Re: Electronic cigarettes and obstetric outcomes: a prospective
observational study
[Author’s title] “Hasten slowly”* and assistance for smoking
cessation. Vaping is not quitting
* Miller SL, Walker DW. The challenge of protecting the perinatal brain
against hypoxic ischaemic injury - hasten slowly. J Physiol
2014;592:425–426.
The study about obstetric outcomes in e-cigarette users (exclusive
n=218, dual n=195), cigarette smokers (n=99) and non-smokers (n=108)
concluding “birthweight of infants born to e-cigarette users is similar
to that of non-smokers and smokers, and significantly greater than
cigarette smokers” deserved comments.(1)
Firstly, smoking is the primary avoidable cause of preterm birth and all
other complications except hypertensive pregnancy but poor care
dominates. The issue is a general one: less than half of oncologists
advise patients to quit and fewer provide cessation treatment despite
smoking seriously affects outcomes.(2) CNN dare to call a spade a spade,
titled “US surgeon general says doctors aren’t encouraging enough
smokers to
quit”.(https://edition.cnn.com/2020/01/23/health/surgeon-general-smoking-cessation-report-bn/index.html)
Further, guidelines with the “5As” beginning with “Advising users to
quit” and “Assessing willingness to quit” are almost programmed
failures.(2) Smokers are aware that suffering and despair follow failed
serial cessation attempts. None believe it is possible to break free
from severe addiction.
Here are some basic principles for care:
Take time for explanations as smokers are: a) ignorant of devastating
effects of compensatory uptake of toxic by-products when trying to
reduce smoking without patches; b) wrongly afraid of smoking with
patches; c) more scared of nicotine than CO or tar.(2)
Do not require smokers to quit but simply to: a) implement the “belt
and braces” strategy (nicotine patches with oral “rescue”
formulations, spray or lozenge, to suppress occasional cravings); b)
increase doses without fear until carving is suppressed.
Do not set a quit date as recommended, smokers will naturally quit when
cravings are gone and when they find smoking cigarettes distasteful. Do
pain doctors set with their patients the date for being be pain free?
Simply “hasten slowly”.
Sadly, fast medicine is the new paradigm: e.g; the “Minute Clinics”
trial recently concluded that a one minute advice in the emergency
setting significantly increased smoking cessation rate from 3.3% to
3.7%.(3) This cannot be clinically relevant for a condition killing one
out of two and, worse the trial was flawed: patients in the control
group received a placebo, not nicotine substitutes, thus nurturing
disillusionment as craving was not suppressed as they expected.
Secondly, vaping is not quitting. Michelangelo warned “The greater
danger for most of us lies not in setting our aim too high and falling
short; but in setting our aim too low, and achieving our mark.” The
tobacco industry previously used the “harm reduction” motto: the
marketing of filters was followed by the promotion of “light” and
“low-tar” cigarettes, always with devastating consequences.(4) Red
flags about vaping toxicity have been accumulating and are increasing.
E.g. e-cigarettes cause lung adenocarcinomas and bladder urothelial
hyperplasia in mice.(5) The International Agency for Research on Cancer
defines Group 2A carcinogen as “limited evidence of carcinogenicity in
humans and sufficient evidence of carcinogenicity in experimental
animals”.
Thirdly, a small series of pregnant women with a short-term follow-up is
inadequate for reassuring conclusions, even more when considering the
complexity of major confounding variables. Certainly, during a face to
face visit, if a healthcare professional fails to target cessation
despite a well-conducted motivational interview, he/she must reassure
the woman who vape. However, at the population level such a message is
not acceptable. Is the French media titled ”[Use of the personal
vaporizer during pregnancy : a reassuring observational study]”
serving the interests of the unborn
child?https://www.psychoactif.org/forum/2020/03/05/Utilisation-vaporisateur-personnel-pendant-grossesse-une-etude-observationnelle-rassurante_50521_1.html?from=encemomentf#p481253)
Alain Braillon
University hospital, 80000 Amiens, France
1 McDonnell BP, Dicker P, Regan CL. Electronic cigarettes and obstetric
outcomes: a prospective observational study. BJOG 2020. Online Feb 9.
doi: 10.1111/1471-0528.16110.
2 Braillon A. The Use of e-Cigarettes in Patients With Cancer-A Double
Shipwreck. JAMA Oncol 2019. Online Jul 25.
doi:10.1001/jamaoncol.2019.2384
3 Li WHC, Ho KY, Wang MP, et al. Effectiveness of a Brief
Self-determination Theory-Based Smoking Cessation Intervention for
Smokers at Emergency Departments in Hong Kong: A Randomized Clinical
Trial. JAMA Intern Med 2019;180:206-214.
4 Braillon A. Electronic Cigarettes and Insanity. Am J Prev Med
2016;50:e27.
5 Tang MS, Wu XR, Lee HW, et al. Electronic-cigarette smoke induces lung
adenocarcinoma and bladder urothelial hyperplasia in mice. Proc Natl
Acad Sci U S A. 2019;116:21727–21731.