Harms of Electronic Cigarettes: What the Healthcare Provider Needs to Know.

Electronic cigarettes (e-cigarettes) reached the market without either extensive preclinical toxicology testing or long-term safety trials that would be required of conventional therapeutics or medical devices. E-cigarettes are considered a tobacco product and as such have no manufacturing quality or safety standards. A growing body of evidence documents severe harms from e-cigarette use, including injuries from product explosions, nicotine poisoning, and severe lung diseases. Commonly used e-cigarette components have significant inhalation toxicity. Emerging evidence from laboratory studies suggests substantial reason for concern for long-term harms, including risk for cardiovascular disease, chronic obstructive lung disease, and cancer. Rather than helping people stop smoking, e-cigarette use is associated with reduced rates of smoking cessation among current smokers and an increased risk of relapse to smoking among former smokers. The World Health Organization advises, "Unlike the tried and tested nicotine and non-nicotine pharmacotherapies that are known to help people quit tobacco use, WHO does not endorse e-cigarettes as cessation aids." Careful evaluation of all the available research justifies a strong recommendation that healthcare providers should neither prescribe nor recommend e-cigarettes for persons who are tobacco dependent. If a patient is dependent on e-cigarettes, the healthcare provider should provide counseling and treatment (of nicotine dependence) to help the patient to stop their e-cigarette use.

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline.

Background: Current tobacco treatment guidelines have established the efficacy of available interventions, but they do not provide detailed guidance for common implementation questions frequently faced in the clinic. An evidence-based guideline was created that addresses several pharmacotherapy-initiation questions that routinely confront treatment teams.Methods: Individuals with diverse expertise related to smoking cessation were empaneled to prioritize questions and outcomes important to clinicians. An evidence-synthesis team conducted systematic reviews, which informed recommendations to answer the questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to rate the certainty in the estimated effects and the strength of recommendations.Results: The guideline panel formulated five strong recommendations and two conditional recommendations regarding pharmacotherapy choices. Strong recommendations include using varenicline rather than a nicotine patch, using varenicline rather than bupropion, using varenicline rather than a nicotine patch in adults with a comorbid psychiatric condition, initiating varenicline in adults even if they are unready to quit, and using controller therapy for an extended treatment duration greater than 12 weeks. Conditional recommendations include combining a nicotine patch with varenicline rather than using varenicline alone and using varenicline rather than electronic cigarettes.Conclusions: Seven recommendations are provided, which represent simple practice changes that are likely to increase the effectiveness of tobacco-dependence pharmacotherapy.

Recommendations for the Appropriate Structure, Communication, and Investigation of Tobacco Harm Reduction Claims. An Official American Thoracic Society Policy Statement.

RATIONALE: The tobacco harm reduction literature is replete with vague language, far-reaching claims, and unwarranted certainty. The American Thoracic Society has increasingly recognized the need for a framework for reliably making such claims. Evidence-based standards improving the scientific value and transparency of harm reduction claims are expected to improve their trustworthiness, clarity, and consistency. METHODS: Experts from relevant American Thoracic Society committees identified key topic areas for discussion. Literature search strategy included English language articles across Medline, Google Scholar, and the Cochrane Collaborative databases, with expanded search terms including tobacco, addiction, smoking, cigarettes, nicotine, and harm reduction. Workgroup members synthesized their evidentiary summaries into a list of candidate topics suitable for inclusion in the final report. Breakout groups developed detailed content maps of each topic area, including points to be considered for suggested recommendations. Successive draft recommendations were modified using an iterative consensus process until unanimous approval was achieved. Patient representatives ensured the document's relevance to the lay public. RESULTS: Fifteen recommendations were identified, organized into four framework elements dealing with: estimating harm reduction among individuals, making claims on the basis of population impact, appropriately careful use of language, and ethical considerations in harm reduction. DISCUSSION: This statement clarifies important principles guiding valid direct and inferential harm reduction claims. Ideals for effective communication with the lay public and attention to unique ethical concerns are also delineated. The authors call for formal systems of grading harm reduction evidence and regulatory assurances of longitudinal surveillance systems to document the impact of harm reduction policies.

The Case for Requiring Graphic Warning Labels on Smokeless Tobacco Product Packages.

On November 10, 2015, the U.S. Food and Drug Administration approved, for the first time, the sale of smokeless tobacco products authorized under the new premarket tobacco application pathway. This Food and Drug Administration regulatory decision draws attention to the growing worldwide use of smokeless tobacco products in general. Use of these tobacco products is particularly popular in low- and middle-income countries of Asia. Due to aggressive and strategic marketing to children, young adults, and current smokers, rates of smokeless tobacco use in men of all ages are on the rise in United States and elsewhere. The tobacco industry also continues to market these products to current cigarette smokers for use in the growing number of "smoke-free environments." Smokeless tobacco products are associated with cancers of the upper aerodigestive tract, particularly the oral cavity, esophagus, and pancreas; cardiovascular diseases; small-for-gestational-age infants; premature births; increased risk of apnea; and stillbirth. There is no convincing evidence regarding the efficacy of smokeless tobacco, including snus, to promote smoking cessation. Rather, studies from Europe and the United States demonstrate that smokeless tobacco use may facilitate regular cigarette smoking by acting as a gateway drug, especially for children. Caution is warranted before proposing smokeless tobacco as a harm-reduction strategy, in part because of the potential for further promoting smokeless tobacco in low- and middle-income countries where use is already widespread. Continued vigilance through comprehensive surveillance is warranted. We strongly recommend the use of graphic warning labels as a "no regrets" strategy for all smokeless tobacco products marketed globally.

An Official American Thoracic Society Research Statement: Current Understanding and Future Research Needs in Tobacco Control and Treatment.

INTRODUCTION: Since the mid-20th century, the scientific community has substantially improved its understanding of the worldwide tobacco epidemic. Although significant progress has been made, the sheer enormity and scope of the global problem put it on track to take a billion lives this century. Curbing the epidemic will require maximizing the impact of proven tools as well as the development of new, breakthrough methods to help interrupt the spread of nicotine addiction and reduce the downstream morbidity. METHODS: Members of the Tobacco Action Committee of the American Thoracic Society queried bibliographic databases, including Medline, Embase, and the Cochrane Collaborative, to identify primary sources and reviews relevant to the epidemic. Exploded search terms were used to identify evidence, including tobacco, addiction, smoking, cigarettes, nicotine, and smoking cessation. Evidence was consolidated into three thematic areas: (1) determinants of risk, (2) maternal-fetal exposure, and (3) current tobacco users. Expert panel consensus regarding current gaps in understanding and recommendations for future research priorities was generated through iterative discussion. RESULTS: Although much has been accomplished, significant gaps in understanding remain. Implementation often lags well behind insight. This report identifies a number of investigative opportunities for significantly reducing the toll of tobacco use, including: (1) the need for novel, nonlinear models of population-based disease control; (2) refinement of "real-world" models of clinical intervention in trial design; and (3) understanding of mechanisms by which intrauterine smoke exposure may lead to persistent, tobacco-related chronic disease. DISCUSSION: In the coming era of tobacco research, pooled talent from multiple disciplines will be required to further illuminate the complex social, environmental and biological codeterminants of tobacco dependence.

Improving Tobacco Dependence Treatment Delivery: Medical Student Training and Assessment.

Tobacco dependence is a chronic condition, with cigarette smoking considered the leading cause of preventable death, disease, and disability in the U.S. Currently, the U.S. adult smoking rate is 17.8%. National surveys reveal that approximately half of all smokers who have been treated by a healthcare provider in the last 12 months received Public Health Service-recommended guideline-concordant tobacco dependence treatment. Although smoking prevalence has been declining, several disparate groups continue to smoke at rates significantly higher than the national average, including those with low income, low educational attainment, or mental health disorders. To address these disparities and more effectively address tobacco use, provision of guideline-concordant tobacco dependence treatment within the healthcare system must improve. We discuss changes to the medical licensing examination that may result in enhanced tobacco dependence treatment education and skills training for students in medical school.

Characteristics of smokers with type 2 diabetes.

AIM: The purpose of this secondary analysis was to identify the characteristics of smokers with type 2 diabetes, enrolled in a smoking cessation program. BACKGROUND: The health consequences of smoking are particularly severe for individuals with diabetes who smoke. METHODS: The characteristics of 227 smokers with type 2 diabetes were analyzed to determine which traits were more likely to be associated with quit success. RESULTS: Results of the data analysis indicate that smokers with type 2 diabetes were more likely to be abstinent 30 days and 6 months after the quit date if they attended a majority of the program classes and support groups; and used cessation medications. Expressing concerns about the expense of cigarettes was also associated with quit success at 6 months. CONCLUSIONS: Although studies have examined compliance with other diabetes care recommendations, few have evaluated the characteristics of individuals with diabetes who smoke.

Leadership initiatives to disseminate the institute of medicine's future of nursing report.

This article discusses the critical role professional nurses will play and the tremendous impact nursing education and leadership development will have on the future of health care, as outlined in the recommendations of the Institute of Medicine's report, "The future of nursing: Leading change, and advancing health." Six doctorate of nursing practice students from Case Western Reserve University analyzed the Institute of Medicine (IOM) report and developed projects to disseminate key components to selected organizations. The students developed two primary initiatives. One initiative involved presenting the report to various professional organizations, including a local chapter of an international honor society, a specialty organization, and a health care organization. The second initiative included interviewing several nurse leaders within a large multihospital health system, and a nursing leader in academia to determine (a) the level of awareness about the IOM report and (b) strategies these leaders have implemented or envisioned to address the report recommendations.

An official American Thoracic Society workshop report: tobacco control initiatives within the American Thoracic Society.

Cigarette smoking represents the single most preventable cause of premature morbidity and mortality in the United States and the burden of tobacco use is apparent world-wide. Cigarette smoking is a major risk factor for chronic obstructive pulmonary disease, the third leading cause of death in the United States in 2004. The American Thoracic Society (ATS) and its members have contributed significantly to an understanding of the biological and pathophysiologic mechanisms responsible for the development and management of tobacco-attributable disease and disability. The society's active involvement in tobacco control advocacy and policy-related initiatives are central to its mission. Within the ATS, there is also increased interest in accelerating the society's efforts to understand the mechanisms responsible for the uptake, persistence, and cessation of tobacco use. Scientific, clinical, and educational activities that include an examination of these underlying mechanisms are warranted. This paper describes findings from an ATS initiative that developed a preliminary strategy for enhancing scientific, clinical, educational, and policy-related tobacco control efforts that are consistent with the vision of the ATS. The specific aims of this project included the identification of existing mechanisms, as well as the current governance in place within the ATS infrastructure, to address tobacco control issues related to scientific inquiry, policy initiatives, and advocacy for tobacco control. This assessment generated recommendations to inform the ATS leadership with regard to the future development of relevant tobacco control initiatives.

A pilot study to examine the effects of smoking cessation on serum markers of inflammation in women at risk for cardiovascular disease.

BACKGROUND: The links among smoking, inflammation, and cardiovascular disease (CVD) are well established. Several studies have demonstrated that quitting smoking reverses the risk of coronary heart disease within 5 to 10 years. However, the immediate effects of quitting smoking on inflammatory biomarkers associated with CVD risk have not been well described. METHODS: In this pilot study, we examined a panel of circulating inflammatory biomarkers associated with CVD in "at-risk" women during the smoking cessation program. Forty-six women enrolled in a smoking cessation program consented to attend four study visits over 6 to 7 weeks. Health/medical information and blood were collected at each visit. Circulating levels of C-reactive protein (CRP), tumor necrosis factor (TNF), interleukin (IL)-6, soluble TNF receptor (sTNFR)-I, sTNFR-II, and soluble vascular cell adhesion molecule (sVCAM)-1 were measured, and changes between baseline levels (visit 1, while smoking) and visits 2 through 4 were determined. RESULTS: Significant reductions in circulating levels of TNF, sTNFR-I, sTNFR-II, and sVCAM-1 were observed among participants over the course of the smoking cessation program. Serum levels of both IL-6 and CRP declined during the smoking cessation program; the changes were not statistically significant, however. CONCLUSIONS: These findings suggest there are rapid consequences of smoking cessation on inflammatory biomarkers in women at risk for CVD. Additional, larger studies including diverse smokers desiring to quit are required to confirm changes in "measurable milestones" that could serve as motivating factors to assist smokers to quit.

Tobacco and law enforcement officers.

The literature on the prevalence of health hazards faced by law enforcement officers indicates that they are at high risk for several morbid diseases and conditions, particularly cardiovascular disease and cancer. To mitigate these risks, quitting smoking is of the utmost importance. This article focuses on reducing tobacco consumption by law enforcement officers in New York.

Tobacco and the health care industry.

The 1964 US Surgeon General's report was the first from the medical profession to document tobacco as a cause of cancers and other serious illnesses. Over the next 40 years, numerous health care groups have worked to decrease tobacco use and lower the associated morbidity and mortality. Registered nurses are the largest group of health care providers and have one of the highest rates of smoking among health care professionals. As such, registered nurses are an important population to target and treat for nicotine addiction. Hospital-based tobacco control programs can provide nurses and other health care professionals with convenient on-site treatment. The chronic care model provides a useful framework for enhancing tobacco control activities and improving outcomes.

Smoking in adolescence: what a clinician can do to help.

Approximately 4400 adolescents try their first cigarette every day in the United States. Trying a few cigarettes or using tobacco more regularly as an adolescent significantly increases the risk of smoking in adulthood. Adolescents can develop nicotine dependency after smoking relatively few cigarettes. This article points out the prevalence and unique aspects of teenage tobacco use. In addition, current recommendations for treating nicotine dependence in adolescents are reviewed.