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.