Jean-François Etter

Electronic cigarettes: a survey of users.

BackgroundLittle is known about users of electronic cigarettes, or their opinions, satisfaction or how and why they use such products.MethodsAn internet survey of 81 ever-users of ecigarettes in 2009. Participants answered open-ended questions on use of, and opinions about, ecigarettes.ResultsRespondents (73 current and 8 former users) lived in France, Canada, Belgium or Switzerland. Most respondents (77%) were men; 63% were former smokers and 37% were current smokers. They had used e-cigarettes for 100 days (median) and drew 175 puffs per day (median). Participants used the ecigarette either to quit smoking (53 comments), to reduce their cigarette consumption (14 comments), in order not to disturb other people with smoke (20 comments), or in smoke-free places (21 comments). Positive effects reported with ecigarettes included their usefulness to quit smoking, and the benefits of abstinence from smoking (less coughing, improved breathing, better physical fitness). Respondents also enjoyed the flavour of ecigarettes and the sensation of inhalation. Side effects included dryness of the mouth and throat. Respondents complained about the frequent technical failures of ecigarettes and had some concerns about the possible toxicity of the devices and about their future legal status.ConclusionsEcigarettes were used mainly to quit smoking, and may be helpful for this purpose, but several respondents were concerned about potential toxicity. There are very few published studies on ecigarettes and research is urgently required, particularly on the efficacy and toxicity of these devices.

Analysis of non-response bias in a mailed health survey

The objective of this study was to identify characteristics of non-respondents and late respondents to a mailed health survey. Persons who returned and those who did not return the questionnaire were compared using health insurance data, which indicated their age, sex, and health care expenditures in the previous year. Insurance and questionnaire data were used to compare early and late survey respondents and to compare categories of non-respondents. Questions covered use of health services, health status, and sociodemographic characteristics. Participants were members of health insurance plans in Geneva, Switzerland, 19-45 years old (n = 1822). Respondents (n = 1424) and non-respondents (n = 398) were of similar age and sex. The proportion of persons who had health care expenditures greater than zero Swiss francs (SFr) was higher among respondents (75%) than among non-respondents (69%, p = 0.03). Among non-respondents, expenditures of persons who explicitly refused to participate (2378 SFr) were higher than expenditures of persons who moved out of Geneva (1085 SFr) or who failed to return the questionnaire (1592 SFr, p = .02). Among respondents, being born in a Switzerland, having completed elementary school, having generated health care expenditures, and reporting good physical health were independent predictors of early response. In conclusion, low response rates to mailed health surveys may result in overestimating the utilization of health services. However, non-respondents did not constitute a homogeneous group, and the strength and even direction of non-response bias depended on the mechanisms of non-response.

Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit

AIMS We reviewed available research on the use, content and safety of electronic cigarettes (EC), and on their effects on users, to assess their potential for harm or benefit and to extract evidence that can guide future policy. METHODS Studies were identified by systematic database searches and screening references to February 2014. RESULTS EC aerosol can contain some of the toxicants present in tobacco smoke, but at levels which are much lower. Long-term health effects of EC use are unknown but compared with cigarettes, EC are likely to be much less, if at all, harmful to users or bystanders. EC are increasingly popular among smokers, but to date there is no evidence of regular use by never-smokers or by non-smoking children. EC enable some users to reduce or quit smoking. CONCLUSIONS Allowing EC to compete with cigarettes in the market-place might decrease smoking-related morbidity and mortality. Regulating EC as strictly as cigarettes, or even more strictly as some regulators propose, is not warranted on current evidence. Health professionals may consider advising smokers unable or unwilling to quit through other routes to switch to EC as a safer alternative to smoking and a possible pathway to complete cessation of nicotine use.

Validation of a French-language version of the MOS 36-Item Short Form Health Survey (SF-36) in young healthy adults

The MOS 36-Item Short Form Health Survey (SF-36) is designed to measure 8 dimensions of health in clinical and general population settings. The main aim of this paper was to examine the reliability and validity of this instrument in young adults. A secondary aim was to document the results of a rapid translation procedure of the instrument, to be compared later to the more thorough official French adaptation. The translated survey was answered in 1992 by 1007 residents of Geneva, Switzerland, 18-44 years old, identified from health insurance rolls (82% response rate). Completion rate for all 8 dimensions of health was 95.5%. The instrument demonstrated excellent covergent (100%) and discriminant (98%) validity against pre-set criteria. Interval scaling of responses could be verified in some, but not all, items. Cronbach alpha (reliability) coefficients ranged from 0.76 to 0.92. Factorial analysis yielded 2 principal components, corresponding to mental and physical health. Thirteen of 16 correlations between health dimensions and principal components were within a pre-established range. Validation by independent clinical variables was also, with few exceptions, consistent with theory. Thus the SF-36 retained excellent psychometric properties even when used in a generally very healthy group. The careful but rapid translation procedure used in this study may be an effective alternative to full-scale cultural adaptations when resources are limited.

Nicotine replacement therapy for long-term smoking cessation: a meta-analysis

Objective: To assess if the effect of a single treatment episode with nicotine replacement therapy (NRT) enhances smoking cessation over many years. Data sources: Meta-analysis of all randomised controlled trials of NRT with final follow-up more than one year after the start of treatment. Twelve eligible trials were identified, all placebo-controlled, having final follow-ups ranging from 2–8 years. All had earlier follow-ups at 12 months. They comprised 2408 active and 2384 placebo treatment participants. Data synthesis: The odds ratio (OR) in favour of NRT at final follow-up was 1.99 (95% confidence interval (CI) 1.50 to 2.64). There was no evidence that the effect varied according to length of final follow-up (β  =  0.92, p  =  0.28) or duration of initial NRT treatment (β  =  0.99, p > 0.5). The overall relapse rate between the 12 months and final follow-up was 30.0% (95% CI 23.5% to 37.5%). This rate did not differ between NRT and control groups (OR 1.11, 95% CI 0.78 to 1.59), or length of initial NRT treatment. There was also no evidence that it varied according to length of final follow up. Due to relapse, the overall efficacy of NRT treatment in terms of additional ex-smokers declined from 10.7% over and above placebo (6.6% to 14.8%) after one year to 7.2% (3.8% to 11.3%) at an average of 4.3 years follow up. Conclusions: The relative efficacy of a single course of NRT remains constant over many years. The majority of relapse after 12 months occurs within the first or second year and is not detectable thereafter, suggesting that NRT has a permanent effect on smoking cessation. However, initial relapse after one year has the effect of diminishing the number of ex-smokers that can be ultimately attributed to NRT. Results after only 6–12 months of follow-up, as used in existing reviews and treatment guidelines, will overestimate the lifetime benefit and cost-efficacy of NRT by about 30%. Because the long-term benefit of NRT is modest, tobacco dependence treatment might be better viewed as a chronic disorder, requiring repeated episodes of treatment.

A Self-Administered Questionnaire to Measure Dependence on Cigarettes: The Cigarette Dependence Scale

A valid measure of dependence on cigarettes is a useful tool for clinicians and researchers. The aim of this study was to develop a new, self-administered measure of cigarette dependence, and to assess its validity. The content of the instrument was generated in qualitative surveys. A long version (114 items) was tested on the internet in 3009 smokers. Subsamples provided retest data after 18 days (n=578), follow-up data after 45 days (n=990) and saliva cotinine (n=105). The study resulted in a 12-item scale labelled the Cigarette Dependence Scale (CDS-12), and in a 5-item version of this scale (CDS-5). Except for tolerance, CDS-12 covers the main components of DSM-IV and ICD-10 definitions of dependence: compulsion, withdrawal symptoms, loss of control, time allocation, neglect of other activities, and persistence despite harm. CDS-5 has similar measurement properties but less comprehensive content. Both scales had a high test–retest reliability (r⩾0.83), and a high internal consistency (Cronbachs α⩾0.84). CDS-12 scores were higher in daily smokers than in occasional smokers (+1.3SD units), and were associated with the strength of the urge to smoke during the last quit attempt (R2⩾0.25), and with saliva cotinine (R2⩾0.17). CDS-12 and CDS-5 scores decreased in daily smokers who switched to occasional smoking at 18-day retest. Dependence scores did not predict smoking abstinence at follow-up. In conclusion, CDS-12 and CDS-5 are reliable measures of cigarette dependence which fulfill several criteria of content validity and construct validity and are sensitive to change over time.

Cross-Cultural Adaptation of a Psychometric Instrument: Two Methods Compared

Cross-cultural adaptations of questionnaires are needed in multilingual research, but little is known about the effectiveness of specific translation methods. We compared properties of two French-language adaptations of the SF36 health survey: (a) a rapid translation developed over 3 months in Geneva in 1992 (Geneva version), based on three initial translations, one synthesis, and two pretests, and (b) a comprehensive adaptation developed by the International Quality of Life Assessment Project between 1991 and 1994 (IQOLA version), which involved back-translations, focus groups, development of equidistant response options, item difficulty and quality ratings, and multiple pretests. Wordings of 34 of 36 items differed. These two instruments were administered 1 year apart to the same sample of 946 young adults. Ceiling effects were somewhat lower for the IQOLA than for the Geneva version (means 30.4% and 35.5%), and missing scores slightly less frequent (IQOLA: mean 0.5%; Geneva: 1.2%). Floor effects (means 2.7% and 2.4%), proportions of consistent respondents (93.4% and 94.0%), and internal consistency coefficients (IQOLA: 0.78-0.89, Geneva: 0.80-0.92) were similar. Factor analysis supported the existence of two main aspects of health (physical and mental) for both versions. A majority of known-group comparisons were compatible with theory, for both versions. In conclusion, the two French-language versions of the SF36 had similar psychometric properties, despite extensive differences in the development process. This suggests that a moderately resource-intensive translation may produce adequate results. More empirical research is needed to understand what translation methods yield the best results.

Analysis of refill liquids for electronic cigarettes

AIMS To assess levels of nicotine, nicotine degradation products and some specific impurities in commercial refill liquids for electronic cigarettes. DESIGN AND SETTING We analyzed 20 models of 10 of the most popular brands of refill liquids, using gas and liquid chromatography. MEASUREMENTS We assessed nicotine content, content of the known nicotine degradation products and impurities, and presence of ethylene glycol and diethylene glycol. FINDINGS The nicotine content in the bottles corresponded closely to the labels on the bottles. The levels of nicotine degradation products represented 0-4.4% of those for nicotine, but for most samples the level was 1-2%. Cis-N-oxide, trans-N-oxide, myosmine, anatabine and anabasine were the most common additional compounds found. Neither ethylene glycol nor diethylene glycol were detected. CONCLUSION The nicotine content of electronic cigarette refill bottles is close to what is stated on the label. Impurities are detectable in several brands above the level set for nicotine products in the European Pharmacopoeia, but below the level where they would be likely to cause harm.

Attitudes toward nicotine replacement therapy in smokers and ex-smokers in the general public

Nicotine replacement therapy (NRT) doubles the chances that a smoker will quit smoking, but most smokers who attempt to quit do not use it at all or only use it inconsistently. We aimed to identify attitudes of smokers and ex‐smokers toward NRT and to develop and assess the validity of a brief scale used to measure these attitudes.

Saliva cotinine levels in users of electronic cigarettes

To the Editors: Electronic nicotine delivery systems (ENDS or electronic cigarettes) look like cigarettes but do not contain or burn tobacco. Instead, they comprise a battery-powered atomiser that produces a vapour for inhalation from cartridges containing humectants (propylene glycol or glycerol), flavours ( e.g. tobacco, mint or fruit) and nicotine. Many smokers report using ENDS to quit smoking or to substitute for tobacco in smoke-free places [1, 2]. ENDS do attenuate craving for tobacco, but appear to deliver little nicotine to the blood [3, 4]. Two studies have evaluated nicotine administration with different ENDS brands in ENDS-naive smokers [3, 4]. In one study, 32 smokers completed two 10-puff “vaping” bouts or smoked a cigarette [3]. In contrast to tobacco cigarettes, ENDS did not increase plasma nicotine reliably (plasma nicotine: 1.4 ng·mL−1 and 0.5 ng·mL−1, respectively, for two ENDS brands). In the other study, smokers used ENDS with a 16-mg nicotine cartridge for 5 min, a nicotine inhaler for 20 min or their usual cigarette for 5 min [4]. Nicotine concentration in plasma, measured after 60 min, was 1.3 ng·mL−1 for ENDS, 2.1 ng·mL−1 for inhalers and 13.4 ng·mL−1 for tobacco cigarettes, but one-third of participants showed no increase in blood nicotine while using the ENDS [4]. The time to maximum concentration of serum nicotine was shorter for ENDS (19.6 min) than for the nicotine inhaler (32.0 min), suggesting some absorption via the respiratory tract [4]. It is possible that serum nicotine levels would have been similar in ENDS and inhaler users, had ENDS users been allowed to use the devices for 20 min as for the inhaler. However, regular ENDS users may draw 120–175 puffs·day−1 on …