Electronic cigarettes for smoking cessation

Feasibility of restricting e-cigarettes to prescription only for smoking cessation

E-cigarette use among youth in Canada has risen to epidemic proportions. E-cigarettes are also moderately useful smoking cessations aids. Restricting e-cigarettes to prescription only smoking cessation aids could help limit youth's access to them while keeping them available as therapies for patients who smoke conventional cigarettes. In Canada, drugs or devices must be approved by regulatory bodies such as Health Canada in order to become licensed prescription medications. A similar situation is underway in Australia, where e-cigarettes have been restricted to prescription only. This commentary explores the feasibility of a similar regulation for e-cigarettes in Canada as prescription smoking cessation aids.

Nicotine Dependency Levels Among Adult Electronic Cigarette Smokers in Jeddah, Saudi Arabia: An Analytical Cross-Sectional Study

BACKGROUND

Electronic cigarettes (ECs) are a recent method to deliver nicotine with less harmful effects than traditional cigarettes. Studying nicotine dependence in adult EC users is a crucial area, but few measures are available to evaluate nicotine dependence induced by EC. Our study aims to estimate the levels of nicotine dependency among adult EC smokers using a modified Fagerström Test of Nicotine Dependence (e-FTND) in Jeddah, Saudi Arabia, and to identify EC-associated sociodemographic and smoking-related factors affecting nicotine dependency.

METHODS

An analytical cross-sectional study was conducted on adults 18 years of age and older in Jeddah, Saudi Arabia, from December 2023 to March 2024. Data were collected from the participants using a pre-tested structured self-administered questionnaire, and nicotine dependence was assessed using the modified e-FTND. Descriptive statistics such as frequency, mean, and standard deviation were applied. Chi-square was used to assess the association between categorical variables. Ordinal regression was used to predict the nicotine dependency levels with different variables.

RESULTS

A total of 344 participants were included in the study. The mean e-FTND score for EC users was 4.14 ± 2.45. Females had a lower likelihood of experiencing higher dependence compared to males (OR = 0.52, 95% CI: 0.32, 0.85). Using ECs for more than three years was associated with higher odds of increased dependence (OR = 3.18, 95% CI: 1.28, 7.98; p < 0.001). The use of Pod system devices lowered the odds of developing high nicotine dependence (OR = 0.32, 95% CI: 0.13, 0.75; p = 0.01) compared to Iqos device users, while mechanical Mod device users exhibited a trend towards higher dependence, although it was not statistically significant. Nicotine concentration in ECs had a significant impact on the degree of nicotine dependence. Higher concentrations were associated with increased odds of higher dependence (12-18 mg: OR = 3.26, 95% CI: 1.55, 6.91; >18 mg: OR = 4.53, 95% CI: 2.37, 8.75; p < 0.001).

CONCLUSION

Most exclusive EC users in the study developed a moderate nicotine dependence level. The EC device type and nicotine concentration were significant drivers of nicotine dependence. Additionally, the personal characteristics of the users, such as male gender and duration of use, were associated with a higher risk of dependence. An in-depth understanding of the magnitude of nicotine dependence among EC users will enhance the opportunity for tailored health-enhancing interventions and policies.

Comparison of bladder carcinogenesis biomarkers in the urine of traditional cigarette users and e-cigarette users

Background

During the use of electronic cigarettes (e-cigarettes), users are still exposed to carcinogens similar to those found in tobacco products. Since these carcinogens are metabolized and excreted in urine, they may have carcinogenic effects on the bladder urinary tract epithelium. This meta-analysis aimed to compare bladder cancer carcinogens in the urine of tobacco users and e-cigarette users using a large number of samples.

Methods

A systematic meta-analysis was performed using data obtained from several scientific databases (up to November 2023). This cumulative analysis was performed following the Preferred Reporting Items for Systematic Evaluation and Meta-Analysis (PRISMA) and Assessing the Methodological Quality of Systematic Evaluations (AMSTAR) guidelines, according to a protocol registered with PROSPERO. This study was registered on PROSPERO and obtained the unique number: CRD42023455600.

Results

The analysis included 10 high-quality studies that considered polycyclic aromatic hydrocarbons (PAHs), volatile organic compounds (VOCs) and tobacco-specific nitrosamines (TSNAs). Statistical indicators show that there is a difference between the tobacco user group and the e-cigarette user group in terms of 1-Hydroxynaphthalene (1-NAP) [weighted mean difference (WMD)10.14, 95% confidence interval (CI) (8.41 to 11.88), p < 0.05], 1-Hydroxyphenanthrene (1-PHE) [WMD 0.08, 95% CI (-0.14 to 0.31), p > 0.05], 1-Hydroxypyrene (1-PYR) [WMD 0.16, 95% CI (0.12 to 0.20), p < 0.05], 2-Hydroxyfluorene (2-FLU) [WMD 0.69, 95% CI (0.58 to 0.80), p < 0.05], 2-Hydroxynaphthalene (2-NAP) [WMD 7.48, 95% CI (4.15 to 10.80), p < 0.05], 3-Hydroxyfluorene (3-FLU) [WMD 0.57, 95% CI (0.48 to 0.66), p < 0.05], 2-Carbamoylethylmercapturic acid (AAMA) [WMD 66.47, 95% CI (27.49 to 105.46), p < 0.05], 4-Hydroxy-2-buten-1-yl-mercapturic acid (MHBMA) [WMD 287.79, 95% CI (-54.47 to 630.04), p > 0.05], 4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNAL) [WMD 189.37, 95% CI (78.45 to 300.29), p < 0.05], or N0-nitrosonornicotine (NNN) [WMD 11.66, 95% CI (7.32 to 16.00), p < 0.05].

Conclusion

Urinary bladder cancer markers were significantly higher in traditional tobacco users than in e-cigarette users.Systematic review registration: PROSPERO (CRD42023455600: https://www.crd.york.ac.uk/PROSPERO/).

Combustible cigarette smokers versus e-cigarette dual users among Latinx individuals: Differences in alcohol and drug use severity

The Latinx population in the United States (U.S.) experiences significant tobacco and other substance use-related health disparities. Yet, little is known about the couse of combustible cigarettes and e-cigarettes (dual use) in relation to substance use behavior among Latinx smokers. The present investigation compared English-speaking Latinx adults living in the United States who exclusively smoke combustible cigarettes versus dual users in terms of alcohol use and other drug use problem severity. Participants were 297 Hispanic/Latinx daily cigarette smokers (36.4% female, Mage = 35.9 years, SD = 8.87) recruited nationally across the United States using Qualtrics Panels to complete self-report measures of behavioral health outcomes. Five analysis of covariance models were conducted to evaluate differences in overall alcohol consumption, dependence, related problems, hazardous drinking, and drug use problem severity between exclusive combustible cigarette smokers (N = 205) and dual users (N = 92). Results indicated that dual users evinced greater levels of alcohol consumption, dependence, alcohol-related problems, and hazardous drinking compared to exclusive combustible cigarette smokers (ps < .001). Dual users also reported greater levels of drug use problems relative to exclusive combustible cigarette smokers (p < .001). The current findings are among the first to document that dual cigarette and e-cigarette use status (compared to exclusive combustible cigarette smoking) may serve as a clinically relevant risk indicator for a range of deleterious substance use problems among Latinx individuals. Future research is needed to corroborate these findings and examine dual-use status as a longitudinal predictor of alcohol and other substance-related problems. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

[The e-cigarette - means of smoking cessation?]

After several years of declining tobacco consumption, the number of smokers in Germany is currently stagnating or rising again. The reasons seem to be manifold, e. g. stress caused by the pandemic with social isolation, rising cost of living and war in Europe.With tobacco use still widespread in the German population, evidence-based tobacco cessation is rarely implemented.According to recent studies, e-cigarettes are involved in the pathogenesis of lung disease, cardiac and vascular damage. In addition, their ingredients also have carcinogenic effects. However, clinical studies on long-term use are not yet available.E-cigarettes as a consumer product are not superior to nicotine replacement products and addiction-reducing medications recommended in guidelines. In the therapeutic setting, they are slightly more effective than nicotine replacement products. However, they are usually consumed continuously and thus perpetuate nicotine dependence. Their use increases the risk of relapse to tobacco smoking.Despite the various new approaches, such as Internet-based offerings, app, etc., talks and pharmacotherapy are the gold standard and more effective than any therapy on its own.

Electronic cigarettes for smoking cessation

BACKGROUND

Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol by heating an e-liquid. People who smoke, healthcare providers and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review.

OBJECTIVES

To examine the safety, tolerability and effectiveness of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence, in comparison to non-nicotine EC, other smoking cessation treatments and no treatment.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register to 1 February 2023, and Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 July 2023, and reference-checked and contacted study authors.

SELECTION CRITERIA

We included trials in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention as these studies have the potential to provide further information on harms and longer-term use. Studies had to report an eligible outcome.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Critical outcomes were abstinence from smoking after at least six months, adverse events (AEs), and serious adverse events (SAEs). We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in pairwise and network meta-analyses (NMA).

MAIN RESULTS

We included 88 completed studies (10 new to this update), representing 27,235 participants, of which 47 were randomized controlled trials (RCTs). Of the included studies, we rated ten (all but one contributing to our main comparisons) at low risk of bias overall, 58 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There is high certainty that nicotine EC increases quit rates compared to nicotine replacement therapy (NRT) (RR 1.59, 95% CI 1.29 to 1.93; I2 = 0%; 7 studies, 2544 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6 more). There is moderate-certainty evidence (limited by imprecision) that the rate of occurrence of AEs is similar between groups (RR 1.03, 95% CI 0.91 to 1.17; I2 = 0%; 5 studies, 2052 participants). SAEs were rare, and there is insufficient evidence to determine whether rates differ between groups due to very serious imprecision (RR 1.20, 95% CI 0.90 to 1.60; I2 = 32%; 6 studies, 2761 participants; low-certainty evidence). There is moderate-certainty evidence, limited by imprecision, that nicotine EC increases quit rates compared to non-nicotine EC (RR 1.46, 95% CI 1.09 to 1.96; I2 = 4%; 6 studies, 1613 participants). In absolute terms, this might lead to an additional three quitters per 100 (95% CI 1 to 7 more). There is moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 1840 participants). There is insufficient evidence to determine whether rates of SAEs differ between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 9 studies, 1412 participants; low-certainty evidence). Due to issues with risk of bias, there is low-certainty evidence that, compared to behavioural support only/no support, quit rates may be higher for participants randomized to nicotine EC (RR 1.88, 95% CI 1.56 to 2.25; I2 = 0%; 9 studies, 5024 participants). In absolute terms, this represents an additional four quitters per 100 (95% CI 2 to 5 more). There was some evidence that (non-serious) AEs may be more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low-certainty evidence; 4 studies, 765 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 0.89, 95% CI 0.59 to 1.34; I2 = 23%; 10 studies, 3263 participants; very low-certainty evidence). Results from the NMA were consistent with those from pairwise meta-analyses for all critical outcomes, and there was no indication of inconsistency within the networks. Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons, hence, evidence for these is limited, with CIs often encompassing both clinically significant harm and benefit.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain due to risk of bias inherent in the study design. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but the longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of adults in the PATH Study in 2017-2019 vs 2019-2021

Introduction

The use of cigarettes and electronic nicotine delivery system (ENDS) has likely changed since 2019 with the rise of pods and disposables, the outbreak of lung injuries related to vaping THC, flavor bans, and the COVID pandemic. We analyzed patterns of initiation, cessation, and transitions between cigarettes, ENDS, and dual use before and after 2019.

Methods

Using the Population Assessment of Tobacco and Health (PATH) Study, we applied a multistate transition model to 28,061 adults in Waves 4-5 (2017-19) and 24,751 adults in Waves 5-6 (2019-21), estimating transition rates for initiation, cessation, and switching products for each period overall and by age group.

Results

Cigarette initiation among adults who never used either product decreased from 2017-19 to 2019-21, but ENDS initiation did not significantly change. Persistence of ENDS-only use remained high, with 75-80% still using ENDS only after 1 year. Cigarette-only use transitions remained similar, with about 88% remaining, 7% transitioning to non-current use, and 5% transitioning to dual or ENDS-only use. In contrast, dual use to ENDS-only transitions increased from 9.5% (95%CI: 7.3-11.7%) to 20.1% (95%CI: 17.5-22.7%) per year from 2017-19 to 2019-21, decreasing the persistence of dual use. The dual use to cigarette-only transition remained at about 25%. These changes were qualitatively similar across adult age groups, though adults ages 18-24 years exhibited the highest probability of switching from cigarette-only use to dual use and from dual use to ENDS-only use.

Conclusions

Persistence of ENDS use among adults remained high in 2019-21, but a larger fraction of dual users transitioned to ENDS-only use compared to 2017-19. Because the fraction of cigarette-only users switching to dual use remained low, the public health implications of the increased dual use to ENDS-only transition are minimal.

Respiratory health effects of e-cigarette substitution for tobacco cigarettes: a systematic review

BACKGROUND

E-cigarettes (electronic nicotine delivery system, ENDS) have been presented as a harm reduction strategy for people who smoke tobacco cigarettes but who cannot achieve abstinence, or for those who wish to continue to enjoy nicotine and the habit of smoking. What are the health effects of the substitution of ENDS for tobacco cigarettes? This systematic review evaluates the evidence of human clinical tests on the respiratory effects of ENDS use in participants who smoke tobacco cigarettes.

METHODS

A registered and published protocol was developed conforming to PRISMA 2020 and AMSTAR2 standards. The literature search was conducted in PubMed, Scopus, and the CENTRAL Cochrane Library and updated to May 2022. Three supplementary searches and a grey literature search were performed. Studies were evaluated with the JBI quality tools and the Oxford Catalogue of Bias. Due to the heterogeneity (diversity) of the studies, a narrative data synthesis was performed on the test findings plus three sub-group analyses.

RESULTS

The review consists of sixteen studies and twenty publications. Spirometry tests comprised the majority of the data. In total, 66 respiratory test measurements were reported, out of which 43 (65%) were not significant. Statistically significant findings were mixed, with 9 tests showing improvements and 14 measuring declines, none of which was clinically relevant. Ten studies were rated at a high risk of bias, and six had some concerns primarily due to inadequate research designs and the conduct of the studies. Reporting bias was documented in thirteen studies.

CONCLUSIONS

Most of the studies showed no difference in respiratory parameters. This indicates that ENDS substitution for smoking likely does not result in additional harm to respiratory health. Due to the low quality of the studies, confidence in the conclusions is rated as low. Robust studies with a longer duration and sufficient power are required to validate any potential benefits or possible harms of ENDS substitution. Registration PROSPERO #CRD42021239094, International Registered Report Identifier (IRRID): DERR1-10.2196/29084.

Analysis of illicit drugs in purchased and seized electronic cigarette liquids from the United Kingdom 2014-2021

Increasing popularity and known shortfalls in the regulation of electronic cigarettes (ECs) emphasises the urgent need for closer content monitoring and for comprehensible information on their possible health effects. This study investigated components of EC liquids in samples submitted from 2014 to 2021 and discussed the trends driven by legislation changes. Samples originating from prisoners, teenagers and 'test purchases' of commercially available ECs were analysed by gas chromatography-mass spectrometry (GC-MS). For those containing delta-9-tetrahydrocannabinol (THC) and/or cannabidiol (CBD), the content of these components was quantified by liquid chromatography with quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) to show variation of these compounds in EC liquids; 112 EC liquids were included in this study. Nicotine was detected in 87 (78%) of the EC liquids analysed. Twenty-two, including samples from before and after introduction of the UK Psychoactive Substances Act (2016), contained one or more synthetic cannabinoid receptor agonist (SCRA). THC was detected in only 11 samples, whereas a single sample was found to contain CBD only. Six samples contained a mixture of THC and CBD. In all cases where information was available, the THC/CBD content was less than that stated on the product label. The data collected showed great variation in EC liquid content. Therefore, it is important that users are educated regarding risks associated with EC use. Additionally, substances now controlled under both the UK Misuse of Drugs Act and Psychoactive Substances Act were present. These substances each carry a potential risk to health, which is possibly exacerbated if multiple compounds are inhaled concomitantly.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

Associations between smoking and vaping prevalence, product use characteristics, and mental health diagnoses in Great Britain: a population survey

BACKGROUND

Rates of diseases and death from tobacco smoking are substantially higher among those with a mental health condition (MHC). Vaping can help some people quit smoking, but little is known about vaping among people with MHCs or psychological distress. We assessed the prevalence and characteristics (heaviness, product type) of smoking and/or vaping among those with and without a history of single or multiple MHC diagnoses and with no, moderate or serious psychological distress.

METHODS

Data from 27,437 adults in Great Britain surveyed between 2020 and 2022. Multinomial regressions analysed associations between smoking, vaping and dual use prevalence, smoking/vaping characteristics and (a) history of a single or multiple MHC and (b) moderate or serious psychological distress, adjusted for age, gender, and socioeconomic status.

RESULTS

Compared with people who had never smoked, those who currently smoked were more likely to report a history of a single (12.5% vs 15.0%, AOR=1.62, 95% CI=1.46-1.81, p<.001) or multiple MHCs (12.8% vs 29.3%, AOR=2.51, 95% CI=2.28-2.75, p<.001). Compared with non-vapers, current vapers were more likely to report a history of a single (13.5% vs 15.5%, AOR=1.28, 95% CI=1.11-1.48, p<.001) or multiple MHCs (15.5% vs 33.4%, AOR=1.66, 95% CI=1.47-1.87, p<.001). Dual users were more likely to report a history of multiple MHCs (36.8%), but not a single MHC than exclusive smokers (27.2%) and exclusive vapers (30.4%) (all p<.05). Similar associations were reported for those with moderate or serious psychological distress. Smoking roll-your-own cigarettes and smoking more heavily, were associated with a history of single or multiple MHCs. There were no associations between vaping characteristics and a history of MHCs. Frequency of vaping, device type and nicotine concentration differed by psychological distress.

CONCLUSIONS

Smoking, vaping and dual use were substantially higher among those with a history of MHC, especially multiple MHC, and experiencing past month distress than those not having a history of MHC or experiencing past month distress respectively. Analysis used descriptive epidemiology and causation cannot be determined.

Rat bronchoalveolar lavage proteome changes following e-cigarette aerosol exposures

E-cigarette liquids are complex mixtures of chemicals consisting of humectants, such as propylene glycol (PG) and vegetable glycerin (VG), with nicotine or flavorings added. Published literature emphasizes the toxicity of e-cigarette aerosols with flavorings whereas much less attention has been given to the biologic effects of humectants. The purpose of the current study was to provide a comprehensive view of the acute biologic effects of e-cigarette aerosols on rat bronchoalveolar lavage (BAL) using mass spectrometry-based global proteomics. Sprague-Dawley rats were exposed to e-cigarette aerosol for 3 h/day for three consecutive days. Groups included: PG/VG alone, PG/VG + 2.5% nicotine (N), or PG/VG + N + 3.3% vanillin (V). Right lung lobes were lavaged for BAL and supernatants prepared for proteomics. Extracellular BAL S100A9 concentrations and BAL cell staining for citrullinated histone H3 (citH3) were also performed. From global proteomics, ∼2,100 proteins were identified from rat BAL. The greatest change in number of BAL proteins occurred with PG/VG exposures alone compared with controls with biological pathways enriched for acute phase responses, extracellular trap formation, and coagulation. Extracellular BAL S100A9 concentrations and the number of citH3 + BAL cells also increased significantly in PG/VG and PG/VG + 2.5% N. In contrast to PG/VG or PG/VG + N, the addition of vanillin to PG/VG + N increased BAL neutrophilia and downregulated lipid transport proteins. In summary, global proteomics support e-cigarette aerosol exposures to PG/VG alone as having a significant biologic effect on the lung independent of nicotine or flavoring with increased markers of extracellular trap formation.

A systematic review and meta-analysis of interventions to induce attempts to quit tobacco among adults not ready to quit

The prevalence of past-year smoking cessation remains below 10% in the U.S. Most who smoke are not ready to quit in the near future. Cessation requires both (a) initiating a quit attempt (QA) and (b) maintaining abstinence. Most research has focused on abstinence among people already motivated to quit. We systematically reviewed interventions to promote QAs among people not motivated to quit tobacco. We searched PubMed, CENTRAL, PsycINFO, Embase, and our personal libraries for randomized trials of tobacco interventions that reported QAs as an outcome among adults not ready to quit. We screened studies and extracted data in duplicate. We pooled findings of the 25 included studies using Mantel-Haenszel random effects meta-analyses when ≥ 2 studies tested the same intervention. Most (24) trials addressed cigarettes and one addressed smokeless tobacco. Substantial heterogeneity among trials resulted in a series of small meta-analyses. Findings indicate varenicline may increase QAs more than no varenicline, n = 320; RR = 1.4, 95% CI [1.1, 1.7]; I² = 0%, and nicotine replacement therapy (NRT) may increase QAs more than no NRT, n = 2,568; RR = 1.1, 95% CI [1.02, 1.3]; I² = 0%. Pooled effects for motivational counseling, reduction counseling, and very low nicotine content cigarettes showed no clear evidence of benefit or harm. The evidence was judged to be of medium to very low certainty due to imprecision, inconsistency, and risk of bias, suggesting that further research is likely to change interpretation of our results. Findings demonstrate the need for more high-quality research on interventions to induce QAs among adults not ready to quit tobacco. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Novel Puff Recording Electronic Nicotine Delivery System for Assessing Naturalistic Puff Topography and Nicotine Consumption During Ad Libitum Use: Ancillary Study

BACKGROUND

Assessing the naturalistic puff topography and associated nicotine consumption during e-cigarette use is important as such information will not only unveil how these products are being consumed in real-world conditions, but also enable investigators and regulatory bodies to conduct quantitative, accurate, and realistic harmful exposure and nicotine abuse liability risk assessments based on actual e-cigarette use. Conventional approaches cannot accurately, conveniently, and noninvasively determine e-cigarette puff topography in a natural use environment. Thus, novel technology-enabled systems that do not primarily rely on self-report mechanisms or intrusive measurements to monitor e-cigarette product use behaviors are highly desired.

OBJECTIVE

This study aimed to explore and demonstrate the feasibility of a novel puff recording electronic nicotine delivery system (PR-ENDS) device for measuring naturalistic puff topography and estimating nicotine consumption during the ad libitum use of products among smokers and vapers.

METHODS

An ancillary data analysis based on a completed parent study was conducted. The parent study was a 1-way randomized controlled open-label puff topography and nicotine pharmacokinetic assessment carried out in 24 healthy adults (12 smokers and 12 vapers). Participants were assigned a randomized product use sequence of a PR-ENDS device within 5 site visits for both controlled and ad libitum product use sessions. Blood samples were obtained for plasma nicotine analysis, and questionnaires were administered at various time points. During the ad libitum use session, puff topography was measured using a Clinical Research Support System (CReSS) device as a benchmark, as well as the PR-ENDS device with a built-in puff recording feature.

RESULTS

There were no significant differences in representative puff topography parameters (number of puffs, total puff duration, and average puff duration) between the PR-ENDS and CReSS devices at the populational level across different device powers, e-liquid nicotine strengths, and flavors. The nicotine consumption estimated by the PR-ENDS device suggested that this device can be employed as a convenient monitoring tool for estimating nicotine use without measuring e-liquid weight loss between puffs. The linear relationship between nicotine consumption estimated by the PR-ENDS device and the pharmacokinetic parameter AUC_{ad lib} (plasma concentration-time curve for 1-hour ad libitum use) substantiated the potential of using this device as a pragmatic, noninvasive, and convenient means for estimating nicotine intake in the human body without blood collection.

CONCLUSIONS

The novel PR-ENDS device was feasible for assessing naturalistic puff topography and estimating nicotine consumption and intake in the human body during ad libitum use. Several key factors can influence users' puff topography, including device power levels, e-liquid nicotine strengths, and flavors. The study results pave the way for further research in the real-time measurement of naturalistic puff topography and puffing behaviors in the real world.

Electronic cigarettes for smoking cessation

BACKGROUND

Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, although some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review.

OBJECTIVES

To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 July 2022, and reference-checked and contacted study authors.  SELECTION CRITERIA: We included randomized controlled trials (RCTs) and randomized cross-over trials, in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report abstinence from cigarettes at six months or longer or data on safety markers at one week or longer, or both.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included the proportion of people still using study product (EC or pharmacotherapy) at six or more months after randomization or starting EC use, changes in carbon monoxide (CO), blood pressure (BP), heart rate, arterial oxygen saturation, lung function, and levels of carcinogens or toxicants, or both. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in meta-analyses.

MAIN RESULTS

We included 78 completed studies, representing 22,052 participants, of which 40 were RCTs. Seventeen of the 78 included studies were new to this review update. Of the included studies, we rated ten (all but one contributing to our main comparisons) at low risk of bias overall, 50 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There was high certainty that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (RR 1.63, 95% CI 1.30 to 2.04; I2 = 10%; 6 studies, 2378 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6). There was moderate-certainty evidence (limited by imprecision) that the rate of occurrence of AEs was similar between groups (RR 1.02, 95% CI 0.88 to 1.19; I2 = 0%; 4 studies, 1702 participants). SAEs were rare, but there was insufficient evidence to determine whether rates differed between groups due to very serious imprecision (RR 1.12, 95% CI 0.82 to 1.52; I2 = 34%; 5 studies, 2411 participants). There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.94, 95% CI 1.21 to 3.13; I2 = 0%; 5 studies, 1447 participants). In absolute terms, this might lead to an additional seven quitters per 100 (95% CI 2 to 16). There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 1840 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 8 studies, 1272 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.66, 95% CI 1.52 to 4.65; I2 = 0%; 7 studies, 3126 participants). In absolute terms, this represents an additional two quitters per 100 (95% CI 1 to 3). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was some evidence that (non-serious) AEs were more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 1.03, 95% CI 0.54 to 1.97; I2 = 38%; 9 studies, 1993 participants).  Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons, hence evidence for these is limited, with CIs often encompassing clinically significant harm and benefit.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the effect size. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates, but further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.

[The e-cigarette - means of smoking cessation?]

After several years of declining tobacco consumption, the number of smokers in Germany is currently stagnating or rising again. The reasons seem to be manifold, e. g. stress caused by the pandemic with social isolation, rising cost of living and war in Europe.With tobacco use still widespread in the German population, evidence-based tobacco cessation is rarely implemented.According to recent studies, e-cigarettes are involved in the pathogenesis of lung disease, cardiac and vascular damage. In addition, their ingredients also have carcinogenic effects. However, clinical studies on long-term use are not yet available.E-cigarettes as a consumer product are not superior to nicotine replacement products and addiction-reducing medications recommended in guidelines. In the therapeutic setting, they are slightly more effective than nicotine replacement products. However, they are usually consumed continuously and thus perpetuate nicotine dependence. Their use increases the risk of relapse to tobacco smoking.Despite the various new approaches, such as Internet-based offerings, app, etc., talks and pharmacotherapy are the gold standard and more effective than any therapy on its own.

Past, present and future of living systematic review: a bibliometrics analysis

INTRODUCTION

In recent years, the concept of living systematic review (LSR) has attracted the attention of many scholars and institutions. A growing number of studies have been conducted based on LSR methodology, but their focus direction is unclear. The objective of this study was to provide a comprehensive review of existing LSR-related studies and to analyse their whole picture and future trends with bibliometrics.

METHODS

A comprehensive search strategy was used to construct a representative dataset of LSRs up to October 2021. GraphPad V.8.2.1 and Mindmaster Pro presented the basic information of the included studies and the timeline of LSR development, respectively. The author and country cooperation network, hotspot distribution clustering, historical citation network and future development trend prediction related to LSR were visualised by VOSviewer V.1.6.16 and R-Studio V.1.4.

RESULTS

A total of 213 studies were eventually included. The concept of LSR was first proposed in 2014, and the number of studies has proliferated since 2020. There was a closer collaboration between author teams and more frequent LSR research development and collaboration in Europe, North America and Australia. Numerous LSR studies have been published in high-impact journals. COVID-19 is the predominant disease of concern at this stage, and the rehabilitation of its patients and virological studies are possible directions of research in LSR for a long time to come. A review of existing studies found that more than half of the LSR series had not yet been updated and that the method needed to be more standardised in practice.

CONCLUSION

Although LSR has a relatively short history, it has received much attention and currently has a high overall acceptance. The LSR methodology was further practised in COVID-19, and we look forward to seeing it applied in more areas.

Assessment of inhalation toxicity of cigarette smoke and aerosols from flavor mixtures: 5-week study in A/J mice

Most flavors used in e-liquids are generally recognized as safe for oral consumption, but their potential effects when inhaled are not well characterized. In vivo inhalation studies of flavor ingredients in e-liquids are scarce. A structure-based grouping approach was used to select 38 flavor group representatives (FGR) on the basis of known and in silico-predicted toxicological data. These FGRs were combined to create prototype e-liquid formulations and tested against cigarette smoke (CS) in a 5-week inhalation study. Female A/J mice were whole-body exposed for 6 h/day, 5 days/week, for 5 weeks to air, mainstream CS, or aerosols from (1) test formulations containing propylene glycol (PG), vegetable glycerol (VG), nicotine (N; 2% w/w), and flavor (F) mixtures at low (4.6% w/w), medium (9.3% w/w), or high (18.6% w/w) concentration or (2) base formulation (PG/VG/N). Male A/J mice were exposed to air, PG/VG/N, or PG/VG/N/F-high under the same exposure regimen. There were no significant mortality or in-life clinical findings in the treatment groups, with only transient weight loss during the early exposure adaptation period. While exposure to flavor aerosols did not cause notable lung inflammation, it caused only minimal adaptive changes in the larynx and nasal epithelia. In contrast, exposure to CS resulted in lung inflammation and moderate-to-severe changes in the epithelia of the nose, larynx, and trachea. In summary, the study evaluates an approach for assessing the inhalation toxicity potential of flavor mixtures, thereby informing the selection of flavor exposure concentrations (up to 18.6%) for a future chronic inhalation study.

Systematic review on e-cigarette and its effects on weight gain and adipocytes

Smoking and obesity are leading causes of morbidity and mortality worldwide. E-cigarette which was first introduced in 2000s is perceived as an effective alternative to conventional tobacco smoking. Limited knowledge is available regarding the risks and benefits of e-cigarettes. This study systematically reviews the current literature on the effects of e-cigarettes on body weight changes and adipocytes. The search was performed using OVID Medline and Scopus databases and studies meeting the inclusion criteria were independently assessed. This review included all English language, empirical quantitative and qualitative papers that investigated the effects of e-cigarettes on bodyweight or lipid accumulation or adipocytes. Literature searches identified 4965 references. After removing duplicates and screening for eligibility, thirteen references which involve human, in vivo and in vitro studies were reviewed and appraised. High prevalence of e-cigarette was reported in majority of the cross sectional studies conducted among respondent who are obese or overweight. More conclusive findings were identified in in vivo studies with e-cigarette causing weight decrease. However, these observations were not supported by in vitro data. Hence, the effect of e-cigarette on body weight changes warrants further investigations. Well-designed population and molecular studies are needed to further elucidate the role of e-cigarettes in obesity.

Investigating the effect of e-cigarette use on quitting smoking in adults aged 25 years or more using the PATH study

Background: The evidence on harms and benefits of e-cigarettes partly concerns whether their use encourages smokers to quit.  We addressed this using data from the nationally representative PATH study, with detailed accounting for potential confounding variables.

Methods: We considered adults aged 25+.  Our original analyses, reported in version 1 of this paper, used data for Waves 1 to 3, separate analyses considering Waves 1 to 2, 2 to 3 and 1 to 3.  These related baseline ever e-cigarette use (or e-product use at Wave 2) to quitting at follow-up, adjusting for confounders derived from 55 candidates.  Sensitivity analyses omitted ever other product users, linked quitting to current e-cigarette use, and used values of some predictors modified using follow-up data.  Additional analyses used data for Waves 1 to 4, separately considering sustained, delayed and temporary quitting during Waves 1 to 3, 2 to 4 and 1 to 4.  Sensitivity analyses considered 30-day quitting, restricted attention to smokers attempting to quit, and considered ever smokeless tobacco or snus use.

Results: In the original analyses, unadjusted odds ratios (ORs) of quitting smoking for ever e-cigarette use were 1.29 (95% CI 1.01-1.66), 1.52 (1.26-1.83) and 1.47 (1.19-1.82) for the Wave 1 to 2, 2 to 3, and 1 to 3 analyses.  These reduced after adjustment, to 1.23 (0.94-1.61), 1.51 (1.24-1.85) and 1.39 (1.11-1.74).  Quitting rates remained elevated in users in all sensitivity analyses.  The additional analyses found associations of e-cigarette use with sustained, delayed and temporary quitting, associations little affected by considering 30-day quitting, and only slightly reduced restricting attention to quit attempters.  Ever use of smokeless tobacco or snus also predicted increased quitting.  

Conclusions: As does most evidence from clinical trials, other analyses of PATH, and other epidemiological studies, our results suggest using e-cigarettes helps adult smokers to quit.

Vaping control in Nova Scotia: using research to catalyze change

The tobacco, and now vaping, industries are skilled at creating falsification campaigns that leave policymakers and the public confused and distracted. As Nova Scotia saw youth vaping rates rise, a non-profit conducted a youth and young adult survey to discover why, what, and how often youth and young adults vape. They discovered that almost 96% of youth prefer flavours, and 48% believed they would quit if flavours were removed. This research was pivotal in capturing the voices of youth, gathering stakeholders, and countering industry opposition. On April 1, 2020, the Nova Scotian government implemented Canada's first ban on flavoured vaping products. This was followed by a nicotine cap of 20 mg/ml and a revamped taxation structure. The survey allowed non-profits to band together and align messages. It also provided government with information to take actions that reduce the prevalence and potential harms of vaping among youth. This commentary describes the advocacy process and opposition faced when advocating for vaping control measures. This approach can serve as a guide for assisting other jurisdictions in advocating for policy changes.

A cross-sectional survey of smoking and cessation support policies in a sample of homeless services in the United Kingdom

BACKGROUND

Smoking is extremely common amongst adults experiencing homelessness. To date, there is no nationally representative data on how tobacco dependence is treated and if and how smoking cessation is supported across the homeless sector. The aim of this study was to document smoking and e-cigarette policies of UK homeless services and identify areas of good practice and where improvements could be made.

METHODS

A cross-sectional survey with homeless centre staff was conducted between June 2020-December 2020 totalling 99 homeless centres. Quotas were stratified based on population and service type across Scotland, Northern Ireland, Wales, and England. Interviews were conducted over the phone or online in a minority of cases. Survey questions were themed to assess, i) onsite smoking and e-cigarette (vaping) policies ii) screening and recording of smoking status, iii) cessation training and resources available to staff, iv) cessation support for service users.

RESULTS

92% accounted for smoking within their policies in some form (stand-alone policy (56%) or embedded within another health and safety policy (36%)). 84% allowed smoking in at least some (indoor and outdoor) areas. In areas where smoking was not allowed, vaping was also disallowed in 96% of cases. Staff smoking rates were 23% and 62% of centres reported staff smoked with service users. Just over half (52%) reported screening and recording smoking status and 58% made referrals to Stop Smoking Services (SSS), although established links with SSS were low (12%) and most centres did not provide staff training on supporting smoking cessation. Areas of good practice included regular offers of smoking cessation support embedded in routine health reviews or visits from SSS and offering tangible harm reduction support. Areas for improvement include staff training, staff smoking with service users and skipping routine screening questions around smoking.

CONCLUSIONS

Smoking is accounted for across different policy types and restricted in some areas within most settings. Smoking cessation support is not routinely offered across the sector and there is little involvement with the SSS.

Smoking cessation aids and strategies: a population-based survey of former and current smokers in Norway

BACKGROUND

In Norway, tobacco consumption is equally divided between combustible (cigarettes) and non-combustible (snus) tobacco. In the process of quitting, people who smoke can choose between several smoking cessation aids and strategies based on what is available on the market or what are recommended as cessation aids. A quit attempt may be planned or unplanned and consist of a gradual decline in consumption or an abrupt quitting. This study explores smoking cessation aids and strategies used at the latest quit attempt among people who have ever smoked. How prevalent is the use of various cessation aids and strategies, and do they correlate with each other? Are there any differences in successful quits depending on the use of a specific cessation aid or strategy?

METHOD

We used repeated cross-sectional representative surveys in Norway for 2017, 2018, 2019 and 2020. The analytic sample consists of people aged 20 years or older who have ever smoked daily, more precisely current daily smokers with at least one quit attempt (n = 476), and former daily smokers who quit in 2012 or later (n = 397). Participants answered questions on cessation aids and strategies used at their last quit attempt. Logistic regression analysis was used to estimate the associations between cessation aids and strategies and sociodemographic and smoking-related variables and successful quit attempts.

RESULTS

Fifty-six percent of people who ever smoked daily reported any use of cessation aids, and nicotine replacement therapy (NRT), snus and e-cigarettes were the most commonly used cessation aids. Snus and web/mobile use was associated with successful quits, while NRT was associated with unsuccessful quit attempts. When exclusive use was separated from the combined use of several aids, only snus was associated with successful quits.

CONCLUSION

Snus use was found to be a "stand-alone" cessation aid, and only weakly associated with the use of other cessation aids. Further investigation of cessation aid preferences is needed, especially among smokers with little or no contact with health services and/or for whom traditional cessation aids have no appeal.

Menthol Flavor in E-Cigarette Vapor Modulates Social Behavior Correlated With Central and Peripheral Changes of Immunometabolic Signalings

The use of electronic cigarette (e-cigarette) has been increasing dramatically worldwide. More than 8,000 flavors of e-cigarettes are currently marketed and menthol is one of the most popular flavor additives in the electronic nicotine delivery systems (ENDS). There is a controversy over the roles of e-cigarettes in social behavior, and little is known about the potential impacts of flavorings in the ENDS. In our study, we aimed to investigate the effects of menthol flavor in ENDS on the social behavior of long-term vapor-exposed mice with a daily intake limit, and the underlying immunometabolic changes in the central and peripheral systems. We found that the addition of menthol flavor in nicotine vapor enhanced the social activity compared with the nicotine alone. The dramatically reduced activation of cellular energy measured by adenosine 5′ monophosphate-activated protein kinase (AMPK) signaling in the hippocampus were observed after the chronic exposure of menthol-flavored ENDS. Multiple sera cytokines including C5, TIMP-1, and CXCL13 were decreased accordingly as per their peripheral immunometabolic responses to menthol flavor in the nicotine vapor. The serum level of C5 was positively correlated with the alteration activity of the AMPK-ERK signaling in the hippocampus. Our current findings provide evidence for the enhancement of menthol flavor in ENDS on social functioning, which is correlated with the central and peripheral immunometabolic disruptions; this raises the vigilance of the cautious addition of various flavorings in e-cigarettes and the urgency of further investigations on the complex interplay and health effects of flavoring additives with nicotine in e-cigarettes.

Longitudinal transition outcomes among adult dual users of e-cigarettes and cigarettes with the intention to quit in the United States: PATH Study (2013-2018)

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Many dual users of e-cigarettes/cigarettes report using e-cigarettes with the ITQ.

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Data was from 3,542 adults (≥18 years) from the PATH cohort (2013–2018).

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Dual users with ITQ were compared with mono cigarette smokers with ITQ.

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Dual users with ITQ were less likely to transition to cessation.

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This needs to be considered when assessing the population impact of e-cigarettes.

Many adult dual users of e-cigarettes and cigarettes in the United States report using e-cigarettes with the intention to quit (ITQ) smoking. This study examined transition outcomes among adult dual users of e-cigarettes and cigarettes with the ITQ compared to mono cigarette smokers with ITQ. We conducted a longitudinal analysis of 3,542 adults aged ≥ 18 years with data from Waves 1 and 4 of the United States Population Assessment of Tobacco and Health study (2013–2018) between May 2021 and January 2022. Current dual users (e-cigarettes and cigarettes use on ≥ 20 days in the past month) with the ITQ were compared to current mono cigarette smokers with the ITQ for transition outcomes (cessation, mono e-cigarette, mono cigarette and dual use) three years later. We conducted multinomial logistic regression modeling adjusting for potential confounders and reported the adjusted relative risk ratios (aRRR) with 95% confidence intervals (CI) for the transition outcomes. Approximately 10.7% (7.8–14.3) of dual users with the ITQ (in 2013) reported cessation (no past-month use of any tobacco) three years later, compared to 16.1% (14.6–17.7) of mono cigarette smokers. Dual users were 83% and 79% less likely to transition to cessation (aRRR: 0.17, 95% CI:0.09–0.32) or mono cigarette use (0.21, 0.14–0.32), respectively, compared to mono cigarette smokers. Our findings show that in a real-world scenario, dual e-cigarette and cigarette use may hinder rather than facilitate smoking cessation among those interested in quitting. This needs consideration when assessing the population impact of e-cigarettes and their role in harm reduction.

Changes in tobacco use at the early stage of the COVID-19 pandemic: Results of four cross-sectional surveys in Hong Kong

INTRODUCTION

Changes in tobacco use since the COVID-19 outbreak differed by countries and little is known about changes in the use of specific tobacco products.

METHODS

We analyzed data from four cross-sectional telephone/online surveys from April to June 2020 to investigate such changes since the 1st and 2nd wave outbreaks (February to April 2020) in Hong Kong. The respondents were 1595 adults (83.2% male) who used tobacco before the COVID-19 outbreak from our previous intervention study and surveys. We investigated the changes in tobacco use, intention to quit and quit attempts during the outbreak.

RESULTS

About two-thirds (65.3%) of respondents reported no change in overall tobacco use, while 23.1% used less (including cessation) and 11.6% used more, resulting in a net decrease of 11.5 percentage points. A greater net decrease was observed for cigarettes (14.3% points) than heated tobacco products (HTPs, 3.3% points) and electronic cigarettes (e-cigarettes, 2.5% points). Decreased use was mainly due to the more extended stay at home (63.2%), health considerations (52.6%) and mask-wearing (47.4%), while increased use was for passing time (75.0%) and releasing stress (46.4%). Eight percent of cigarette, HTP and e-cigarette users reported a higher intention to quit since the pandemic outbreak. Nineteen percent of tobacco users (176/948) attempted to quit during the pandemic. Only 2.9% (46/1569) were abstinent at the time of the survey.

CONCLUSIONS

Overall tobacco use decreased after the first two waves of the COVID-19 outbreak in Hong Kong. A greater proportion of cigarette users decreased use than HTP and e-cigarette users. Given the different methods used in the four surveys, future studies should aim for a large and representative sample.

Electronic cigarette related topics with conflicting arguments in Chinese newspapers

INTRODUCTION

While debates on e-cigarettes are mainly conducted in scientific fora, media are the most accessible information source for the public, shaping their perceptions of health issues. This study is the first to examine e-cigarette related topics with conflicting arguments presented in Chinese newspapers.

METHODS

The Chinese terms for ‘e-cigarettes’ were searched in a widely used Chinese news database Wisenews. Content analysis of the full text of 639 news articles was conducted to identify topics with conflicting arguments and examine whether the dominant argument in each topic changed across four time periods from 2004 to 2019.

RESULTS

Twelve e-cigarette related topics with conflicting arguments were identified. The most frequently reported topic was health impact of e-cigarettes, followed by impact of secondhand aerosol exposure, smoking cessation, relative health impact of e-cigarettes compared to cigarettes, and e-cigarette policies outside China. At the same time, the price was the least frequently reported topic. Overall, negative arguments outnumbered positive arguments in the study period. The dominant arguments within many topics changed across time periods; however, within the topics of relative health impact of e-cigarettes compared to cigarettes, taste/flavor, and economic prospects of the industry, positive arguments were more frequently reported in almost all periods. Within the topics of addiction, policies in China, and policies outside China, negative arguments were more frequently reported in virtually all periods.

CONCLUSIONS

Though overall the dominant argument about e-cigarettes and health was ‘e-cigarettes are harmful’, in the early time periods, e-cigarettes were reported as ‘harmless’ or even ‘healthy’. As China began to regulate e-cigarettes, the reporting on e-cigarettes more frequently included the ‘e-cigarettes are harmful’ argument. The consistent, more frequent reporting of ‘good e-cigarette taste/flavor’ has the potential to attract young people to e-cigarette products. The increased reporting on policies unfavorable to e-cigarettes aligned with the growing number of regulations restricting e-cigarettes.

Relationships Between Depressive Symptoms, Anxiety, Impulsivity and Cigarette and E-cigarette Use Among Young Adults

Depression and anxiety have been associated with cigarette use among young people. Higher impulsivity has also been associated with increased smoking behavior. However, relatively less is known about the associations between depression, anxiety, impulsivity and e-cigarette use and how these associations compare with the associations between depression, anxiety, impulsivity and cigarette smoking. In addition, little is known about how impulsivity influences the relationships between depression, anxiety, cigarette, and e-cigarette use. This study tested the hypothesis that higher depression and anxiety symptoms are associated with higher e-cigarette use and cigarette smoking in a similar way, and that these associations would be stronger among those with higher impulsivity. A sample of 2,622 young adults (18-25 year olds; 54% women) enrolled in 4-year and 2-year colleges in Hawai'i participated in a cross-sectional survey. Approximately 68% of the sample reported no use of either e-cigarettes or cigarettes, 13% reported only e-cigarette use, 9% reported only cigarette smoking, and 11% reported use of both. The study found that higher depressive and anxiety symptoms and higher impulsivity were significantly associated with current cigarette and e-cigarette use. For example, one unit increases in depression, anxiety, and impulsivity were associated with 34%, 17%, and 38% increased odds of e-cigarette use versus non-use, respectively. Impulsivity was found to significantly moderate the association between higher anxiety and higher cigarette smoking, such that the association was stronger among those with higher impulsivity. Impulsivity was not found to moderate any other association. Results suggest that tobacco product use prevention education should target children and young adults with higher internalizing symptoms, with particular attention to those who show higher impulsivity.

Reductions in biomarkers of exposure to selected harmful and potentially harmful constituents following exclusive and partial switching from combustible cigarettes to myblu™ electronic nicotine delivery systems (ENDS)

Electronic nicotine delivery systems (ENDS) offer adult combustible cigarette smokers an alternative, potentially reduced harm, mode of nicotine delivery, attributed to fewer and reduced levels of harmful and potentially harmful constituents (HPHCs) in their aerosols compared to cigarette smoke. These two identical, randomised, open label, two-part studies aimed to compare levels of 15 biomarkers of exposure (BoE) to selected HPHCs associated with tobacco smoking in healthy US adult smoker subjects (n = 72). Following 9 days of exclusive use of a range of allocated myblu™ ENDS variants, subjects' levels of 14 non-nicotine BoE were substantially reduced compared to baseline values (combustible cigarette use), in the range of 46-97%. BoE reductions were sustained in subjects who continued myblu use exclusively (n = 25) for a further 5 days, and returned to near baseline levels in subjects who returned to exclusive combustible cigarette use (n = 21). Dual users (n = 24) demonstrated reductions in BoE to a lesser extent than with exclusive myblu use. Measured nicotine equivalents did not significantly change throughout the study. These data suggest exclusive use of ENDS provides adult smokers seeking an alternative to combustible cigarettes with substantial reductions in HPHC exposures whilst achieving satisfying levels of nicotine delivery. Dual use involving substitution of cigarettes may also provide some of this advantage, but to lesser extent. Overall, the data contribute to the weight of evidence that ENDS are an important tool in tobacco harm reduction for adult smokers unwilling to or uninterested in quitting smoking. Study 1: NCT04430634, study 2: NCT04429932, clinicaltrials.gov (10-06-2020).

Challenges associated with e-cigarette use by people in custody in Scottish prisons: a qualitative interview study with prison staff

OBJECTIVES

Little is known about the perspectives of staff working in prisons where e-cigarettes are permitted. Scotland now permits people in custody (PiC), but not staff/visitors to use e-cigarettes, following implementation of smoke-free prisons policy in 2018. Previous studies, conducted before and immediately after the introduction of e-cigarettes in Scottish prisons, have evidenced stakeholder support for their use by PiC. This study focuses on key challenges associated with e-cigarette use in prisons, using data collected from prison staff once e-cigarettes had been allowed in a smoke-free environment for 6-9 months.

SETTING

Five prisons in Scotland.

PARTICIPANTS

Sixteen qualitative interviews were conducted with prison staff from five prisons varying by population (sex, age and sentence length). Data were managed and analysed using the framework approach.

RESULTS

While these staff confirmed strong support for the smoke-free prison policy and reported some benefits of replacing tobacco with e-cigarettes, they also spoke of the challenges e-cigarettes pose. These included: workplace e-cigarette vapour exposures; perceptions that e-cigarettes provide a new, effective way for some PiC to take illegal drugs, particularly new psychoactive substances; organisational challenges relating to the value attached to e-cigarettes in prisons; and implications for long-term nicotine use and tobacco cessation. Staff anticipated difficulties in tightening restrictions on e-cigarette use by PiC given its scale and significance among this population.

CONCLUSIONS

Maximising the benefits of e-cigarette use by PiC is likely to require multiple measures to support effective and safe use and e-cigarette reduction/cessation where desired. This includes monitoring any misuse of e-cigarettes, and provision of guidance and support on appropriate e-cigarette use and how to limit or quit use if desired. Findings are relevant to jurisdictions considering or planning changes in prison smoking or vaping policies.

Optimal use of smoking cessation pharmacotherapy

The most effective intervention for stopping smoking is a combination of professional counselling and pharmacotherapy. Medicines are recommended for all smokers who are motivated to quit and are nicotine dependent. Combination nicotine replacement therapy with a patch and an oral product is more effective than the patch alone. An adequate dose of nicotine must be used for an adequate duration. Varenicline is the most effective oral drug. It is safe in people with stable mental illness. Vaping nicotine is a second-line treatment which can be considered for smokers who are unable to quit with other methods.

Electronic Cigarettes or Vaping: Are There Any Differences in the Profiles, Use and Perceptions between a Developed and a Developing Country?

The use of electronic cigarettes or vaping is currently increasing in popularity globally. Debate continues regarding their potential role for smoking cessation. We aimed to compare the profiles, use and perceptions of using e-cigarettes amongst online forum users in a developed and a developing country. A cross-sectional survey was conducted among members of different popular online forums in Australia and Bangladesh who were current or ex-users of e-cigarettes. There were 422 study participants, 261 (62%) from Australia and 161 (38%) from Bangladesh. The mean age was 36.3 (±12) years and 83% were men. Australians were more likely to be exclusive users of e-cigarettes (70% vs. 30%, AOR 3.05 [95% CI 1.63–5.71]), but less likely to be dual users of smoking and e-cigarettes (43% vs. 57%, 0.36 [0.19–0.69]); they were also more likely to mention that the perceived reasons for using were their low cost, good taste/flavour, safety and assistance in reducing or quitting smoking (66% vs. 34%, 5.10 [2.04–12.8]), but less likely to mention a social/cool image as a reason for use (23% vs. 77%, 0.11 [0.01–0.87]) compared with Bangladeshi participants. About two-thirds of the participants in both countries perceived the use of e-cigarettes as less addictive than cigarettes and more than three-quarters perceived them as less harmful. E-cigarette users in Australia were more likely to use them to reduce or quit cigarettes compared with those in Bangladesh, and dual use was common in Bangladesh. These findings warrant the consideration of precautions for promoting e-cigarettes as a harm reduction strategy for smoking cessation in developing countries, such as Bangladesh.

Knowledge and attitudes on smoking cessation of e-cigarettes: a mixed-methods study of pharmacy students in Surabaya, Indonesia

Background

Pharmacy students as candidates for health workers who will take part in smoking cessation. Knowledge and attitudes of smoking cessation can help map the behavior of pharmacists in the future. This study aimed to explore knowledge and attitudes on smoking cessation of e-cigarettes with the mixed methods study of pharmacist students.

Method

This research was conducted in Januari-Juni 2021 in Surabaya. The research design was mix-method with sequential explanatory strategy. The variables were knowledge and attitudes on smoking cessation of e-cigarettes. The sample in this qualitative approach was derived from a sample of quantitative data. Respondents were interviewed in depth until the data reached the saturation level in order to obtain good and usable qualitative data.

Results

This study involved 31 respondents. The highest level of knowledge about dangers of e-cigarettes, especially related to nicotine (100% of respondents answered correctly). The highest positive level of attitude about dangers of e-cigarettes, especially e-cigarettes harmful to passive smokers (27% of respondents had positive attitude). Cigarettes were harmful to lung and cardiovascular health, regarding the dangers of passive smoking, some agree and disagree. Non-smokers didn't need to be recommended for e-cigarettes, e-cigarettes can be recommended for tobacco smokers, e-cigarettes cause addiction, and e-cigarettes can be a good recommendation for those who want to carry out smoking cessation. Regulation of e-cigarettes in Indonesia was considered to be lacking and needs to be improved.

Conclusions

Pharmacist students have a high level of knowledge and a positive attitude towards smoking cessation.

From Tobacco Cigarettes to Electronic Cigarettes: The Two Sides of a Nicotine Coin

Tobacco smoking-related diseases, including cardiovascular disease, pulmonary disease, stroke, and cancer in multiple organ sites, are the leading causes of preventable death, worldwide. Youth electronic cigarette use (vaping) is an evolving public health problem in the United States and around the world. Many of the same toxicants and carcinogens present in tobacco smoke are also found in electronic cigarette vapor, although mostly at substantially lower levels. The reduced concentrations of these chemicals in electronic cigarette vapor may imply lower health risk; however, they cannot equate to no risk. To date, the long-term health consequences of vaping are largely unknown. This “Perspective” provides a concise chronology of events leading up to an unprecedented global challenge, namely the convergence of global tobacco epidemic and youth vaping epidemic. Current state of knowledge, outstanding questions in the field, present challenges, and future directions in research are highlighted. The existing data show a continued and dynamic evolution of the converged epidemics. The goal should be to prevent youth vaping while improving smoking cessation strategies. In smokers who are unable or unwilling to quit smoking, the objective should be to provide “provably” safe or less-harmful alternatives, which should “completely” or “substantially” substitute tobacco cigarettes.

Do e-cigarettes attract youths who are otherwise unlikely to use addictive substances? Cross-sectional analyses of Dutch and Flemish secondary school students

INTRODUCTION

E-cigarettes are popular among youth. There are concerns that e-cigarettes attract youth that would otherwise not use addictive substances. While e-cigarettes are thought to be less harmful than tobacco, there is reason for caution. We examined to what extent adolescent e-cigarette users have characteristics associated with increased risk of substance use.

METHODS

We collected cross-sectional survey data in 2018 among 10 schools throughout the Netherlands and Belgium (N=2794; age 10-18 years). We examined differences in characteristics and behaviors between e-cigarette ever users and never users, and former users and current users. We also explored differences in use of flavors and use of nicotine.

RESULTS

Compared to never-users, e-cigarettes users more often were boys, older, had lower education level, non-Dutch or non-Belgian ethnicity, reported more combustible tobacco use, more smoking family members or family with problematic substance use, more smoking friends, more depressive symptoms, more impulsivity, more delinquent behavior, were more susceptible to smoking, had more positive smoking expectancies, and more ever use of substances. Users of non-tobacco flavored e-cigarettes and e-cigarettes without nicotine had fewer characteristics known to be related to an increased risk of substance use, compared to users of tobacco-flavored e-cigarettes and e-cigarettes with nicotine.

CONCLUSIONS

Adolescent e-cigarette users are more like youths who experiment with addictive substances compared to non-users. Thus, e-cigarettes users were more likely to use substances, regardless of whether they used e-cigarettes first. This may not be true for all types of e-cigarettes, as users of e-cigarettes without nicotine or with non-tobacco flavors were less like youths who experiment with substances.

The Effects of E-Cigarette Use on Alcohol and Marijuana Abuse Symptoms in an Ethnically Diverse Sample of Young Adults

BACKGROUND

We examined e-cigarette use as a prospective predictor of alcohol and marijuana abuse symptoms in a sample consisting of Native Hawaiian and Other Pacific Islander (NHPI), Filipino, Asian (i.e., Japanese, Chinese, Korean), and White young adults. NHPI represent a highly vulnerable group with regard to substance use and are severely understudied.

METHODS

Data were collected from 1463 young adults (M age = 22.2, SD = 3.2; 59.5% women) enrolled across community colleges in Hawai'i at two time-points six months apart.

RESULTS

Higher frequency of e-cigarette use at baseline was predictive of higher alcohol (B = 0.06, SE = 0.02, p < 0.01) and marijuana (B = 0.06, SE = 0.02, p < 0.01) use problems at six-month follow up, adjusting for baseline cigarette smoking, problem alcohol/marijuana use, sensation seeking, and demographic variables. Ethnicity was found to significantly moderate the relationship between baseline e-cigarette use and problem marijuana use later, such that White and NHPI ethnicities were particularly vulnerable to the effects of e-cigarette use on problem marijuana use.

CONCLUSION

NHPI are often combined with Asians in national surveys, which obfuscates the higher risks faced by NHPI compared with groups that are routinely classified as Asians (e.g., Chinese, Japanese, Filipinos). The current research highlights the NHPI's vulnerability in terms of the effects of e-cigarette use on marijuana and alcohol abuse symptoms.

Efficacy and safety of electronic cigarettes as a smoking cessation intervention: A systematic review and network meta-analysis

INTRODUCTION

This systematic review of randomized controlled trials (RCTs) evaluated the efficacy and safety of electronic cigarettes (e-cigarettes, ENDS) in helping people who smoke to achieve abstinence compared with electronic non-nicotine delivery systems (ENNDS, no nicotine) or any smoking cessation comparator treatment or combination of treatments at 24–26 weeks and at 52 weeks.

METHODS

Systematic review techniques involved searches of three databases in February 2020 with update searches run on 14 May 2021, two-person independent screening, two-person independent assessment of bias, formal extraction of data with verification by a second person, a feasibility assessment to decide if meta-analysis was appropriate, and network meta-analysis (NMA) of data at 24–26 weeks. Data at 52 weeks were narratively summarized.

RESULTS

Ten RCTs met the inclusion criteria, eight for efficacy and ten for safety. Eight of the nine RCTs were assessed as at high risk of bias. The sample sizes of the RCTs were 30–2012. Using nicotine replacement therapy (NRT) as the reference treatment, the incidences of smoking cessation at 24–26 weeks were comparable between ENDS and NRT groups (RR=1.17; 95% CrI: 0.66–1.86). Three sensitivity analyses were carried out indicating the main findings for 24–26 weeks were robust to assumptions. The findings at 52 weeks were inconclusive.

CONCLUSIONS

This systematic review and NMA indicates that there is no clear evidence of a difference in effect between nicotine containing e-cigarettes and NRT on incidences of smoking cessation at 24–26 weeks, and substantial uncertainty remains.

Fundamentals of vaping-associated pulmonary injury leading to severe respiratory distress

Vaping of flavored liquids has been touted as safe alternative to traditional cigarette smoking with decreased health risks. The popularity of vaping has dramatically increased over the last decade, particularly among teenagers who incorporate vaping into their daily life as a social activity. Despite widespread and increasing adoption of vaping among young adults, there is little information on long-term consequences of vaping and potential health risks. This study demonstrates vaping-induced pulmonary injury using commercial JUUL pens with flavored vape juice using an inhalation exposure murine model. Profound pathological changes to upper airway, lung tissue architecture, and cellular structure are evident within 9 wk of exposure. Marked histologic changes include increased parenchyma tissue density, cellular infiltrates proximal to airway passages, alveolar rarefaction, increased collagen deposition, and bronchial thickening with elastin fiber disruption. Transcriptional reprogramming includes significant changes to gene families coding for xenobiotic response, glycerolipid metabolic processes, and oxidative stress. Cardiac systemic output is moderately but significantly impaired with pulmonary side ventricular chamber enlargement. This vaping-induced pulmonary injury model demonstrates mechanistic underpinnings of vaping-related pathologic injury.

Developing Graphic Messages for Vaping Prevention Among Black and Latino Adolescents: Participatory Research Approach

Background

As an important transition stage in human development, adolescence is a critical window for vaping prevention. There is a substantial gap in communication research on vaping prevention among racial and ethnic minority groups. Their representation is essential to develop, implement, and disseminate innovative and effective interventions for vaping prevention.

Objective

The aim of this study is to describe the participatory research (PR) procedures used with Black and Latino adolescents to develop culturally and linguistically appropriate graphic messages for vaping prevention.

Methods

This PR study used a qualitative, user-centered design method. We conducted a series of focus groups with 16 Black and Latino adolescents to develop culturally and linguistically appropriate graphic messages for vaping prevention. The biobehavioral model of nicotine addiction provided a framework for the development of the graphic messages. Participants met 4 times to provide iterative feedback on the graphic messages until they reached a consensus on overall quality and content.

Results

At baseline, the participants’ mean age was 15.4 years (SD 1.4). Of the participants, 50% (8/16) were female, 88% (14/16) were heterosexual, 56% (9/16) were Black/African American, and 44% (7/16) were Hispanic/Latino. A total of 12 of the 16 participants (75%) chose to participate in the English sessions. Participants decided to create four types of graphic messages: (1) financial reward, (2) health reward, (3) social norms, and (4) self-efficacy. Meeting 4 times with the 4 groups provided sufficient opportunities for iterative feedback on the graphic messages to reach a consensus on overall quality and content.

Conclusions

It is feasible and practical to build PR among Black and Latino adolescents focused on vaping prevention. Adolescents added innovation and creativity to the development of culturally and linguistically appropriate graphic messages for vaping prevention. Appropriate staffing, funding, and approaches are key for successful PR efforts among Black and Latino adolescents. Future research is needed to evaluate the impact of the graphic messages on vaping prevention.

A novel role for vaping in mitochondrial gene dysregulation and inflammation fundamental to disease development

We constructed and analyzed the whole transcriptome in leukocytes of healthy adult vapers (with/without a history of smoking), ‘exclusive’ cigarette smokers, and controls (non-users of any tobacco products). Furthermore, we performed single-gene validation of expression data, and biochemical validation of vaping/smoking status by plasma cotinine measurement. Computational modeling, combining primary analysis (age- and sex-adjusted limmaVoom) and sensitivity analysis (cumulative e-liquid- and pack-year modeling), revealed that ‘current’ vaping, but not ‘past’ smoking, is significantly associated with gene dysregulation in vapers. Comparative analysis of the gene networks and canonical pathways dysregulated in vapers and smokers showed strikingly similar patterns in the two groups, although the extent of transcriptomic changes was more pronounced in smokers than vapers. Of significance is the preferential targeting of mitochondrial genes in both vapers and smokers, concurrent with impaired functional networks, which drive mitochondrial DNA-related disorders. Equally significant is the dysregulation of immune response genes in vapers and smokers, modulated by upstream cytokines, including members of the interleukin and interferon family, which play a crucial role in inflammation. Our findings accord with the growing evidence on the central role of mitochondria as signaling organelles involved in immunity and inflammatory response, which are fundamental to disease development.

Prevalence and characteristics of ever regular use of non-combustible nicotine for 1 year or more: a population survey in England

INTRODUCTION

Up-to-date monitoring of non-combustible nicotine products (e.g. e-cigarettes, nicotine replacement therapies (NRT), heated tobacco products (HTP); NNP) is important to assess their impact. To date, there is little evidence on the association between ever regular use (defined here as 1 year or more) of NNP and current smoking status.

AIMS/METHODS

The purpose of this study was to examine the prevalence, and sociodemographic, alcohol and smoking status correlates, of ever regular use of NNP in England in 2020. A cross-sectional survey of adults in England was conducted between February and June 2020.

RESULTS

A total of 8486 adults were surveyed; 94.9% (8055) were complete cases. The weighted prevalence of ever regular NNP use was 5.4% (n = 436; 95% CI 5.0-6.0), of which 82% (n = 360; 95% CI 78.7-85.8) was single and 18% (n = 79; 95% CI 14.8-22) multiple product use. Amongst ever regular NNP users, the prevalence of ever regular NRT, e-cigarette and HTP use was 64.7% (95% CI 60.1-69), 43.4% (95% CI 38.8-48) and 2.5% (95% CI 1.4-4.5), respectively. In adjusted analysis, ever regular NNP use was associated with smoking status, being significantly higher among current (22.3%; adjusted OR (aOR) 34.9, 95% CI 24.0-50.8) and ex-smokers (12.7%, aOR 19.8, 95% CI 11.1-14.4) than among never-smokers (0.6%). More advantaged occupational grade (aOR, 1.27 95% CI 1.02-1.57) and at least hazardous alcohol use (aOR, 1.38 95% CI 1.06-1.78) were associated with greater prevalence of ever regular NNP use.

CONCLUSIONS

Ever regularly using NNP was highest among smokers and ex-smokers and rare among never-smokers. Among people who have ever regularly used NNP, NRT is the most popular.

How to manage cigarette smoking in kidney transplant candidates and recipients?

Tobacco smoking is a frequent problem affecting many kidney transplant (KT) candidates and recipients. The negative impact of active smoking on KT outcomes has been demonstrated. Consequently, most guidelines strongly recommend quitting smoking before considering kidney transplantation. However, nicotine addiction is a complex multifactorial disease and only 3–5% of the patients who try to quit by themselves achieve prolonged abstinence. Smoking cessation programmes (SCPs) have proven their efficacy in the general population to increase the rate of quitting and should therefore be proposed to all smoking KT candidates and recipients. Nevertheless, SCPs have not been evaluated in the KT field and not all KT centres have easy access to these programmes. In this work, we aim to review the current knowledge on the subject and provide an overview of the available interventions to help smoking patients quit. We detail non-pharmaceutical and pharmaceutical approaches and discuss their use in KT candidates and recipients.

Primary Care Physician Perspectives on Recommending E-cigarettes to Smokers: a Best-Worst Discrete Choice Experiment

BACKGROUND

Recent clinical trials suggest that e-cigarettes may be more effective for smoking cessation than traditional cessation aids, yet primary care physician (PCP) practices regarding e-cigarette recommendations for smokers have not been studied in-depth.

OBJECTIVE

To identify factors influencing PCP recommendation of e-cigarettes for smoking cessation.

DESIGN

Discrete choice experiment and survey.

PARTICIPANTS

Florida PCPs.

MEASURES

The survey included a discrete choice experiment in which PCPs indicated whether they would recommend e-cigarettes for each of 8 hypothetical patient profiles with the following contrasting characteristics: e-cigarette use, interest in approved cessation methods, smoking intensity, prior experience with approved cessation medications, quit intention, age, and comorbidity. Responses were summarized using descriptive statistics and standardized scores (SS).

KEY RESULTS

The sample (n = 216) was predominately male (76%), white (66%), and non-Hispanic (78%), and most respondents had held their medical degree for 20+ years (77%). The response rate was 28.7%. Most PCPs thought e-cigarettes were at least somewhat effective for smoking cessation (66%) and lowering disease risk (65%); 31% perceived e-cigarettes to be equally/more effective than traditional cessation aids. PCPs were split regarding whether e-cigarettes were less (50%) or equally harmful (38%) as cigarettes. Yet, few were very confident in their ability to counsel patients on e-cigarettes risks (27%) or benefits (15%). PCPs recommended e-cigarettes in 27% of patient profiles they evaluated. The most important factors influencing the decision to recommend or not recommend e-cigarette were patients' prior use of nicotine replacement therapy with (SS = 0.22, 95% CI = 0.17-0.27) and without use of other medications for cessation (SS = 0.18, 95% CI = 0.13-0.23), and being middle age (50 years old) with chronic obstructive pulmonary disease (SS = 0.16, 95% CI = 0.10-0.23).

CONCLUSIONS

Considering the increased patient use of e-cigarettes and increasing use for cessation, this study highlights the need for guidelines and education to aid PCPs' counseling of patients about e-cigarette use.

Electronic cigarette use and smoking cessation in cohort studies and randomized trials: A systematic review and meta-analysis

INTRODUCTION

The aim of this systematic review and meta-analysis was to assess the association between e-cigarette use and subsequent smoking cessation in cohort studies and randomized controlled trials (RCT).

METHODS

A systematic literature search was finalized 11 November 2019 using EMBASE, Cochrane Library, Scopus, PubMed Health, NICE evidence search, PROSPERO, CRD, PsycInfo, and PubMed including Medline. Inclusion criteria were: reporting empirical results; longitudinal observational design with a minimum of 3 months of follow-up; including general population samples; and allowing for comparison between users and non-users of e-cigarettes. Studies rated as having high risk of bias were excluded. The procedures described by PRISMA were followed, and the quality of evidence was rated using GRADE.

RESULTS

Twenty-eight longitudinal, peer-reviewed publications from 26 cohort studies, and eight publications from seven RCTs assessing the association between e-cigarette use and smoking cessation were included in this review. A random-effects meta-analysis based on 39147 participants in cohort studies showed a pooled unadjusted odds ratio (OR) for smoking cessation among baseline e-cigarette users compared with baseline non-users of 0.97 (95% CI: 0.67-1.40), while the adjusted OR was 0.90 (95% CI: 0.63-1.27). The pooled odds ratio for smoking cessation in RCTs was 1.78 (95% CI: 1.41-2.25). The evidence for cohort studies was graded as very low and for RCTs as low.

CONCLUSIONS

We did not find quality evidence for an association between e-cigarette use and smoking cessation. Although RCTs tended to support a more positive association between e-cigarette use and smoking cessation than the cohort studies, the grading of evidence was consistently low.

Key Informant Perspectives on Somali Adolescent Tobacco Use: Contextualizing Influences and Prevention Opportunities

INTRODUCTION

Somali American adolescent tobacco use has increased over the past decade amid a high prevalence of tobacco use among Somali American adults. While established adolescent tobacco use determinants may apply for Somali youth, a deeper understanding of these influences is imperative to the development of effective prevention strategies for this population. This study aimed to identify risk and protective factors influencing Somali American adolescent tobacco use decision making and potential family and community roles in tobacco prevention.

METHOD

We conducted 15 semistructured, in-depth interviews with 12 Somali and 3 non-Somali professionals serving Minnesotan metropolitan Somali communities in clinical, educational, religious, and other community organizations. Grounded Theory informed our data collection and analysis.

RESULTS

Key informants cited three major influences on Somali adolescent tobacco use: evolving norms and increasing exposure to tobacco products in the United States, low risks perception, especially for waterpipes, and conflicting interpretations of faith. Informants highlighted the important roles of families in Somali youth tobacco prevention while acknowledging areas where families would benefit from greater support. Proposed sources of support included faith communities and nonparental, ethnically similar adult mentors. Informants acknowledged challenges to addressing youth tobacco prevention in clinics and underscored the importance of youth involvement in developing prevention strategies.

CONCLUSIONS

Our results indicate Somali adolescent tobacco prevention efforts should address the evolving tobacco use exposures and norms, low risk perceptions, and clarify faith messaging. Effective strategies may include strengthening family-based tobacco prevention approaches that also engage faith and other community leaders along with youth themselves.

Counseling in Vape Shops: A Survey of Vape Shop Managers in Switzerland

Vaporizers (e-cigarettes) are the most common smoking cessation aids in Switzerland, but we do not know what information customers receive in vape shops. We surveyed vape-shop managers to find out what recommendations they make to their customers. An interdisciplinary group developed the questionnaire. Respondents self-reported their smoking history, demographics, and the recommendations they thought they would give to hypothetical customers in clinical vignettes. We also queried if they collaborated with health care professionals. Of those contacted, 53.8% (70/130) of vape-shop managers responded, and 52.3% (68/130) were included in the final analysis. Managers were mostly male and ex-smokers who switched to vaporizers; 60.3% would encourage a hypothetical smoker with high nicotine dependence to start with the highest possible nicotine concentration when switching to vaporizers. For this smoker, 36.9% would recommend high (≥15 mg/mL), 32.3% medium (6–14 mg/mL), and 3.1% low (1–5 mg/mL) nicotine concentrations. The rest adapted their recommendations to fit the customer or device; 76.5% reported that physicians referred customers to them, and 78.8% would attend a course given by experts in the field of vaporizers and smoking cessation. Vape-shop managers varied widely in the recommendations they gave customers. Most reported ongoing collaboration with health care professionals and were interested in improving their counselling skills through training.

[Diversification of smoking cessation programmes-the role of e-cigarettes]

The question of whether e‑cigarettes are a useful tool for smoking cessation is part of an ongoing and highly controversial scientific debate. In practice, however, the number of people trying to quit tobacco consumption by using these products is steadily increasing. This discussion article provides an outline of the current state of research on the issue of whether and to what extent e‑cigarettes can help people quit smoking.Of course, e‑cigarettes also have a certain potential for harm, especially if nicotine dependence is unnecessarily prolonged. Nevertheless, it can make an important contribution to harm reduction in nicotine consumption. Hence, the product should get treated as a serious alternative to nicotine replacement therapies (NRTs) in the scientific discussion. Like NRTs, e‑cigarettes offer a less harmful way of consuming nicotine that greatly reduces many of the health risks associated with tobacco consumption, such as the absorption of carcinogenic substances. Recent studies and reviews suggest that the product can be at least as effective as nicotine replacement therapies in helping people quit smoking. Individual studies even demonstrate the increased effectiveness of e‑cigarettes in supporting smoking cessation.Nevertheless, the review of the current literature shows that more high-quality research is needed to further understand the product and its properties. In terms of the harm reduction approach, however, it would already be more appropriate to also rely on e‑cigarettes instead of trying to force immediate and complete nicotine abstinence. After all, in the process of quitting smoking, the fastest possible cessation of the more unhealthy consumption of tobacco should be prioritized in order to immediately minimize unnecessary health risks.

Interventions for preventing weight gain after smoking cessation

BACKGROUND

Most people who stop smoking gain weight. This can discourage some people from making a quit attempt and risks offsetting some, but not all, of the health advantages of quitting. Interventions to prevent weight gain could improve health outcomes, but there is a concern that they may undermine quitting.

OBJECTIVES

To systematically review the effects of: (1) interventions targeting post-cessation weight gain on weight change and smoking cessation (referred to as 'Part 1') and (2) interventions designed to aid smoking cessation that plausibly affect post-cessation weight gain (referred to as 'Part 2').

SEARCH METHODS

Part 1 - We searched the Cochrane Tobacco Addiction Group's Specialized Register and CENTRAL; latest search 16 October 2020. Part 2 - We searched included studies in the following 'parent' Cochrane reviews: nicotine replacement therapy (NRT), antidepressants, nicotine receptor partial agonists, e-cigarettes, and exercise interventions for smoking cessation published in Issue 10, 2020 of the Cochrane Library. We updated register searches for the review of nicotine receptor partial agonists.

SELECTION CRITERIA

Part 1 - trials of interventions that targeted post-cessation weight gain and had measured weight at any follow-up point or smoking cessation, or both, six or more months after quit day. Part 2 - trials included in the selected parent Cochrane reviews reporting weight change at any time point.

DATA COLLECTION AND ANALYSIS

Screening and data extraction followed standard Cochrane methods. Change in weight was expressed as difference in weight change from baseline to follow-up between trial arms and was reported only in people abstinent from smoking. Abstinence from smoking was expressed as a risk ratio (RR). Where appropriate, we performed meta-analysis using the inverse variance method for weight, and Mantel-Haenszel method for smoking.

MAIN RESULTS

Part 1: We include 37 completed studies; 21 are new to this update. We judged five studies to be at low risk of bias, 17 to be at unclear risk and the remainder at high risk.  An intermittent very low calorie diet (VLCD) comprising full meal replacement provided free of charge and accompanied by intensive dietitian support significantly reduced weight gain at end of treatment compared with education on how to avoid weight gain (mean difference (MD) -3.70 kg, 95% confidence interval (CI) -4.82 to -2.58; 1 study, 121 participants), but there was no evidence of benefit at 12 months (MD -1.30 kg, 95% CI -3.49 to 0.89; 1 study, 62 participants). The VLCD increased the chances of abstinence at 12 months (RR 1.73, 95% CI 1.10 to 2.73; 1 study, 287 participants). However, a second study  found that no-one completed the VLCD intervention or achieved abstinence. Interventions aimed at increasing acceptance of weight gain reported mixed effects at end of treatment, 6 months and 12 months with confidence intervals including both increases and decreases in weight gain compared with no advice or health education. Due to high heterogeneity, we did not combine the data. These interventions increased quit rates at 6 months (RR 1.42, 95% CI 1.03 to 1.96; 4 studies, 619 participants; I² = 21%), but there was no evidence at 12 months (RR 1.25, 95% CI 0.76 to 2.06; 2 studies, 496 participants; I² = 26%). Some pharmacological interventions tested for limiting post-cessation weight gain (PCWG) reduced weight gain at the end of treatment (dexfenfluramine, phenylpropanolamine, naltrexone). The effects of ephedrine and caffeine combined, lorcaserin, and chromium were too imprecise to give useful estimates of treatment effects. There was very low-certainty evidence that personalized weight management support reduced weight gain at end of treatment (MD -1.11 kg, 95% CI -1.93 to -0.29; 3 studies, 121 participants; I² = 0%), but no evidence in the longer-term 12 months (MD -0.44 kg, 95% CI -2.34 to 1.46; 4 studies, 530 participants; I² = 41%). There was low to very low-certainty evidence that detailed weight management education without personalized assessment, planning and feedback did not reduce weight gain and may have reduced smoking cessation rates (12 months: MD -0.21 kg, 95% CI -2.28 to 1.86; 2 studies, 61 participants; I² = 0%; RR for smoking cessation 0.66, 95% CI 0.48 to 0.90; 2 studies, 522 participants; I² = 0%). Part 2: We include 83 completed studies, 27 of which are new to this update. There was low certainty that exercise interventions led to minimal or no weight reduction compared with standard care at end of treatment (MD -0.25 kg, 95% CI -0.78 to 0.29; 4 studies, 404 participants; I² = 0%). However, weight was reduced at 12 months (MD -2.07 kg, 95% CI -3.78 to -0.36; 3 studies, 182 participants; I² = 0%). Both bupropion and fluoxetine limited weight gain at end of treatment (bupropion MD -1.01 kg, 95% CI -1.35 to -0.67; 10 studies, 1098 participants; I² = 3%); (fluoxetine MD -1.01 kg, 95% CI -1.49 to -0.53; 2 studies, 144 participants; I² = 38%; low- and very low-certainty evidence, respectively). There was no evidence of benefit at 12 months for bupropion, but estimates were imprecise (bupropion MD -0.26 kg, 95% CI -1.31 to 0.78; 7 studies, 471 participants; I² = 0%). No studies of fluoxetine provided data at 12 months. There was moderate-certainty that NRT reduced weight at end of treatment (MD -0.52 kg, 95% CI -0.99 to -0.05; 21 studies, 2784 participants; I² = 81%) and moderate-certainty that the effect may be similar at 12 months (MD -0.37 kg, 95% CI -0.86 to 0.11; 17 studies, 1463 participants; I² = 0%), although the estimates are too imprecise to assess long-term benefit. There was mixed evidence of the effect of varenicline on weight, with high-certainty evidence that weight change was very modestly lower at the end of treatment (MD -0.23 kg, 95% CI -0.53 to 0.06; 14 studies, 2566 participants; I² = 32%); a low-certainty estimate gave an imprecise estimate of higher weight at 12 months (MD 1.05 kg, 95% CI -0.58 to 2.69; 3 studies, 237 participants; I² = 0%).

AUTHORS' CONCLUSIONS

Overall, there is no intervention for which there is moderate certainty of a clinically useful effect on long-term weight gain. There is also no moderate- or high-certainty evidence that interventions designed to limit weight gain reduce the chances of people achieving abstinence from smoking.