National Health and Medical Research Council statement on electronic cigarettes: 2022 update

INTRODUCTION

Electronic cigarette (e-cigarette) use in Australia has rapidly increased since the 2017 National Health and Medical Research Council (NHMRC) Chief Executive Officer (CEO) statement on e-cigarettes. The type of products available and the demographic characteristics of people using these products have changed. New evidence has been published and there is growing concern among public health professionals about the increased use, particularly among young people who do not currently smoke combustible cigarettes. The combination of these issues led NHMRC to review the current evidence and provide an updated statement on e-cigarettes. In this article, we describe the comprehensive process used to review the evidence and develop the 2022 NHMRC CEO statement on electronic cigarettes.

MAIN RECOMMENDATIONS

E-cigarettes can be harmful; all e-cigarette users are exposed to chemicals and toxins that have the potential to cause adverse health effects. There are no health benefits of using e-cigarettes if you do not currently smoke tobacco cigarettes. Adolescents are more likely to try e-cigarettes if they are exposed to e-cigarettes on social media. Short term e-cigarette use may help some smokers to quit who have been previously unsuccessful with other smoking cessation aids. There are other proven safe and effective options available to help smokers to quit.

CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT

The evidence base for the harms of e-cigarette use has strengthened since the previous NHMRC statement. Significant gaps in the evidence base remain, especially about the longer term health harms of using e-cigarettes and the toxicity of many chemicals in e-cigarettes inhaled as an aerosol.

Tobacco dependence management in a smoke-free inpatient drug and alcohol unit

OBJECTIVE

Various smoke-free policies and practices (carbon monoxide monitoring, nicotine replacement therapy, pharmacotherapy, behavioural interventions) have been introduced to manage tobacco dependence in inpatient drug and alcohol facilities. Since the introduction of a smoke-free policy to our inpatient drug and alcohol facility, there has been no objective evaluation of its practices or patients' views.

METHODS

We administered a questionnaire to 42 inpatients identified as smokers. A retrospective record review was performed on those patients for demographic data, substance use, psychiatric conditions and tobacco dependence assessment and management. Descriptive analyses and tests of association were conducted. Open-ended questions were subjected to content analysis.

RESULTS

Tobacco dependence assessment was mostly completed with daily cigarette consumption documented for 41 (98%), time to first cigarette for 39 (93%) and CO monitoring performed for 42 (100%) patients. Patients' views of the various management strategies were positive, although many were underutilised. Those with high tobacco dependence were more likely to approve of nicotine replacement therapy patches than those with low tobacco dependence (p = 0.009).

CONCLUSION

The results demonstrate that while the various interventions provided were reported to be helpful, many were underutilised. Future research could consider why certain strategies were not utilised and help improve uptake.

Asthma and smoking--healthcare needs and preferences of adults with asthma who smoke

OBJECTIVE

People with asthma smoke at least as much as, if not more than, people without asthma. The aim of this study was to explore the unique healthcare needs and preferences of smokers with asthma, in terms of smoking topography and initiation, perceived interplay between asthma and smoking, motivation and readiness to quit, and proposed smoking cessation techniques.

METHODS

Qualitative, semi-structured, in-depth telephone interviews with adult smokers who have concurrent asthma were conducted. Participants were recruited through flyers displayed at community pharmacies, general practice surgeries, university campuses, and respiratory clinics of tertiary hospitals and through an advertisement on the "Asthma Foundation" website. Recorded interviews were transcribed verbatim and analysed using NVivo 10 software (QSR International, Melbourne, Victoria, Australia). Obtained data were content-analysed for emergent themes using the 'framework approach'.

RESULTS

Twenty-four semi-structured interviews were conducted. Most participants believed that smoking often worsens their asthma and increases the frequency and severity of their symptoms. Fear of asthma-related exacerbations and poor self-control appeared to be the major triggers for quitting smoking. Most patients reported being motivated to quit smoking; however, in many cases, determination and strong will power need to be coupled with public, social, professional, and therapeutic support to achieve and maintain success.

CONCLUSIONS

Given the unique needs of people with asthma who smoke, it is imperative that evidence-based smoking cessation programs be designed and tailored to assist them in effectively quitting smoking.

A workshop on smoking cessation for pharmacy students

OBJECTIVE

To develop, implement, and evaluate a targeted educational intervention focusing on smoking cessation with final-year undergraduate pharmacy students.

DESIGN

A smoking-cessation educational workshop entitled Smoking Cessation in Pharmacy (SCIP) was designed on the principles of adult learning and implemented with a full cohort of final-year undergraduate pharmacy students at the University of Sydney. A previously validated questionnaire testing the knowledge and attitudes of respondents was administered both before and after implementation of the designed workshop to evaluate changes resulting from the intervention. Informal feedback was obtained from students.

ASSESSMENT

Pre-course mean total knowledge and attitude scores calculated were 65.8±9.1 and 86.4±12.1, respectively. The post-course mean total knowledge score was 74.9±8.1, and the attitude score was 88.8±9.1 Improvement in knowledge and attitudes was significant (p<0.05).

CONCLUSION

Educational interventions for pharmacy students designed with careful attention to pedagogic principles can improve knowledge about evidence-based smoking-cessation strategies and enhance positive attitudes to pharmacist roles in smoking cessation.

Smoking cessation in community pharmacy practice-a clinical information needs analysis

Background

With the emerging role of pharmacists in implementing smoking cessation services and the recent evidence about smoking cessation pharmacotherapies, a needs analysis to assess baseline knowledge about current smoking cessation practice is needed; hence, training and development in this area can target possible ‘gaps’.

Objective

This study aimed at exploring pharmacy students’ knowledge about and attitudes toward smoking cessation, as compared to practicing community pharmacists and smoking cessation educators. The overall objective was to uncover underlying ‘gaps’ in pharmacy-based smoking cessation practice, particularly clinical gaps.

Setting

Final-year pharmacy students at the University of Sydney, practicing community pharmacists and smoking cessation educators in Australia.

Method

As no previous standard pharmacist-focused smoking cessation knowledge questionnaires exist, a review of the literature informed the development of such a questionnaire. The questionnaire was administered to a cohort of fourth-year pharmacy students at the University of Sydney, practicing pharmacists and smoking cessation educators. Data analysis was performed using Predictive Analytics SoftWare (PASW® Statistics 18). Mean total scores, independent t-tests, analysis of variances and exploratory factor analysis were performed.

Main outcome measure

To determine areas of major clinical deficits about current evidence related to smoking cessation interventions at the pharmacy level.

Results

Responses from 250 students, 51 pharmacists and 20 educators were obtained. Smoking educators scored significantly higher than pharmacists and students (P < .05), while score differences in the latter two groups were not statistically significant (P > .05). All groups scored high on ‘general’ knowledge questions as compared to specialised pharmacologic and pharmacotherapeutic questions. All respondents demonstrated positive attitudes toward the implications of smoking cessation. Factor analysis of the 24-item knowledge section extracted 12 items loading on 5 factors accounting for 53% of the total variance.

Conclusions

The results provide a valid indication of ‘gaps’ in the practice of up-to-date smoking cessation services among Australian pharmacy professionals, particularly in clinical expertise areas involving assessment of nicotine dependence and indications, dosages, adverse effects, contraindications, drug interactions and combinations of available pharmacotherapies. These gaps should be addressed, and the results should inform the design, implementation and evaluation of a pharmacy-based educational training program targeting current clinical issues in smoking cessation.

A Combination Nicotine Replacement Therapy (NRT) Algorithm for Hard-to-Treat Smokers

Many smokers have not succeeded in quitting using a single nicotine replacement mode. An algorithm was developed for clinicians to enhance success rates when recommending nicotine replacement therapy (NRT) to smoking patients. The algorithm is based on clinical experience with chronic smokers with respiratory illnesses attending one-on-one smokers clinics in the Central Sydney Area Health Service. Based on transdermal nicotine therapy (patch) other forms of NRT are added if required for ‘breakout’ smoking for 2 weeks. Outcomes have shown 60% confirmed continuous abstinence at 3 months. Smokers can be safely and successfully treated symptomatically for nicotine withdrawal relief using combination NRT aggressively. This enhances treatment efficacy by minimising relapse in the first few weeks and months of quitting.

Smoking cessation in pregnancy

Managing smoking cessation during pregnancy is vital to the wellbeing of the fetus and the mother. Women who continue to smoke during pregnancy expose the fetus to thousands of chemicals which have been shown to cause deleterious short- and long-term effects. Although a large majority of women cease smoking early in the pregnancy, many of them relapse following delivery. Following a review of current research, an overview of the safety and efficacy of smoking cessation treatments for pregnant women will be considered. Limited research has been performed in this field; however, it can be concluded that low-dose intermittent nicotine replacement therapy is a safe treatment modality for women who smoke during pregnancy. At present there has been no research on other current smoking cessation treatments; however, we will suggest techniques to improve cessation rates and strategies to reduce relapse.

The four Ds deconstructed

For decades, pamphlets provided by credible government authorities have reproduced tips for quitting smoking, recommended with certainly, but with no basis in facts, findings or substantiated outcomes. The 'four Ds' are an example of a universally accepted set of instructions to quit smoking that has little basis in science. This anomaly is at odds with the era of evidence-based medical interventions and should be addressed.

Smokers can learn to influence their urge to smoke

Forty heavy smokers participated in a within-subject experiment in which the association between smoking-related cues and nicotine intake was made conditional on two neutral stimuli. Two colored cards indicated whether smoking-related cues, placed on the cards, would or would not be followed by nicotine intake. In the presence of each card, subjects were asked to rank their urge to smoke before and during the exposure to the smoking cues. The results of the present study revealed that the predictive value of a cue, in regard to the occurrence of nicotine intake, strongly determines its ability to generate craving. It was concluded that participants learned a modified predictive value of smoking cues, through a process of conditioning, and in this way influenced their urge to smoke. Furthermore, the findings suggest the reconditioning of CS-US associations as an aid in the treatment of smoking addiction.

Recurrent aphthous ulcers and nicotine

OBJECTIVE

The aim of this study was to investigate the effect of nicotine, in the form of Nicorette tablets, on aphthous ulcers in non-smoking patients. The study was prompted by the observations that smokers are less likely to suffer from mouth ulcers, that some smokers on quitting develop them, and that patients on nicotine replacement therapy are less likely to develop ulcers than those having other types of smoking cessation therapy.

CLINICAL FEATURES

The three non-smoking patients who were selected for the study each had a long history of recurrent aphthous ulcers with no remissions.

INTERVENTION AND OUTCOME

Each patient was given up to four 2 mg Nicorette chewing tablets per day. After one month of this regimen each patient was weaned off the tablets. In each case the ulcers healed and new ulcers did not appear during Nicorette therapy. Two of the patients relapsed when weaned off the tablets.

CONCLUSIONS

This preliminary trial shows that nicotine may have a beneficial effect on aphthous ulcers. Further studies are necessary to elucidate the mechanism.

Smoking in hospitalised patients

A survey was conducted in a large inner-city hospital to examine the extent of overt and covert smoking being carried out by patients while they were in hospital. There were 311 patients studied. Twenty percent of all patients tested admitted to smoking during their admission, and another 8% showed expired carbon monoxide levels indicative of recent smoking, but denied they had smoked. The percentage of any one ward that were smoking varied from 4% to 41%. Patients with cardiac and respiratory disease were much more likely to lie about their smoking than those with other diseases. Smokers were more than twice as likely to be readmitted for the same condition than nonsmokers.

Conditions for effective Nd-YAG laser angioplasty

To establish the optimal conditions for recanalisation of obstructed arteries without damage to vessel walls, a Nd-YAG laser coupled to a 0.2 mm diameter optic fibre was used on obstructed human cadaver coronary and peripheral arteries and on popliteal arteries in amputated limbs. Vaporization of atheromatous plaques was consistently obtained with an energy of 360-600 J and a diluted blood perfusate (3 g/100 ml haemoglobin) at a rate of 20 ml/min. The arterial wall was protected from thermal injury by inserting the optic fibre into an inflated balloon catheter and by cooling the system with the perfusate. Since recanalisation of occluded arteries was consistently obtained without damage to the arterial wall or debris and thin and flexible optic fibres were easy to guide in the arteries, percutaneous transluminal Nd-YAG laser angioplasty was used in obstructed femoral and popliteal arteries in three patients. The first European trials in man showed the method to be feasible, effective, and harmless, although further studies are required to improve penetration of the obstruction and increase the diameter of tunnel.