Systematic Review and Critical Analysis of Longitudinal Studies Assessing Effect of E-Cigarettes on Cigarette Initiation among Adolescent Never-Smokers.

Prospective longitudinal studies mainly conclude on a causal role of e-cigarettes in the initiation of cigarettes in flagrant contradiction with conclusions drawn from epidemiology and other studies showing a sharp decline in cigarette use in parallel with the spread of e-cigarette use. This systematic review explores the reasons for this discrepancy. METHODS: Among 84 publications on e-cigarette/cigarette association in adolescents identified in the Medline database from 2011 to 2022, 23 concern 22 never-smoker longitudinal sub-cohorts. RESULTS: A link between e-cigarette experimentation at T1 and cigarette initiation at T2 is reported in sub-cohort analyses of never-smokers (AOR: 1.41 to 8.30). However, studies exclude 64.3% of T1 e-cigarette experimenters (because of dual-use) and 74.1% of T2 cigarette experimenters. With this study design, e-cigarettes contribute only to 5.3% of T2 cigarette experimentation, casting major doubt on the external validity of results and authors' conclusions that e-cigarettes have a significant effect on the initiation of cigarettes (Gateway effect) at the population level. This sub-cohort design prohibits highlighting any Diversion effect, which is the most likely mechanism accounting for the competition between these two products. CONCLUSIONS: While nicotine abstinence remains the best medical option, over-regulation of e-cigarettes because of misinterpretation of longitudinal study results may be detrimental to public health and tobacco control.

What differentiates youths who use e-cigarettes from those who smoke traditional tobacco products?

BACKGROUND: Electronic cigarette (e-cigarette) use has spread among adolescents in many countries, however users' characteristics are not well known. We aimed to compare characteristics of exclusive e-cigarette users to those of exclusive tobacco users and dual users. METHODS: Data come from a representative sample of 11-19 years old students in Paris, surveyed each year between 2013 and 2017. Current e-cigarette and tobacco use were ascertained in the preceding 30 days. Data were analyzed using random intercept multinomial logistic regression models, exclusive tobacco smokers being the reference group. RESULTS: Among the 17,435 students included, 2.3% reported exclusive e-cigarette use, 7.9% exclusive tobacco use and 3.2% dual e-cigarette and tobacco use. Compared to exclusive tobacco smokers, e-cigarette users were: a) less likely to use cannabis (adjusted Odds-Ratio (aOR) = 0.15, 95% confidence interval (95% CI) = 0.09-0.25); b) more likely to initiate smoking with an e-cigarette or a hookah rather than traditional cigarettes (aOR = 2.91, 95% CI = 1.74-4.87 and aOR = 15.99, 95% CI = 8.62-29.67, respectively). Additionally, exclusive e-cigarette users are younger with an aOR = 0.29 (95% CI = 0.17-0.49) among 13-15 years and aOR = 0.11 (95% CI = 0.06-0.21) among > 17 years as compared to 11-13 years. The probability of being an exclusive e-cigarette user is lower among participants whose best friend smokes tobacco (aOR = 0.30, 95% CI = 0.20-0.44). Exclusive tobacco users and dual users have similar profiles. CONCLUSIONS: Adolescents who only used e-cigarettes had intermediate levels of risk compared to nonusers and those who used tobacco and/or e-cigarettes, suggesting that e-cigarettes use extends to young people at low-risk of using tobacco products.

Nicotine patches in patients on mechanical ventilation for severe COVID-19: a randomized, double-blind, placebo-controlled, multicentre trial.

PURPOSE: Epidemiologic studies have documented lower rates of active smokers compared to former or non-smokers in symptomatic patients affected by coronavirus disease 2019 (COVID-19). We assessed the efficacy and safety of nicotine administered by a transdermal patch in critically ill patients with COVID-19 pneumonia. METHODS: In this multicentre, double-blind, placebo-controlled trial conducted in 18 intensive care units in France, we randomly assigned adult patients (non-smokers, non-vapers or who had quit smoking/vaping for at least 12 months) with proven COVID-19 pneumonia receiving invasive mechanical ventilation for up to 72 h to receive transdermal patches containing either nicotine at a daily dose of 14 mg or placebo until 48 h following successful weaning from mechanical ventilation or for a maximum of 30 days, followed by 3-week dose tapering by 3.5 mg per week. Randomization was stratified by centre, non- or former smoker status and Sequential Organ Function Assessment score (< or ≥ 7). The primary outcome was day-28 mortality. Main prespecified secondary outcomes included 60-day mortality, time to successful extubation, days alive and free from mechanical ventilation, renal replacement therapy, vasopressor support or organ failure at day 28. RESULTS: Between November 6th 2020, and April 2nd 2021, 220 patients were randomized from 18 active recruiting centers. After excluding 2 patients who withdrew consent, 218 patients (152 [70%] men) were included in the analysis: 106 patients to the nicotine group and 112 to the placebo group. Day-28 mortality did not differ between the two groups (30 [28%] of 106 patients in the nicotine group vs 31 [28%] of 112 patients in the placebo group; odds ratio 1.03 [95% confidence interval, CI 0.57-1.87]; p = 0.46). The median number of day-28 ventilator-free days was 0 (IQR 0-14) in the nicotine group and 0 (0-13) in the placebo group (with a difference estimate between the medians of 0 [95% CI -3-7]). Adverse events likely related to nicotine were rare (3%) and similar between the two groups. CONCLUSION: In patients having developed severe COVID-19 pneumonia requiring invasive mechanical ventilation, transdermal nicotine did not significantly reduce day-28 mortality. There is no indication to use nicotine in this situation.

Use of a Smartphone Self-assessment App for a Tobacco-Induced Disease (COPD, Cardiovascular Diseases, Cancer) Screening Strategy and to Encourage Smoking Cessation: Observational Study.

BACKGROUND: Patient self-assessment via a mobile app detects actionable symptoms and has been shown to detect lung cancer relapses early, thereby lengthening survival. OBJECTIVE: The purpose of this study was to assess the incidence of chief symptoms associated with the main tobacco-induced pathologies in both current and ex-smokers through a self-assessment smartphone app and to evaluate the app's capacity to encourage users to quit smoking or reduce consumption, as well as its impact on early lung cancer stages at the time of diagnosis. METHODS: Current and ex-smokers were recruited through an advertising campaign in Sarthe county (France) proposing the free download of a smartphone app. App users were asked to answer 13 questions related to symptoms associated with tobacco-induced diseases (chronic obstructive pulmonary disease [COPD], cardiovascular diseases, cancer). In the event of any positive answer, a message was displayed recommending the user to consult a physician. In addition, they were asked about smoking cessation intention before and after answering these 13 questions. Finally, incidence of stage 1 or 2 lung cancers diagnosed during the launch period of our application was evaluated by comparing data from various sources to those from the same period during the previous year. RESULTS: Of the 5671 users who were eligible for evaluation, an alert was sent to the majority (4118/5671, 72.6%), with a higher incidence for current smokers (2833/3679, 77.0% vs 1298/1992, 65.2%; P<.001). The most frequent symptoms triggering the notifications were fatigue (2023/5671, 35.7%), cough (1658/5671, 29.2%), dyspnea (1502/5671, 26.5%), and persistent chest pain (1286/5671, 22.7%). Of the current smokers, 14.0% (515/3679) showed symptoms suggesting COPD, 15.5% (571/3679) showed symptoms suggesting stable angina, 12.4% (455/3679) probably had lower extremity artery disease, and 6.8% (249/3679) had possible cancer. Of the users, 36.5% (1343/3679) claimed that they thought about quitting smoking, and 48.7% (1795/3679) had thought about reducing their consumption. Surgery-eligible stage 1 and 2 lung cancer incidence was 24% (14/58) during the study period versus 9% (5/54) during the previous year in Sarthe county (P=.04), whereas it remained unchanged in the neighboring county of Maine-et-Loire. CONCLUSIONS: A majority of current and ex-smokers showed worrying symptoms, and the use of a self-assessment smartphone app may drive a majority of smokers toward the intention of smoking cessation or decreasing consumption. A randomized study should be performed to confirm this intention and to support the potential increase of symptomatic lung cancer detection at early, surgery-accessible stages. TRIAL REGISTRATION: ClinicalTrials.gov NCT04048954; https://www.clinicaltrials.gov/ct2/show/NCT04048954.

Impact of Tobacco Smoking on the Risk of COVID-19: A Large Scale Retrospective Cohort Study.

INTRODUCTION: Preliminary reports indicated that smokers could be less susceptible to coronavirus SARS-CoV-2, which causes Covid-19. However, once infected an increased risk of severe disease is reported. We investigated the association between smoking and COVID-19 during an outbreak of the disease on a naval vessel. METHODS: We conducted a cross-sectional, observational study on the 1769 sailors of the same navy aircraft carrier at sea exposed at the same time to SARS-CoV2 to investigate the link between tobacco consumption and Covid-19. RESULTS: Among the 1688 crewmembers (87% men; median age = 28 [interquartile range 23-35]) included, 1279 (76%) developed Covid-19 (1038 [62%] reverse-transcriptase- polymerase chain reaction testing-positive and 241 [14%] with only clinical signs). One hundred and seven patients were hospitalized. The univariable analysis odds ratio (OR) for Covid-19 infection was 0.59 (95% confidence interval [CI], 0.45-0.78; p < .001) for current smokers versus former and nonsmokers; sex, body mass index or blood group had no significant impact. Crewmembers >50 years old had an increased risk of contracting Covid-19 (OR, 2.84 [95% CI, 1.30-7.5]; p = .01). Multivariable analysis retained the lower risk of current smokers becoming infected (OR, 0.64 [0.49-0.84]; p < .001) and age >50 years was significatively associated with Covid-19 (OR, 2.6 [1.17-6.9]; p = .03). CONCLUSIONS: Current smoking status was associated with a lower risk of developing Covid-19 but cannot be considered as efficient protection against infection. The mechanism of the lower susceptibility of smokers to SARS-CoV-2 requires further research. TRIAL REGISTRATION: IRB no.: 0011873-2020-09. IMPLICATIONS: (1) Recent epidemiologic data suggest a paradoxical link between smoking and COVID-19. (2) Among the 1688 crewmembers (with an attack rate of 76% and exposed at the same time in the same place to SARS-CoV2), we found a significantly lower risk for developing COVID-19 in current smokers (71%) versus former and nonsmokers (80%). This finding strongly supports the need for further research on nicotine physiological pathway and its impact on COVID-19 infection whilst emphasizing that tobacco smoking should not be considered as efficient protection against COVID-19.

Randomised, placebo-controlled, double-blind, double-dummy, multicentre trial comparing electronic cigarettes with nicotine to varenicline and to electronic cigarettes without nicotine: the ECSMOKE trial protocol.

INTRODUCTION: Electronic cigarettes (EC) mainly with nicotine content are widely used worldwide. Although the number of publications about its use is increasing exponentially, evidence-based, unbiased, conclusive, head-to-head comparisons about its efficacy and safety as an aid for smoking cessation are lacking. METHODS AND ANALYSIS: Design: randomised, placebo and reference treatment-controlled, multicentre, double-blind, double-dummy, parallel-group trial. Participants: smokers smoking at least 10 cigarettes/day in the past year and motivated to quit, aged 18-70 years. Interventions: (A) EC without nicotine (ECwoN) plus placebo tablets of varenicline administered by oral route: placebo condition, (B) EC with nicotine (ECwN) plus placebo tablets of varenicline: ECwN condition. Voltage regulated EC will be used with liquid containing 12 mg/mL of nicotine for ad libitum use. Flavour: blond tobacco. (C) Reference: ECwoN plus 0.5 mg varenicline tablets: varenicline condition. Varenicline administered according to the marketing authorisationauthorisation. Treatment duration: 1 week+3 months. Primary outcome: continuous smoking abstinence rate (CAR) (abstinence from conventional/combustible cigarettes) during the last 4 weeks (weeks 9-12) of the treatment period defined as self-report of no smoking during the previous 2 weeks and expired air carbon monoxide ≤8 at visit 4 at week 10 after target quit date (TQD), that is, 11 weeks after treatment initiation AND at visit 5, week 12 after TQD, that is, 13 weeks after treatment initiation. Secondary outcomes: safety profile; point prevalence abstinence rate; CAR confirmed by urinary anabasine concentration; changes in cigarettes/day consumption; craving for tobacco and withdrawal symptoms with respect of baseline. ETHICS AND DISSEMINATION: The ethics committee approval was obtained on 17 April 2018. All data collected about the study participants will be anonymised. Investigators will communicate trial results to participants, health authorities, healthcare professionals, the public and other relevant groups without any publication restrictions. TRIAL REGISTRATION NUMBER: NCT03630614; Pre-results.

Patients with lung cancer: Are electronic cigarettes harmful or useful?

E-cigarettes remain controversial because the scientific evidence of short term and long term effects on tolerance and the health value of a switch from tobacco to e-cigarettes is contested and controversial. Nevertheless the quality of e-cigarettes and e-liquids has improved. The main ingredients, propylene glycol, vegetable glycerine and nicotine are pharmaceutical-grade quality in most e-liquids. Flavors are almost all food grade. The high quality of ingredients has decreased the presence of impurities in e-liquids. The emissions of e-cigarettes do not contain solid particles or carbon monoxide. Nitrosamine content is at least one hundred times lower than in tobacco smoke. E-cigarette emissions in normal use do not contain any harmful constituents at significant levels except nicotine. UK public health authorities have stated that e-cigarette use is likely to be at least 95% less toxic than cigarette use. There are benefits from having a well-regulated legal market. In countries where e-liquid containing nicotine is not allowed, "do-it-yourself" liquids are common and have handling risks and may sometimes contain toxic impurities. Though e-cigarettes should never be assumed safe products for non-smokers, for smokers, the e-cigarette is at least 20 times less dangerous than the cigarette. Tobacco cessation specialists in countries where nicotine containing e-cigarettes are available increasingly provide counselling for e-cigarette use to stop smoking or to reduce smoking at the request of patients. Based on current knowledge, for patients with lung or other forms of cancer who would otherwise continue to smoke, e-cigarettes offer an alternative way to quit smoking while they undergo medical treatment.

Recommendations to improve smoking cessation outcomes from people with lung conditions who smoke.

This study aimed to gain insight into the impact of lung conditions on smoking behaviour and smoking cessation, and identify recommendations for smoking cessation and professional-patient communications. The study was led by the European Lung Foundation in collaboration with the European Respiratory Society Task Force on "Statement on smoking cessation on COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit". A web-based observational cross-sectional questionnaire was developed from a patient-centered literature review. Topics covered were: cohort characteristics; perspectives on smoking cessation; interactions with healthcare professionals; and recommendations to improve cessation outcomes. The questionnaire was disseminated via existing patient and professional networks and social media channels. The survey was available online for a period of 4 months in 16 languages. The data were analysed as a whole, not by country, with thematic analysis of the open responses. Common characteristics were: male (54%); age 40-55 years (39%); 11-20 cigarettes a day (39%); smokes within 30 min of waking (61%); and has made 1-5 cessation attempts in the previous 12 months (54%). 59% had tried cessation treatments, but, of these, 55% had not found any treatments helpful. Recommendations were: earlier intervention; discussion of the patient's smoking beliefs, behaviours and motivation; giving constructive advice; understanding addiction; informed decision-making; and treatment options. Areas for new and further research have been highlighted through exploring the smoking cessation perspectives and recommendations of people with lung conditions in Europe who smoke.

Factors associated with experimentation of electronic cigarettes among Parisian teenagers in 2013.

BACKGROUND: Electronic cigarettes (e-cig.) became widely used among adults. Data are insufficient about e-cig. experimentation among youth. METHODS: To assess prevalence of e-cig. experimentation and associated factors among the 12 to 19 years old we analyse a cross sectional school based survey in the city of Paris, France in 2013 on a randomly selected sample of 2 % of schoolchildren (n = 3 279). Self-report questionnaire include demographic, individual and family smoking characteristics and questions about e-cig: "Have you ever used an e-cigarette?"- "Did you use e-cigarette in the last 30 days?"-"Did you try e-cigarette as a first tobacco product?". RESULTS: In 2013, 17.9 % (564) schoolchildren reported having experienced the e-cig (boys: 19.0 %, girls: 16.8 %) compared to 9.8 % in 2012. Experimentation rate increases from 5 % among the 12 to 30 % among the 16-year-old. E-cig. experimentation was significantly associated with 11 parameters including : age >15 years (OR: 0.66 (IC95 % = 0.46-0.94)); smoking 10 cigarettes or more (OR = 5.67 (IC95 % = 3.11-10.34)), best friends and siblings smoker (OR = 1.54 (IC95 % = 1.11-2.14)) and (OR = 1.88 (IC95 % = 1.41-2.52)); experimentation of shisha (OR = 2.60 (IC95 % = 1.75-3.86)), cannabis use (OR = 1.90 (IC95 % = 1.32-2.72)); having two parents who forbid smoking (OR = 2.32 (IC95 % = 1.63-3.30)). Only 5.6 % of the study population (and 32.5 % of e-cig. experimenters (183/564)) have used it in the last 30 days; 1.7 % of the study population and 10.0 % of e-cig. experimenters were non-smokers (56/564). CONCLUSIONS: Rate of e-cig. experimentation among schoolchildren increased by 8.1 % in 1 year. Non-smoking youth may use e-cig. Prospective studies are urgently needed to assess the evolution of e-cig. use both among smoking and non-smoking youth.

Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit.

Chronic obstructive pulmonary disease (COPD), lung cancer, asthma and pulmonary tuberculosis are common pulmonary diseases that are caused or worsened by tobacco smoking. Growing observational evidence suggests that symptoms and prognosis of these conditions improve upon smoking cessation. Despite increasing numbers of (small) randomised controlled trials suggesting intensive smoking cessation treatments work in people with pulmonary diseases many patients are not given specific advice on the benefits or referred for intensive cessation treatments and, therefore, continue smoking.This is a qualitative review regarding smoking cessation in patients with COPD and other pulmonary disorders, written by a group of European Respiratory Society experts. We describe the epidemiological links between smoking and pulmonary disorders, the evidence for benefits of stopping smoking, how best to assess tobacco dependence and what interventions currently work best to help pulmonary patients quit. Finally, we describe characteristics and management of any "hardcore" smoker who finds it difficult to quit with standard approaches.

WITHDRAWN: Patients with lung cancer: Are electronic cigarettes harmful, useful?

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

[Electronic cigarette: Reliable and efficient?]. / La cigarette électronique est-elle fiable et efficace ?

Before 2010, the e-cigarette remains inefficient then, its dissemination explodes in 2013 where more than 10 million people have tried it in France. The best made e-cigarette will always be potentially toxic and an addictive product. The e-cigarette is not a suitable product for non-smokers and could participate to normalize tobacco in society. To end tobacco, e-cigarette must provide a pleasant throat hit to the smoker in the first 6 seconds then deliver an adequate dose of nicotine. The majority of smokers who have tried the e-cigarette do not adopt the product because they did not like it. Health professional must help those who smoke and use e-cigarettes to remove the last cigarettes.

[Smoking prevention in preoperative patient factsheets]. / Prévention du tabagisme dans les fiches d'information préopératoires des patients.

INTRODUCTION: Information for patients undergoing elective surgery is often supported by factsheets. This information is required for ethical and legal reasons. Among the 11 million surgical procedures performed annually in France, three million concern smokers. Data of a 2005 French Expert's conference show that smoking doubles or triples the risk of postoperative complications and quitting smoking cancels this risk. METHODS: By a query on www.google.fr, 100 factsheets were collected in 2009 (pilot study) and 500 in 2012. These factsheets were systematically analyzed on tobacco information. Issuers were contacted by mail, email and telephone to suggest improvements on these factsheets. A return to the websites where the 500 factsheets have been issued was performed 6 months later. RESULTS: In 2009, only 24.0% of factsheets mentioned tobacco. In 2012, 29.4% of factsheets evoked tobacco. When tobacco is mentioned, information's were rarely complete. Cosmetic surgeons, maxillofacial surgeons and to a lesser extent orthopaedists are those who raise most often the tobacco issue. After contact with issuers, 41 factsheets were removed from the sites. Factsheets with tobacco information increased from 147/500 (29.4%) to 175/459 (38.1%) and the quality score of the information increased from 3.4 to 6.0. The message suggested by OFT was: "Smoking increases the risk of surgical complications of any surgery. Quitting smoking 6-8 weeks before surgery eliminates this additional risk. If you smoke, talk to your doctor, your surgeon and your anesthesiologist or call the French quitline TIS 3989 to help you to reduce the risk and put all the chances on your side". This sentence was included in 54 factsheets. CONCLUSION: There is still work to do to improve information's on smoking risk in perioperative factsheets. The aim is to reduce postoperative complications, costs and avoid court sentences against practitioner who do not inform properly on the risks of smoking on surgical procedures.

[Methods and results of smoking cessation in cancer smoker's]. / Sevrage tabagique, mise au point sur la prise en charge actuelle et ses résultats.

Tobacco prevention is the most effective prevention of cancer. Daily smoking promotes tumor progression, increases the risk of second cancer and decreases survival. The diagnosis of smoking and support for cessation and preventing recurrence is an integral part of cancer treatment. Smoking increases side effects of chemotherapy and surgery and reduces the effectiveness of radiotherapy and chemotherapy. Smokers with cancer do not smoke by life-style choice but because they are highly addicted and are suffering from a chronic relapsing disease: tobacco dependence, which justifies intensive medical management. The oncologist himself may perform this support or coordinate with other physicians in charge of the patient or with a tobacco cessation clinic, but patients are often unable to stop alone, as evidenced by the continued to use tobacco despite a cancer diagnosis. Treatment will always include a therapeutic education, compartmental behavioral therapy and medication. The patches and oral nicotine replacement or varenicline are the two most effective treatments that can be prescribed to smokers suffering of cancer, without including those with any motivation to quit. Smoking reducing occurred in a few days or weeks on treatment will allow them to reconsider the judgment. The full stop is always the goal for the doctor, even if it is not the patient initial goal. After stopping, the patient is not cured but still a patient with tobacco dependence who does not smoke. The risk of relapse in the year being 50%. The cancer patient management will use every visit to the point tobacco dependence and prevent relapse, alone or with assistance of a specialist. There is a lack of data on smoking cessation in cancer patients, but no item calls for a three-month quit rate of 50% as observed in the general population after an optimal management of tobacco cessation.

Exposure to secondhand smoke in terraces and other outdoor areas of hospitality venues in eight European countries.

BACKGROUND: Outdoor secondhand smoke (SHS) concentrations are usually lower than indoor concentrations, yet some studies have shown that outdoor SHS levels could be comparable to indoor levels under specific conditions. The main objectives of this study were to assess levels of SHS exposure in terraces and other outdoor areas of hospitality venues and to evaluate their potential displacement to adjacent indoor areas. METHODS: Nicotine and respirable particles (PM2.5) were measured in outdoor and indoor areas of hospitality venues of 8 European countries. Hospitality venues of the study included night bars, restaurants and bars. The fieldwork was carried out between March 2009 and March 2011. RESULTS: We gathered 170 nicotine and 142 PM2.5 measurements during the study. The median indoor SHS concentration was significantly higher in venues where smoking was allowed (nicotine 3.69 µg/m3, PM2.5: 120.51 µg/m3) than in those where smoking was banned (nicotine: 0.48 µg/m3, PM2.5: 36.90 µg/m3). The median outdoor nicotine concentration was higher in places where indoor smoking was banned (1.56 µg/m3) than in venues where smoking was allowed (0.31 µg/m3). Among the different types of outdoor areas, the highest median outdoor SHS levels (nicotine: 4.23 µg/m3, PM2.5: 43.64 µg/m3) were found in the semi-closed outdoor areas of venues where indoor smoking was banned. CONCLUSIONS: Banning indoor smoking seems to displace SHS exposure to adjacent outdoor areas. Furthermore, indoor settings where smoking is banned but which have a semi-closed outdoor area have higher levels of SHS than those with open outdoor areas, possibly indicating that SHS also drifts from outdoors to indoors. Current legislation restricting indoor SHS levels seems to be insufficient to protect hospitality workers--and patrons--from SHS exposure. Tobacco-free legislation should take these results into account and consider restrictions in the terraces of some hospitality venues to ensure effective protection.