratories has a continuous glucose monitor model in the works. Their goal is to provide a lower cost alternative that has a fine tuned alarm mechanism. The Abbott model, Freestyle Libre, consists of a quarter sized sensor designed to be worn on the patient’s arm.3 The sensor is attached to a filament implanted in the skin. The sensor will perform blood sugar readings every minute. To access the readings the patient has to wave the handheld device over the sensor. Unlike the DexCom models, the Freestyle Libre does not require any calibration and it does not trigger an alarm if blood sugar readings are minor deviations outside the established safe range. From a cost perspective, replacing the sensor every 2 weeks as suggested costs $1,800 annually. While the Freestyle Libre is already on the market in Europe, Abbott has not established the expected date it will be available in the United States upon achieving FDA approval.

Google, in conjunction with Alcon, is working to set the bar even higher for the future of glucose monitoring. Brian Otis is currently the head of a project that seeks to develop contact lenses that will use tears to provide a glucose assessment. The lenses would then be able to assess glucose levels every second. This idea is centered on the use of computer microchip technology to make a miniature glucose sensor that will fit inside the lenses.3 To function, a wireless antenna and length-durable battery are required. There may be some concern about how the patient could wear such a device comfortably; Otis has designed the lenses to sit over the iris instead of the pupil.3 While the concept is admirable, this project remains in its early stages of development and continues to work out the kinks. There is hope that the lenses may be available for patients several years down the road. Upon product completion, Alcon would go on to seek device regulation approval via the FDA and would also carry out all manufacturing.

Overall, diabetes is a condition that cannot be taken lightly. Patients face too many potential complications if their disease is not maintained appropriately. These devices discussed may hold potential for the future of diabetic monitoring but it is important to thoroughly review the pros and cons of their use in each patient. We want to improve their quality of life by eventually eliminating the need for constant finger sticks. We also want to prevent placing them in a financial burden or sending them into information overload by expecting them to use a high tech device and smartphone. Each patient will require a training session if they are going to be using a continuous glucose monitor to ensure the device will be used effectively and appropriately.


Katelyn Hoyt

2016 Pharm.D. Candidate

St. Louis College of Pharmacy


  • American Diabetes Association. National Diabetes Statistics Report 2014. 29 June 2015.
  • Neithercott T. Continuous Glucose Monitors. Diabetes Forecast. 2014. Web. 29 June 2015.
  • Walker J. Easier Blood Sugar Monitoring for Diabetics. Wall Street Journal. 2015. Web. 29 June 2015.