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Rapid response to:

Clinical Review State of the Art Review

What are the respiratory effects of e-cigarettes?

BMJ 2019; 366 doi: (Published 30 September 2019) Cite this as: BMJ 2019;366:l5275

Rapid Response:

Adolescents and Clinicians need appropriate and clear guidance on electronic cigarette (vaping) use and its potential benefits and harm to help them make the right decisions.

We thank The BMJ and Gotts and his colleagues for their timely important contribution to e-cigarette prevention (1). Even though e cigarette industry is aggressively advocating and promoting nicotine vaping as a safest tobacco cessation tool “few adolescents try to quit smoking using any sort of cessation aid or professional intervention and the efficacy of e-cigarettes in improving smoking cessation in youth is equivocal”(2).

It is interesting to know even reputed medical journals (3) have explicitly stated that there is growing evidence to support e-cigarettes and their effectiveness and safety for smoking cessation and harm reduction, and unfortunately these statements does not reflect the current best evidence and the efficacy of e-cigarettes for successful smoking cessation is inconclusive (4, 5).

We certainly agree that these inconsistent conclusions reflect uncertainty about the long term health effects of e-cigarettes, their effectiveness as smoking cessation agents, and their effect on children (1). Moreover, industry funding is strongly associated with finding no harm of e-cigarettes, compared with studies without a potential conflict of interest (1).

We strongly believe that the enthusiasm for a new therapeutic tool for tobacco addiction needs to be supported by best evidence. Despite lack of evidence of effectiveness, some clinicians are, in fact, advising smokers to use them (6). Also, many clinicians feel that they lack sufficient knowledge about the e-cigarette and express interest in learning more (6).

Therefore, the physicians need evidence-based information (in straight forward simple language) to help them appropriately address e-cigarettes in primary care (7, 8. 9). It is crucial that the British Medical Association (BMA) provides clinicians with evidence-based guidance on e-cigarettes (1).

It is also true that many adolescents face tough choices regarding tobacco, alcohol and drug use due to peer pressure and lack of accurate information. Adolescents need appropriate and clear guidance on electronic cigarette use and its potential benefits and harm to help them make the right decisions. Empowering adolescents to embrace healthy behaviors is very significant and we believe it is an important social responsibility. We thank The BMJ for continued advocacy in support of the adolescent health and well-being (1). Getting adolescents involved in this prevention program is crucial and the key to success.

We urge The BMJ to take a leadership role in a world-wide comprehensive school prevention program. We could perhaps tailor e-cigarette prevention programs similar to the old combustible cigarette prevention education programs. We need an effective social media campaign to enhance adolescents’ knowledge about the ingredients in e-cigarettes, their potential adverse effects and the known health hazards of prolonged use and misuse. There also needs to be a strong public education and awareness campaign to counter common myths and misconceptions (e.g., like e-cigarettes are a therapeutic tool).Comprehensive global prevention programs targeting adolescents are urgently needed. They need to be launched with the collaboration of schools, school boards, school administrators, parents, caregivers and youth organizations.

It is urgently needed to introduce a brief online training module as part of continuing medical education (CME) on how to use every opportunity of “teachable moments in the respective clinical practice”. “Teachable moments” has been commonly described as an opportunity to facilitate education and patient behavior change. Every clinical visits potentially could be an instance of a ‘‘teachable moment’’ to help educate young patients with vaping related potential serious health problems and motivate behavioral change. It is important that the training module should develop in consultation with the World Medical Association as well as the BMA. It is also important to involve adolescents in the process. Educational tool may be designed taking in to consideration of the context of interactive clinical scenarios.

(1). Gotts JE, Jordt SE, McConnell R, Tarran R. What are the respiratory effects of e-cigarettes? BMJ. 2019 Sep 30;366:l5275. doi: 10.1136/bmj.l5275. Review.
(2). Wolfenden L, Stockings E, Yoong SL. Regulating e-cigarettes in Australia: implications for tobacco use among young people. Med J Aust 2017; 208 (1):1. || doi: 10.5694/mja17.00787
(3). Warner KE, Schroeder SA. FDA's Innovative Plan to Address the Enormous Toll of Smoking. JAMA. 2017 Nov 14;318(18):1755-1756. doi: 10.1001/jama.2017.14336.
(4). Halpern SD, Harhay MO, Saulsgiver K, Brophy C, Troxel AB, Volpp KG. A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for Smoking Cessation. N Engl J Med. 2018;14;378(24):2302-2310. doi: 10.1056/NEJMsa1715757.
(5). Hartmann-Boyce J, Begh R, Aveyard P. Electronic cigarettes for smoking cessation. BMJ. 2018;360:j5543.PubMedGoogle ScholarCrossref
(6). Steinberg MB, Giovenco DP, Delnevo CD. Patient-physician communication regarding electronic cigarettes. Prev Med Rep. 2015; 2;2:96-8. doi: 10.1016/j.pmedr.2015.01.006. eCollection 2015.
(7). Doescher MP, Wu M, Rainwater E, Khan AS, Rhoades DA. Patient Perspectives on Discussions of Electronic Cigarettes in Primary Care. J Am Board Fam Med. 2018;31(1):73-82. doi: 10.3122/jabfm.2018.01.170206.
(8). Pepper JK, Gilkey MB, Brewer NT. Physicians' Counseling of Adolescents Regarding E-Cigarette Use. J Adolesc Health. 2015;57(6):580-6. doi: 10.1016/j.jadohealth.2015.06.017.
(9). Bandara NA, Mehrnoush V. E-Cigarettes, Incentives, and Drugs for Smoking Cessation.N Engl J Med. 2018 Sep 6;379(10):991. doi: 10.1056/NEJMc1809349.

Competing interests: No competing interests

06 October 2019
Aki Nilanga Bandara
Research Assistant
Senara Wanni and Vahid Mehrnoush
Emergency Medicine and Trauma Surgery-University of British Columbia
The University of British Columbia, 2357 Main Mall, Vancouver, BC V6T 1Z4 Canada.