Position statement on electronic cigarettes or electronic nicotine delivery systems [Official statement]

Prediction of potential passive exposure from commercial electronic nicotine delivery systems using exhaled breath analysis and computational fluid dynamic techniques

Use of computational fluid dynamic (CFD) modeling to predict temporal and spatial constituent exposure for non-electronic nicotine delivery systems (ENDS) users (passive exposure) provides a more efficient methodology compared to conducting actual exposure studies. We conducted a clinical study measuring exhaled breath concentrations of glycerin, propylene glycol, nicotine, benzoic acid, formaldehyde, acetaldehyde, acrolein, menthol and carbon monoxide from use of eight different commercial ENDS devices and a non-menthol and menthol cigarette. Because baseline adjusted levels of other constituents were not consistently above the limit of detection, the mean minimum and maximum per puff exhaled breath concentrations (N= 20/product) of glycerin (158.7-260.9µg), propylene glycol (0.941-3.58µg), nicotine (0.10-1.06µg), and menthol (0.432-0.605µg) from use of the ENDS products were used as input parameters to predict temporal and spatial concentrations in an environmental chamber, office, restaurant, and car using different ENDS use scenarios. Among these indoor locations and ENDS use scenarios, the car with closed windows resulted in the greatest concentrations while opening the car windows produced the lowest concentrations. The CFD predicted average maximum glycerin and propylene glycol concentration ranged from 0.25 to 1068µg m^-3and 1.5 pg m^-3to 13.56µg m^-3,respectively. For nicotine and menthol the CFD predicted maximum concentration ranged from 0.16 pg m^-3to 4.02µg m^-3and 0.068 pg m^-3to 2.43µg m^-3, respectively. There was better agreement for CFD-predicted nicotine concentrations than glycerin and propylene glycol with published reports highlighting important experimental and computational variables. Maximum measured nicotine levels from environmental tobacco smoke in offices, restaurants, and cars exceeded our maximum average CFD predictions by 7-97 times. For all the measured exhaled breath constituents and CFD predicted constituents, except for propylene glycol and glycerin, concentrations were less from use of ENDS products compared to combustible cigarettes. NCT number: NCT04143256.

Toxicity of electronic cigarettes: A general review of the origins, health hazards, and toxicity mechanisms

Electronic cigarettes (E-cigarette) are an alternative for traditional cigarette smokers to quit smoking. Based on the current understanding, electronic cigarettes have rapidly become popular among existing smokers and former non-smokers. However, increasing research at different levels reveals that e-cigarettes are unsafe. This review provides an overview of the toxicology of e-cigarettes based on existing in vivo and in vitro studies and compares their toxicity with that of traditional cigarettes. Moreover, we describe the associated toxicity components in e-cigarettes, as well as the potential mechanism by which e-cigarettes exert toxic effects. As is known to all, the nicotine in traditional cigarettes and e-cigarettes has certain toxicity. Besides, a few studies have shown that propylene glycol and vegetable glycerin mixture and flavoring agents in e-cigarettes also are the key components causing adverse effects in animals or cells. There is insufficient scientific evidence on the toxicity of e-cigarettes due to the lack of standardized research methods, prompting the need to conduct a comprehensive toxicity assessment of e-cigarette toxicity to elucidate the safety issues of e-cigarettes. Eventually, a basis for decision-making on whether people use e-cigarettes will be obtained.

Room air constituent concentrations from use of electronic nicotine delivery systems and cigarettes using different ventilation conditions

To assess potential exposure of non-users to exhaled constituents from pod and cartridge electronic nicotine delivery systems (ENDS) products, an environmental clinical study was conducted with (n = 43) healthy adult smokers. Room air concentrations of 34 selected constituents (nicotine, propylene glycol, glycerin, 15 carbonyls, 12 volatile organic compounds, and 4 trace metals) and particle number concentration (0.3 to 25 µm) were compared from use of two ENDS products and conventional cigarettes using room ventilations representative of a residential, an office or a hospitality setting over a 4-h. exposure period. Products used were JUUL ENDS, Virginia Tobacco flavor (Group I), VUSE Solo, Original flavor (Group II) (5.0 and 4.8% nicotine by weight, respectively) and subjects' own conventional cigarettes (Group III). Cumulative 4-h room air sampling and particle counting were performed during prescribed (Groups I and II) and ad libitum product use (all Groups). Conventional cigarette use resulted in significantly more constituents detected and higher 4-h cumulative constituent concentrations compared to use of the ENDS products tested, except for the predominant ENDS ingredients, propylene glycol and glycerin. Use of conventional cigarettes also resulted in greater total particle number concentration than either prescribed or ad libitum use of either of the ENDS used in this study.

Use of heated tobacco products in smoke-free locations in Japan: the JASTIS 2019 study

OBJECTIVE

We aimed to examine the use of heated tobacco products (HTPs) in locations where cigarette smoking was not allowed, and to explore the factors associated with such use among Japanese HTP users.

METHODS

An internet-based self-reported questionnaire survey was conducted in 2019 as part of the Japan Society and New Tobacco Internet Survey. The study subjects were respondents who self-reported having used HTPs in the last year. The proportions of those who had ever used or frequently used HTPs in locations where tobacco smoking was not allowed in the last year were calculated. These locations included home, restaurants and workplaces. Furthermore, potential factors associated with HTP use in such smoke-free locations were examined using multivariable logistic regression analyses.

RESULTS

The proportion of HTP users who had ever used HTPs in smoke-free locations in the last year was 20.7% (148/716) at home, 11.8% (128/1081) in restaurants and 11.9% (113/950) in workplaces. The proportion of those who had frequently used HTPs in those locations was 9.5% (68/716) at home, 4.8% (52/1081) in restaurants and 8.0% (76/950) in workplaces. The statistically significant factors associated with HTP use varied by location. Generally, respondents who thought HTP use was not forbidden in places where tobacco smoking is forbidden were likely to use HTPs in such locations.

CONCLUSION

In Japan, a considerable number of people used HTPs in locations where tobacco smoking was not allowed. Policymakers should establish clear rules about use of HTPs in smoke-free environments.

Electronic Cigarettes and Head and Neck Cancer Risk-Current State of Art

E-cigarettes have become increasingly popular in the last decade and are considered less harmful than traditional tobacco products due to the lower content of toxic and carcinogenic compounds. However, this is still a controversial issue. This paper contains a review of previous reports on the composition of e-cigarettes and their impact on the pathogenesis and risk of head and neck cancer (HNC). The objective of the review was to compare the molecular and health effects of e-cigarette use in relation to the effects of traditional cigarette smoking in the upper respiratory tract, and to assess the safety and effect of e-cigarettes on HNC risk. A review for English language articles published until 31 August 2020 was made, using a PubMed (including MEDLINE), CINAHL Plus, Embase, Cochrane Library and Web of Science data. The authors reviewed articles on both toxic and carcinogenic compounds contained in e-cigarettes and their molecular and health effects on the upper respiratory tract in comparison to tobacco cigarettes. The risk of developing head and neck squamous cell carcinoma (HNSCC) remains lower in users of e-cigarettes compared with tobacco smokers. However, more long-term studies are needed to better address the safety of e-cigarettes.

Workplace smoke-free policies that allow heated tobacco products and electronic cigarettes use are associated with use of both these products and conventional tobacco smoking: the 2018 JASTIS study

OBJECTIVES

Heated tobacco products (HTPs) and electronic cigarettes (e-cigarettes) are rapidly gaining popularity, especially in Japan. However, at the time of the survey (2018), there was no national legislation banning HTPs or e-cigarette use in the workplace. The objective is to examine the current situation for workplace smoke-free policies which ban the use of HTPs/e-cigarettes and the associations of such rules with the use of HTP and e-cigarette as well as conventional cigarette smoking.

METHODS

An internet-based self-reported questionnaire survey was conducted in 2018 as a part of the Japan Society and New Tobacco Internet Survey study. 5646 eligible employees aged 15-72 years were analysed. Proportions and adjusted rate ratios for HTP and e-cigarette use were calculated according to covariates, using Poisson regression models. Those who reported HTP or e-cigarette use within 30 days were defined as current user of the products.

RESULTS

In workplaces which prohibited smoking indoors but permitted the use of HTPs/e-cigarettes, the rate ratios of HTP use was 2.19 (95% CI 1.57 to 3.06), e-cigarette use was 3.86 (95% CI 1.97 to 7.57) and combustible cigarette use was 1.67 (95% CI 1.19 to 2.34) when using workplaces which also prohibited HTPs/e-cigarettes as a reference category.

CONCLUSIONS

Workplaces that allow HTP/e-cigarette use indoors were associated with higher rate for HTP and e-cigarette users, and for combustible cigarette smokers. National legislation banning tobacco should be enforced and also cover HTPs and e-cigarettes in order to avoid renormalisation of smoking and nicotine addiction.

Determinants of e-cigarette use among a sample of high school students in Jakarta, Indonesia

OBJECTIVES

The aim of this study was to determine the predisposing, enabling and reinforcing factors associated with electronic cigarette (e-cigarette) use among high school students in Jakarta, Indonesia.

METHODS

This cross-sectional study took place in eight high schools in Jakarta, Indonesia. A total of 767 students were recruited by multistage cluster random sampling. Bivariate and multivariate statistical analyses were employed to determine the associations between socio-demographic, predisposing, reinforcing and enabling factors and e-cigarette use.

RESULTS

Respondents were 54.1% male and the mean age was 16 years old [standard deviation (SD): 1.02]. In this sample, 32.2% of students (n = 247) had ever used e-cigarettes and 11.8% of students were e-cigarette users (n = 90). Several measured factors were positively associated with e-cigarette use, including: current smoking of conventional cigarettes [odds ratio (OR): 2.06]; perception that e-cigarettes are less addictive than conventional cigarettes (OR: 1.98); perception that e-cigarettes do not cause cancer (OR: 2.38); parental acceptance of e-cigarette use (OR: 3.80); and having enough money to buy e-cigarettes (OR: 3.24). The only variable found that was negatively associated with e-cigarette use was teacher's use of e-cigarettes (OR: 0.34).

CONCLUSIONS

This study found that student social influences, perceptions about and accessibility to e-cigarettes were significantly positively associated with e-cigarette use among high school students in Jakarta, Indonesia. This study highlights the importance of educating students, their parents and teachers regarding safety and potential health hazards of using e-cigarettes. Efforts to implement and enforce youth access restrictions on e-cigarettes in Indonesia are crucial to preventing further uptake of these products.

Electronic cigarettes and narghile users in Brazil: Do they differ from cigarettes smokers?

BACKGROUND

Cigarette smoking prevalence is declining, however, other tobacco products have emerged recently, such as electronic cigarettes (e-cigarettes) and narghile (hookah/shisha/waterpipe). Narghile sales are not prohibited in Brazil, but e-cigarettes are. Accurate estimates of such products are key for proper monitoring and control.

OBJECTIVE

To describe the prevalence of e-cigarettes and narghile use and to investigate whether sociodemographic characteristics of individuals who are using these products differ from those who are using manufactured cigarettes.

METHODS

Using a nationally representative sample survey of Brazilians aged 12-65 years in 2015, we estimated the prevalence rates of each tobacco products within the last 12-months, stratified by macro-region, municipality size, sex-at-birth, sexual orientation, color/race, age-group, and monthly income. Multivariable logistic models were fitted to understand determinants of each tobacco product use, considering the complex sample design.

RESULTS

E-cigarette, narghile, and cigarette prevalence rates were estimated at 0.43%, 1.65% and 15.35%, respectively, corresponding to around 0.6million e-cigarette users, 2.5 million narghile users and 23.5 million cigarette users. Non-heterosexual individuals were a most-at-risk group for both e-cigarette/narghile and cigarette use. Despite similarities, e-cigarette/narghile users were younger and had higher socioeconomic status than cigarette users. Additional analyses showed that recent cigarette use seems to be more associated with e-cigarette/narghile use among youth than among adults.

CONCLUSIONS

Our findings may provide valuable information about e-cigarette/narghile use in Brazil. Prevention strategies targeted to youth to both narghile and e-cigarettes use should be implemented together, which might be one strategy to prevent the emergency of a new generation of smokers in Brazil.

Perceived threats, benefits and barriers of e-cigarette use during pregnancy. A qualitative analysis of risk perception within existing threads in online discussion forums

OBJECTIVE

Previous studies have shown that e-cigarettes are perceived as being less harmful than tobacco cigarettes by pregnant women and might be used to quit smoking during pregnancy. Our aim was to further explore and characterise perceived threats, benefits and barriers of e-cigarette use during pregnancy.

METHODS

Our STudy on E-cigarettes and Pregnancy (STEP) was, among others, based on a netnographic approach of analysing existing threads in German-speaking online discussion forums dealing with perceived threats and benefits of e-cigarette use during pregnancy. For the analysis, we used an inductive-deductive qualitative content analysis.

FINDINGS

Based on 25 online discussion threads containing 1552 posts, we identified perceived threats, perceived benefits and perceived barriers to e-cigarette use during pregnancy, among others, as main themes. Subthemes identified within the main theme perceived threats were severe nicotine related health risks, potential health risks of additional ingredients, relative risks and lack of knowledge and research studies. As perceived benefits, we identified possibility and facilitation of smoking cessation, harm reduction and financial benefits. Perceived barriers were lack of satisfaction and social stigma.

CONCLUSION

Our qualitative results suggest that the perception of the health threats related to e-cigarette use during pregnancy varies according to the nicotine content and the perception of relative risks compared with tobacco cigarettes. In addition to this, risk perception is defined through further health and non-health related barriers and benefits (e.g. suitability of e-cigarettes as a smoking cessation aid, social stigma).

Secondhand exposure to e-cigarette aerosols among smokers: A cross-sectional study in six European countries of the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

Electronic cigarette (e-cigarette) use has grown significantly in some European Union (EU) Member States (MS). A better understanding of the exposure to secondhand e-cigarette aerosols (SHA) is necessary to develop and implement comprehensive regulations on e-cigarette use in public places. This study aims to assess the observation of e-cigarette use in public places, the self-reported exposure to SHA, and the level of users' comfort using e-cigarettes in the presence of others.

METHODS

This is a cross-sectional study of the Wave 1 International Tobacco Control 6 European Countries Survey recruiting adult smokers (n=6011) across six EU MS: Germany, Greece, Hungary, Poland, Romania, and Spain, within the EURESTPLUS Project. A descriptive analysis was conducted to estimate the prevalence (%) of observed e-cigarette use in different places, frequency of self-reported exposure to SHA, and level of comfort using e-cigarettes in the presence of others.

RESULTS

In all, 31.0% of smokers observed others using e-cigarette in public places, 19.7% in indoor places where smoking is banned, and 14.5% indoors at work. Almost 37% of smokers reported to be ever exposed to SHA, ranging from 17.7% in Spain to 63.3% in Greece. The higher prevalence of observed e-cigarette use and passive exposure to SHA was reported by smokers of younger age, of higher educational level and those being current or former e-cigarette users. Part (8.8%) of the smokers who were also e-cigarette users reported feeling uncomfortable using e-cigarettes in the presence of others.

CONCLUSIONS

A third of smokers from six EU MS reported being exposed to SHA. Prevalence differences were observed among the countries. In the context of scarce evidence on long-term health effects of exposure to SHA, precautionary regulations protecting bystanders from involuntary exposure should be developed.

5. Lifestyle Management: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

[Tobacco smoking and stopping smoking interventions in patients with TB]

Tuberculosis and tobacco smoking are two major public health problems causing significant mortality worldwide. Tobacco smoke increases the risk of Mycobacterium tuberculosis infection, severe pulmonary or extrapulmonary TB, and death of TB. In emerging countries, quitting smoking is one way to control the TB epidemic. Compared with non-smokers, smokers with tuberculosis are less observant of anti-tuberculosis treatment. Smoking abstinence improves the course of their illness, the treatment compliance and facilitates the final cure justifying smoking cessation interventions. The involvement of all healthcare professionals in helping smokers stopping smoking is required.

Study Profile: The Japan "Society and New Tobacco" Internet Survey (JASTIS): A Longitudinal Internet Cohort Study of Heat-Not-Burn Tobacco Products, Electronic Cigarettes, and Conventional Tobacco Products in Japan

Background

Japan became the first country where heat-not-burn tobacco products were sold. Therefore, there was no information for actual status on the actual use status or the harms of heat-not-burn tobacco products. The objectives of the study profile are to generate data that can be freely available to external researchers, and to create collaborative research projects in the future.

Methods

The Japan “Society and New Tobacco” Internet Survey (JASTIS) is a longitudinal internet cohort study which investigates perception, attitude, and use of heat-not-burn tobacco, electronic cigarettes (e-cigarettes), and conventional tobacco products in Japan. The survey also includes demographic, health-related, and socioeconomic factors. Participants were randomly selected and invited from internet panelists. The baseline survey was closed when the target number of respondents who had answered the questionnaire was met.

Results

The study includes three cohorts (1–3) from the 2015 baseline survey and a cohort (4) from the 2017 baseline survey: cohorts 1 and 4 were recruited based on sex and age: men and women aged 15–69 years (n = 8,240 for cohort 1 and n = 5,897 for cohort 4); cohorts 2 and 3 were created using status-based recruiting: e-cigarette and/or heat-not-burn tobacco ever users (n = 2,188; cohort 2) and combustible cigarette smokers without e-cigarette/heat-not-burn tobacco experience (n = 724; cohort 3). The completion rates were 8.5% to 9.9%. All subjects were followed and assessed annually. Response rates for the follow-up survey were 65.5% in 2016, 55.3% in 2017, and 50.9% in 2018. Because Internet-based responders are not a representative sample of the general population of Japan, we conducted adjustment to account for “being an internet survey respondent” and reported tobacco product use in Japan. A recent JASTIS study reported that prevalence of IQOS current-use among Japanese adults had rapidly increased from 0.3% in 2015 to 3.6% in 2017.

Conclusion

The JASTIS study provides the first estimates for heat-not-burn tobacco use in the world and e-cigarette use in Japan. For information on collaboration, please contact the corresponding author.

Electronic cigarette chemicals transfer from a vape shop to a nearby business in a multiple-tenant retail building

BACKGROUND

Electronic cigarettes (ECs) are nicotine delivery devices that produce aerosol without combustion of tobacco; therefore, they do not produce sidestream smoke. Nevertheless, many users exhale large clouds of aerosol that can result in passive exposure of non-users. Analogous to thirdhand cigarette smoke, the exhaled aerosol also settles on indoor surfaces where it can produce a residue. We refer to this residue as EC exhaled aerosol residue (ECEAR). Our objective was to determine if exhaled EC aerosol transferred from a vape shop in a multiple-tenant retail building, where it was produced, to a nearby business (field site) where it could deposit as ECEAR.

METHODS

We examined the build-up of ECEAR in commonly used materials (cotton towel and paper towels) placed inside the field site across from the vape shop. Materials were subjected to short-term (days) and long-term (months) exposures. Nicotine, other alkaloids and tobacco-specific nitrosamines (TSNAs) were identified and quantified in controls and field site samples using analytical chemical techniques.

RESULTS

Nicotine and other alkaloids were detected after 1 day of exposure in the field site, and these chemicals generally increased as exposure times increased. TSNAs, which have been linked to carcinogenesis, were also detected in short-term and long-term exposed samples from the field site.

CONCLUSIONS

In a multiple-tenant retail building, chemicals in EC aerosol travelled from a vape shop into an adjacent business where they deposited forming ECEAR. Regulatory agencies and tenants occupying such buildings should be aware of this potential environmental hazard.

Weighing the Risks and Benefits of Electronic Cigarette Use in High-Risk Populations

This article reviews the current evidence on electronic cigarette (e-cigarette) safety and efficacy for smoking cessation, with a focus on smokers with cardiovascular disease, pulmonary disease, or serious mental illness. In the United States, adult smokers use e-cigarettes primarily to quit or reduce cigarette smoking. An understanding of the potential risks and benefits of e-cigarette use may help clinicians counsel smokers about the potential impact of e-cigarettes on health.

4. Lifestyle Management: Standards of Medical Care in Diabetes-2018

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Determination of Selected Chemical Levels in Room Air and on Surfaces after the Use of Cartridge- and Tank-Based E-Vapor Products or Conventional Cigarettes

There is an ongoing debate regarding the potential of secondhand exposure of non-users to various chemicals from use of e-vapor products (EVPs). Room air levels of 34 chemicals (nicotine, propylene glycol (PG), glycerol, 15 carbonyl chemicals, 12 volatile organic chemicals (VOCs), and four selected trace elements) were measured where EVPs and cigarettes were used by n = 37 healthy adult tobacco users in an exposure chamber. The products used were MarkTen^® 2.5% Classic (Group I), a Prototype GreenSmoke^® 2.4% (Group II), Ego-T^® Tank with subjects' own e-liquids (Group III) and subjects' own conventional cigarettes (Group IV). Products were used under controlled conditions and 4-h ad libitum use. Background (without subjects) and baseline levels (with subjects) were measured. Cumulative 4-h. levels of nicotine, PG and glycerol measured were several-fold below the time-weighted average limits used in workplace exposure evaluation. Most the other chemicals (>75%) were at or below the limit of quantification during EVP use. Significant levels of chemicals (17 out of 34) were observed in Group IV. Overall, our results indicate that under the study conditions with the products tested, cumulative room air levels of the selected chemicals measured over 4-h were relatively small and were several-fold below the current occupational regulatory and consensus limits.

Electronic cigarette use in restaurants and workplaces where combustible tobacco smoking is not allowed: an Internet survey in Japan

BACKGROUND

The present study aimed to examine the experience of actual electronic cigarette (e-cigarette) use in smoke-free areas of restaurants and workplaces and to explore the determinants associated with such use among Japanese adults who reported any experience using e-cigarettes (e-cigarette ever-users).

METHODS

An Internet-based self-reported questionnaire survey was conducted in 2015 on Japanese e-cigarette ever-users. The proportion of the respondents who had ever used or frequently used e-cigarettes in smoke-free restaurants and/or workplaces was calculated. Potential factors associated with e-cigarette use in those smoke-free areas were also examined by using multivariable logistic regression analyses.

RESULTS

In total, 1243 e-cigarette ever-users (662 current and 581 former e-cigarette users) were analysed. The majority of them (1020/1243, 82.1%) were male and their mean age ± SD was 47.0±10.4 years. The proportion of those who had ever used e-cigarettes in smoke-free restaurants was 28.8% (358/1243) and that in smoke-free workplaces was 25.5% (317/1243), respectively. The proportion of those who had frequently used e-cigarettes in smoke-free restaurants was 18.5% (230/1243) and that in smoke-free workplaces was 16.3% (202/1243), respectively. In general, the proportion of e-cigarette use in those smoke-free areas was higher among those having a higher educational level than those having a lower educational level.

CONCLUSION

Among adult Japanese e-cigarette ever-users, approximately 26%-29% had ever used and 16%-19% had frequently used e-cigarettes in restaurants and/or workplaces where combustible tobacco smoking is not allowed. Policy-makers may need to establish explicit rules as to e-cigarette use in smoke-free environments.

Die E–Zigarette – Verbreitung, Konsummuster und Nutzermotive bei Siebt- und Achtklässlern

Zusammenfassung. Zielsetzung: E–Zigaretten erfreuen sich weltweit zunehmender Beliebtheit. In der vorliegenden Studie haben wir ein vergleichsweise junges Kollektiv deutscher Schülerinnen und Schüler nach Bekanntheit, Konsum und Konsummustern befragt, typische Nutzergruppen identifiziert und Motive der Nutzung untersucht. Methodik: Im Rahmen der hier erstmals vorgestellten PrevEND study II wurden zwischen 10/2014 und 03/2015 insgesamt 840 Schülerinnen und Schüler aus siebten und achten Klassen der Metropolregion Rhein-Neckar anonym mittels eines standardisierten Fragebogens zu E–Zigaretten (einschließlich E–Shishas) befragt. Ergebnisse: Nahezu alle befragten Schülerinnen und Schüler kannten die E–Zigarette (98 %) und 16 % hatten schon mindestens einmal eine E–Zigarette benutzt. Es zeigt sich ein sozialer Gradient, wonach 9 % aller Gymnasiasten und Gesamtschüler und 17 % aller Real- und 33 % aller Werkreal- und Hauptschüler schon einmal E–Zigaretten konsumiert hatten (p < 0,001). Nutzer von E–Zigaretten waren mehrheitlich Nichttabakraucher. E–Zigarettenkonsum in der Peergroup ist die bedeutendste Determinante des eigenen Konsums. Außerdem war die Lebenszeitprävalenz für E–Zigarettenkonsum höher als die Lebenszeitprävalenz für den Konsum von Tabakzigaretten. Schlussfolgerungen: Die Ergebnisse zeigen eine weite Verbreitung der E–Zigarette unter Jugendlichen und legen u. a. ein bundesweites Monitoring sowie eine weitere Untersuchung des Risikoprofils dieser Produktinnovation nahe.

The efficacy and short-term effects of electronic cigarettes as a method for smoking cessation: a systematic review and a meta-analysis

OBJECTIVES

E-cigarettes are increasingly popular as smoking cessation aids. This review assessed the efficacy of e-cigarettes for smoking cessation as well as desire to smoke, withdrawal symptoms, and adverse events in adult smokers.

METHODS

A systematic review was conducted. Studies comparing e-cigarettes to other nicotine replacement therapies or placebo were included. Data were pooled using meta-analysis.

RESULTS

Of 569 articles, 5 were eligible. Study participants were more likely to stop smoking when using nicotine e-cigarettes (43/489, 9 %) versus placebo e-cigarettes (8/173, 5 %); however, this difference was not statistically significant (RR 2.02; 95 % CI 0.97, 4.22). The pooled effect estimates for the desire to smoke (RR -0.22; 95 % CI -0.80, 0.36), irritability (RR -0.03; 95% CI -0.38, 0.31), restlessness (RR -0.03; 95 % CI -0.42, 0.35), poor concentration (RR -0.01; 95 % CI -0.35, 0.32), depression (RR -0.01; 95 % CI -0.22, 0.20), hunger (RR -0.01; 95 % CI -0.32, 0.30), and average number of non-serious adverse events (RR -0.09; 95 % CI -0.28, 0.46) were not statistically significantly different. Only one study reported serious adverse events with no apparent association with e-cigarette use.

CONCLUSIONS

Limited low-quality evidence of a non-statistically significant trend toward smoking cessation in adults using nicotine e-cigarettes exists compared with other therapies or placebo. Larger, high-quality studies are needed to inform policy decisions.

Vaping as a Catalyst for Smoking? An Initial Model on the Initiation of Electronic Cigarette Use and the Transition to Tobacco Smoking Among Adolescents

INTRODUCTION

The popularity of electronic cigarettes (e-cigarettes) among adolescents is growing worldwide. A more accurate model than the much discussed but inadequate Gateway Hypothesis is needed to explain some adolescents' initial preference for e-cigarettes over tobacco cigarettes, as well as any transition from e-cigarettes to tobacco smoking. Our aim was to summarize the diffuse fear that adolescents will be indirectly encouraged to begin smoking tobacco via the use of e-cigarettes and to systematize the disparate causal hypotheses used thus far in relevant literature.

METHODS

We summarized the vague and fragmented hypotheses formulated thus far in literature on both trajectories from abstinence to e-cigarette use and from there to tobacco smoking into a set of empirically testable hypotheses and organized them into a comprehensive model.

RESULTS

Our results indicate that the perceived health risks, specific product characteristics (such as taste, price and inconspicuous use), and higher levels of acceptance among peers and others potentially make e-cigarettes initially more attractive to adolescents than tobacco cigarettes. Later, increasing familiarity with nicotine could lead to the reevaluation of both electronic and tobacco cigarettes and subsequently to a potential transition to tobacco smoking. The suggested "catalyst model" takes variations in the nicotine content of e-cigarettes as well as the dual use of different substances into account.

CONCLUSION

Our model provides causal hypotheses for the initiation of e-cigarette use and for the potential transition to tobacco smoking which, after being tested in empirical studies, could lead to the formulation of concrete recommendations for healthcare intervention and prevention measures.

IMPLICATIONS

We developed a model that provides causal hypotheses for the initiation of e-cigarette use and for the potential transition to tobacco smoking.

A public health strategy for e-cigarettes

The e-cigarette may present a new and significant Public Health problem: Studies published so far do not seem to indicate that e-cigarette use is just a passing trend. If e-cigarette use is less harmless than it is portrayed in many advertisements, Public Health would do well to start a serious discussion about a suitable prevention policy as soon as possible.The aim of this short paper is to discuss a range of measures designed to prevent e-cigarette consumption.Concretely, we suggest to monitor e-cigarette use, the e-cigarette industry and prevention policies, to implement a vapor-free policy, to develop help to quit e-cigarette use, to inform about the health risks of e-cigarette use, to establish regulations on e-cigarette advertising, promotion and sponsorship, and to introduce taxes on e-cigarettes.

Cigarette Alternatives: Are they Safe?

In spite of limited data regarding the safety or effectiveness of electronic cigarette introduced into the market as a healthier alternative to tobacco smoking, its popularity has increased enormously. E-cigarettes have penetrated the market rapidly owing to the elaborate marketing network and attractive marketing strategies. Stated advantages include the claim that they help quit smoking and produce less exposure than conventional smoking. The list of disadvantages is even more elaborate. While the majority of the studies supporting health claims and efficacy for quitting smoking are not scientifically sound, they are also challenged by studies providing contradictory results. Owing to the limited evidence on the potential advantages and disadvantages of e-cigarettes, the debate on their safety continues.

The impact of electronic cigarettes on the paediatric population

OBJECTIVE

To review the impact of electronic cigarettes (e-cigarettes) on children.

METHODS

Five electronic databases were searched through 31 December 2013. Studies in English that included data for children younger than 18 years of age were included. In addition, relevant data from articles identified during searches of the e-cigarette literature, relevant state survey data and paediatric voluntary adverse event reports submitted to the US Food and Drug Administration (FDA) were reviewed and included.

RESULTS

Use of e-cigarettes by youth is increasing and is not limited to traditional cigarette smokers. Data regarding the reasons for youth e-cigarette initiation and ongoing use are limited. The effects of e-cigarette marketing and the availability of flavoured e-liquids on youth use are unknown. The abuse liability of e-cigarettes in youth is also not known. Unintentional exposures to e-cigarettes and e-liquids have been reported in children. The number of e-cigarette-related reports received by poison centres is increasing. No data are available on secondhand and thirdhand e-cigarette aerosol exposures in children.

CONCLUSIONS

Data on the impact of e-cigarettes on children are extremely limited. The available data indicate that youth awareness is high and use is increasing rapidly. The extent to which e-cigarette use in youth will result in nicotine dependence and subsequent use of other tobacco products is unknown. e-cigarettes present risks of unintentional nicotine exposure and are potential choking hazards. A greater understanding of the impact of e-cigarettes on children is needed and will be important in the evaluation of the effects of these products on the public health.

Electronic cigarettes for smoking cessation and reduction

BACKGROUND

Electronic cigarettes (ECs) are electronic devices that heat a liquid - usually comprising propylene glycol and glycerol, with or without nicotine and flavours, stored in disposable or refillable cartridges or a reservoir - into an aerosol for inhalation. Since ECs appeared on the market in 2006 there has been a steady growth in sales. Smokers report using ECs to reduce risks of smoking, but some healthcare organisations have been reluctant to encourage smokers to switch to ECs, citing lack of evidence of efficacy and safety. Smokers, healthcare providers and regulators are interested to know if these devices can reduce the harms associated with smoking. In particular, healthcare providers have an urgent need to know what advice they should give to smokers enquiring about ECs.

OBJECTIVES

To examine the efficacy of ECs in helping people who smoke to achieve long-term abstinence; to examine the efficacy of ECs in helping people reduce cigarette consumption by at least 50% of baseline levels; and to assess the occurrence of adverse events associated with EC use.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Groups Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and two other databases for relevant records from 2004 to July 2014, together with reference checking and contact with study authors.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in which current smokers (motivated or unmotivated to quit) were randomized to EC or a control condition, and which measured abstinence rates or changes in cigarette consumption at six months or longer. As the field of EC research is new, we also included cohort follow-up studies with at least six months follow-up. We included randomized cross-over trials and cohort follow-up studies that included at least one week of EC use for assessment of adverse events.

DATA COLLECTION AND ANALYSIS

One review author extracted data from the included studies and another checked them. Our main outcome measure was abstinence from smoking after at least six months follow-up, and we used the most rigorous definition available (continuous, biochemically validated, longest follow-up). For reduction we used a dichotomous approach (no change/reduction < 50% versus reduction by 50% or more of baseline cigarette consumption). We used a fixed-effect Mantel-Haenszel model to calculate the risk ratio (RR) with a 95% confidence interval (CI) for each study, and where appropriate we pooled data from these studies in meta-analyses.

MAIN RESULTS

Our search identified almost 600 records, from which we include 29 representing 13 completed studies (two RCTs, 11 cohort). We identified nine ongoing trials. Two RCTs compared EC with placebo (non-nicotine) EC, with a combined sample size of 662 participants. One trial included minimal telephone support and one recruited smokers not intending to quit, and both used early EC models with low nicotine content. We judged the RCTs to be at low risk of bias, but under the GRADE system the overall quality of the evidence for our outcomes was rated 'low' or 'very low' because of imprecision due to the small number of trials. A 'low' grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A 'very low' grade means we are very uncertain about the estimate. Participants using an EC were more likely to have abstained from smoking for at least six months compared with participants using placebo EC (RR 2.29, 95% CI 1.05 to 4.96; placebo 4% versus EC 9%; 2 studies; GRADE: low). The one study that compared EC to nicotine patch found no significant difference in six-month abstinence rates, but the confidence intervals do not rule out a clinically important difference (RR 1.26, 95% CI: 0.68 to 2.34; GRADE: very low). A higher number of people were able to reduce cigarette consumption by at least half with ECs compared with placebo ECs (RR 1.31, 95% CI 1.02 to 1.68, 2 studies; placebo: 27% versus EC: 36%; GRADE: low) and compared with patch (RR 1.41, 95% CI 1.20 to 1.67, 1 study; patch: 44% versus EC: 61%; GRADE: very low). Unlike smoking cessation outcomes, reduction results were not biochemically verified.None of the RCTs or cohort studies reported any serious adverse events (SAEs) that were considered to be plausibly related to EC use. One RCT provided data on the proportion of participants experiencing any adverse events. Although the proportion of participants in the study arms experiencing adverse events was similar, the confidence intervals are wide (ECs vs placebo EC RR 0.97, 95% CI 0.71 to 1.34; ECs vs patch RR 0.99, 95% CI 0.81 to 1.22). The other RCT reported no statistically significant difference in the frequency of AEs at three- or 12-month follow-up between the EC and placebo EC groups, and showed that in all groups the frequency of AEs (with the exception of throat irritation) decreased significantly over time.

AUTHORS' CONCLUSIONS

There is evidence from two trials that ECs help smokers to stop smoking long-term compared with placebo ECs. However, the small number of trials, low event rates and wide confidence intervals around the estimates mean that our confidence in the result is rated 'low' by GRADE standards. The lack of difference between the effect of ECs compared with nicotine patches found in one trial is uncertain for similar reasons. ECs appear to help smokers unable to stop smoking altogether to reduce their cigarette consumption when compared with placebo ECs and nicotine patches, but the above limitations also affect certainty in this finding. In addition, lack of biochemical assessment of the actual reduction in smoke intake further limits this evidence. No evidence emerged that short-term EC use is associated with health risk.