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.

Combat, Posttraumatic Stress Disorder, and Smoking Trajectory in a Cohort of Male Australian Army Vietnam Veterans.

Background: Whether trauma exposure itself or consequent posttraumatic stress disorder (PTSD) is primarily responsible for smoking and failure to quit remains unclear. Methods: A cohort of male Australian Vietnam veterans (N = 388) was interviewed twice, 22 and 36 years after their return to Australia using standardized psychiatric diagnostic and health interviews and assessment of combat exposure. The smoking trajectory over time revealed a spectrum of outcomes (never smoked, early quitters, late quitters, and continuing smokers). Analysis used multivariate statistics to assess the relative contributions of combat trauma exposure and PTSD while controlling for potential confounders. Results: The trajectory of smoking over time revealed that 21.9% of veterans had never smoked, 45.1% had quit smoking by the time of wave 1, 16.2% were current smokers at wave 1 who had quit by the time of wave 2, 2.8% were late adopters who were current smokers, and 13.9% were continuing smokers. Smoking was associated in single-predictor models with demographics, intelligence, combat exposure, PTSD symptom clusters and diagnosis, and alcohol disorders. Multivariate analysis revealed that PTSD, combat, and intelligence were related to the smoking spectrum but, after adding demographics and other Axis I psychiatric diagnoses, only combat remained significant. No PTSD symptom cluster uniquely predicted smoking status. Conclusions: The results suggest that trauma exposure in the form of military combat may be a more robust predictor of smoking status over time than PTSD. It may be stress itself, rather than poststress disorder, that is more germane to smoking and failure to quit. Implications: Exposure to traumatic stress and development of PTSD have been implicated separately in the maintenance of smoking. This longitudinal cohort study of smoking in war veterans up to three decades postwar enabled evaluation of traumatic stress exposure in combat and the course of PTSD in smoking and quitting while controlling for intelligence, background disadvantage, and other psychiatric conditions. Combat rather than PTSD emerged as more significant to smoking status, suggesting that it may be the traumatic stress itself rather than the development of a poststress disorder that is more germane to smoking in war veterans.

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.

Exploring General Practitioners' Knowledge, Attitudes, and Practices towards E-Cigarette Use/Vaping in Children and Adolescents: A Pilot Cross-Sectional Study in Sydney.

(1) Background: The increasing use of e-cigarettes/vaping in children and adolescents has been recognised as a global health concern. We aim to explore the Knowledge, Attitude, and Practice of General Practitioners (GPs) in Sydney regarding the use of e-cigarettes in children and adolescents and identify the barriers to addressing this issue. (2) Methods: This pilot study was a cross-sectional study conducted using an electronic questionnaire with a Likert scale and free-text responses. (3) Results: Fifty-three GPs participated in the study (male = 24 and female = 29) with a mean age of 50 ± 5.5 years. There was strong agreement (mean 4.5) about respiratory adverse effects and addictive potential. However, there was less awareness of cardiac side effects and the occurrence of burns. There is a lack of conversation about e-cigarettes in GP practice and a deficit of confidence in GPs regarding managing e-cigarette use in children and adolescents. (4) Conclusions: Our pilot study has shown that GPs are somewhat knowledgeable about the potential adverse effects of the use of e-cigarettes in children and adolescents, though there is a lack of knowledge of the complete spectrum of adverse effects and more importantly, there is a paucity of a structured approach to discuss the use of e-cigarettes with children and adolescents, and there is a low level of confidence in addressing these issues. There is a need for educational interventions for GPs to increase awareness of the potential adverse effects of using e-cigarettes and build confidence in providing management to children and adolescents regarding the use of e-cigarettes.

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.

Provision of smoking cessation services in Australian community pharmacies: a simulated patient study.

BACKGROUND: With the rising interest in expanding pharmacists' role in smoking cessation, it is pertinent that community pharmacists be equipped with up-to-date knowledge and competence to provide optimal therapeutic services that meet the demands of various presenting subsets of smokers. OBJECTIVE: To investigate and evaluate responses to requests of quitting smoking from 'high risk' smokers seeking assistance and treatment within the pharmacy venue. SETTING: Community pharmacies located within Sydney greater metropolitan area, New South Wales, Australia. METHOD: A simulated patient methodology was utilised. Two scenarios were developed and enacted by two trained simulated patients in 100 randomly selected pharmacies. Scenario 1 involved a 28-year-old pregnant female who presents with a request for help in quitting smoking. Scenario 2 involved a 22-year-old female requesting a quit smoking product for her 55-year-old father who has cardiovascular problems. A standardised scoring key was designed to assess the performance of pharmacists during each encounter. MAIN OUTCOME MEASURE: The primary outcome measure was the supply/non-supply of nicotine replacement products and the corresponding provision of counselling and advice to facilitate smoking cessation. RESULTS: A product(s) was supplied in 42 % of the 100 encounters, while a product was adequately suggested pending doctor's referral in 45 %. In 13 % of the cases, a product was not supplied based on inappropriate notions of nicotine replacement therapy not being safe in the presented scenario. Pharmacists performed better in dispensing scores (counselling about product use) as compared to pre-dispensing scores (eliciting patient history). ANOVA followed by regression analysis indicated that the estimated age and gender of the pharmacist/staff were significant predictors affecting total scores. CONCLUSION: Whilst pharmacists' counselling about smoking cessation aids seems satisfactory, further education is required to improve practice standards in terms of matching a patient's history and smoking status to an appropriate product.

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.

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.