Sara Kalkhoran

E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis

BACKGROUND Smokers increasingly use e-cigarettes for many reasons, including attempts to quit combustible cigarettes and to use nicotine where smoking is prohibited. We aimed to assess the association between e-cigarette use and cigarette smoking cessation among adult cigarette smokers, irrespective of their motivation for using e-cigarettes. METHODS PubMed and Web of Science were searched between April 27, 2015, and June 17, 2015. Data extracted included study location, design, population, definition and prevalence of e-cigarette use, comparison group (if applicable), cigarette consumption, level of nicotine dependence, other confounders, definition of quitting smoking, and odds of quitting smoking. The primary endpoint was cigarette smoking cessation. Odds of smoking cessation among smokers using e-cigarettes compared with smokers not using e-cigarettes were assessed using a random effects meta-analysis. A modification of the ACROBAT-NRSI tool and the Cochrane Risk of Bias Tool were used to assess bias. This meta-analysis is registered with PROSPERO (number CRD42015020382). FINDINGS 38 studies (of 577 studies identified) were included in the systematic review; all 20 studies with control groups (15 cohort studies, three cross-sectional studies, and two clinical trials) were included in random effects meta-analysis and sensitivity analyses. Odds of quitting cigarettes were 28% lower in those who used e-cigarettes compared with those who did not use e-cigarettes (odds ratio [OR] 0·72, 95% CI 0·57-0·91). Association of e-cigarette use with quitting did not significantly differ among studies of all smokers using e-cigarettes (irrespective of interest in quitting cigarettes) compared with studies of only smokers interested in cigarette cessation (OR 0·63, 95% CI 0·45-0·86 vs 0·86, 0·60-1·23; p=0·94). Other study characteristics (design, population, comparison group, control variables, time of exposure assessment, biochemical verification of abstinence, and definition of e-cigarette use) were also not associated with the overall effect size (p≥0·77 in all cases). INTERPRETATION As currently being used, e-cigarettes are associated with significantly less quitting among smokers. FUNDING National Institutes of Health, National Cancer Institute, FDA Center for Tobacco Products.

Historical, Clinical, and Dermoscopic Characteristics of Thin Nodular Melanoma

BACKGROUND Nodular melanoma (NM), representing 15% to 30% of all melanomas, constitutes nearly half of all melanomas thicker than 2 mm. Nodular melanoma frequently lacks clinical features seen in other melanoma subtypes and has a faster growth rate. We reviewed a series of cases of NM that was less than 1.3 mm thick to identify historical, clinical, and dermoscopic factors that may facilitate earlier diagnosis of NM, with the hope of reducing its associated morbidity and mortality. OBSERVATIONS The thin NM lesions we analyzed had a rather subtle clinical appearance, often lacking the ABCD (asymmetry, border irregularity, color variegation, and diameter greater than 6 mm) criteria. On dermoscopy, most lesions had a homogeneous disorganized asymmetric pattern or a featureless pattern with atypical vessels. Although many dermoscopic features seen in other melanoma subtypes were frequently absent, some features such as a blue-white veil, structureless areas, and atypical vascular structures were often identified. CONCLUSIONS The often unremarkable clinical presentation of NM necessitates physicians and patients to be wary of new or changing lesions. Dermoscopy may help increase suspicion in early NM because dermoscopic features are typically more suggestive of malignancy than clinical ones. We hope that secondary prevention efforts combined with prompt dermatologic consultations will allow for the timely diagnosis and management of NM.

Dual use of smokeless tobacco or e-cigarettes with cigarettes and cessation.

OBJECTIVES To evaluate predictors of dual use of cigarettes with smokeless tobacco or e-cigarettes. METHODS Adult smokers (N = 1324) completed online cross-sectional surveys. Logistic regression evaluated predictors of dual use and cigarette quit attempts. RESULTS Smokeless tobacco dual use was associated with past attempts to quit smoking by switching to smokeless products. E-cigarette dual use was associated with using stop-smoking medication and strong anti-tobacco industry attitudes. Ever use of stop-smoking medication was associated with quit attempts among dual e-cigarette users and cigarette-only users. CONCLUSIONS Dual users are more likely than cigarette-only users to endorse certain cessation-related attitudes and behaviors. This may provide an opportunity for clinicians or others to discuss evidence-based strategies for smoking cessation.

Secondhand Smoke Exposure and Smoking Behavior Among Young Adult Bar Patrons

OBJECTIVES We described frequency of secondhand smoke (SHS) exposure among young adults patronizing bars and associations between SHS exposure, attitudes, and smoking behavior. METHODS We collected cross-sectional surveys from randomized time-location samples of bar patrons aged 18 to 26 years in San Diego, California, and Oklahoma City and Tulsa, Oklahoma, in 2010 to 2011. Multivariate logistic regression evaluated associations between SHS exposure, attitudes about dangers of SHS, susceptibility to smoking initiation among nonsmokers, and quit attempts among current smokers. RESULTS More than 80% of respondents reported past 7-day exposure to any SHS, and more than 70% reported exposure at a bar. Current smokers reported more SHS exposure in cars and their own homes than did nonsmokers. Among nonsmokers, SHS exposure was associated with susceptibility to initiation, but those who believed that SHS exposure is harmful were less susceptible. Belief that SHS is dangerous was associated with quit attempts among smokers. CONCLUSIONS Smoke-free environments and education about the harms of SHS may decrease tobacco use among young adults who frequent bars, where they are heavily exposed to SHS.

Use of Electronic Cigarettes Among U.S. Adults With Medical Comorbidities

INTRODUCTION Electronic cigarette (e-cigarette) use is rising in the U.S. Smokers with comorbidities may increasingly use e-cigarettes if they believe e-cigarettes reduce smoking-related harm. This study examined e-cigarette use among adults with medical comorbidities. METHODS In 2016, this study analyzed 68,136 U.S. adults in the 2014 and 2015 National Health Interview Survey. Prevalent e-cigarette use by medical comorbidities and adjusted odds of e-cigarette use were calculated. RESULTS Among current cigarette smokers, ever use of e-cigarettes was more often reported by adults with one or more medical comorbidity versus those without comorbidity (18-24 years: 73.5% vs 61.4%; 25-44 years: 60.6% vs 54.3%; 45-64 years: 46.5% vs 40.3%; ≥65 years: 35.2% vs 19.4%; all p<0.05). Current smokers aged 25-64 years with one or more comorbidity reported current e-cigarette use more often than those without comorbidity (25-44 years, 17.8% vs 14.3%, p=0.03; 45-64 years, 15.9% vs 11.5%, p=0.02). Current smokers with chronic obstructive pulmonary disease, asthma, and cardiovascular disease had higher odds of ever e-cigarette use versus those without comorbidity. Current smokers with asthma and cardiovascular disease had higher odds of current e-cigarette use. Former smokers with chronic obstructive pulmonary disease had higher odds of ever and current e-cigarette use and former smokers with cancer had lower odds of current e-cigarette use. CONCLUSIONS E-cigarette use by current and former smokers with medical comorbidities is substantial, especially among individuals with chronic lung or cardiovascular disease. Clinicians should routinely ask these patients about e-cigarette use, actively consider all pathways to help their patients quit combustible cigarettes, and recommend evidence-based treatments.

Effect of Uruguay's National 100% Smokefree Law on Emergency Visits for Bronchospasm

INTRODUCTION Implementation of smokefree laws is followed by drops in hospital admissions for cardiovascular diseases and asthma. The impact of smokefree laws on use of non-hospital medical services has not been assessed. The purpose of this study is to evaluate the impact of Uruguays national 100% smokefree legislation on non-hospital emergency care visits, hospitalizations for bronchospasm, and bronchodilator use. METHODS The monthly number of non-hospital emergency care visits and hospitalizations for bronchospasm, as well as monthly puffs of bronchodilators (total and per person), from 3 years prior to the adoption of the 100% smokefree policy on March 1, 2006, through 5 years after the policy were assessed using interrupted time series negative binomial regression. Data analysis was conducted in 2014. RESULTS The incidence of non-hospital emergency visits for bronchospasm decreased by 15% (incidence rate ratio [IRR]=0.85, 95% CI=0.76, 0.94) following implementation of the law. Hospitalizations for bronchospasm did not change significantly (IRR=0.89, 95% CI=0.66, 1.21). Total monthly puffs of salbutamol and ipratropium administered in the non-hospital emergency setting decreased by 224 (95% CI=-372, -76) and 179 (95% CI=-340, -18.6), respectively, from means of 1,222 and 1,007 before the law. CONCLUSIONS Uruguays 100% smokefree law was followed by fewer emergency visits for bronchospasm and less need for treatment, supporting adoption of such policies in low- and middle-income countries to reduce the disease burden and healthcare costs associated with smoking.

Smoke-free policies: cleaning the air with money to spare.

1526 www.thelancet.com Vol 383 May 3, 2014 One reason that politicians are reluctant to invest in aggressive tobacco control policies and programmes is the perception that the costs (money and the risk of irritating tobacco companies) come now, whereas the benefi ts (reduced disease and medical costs) are years away. In The Lancet, Jasper Been and colleagues’ metaanalysis adds another dimension to the already strong case that this perception is wrong. Drawing on 11 studies done in North America and Europe, including more than 2·5 million births and nearly 250 000 asthma exacerbations, Been and colleagues show that smoke-free workplace and public place laws were followed by immediate drops in preterm births (10·4%, 95% CI 2·0–18·8%) and childhood emergency department visits and hospital attendances (10·1%, 5·0–15·2). Although there was no signifi cant change in low birthweight (–1·7%, –5·1 to 1·6%), there was a decline in children being very small for gestational age (5·3%, 5·2–5·4). In addition to clearing the air, smoke-free laws bring rapid health benefi ts and improved lives, whilst, at the same time, reducing medical costs by avoiding emergency department visits and admissions to hospitals. Smoke-free laws are also followed by benefi ts for adults, including drops in hospital admissions for cardiac disease, cerebrovascular accidents, and respiratory disease, and reduced ambulance calls. This fall in adverse events shows up in hospital costs: after German states enacted weak smoking restrictions in restaurants (policies that generally allowed smoking in small bars Smoke-free policies: cleaning the air with money to spare alternative medical countermeasures eff ective against variants of variola virus resistant to antiviral drugs and vaccines, which could arise either naturally or by synthetic biology carried out with malicious intent. Improved countermeasures against smallpox will require assessment against authentic variola virus in vitro, and potentially in animal models for human orthopoxvirus infections. Of course, it is important that the discussion about new product development should make clear how the benefi ts of these discoveries will be shared. DR Congo and Congo are, at present, dealing with ongoing outbreaks of monkeypox. In view of the shortage of aff ordable diagnostics suitable for fi eld use, the full extent of this problem is possibly more widespread than suggested by numbers of confi rmed cases. Available data indicate that the effi ciency of person-to-person spread of monkeypox virus is evolving, and that the severity of disease being seen is increasing. Treatment of patients with the existing leading drug candidates is not practical. However, if alternative, more aff ordable drugs were identifi ed for smallpox, these same drugs could be used to treat patients with monkeypox and potentially curb outbreaks. Curtailing further investigation of these alternative and potentially cost-eff ective strategies to mitigate the potential impact of a monkeypox outbreak to achieve symbolic destruction of the approved variola virus reference collections is, therefore, not in the best interests of public health.

Disparities in receipt of 5As for smoking cessation in diverse primary care and HIV clinics

Clinical practice guidelines recommend that clinicians implement the 5As (Ask, Advise, Assess, Assist, and Arrange) for smoking cessation at every clinical encounter. We sought to examine the prevalence of patient- and clinician-reported 5As in two primary care and one HIV care clinics in San Francisco, California between August 2013 and March 2014 (n = 462 patients and n = 61 clinicians). We used multivariable logistic regression analysis to identify factors associated with receipt of the 5As, adjusting for patient demographics, patient insurance, clinic site, patient tobacco use, and patient comorbidities. The patient-reported prevalence of 5As receipt was as follows: Ask, 49.9%; Advise, 47.2%; Assess, 40.6%; any Assist, 44.9%; and Arrange, 22.4%. In multivariable analysis, receipt of Advise, Assess, and Assist were associated with older patient age. Whereas patients with HIV had a lower odds of reporting being advised (AOR 0.5, 95% CI 0.3–0.8) or assessed for readiness to quit (AOR 0.6, 95% CI 0.4–0.9), patients with pulmonary diseases had higher odds of reporting being assisted (AOR 1.6, 95% 1.0–2.6) than patients without these diagnoses. Although the majority of clinicians reported asking (91.8%), advising (91.8%), and assessing (93.4%) tobacco use ‘most of the time’ or ‘always’ during a clinical encounter, fewer reported assisting (65.7%) or arranging (19.7%) follow-up. Only half of patients reported being screened for tobacco use and fewer reported receipt of the other 5As, with significant disparities in receipt of the 5As among patients with HIV. Our findings confirm the need for interventions to increase clinician-delivered cessation treatment in primary and HIV care.

Multiple tobacco product use among young adult bar patrons in New Mexico.

INTRODUCTION Use of non-cigarette tobacco products is common, and e-cigarette use is increasing among young adults. We aimed to identify use of other tobacco products among young adult bar patrons in the context of a bar-based intervention to decrease cigarette smoking. METHODS 2291 cross-sectional surveys were collected from young adults in bars in Albuquerque, New Mexico using time-location sampling between 2011 and 2013 (N=1142 in 2011, N=1149 in 2012-2013), 2 and 3years into an intervention to reduce cigarette use, and analyzed in 2014-2015. Participants reported current (i.e. past 30-day) use of cigarettes, snus, dip, cigarillos, hookah, and e-cigarettes, demographics, and tobacco-related attitudes. Multiple imputation was used to account for planned missing data. Logistic regression determined correlates of multiple tobacco product use. RESULTS Cigarette smoking in the population decreased during the intervention from 43% to 37%. Over 60% of current cigarette smokers reported poly-use, most frequently with e-cigarettes (46%) and hookah (44%), followed by cigarillos (24%), dip (15%), and snus (14%) in 2012-2013. Among cigarette smokers, current e-cigarette use increased, while use of other products decreased during the intervention. Odds of poly-use (versus smoking cigarettes only) were greater among males and those reporting past 30-day binge drinking, and lower in those who strongly believed secondhand smoke exposure is harmful. CONCLUSIONS Among young adult bar patrons in Albuquerque, New Mexico, most cigarette smokers reported currently using at least one other tobacco product. Public health interventions should address use of all tobacco products, use of which may rise despite decreased cigarette use.

AIDS education in an Islamic nation: content analysis of Farsi-language AIDS-education materials in Iran

Inconsistent statistics about the number of HIV/AIDS cases in Iran and misinformation about HIV/AIDS among Iranian adolescents necessitate proper understanding and knowledge of HIV/AIDS transmission and prevention. This is particularly important since many issues related to HIV/AIDS, such as sex, homosexuality, and drug use, are taboo topics in the Islamic world. We analyzed Farsi-language educational and informational small media items to ascertain the nature of HIV/AIDS-related material available in society. While all of the documents mentioned sexual contact as a means of transmitting the virus, and the majority (87%) mentioned condom use as a preventive means, mention of homosexuality (43%) and prostitution (17%) was lacking in most. Thus, mention of “safe sex” strategies was not avoided due to fear of promoting sex outside of marriage, as has been noted in other Islamic nations. Mention of intravenous drug use in 90% of the documents shows an acknowledgment of the drug problem in the nation, and an effort to curb its harmful sequelae. Therefore, while certain issues such as sex, condoms, and drug use were well represented in the documents analyzed, additional inclusion of topics such as homosexuality and prostitution, issues already discussed infrequently in society, can help to better educate the population and curb the spread of this life-threatening disease. (Promot Educ 2008;15(3): 21-25)