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Non-Commercial Use Only 2020; volume 8:9493 Well-being and harm reduction, the consolidated reality of electronic ciga- rettes ten years later from this emerging phenomenon: A narrative review Pasquale Caponnetto,1-4 1Faculty of Health Sciences and Sport, University of Stirling, UK; 2Centro per la Prevenzione e Cura del Tabagismo (CPCT), Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico-S.Marco”, University of Catania; 3Department of Educational Sciences, University of Catania; 4Center of Excellence for the Acceleration of Harm Reduction (COEHAR), University of Catania Abstract Introduction Tobacco use is the greatest threat to public health worldwide, Amongst the World Health Organization (WHO) regions, in killing more than seven million people annually. This paper, about 2015, over 1.1 billion people smoked tobacco. Far more males 10 years after the first review on electronic cigarettes, analyses the (36.1%) than females (6.8%) smoked tobacco. Although it is evolution that this tool has had in these years. It concludes with declining worldwide and in many countries, the prevalence of comments on the significance of the research and why it consti- tobacco smoking appears to be increasing in the WHO Eastern tutes an original contribution. We searched PubMed (National Mediterranean Region and the African Region. Amongst the Library of Medicine), and PsycINFO (Ovid) (2006-2020) for stud- WHO regions Europe has the highest prevalence of tobacco smok- ies on e-cigarettes (harms and benefits, e-cigarette use, craving ing amongst adults (28%) only(WHO, 2018). In Italy, adult smoking and smoking cessation) and smoking cessation treatment (smok- prevalence has consistently decreased since recording started in ing cessation treatment or varenicline or tobacco cessation or 1957 (Gallus, Lugo, Colombo, Pacifici, La Vecchia, 2013). From reduction or bupropion or NRT or behavioral treatment or e- 2013 to 2014, Lugo et al. (2015) found an overall smoking preva- cigarette) and evidence suggests that they may effective as smok- lence amongstuse Italian adults of 21% (26% of men and 17% of ing cessation tool and may be less harmful alternatives to com- women). This agrees with recent data from a large household sur- bustible cigarette smoking. Consequently, e-cigarettes could be vey (based on 60,000 families and 130,000 individuals) conducted considered as an applicable instrument for Tobacco Harm in 2013 by the National Institute of Statistics (ISTAT), showing an Reduction (THR) and smoking cessation. adult smoking rate of 21% (26% in men and 16% in women) (ISTAT, 2015). Another study confirmed the decreasing trend observed over the last five decades in men and over the last two decades in women (Gallus et al., 2013). However, no significant decrease in terms of smoking prevalence has been observed in men or women between 2007 and 2014. This likely reflects the lack of adoption of effective and relevant additional antismoking measures after the successful ban introduced in 2005 (Joossens & Correspondence: Pasquale Caponnetto, Department of Educational Raw, 2014) and smoking prevalence has levelled off over the last Sciences, University of Catania, Palazzo Ingrassia Via Biblioteca, 4, few years (Osservatorio Fumo, Droga e Alcol, 2016). In 2005 the 95124, Catania, Italy. Italian government banned smoking in all indoor public places, E-mail: [email protected] including offices, cafes, restaurants (except for a few with separate Key words: Smoking; e-cigarette; smoking cessation; smoking reduc- and regulated smoking areas), airports, and railway stations. Italy tion; harm reduction. Non-commercialwas the first large country in Europe to introduce a comprehensive smoking ban, which resulted in a further acceleration of the Conflict of interest: PC is paid by the University of Catania as an exter- decreasing trend of smoking prevalence in both sexes (Gallus et nal part time researcher and adjunct professor of clinical, addiction and al., 2006; ISTAT, 2015; Tramacere et al., 2009). In February 2016, general psychology. He has been affiliated to the CoEHAR since the Italian government established new legislation regarding December 2019 in a pro bono role. He is co-author of a protocol paper tobacco smoking. New anti-smoking laws have imposed large supported by an Investigator-Initiated Study award program established fines for several offences and make it illegal to smoke in a car car- by Philip Morris International in 2017. rying children or pregnant women. The laws require cigarette packs to carry health warnings about the effects of smoking. Received for publication: 18 November 2020. Smoking is also prohibited outdoors near schools and hospitals. Accepted for publication: 24 December 2020. Tobacconists caught selling cigarettes to minors risk heavy fines This work is licensed under a Creative Commons Attribution- and losing their license. Throwing cigarette butts on the pavement NonCommercial 4.0 International License (CC BY-NC 4.0). could cost an offender up to 300 Euros (OSSFAD, 2016). However, after the positive initial effects of the law of 2005, the ©Copyright: the Author(s), 2020 prevalence of smokers in Italy has not decreased further and has Licensee PAGEPress, Italy instead remained static (OSSFAD, 2018). Health Psychology Research 2020; 8:9463 Smoking traditional cigarettes is one of the largest risk factors doi:10.4081/hpr.2020.9463 for premature mortality from non-communicable diseases in the [page 200] [Health Psychology Research 2020; 8:9463] Review general population (Stringhini et al., 2017). Tobacco use is the in males (Ezzati & Lopez, 2003). The risk of developing lung can- greatest threat to public health worldwide, killing more than seven cer seems to be affected by the duration of smoking and the num- million people each year (WHO, 2017). Cigarette smoking is the ber of cigarettes (or cigars, or pipes) smoked daily (La Vecchia single most preventable cause of death and disease. Smoking-relat- Franceschi, & Levi, 2003). The Relative Risk (RR) ratio between ed death is principally caused by lung and other cancers, ischemic the occurrence of lung cancer amongst smokers and nonsmokers is heart disease and Chronic Obstructive Pulmonary Disease (COPD) 15 overall and 25 for heavy smokers (Doll et al., 2004). Reducing (WHO, 2012; Doll, Peto, Boreham, & Sutherland, 2004). The risk the intake of traditional cigarettes smoked per day may support a of serious disease has been shown to diminish rapidly after smok- harm reduction approach but the US Cancer Prevention Study II ing cessation – ‘quitting’ – and permanent abstinence markedly has shown that the number of years of tobacco smoking is far more reduces the risk of lung cancer and other cancers, ischemic heart critical in predicting lung cancer risk than the number of cigarettes disease and COPD. Considering that the main types of these non- smoked daily (Alberg & Samet, 2003). The age of starting smok- communicable diseases are Cardiovascular Diseases (CVDs), can- ing increases lung cancer risk (Flanders, Lally, Zhu, Henley, & cers and chronic respiratory diseases, helping traditional cigarette Thun, 2003); hence, promoting interventions to avoid smoking ini- smokers quit and remain abstinent is one of the most effective tiation (typically during the adolescence) are important. ways we can improve the public health of Italy, UK and the rest of Smoking is also the main cause of many respiratory diseases the world. The associations between traditional cigarette smoking (CDC, 2004). COPD is predicted to become the third leading cause and hazards to physical health are described below. Cigarette of death in 2030 (WHO, 2008). Cigarette smoking is the most smoking is probably the most complex and the least understood important risk factor for COPD and it can also promote the onset amongst the risk factors for CVDs. Cigarette smoke contains sev- of exacerbations (Wedzicha & Donaldson, 2003). Data collected in eral thousand chemicals, though there isn’t concordance about the European countries show that self-reported diagnosis of chronic exact number of chemicals. Two studies report traditional bronchitis/emphysema (Viegi et al., 1999) or spirometry signs of cigarettes contain ≈4000 different chemicals with sizes ranging airflow obstruction (Lundback et al., 2003) are more frequent in from atoms to particulate matter (Burns, 1991; Zemann, 2011) and smokers than nonsmokers. The risk of developing COPD may be other two more recent papers demonstrate tobacco smoke contains increased not only byonly the average daily number of cigarettes more than 7000 chemicals (Perfetti & Rodgman, 2013; Tobacco smoked but even more by cumulative pack-years (Viegi et al., Atlas, 2015). Individual smoking behavior, intensity of smoking 1999). Moreover, a study has shown that smokers with COPD have and the brand of cigarettes smoked further modulate the amount, higher tobacco consumption, higher CO levels in exhaled air and number, and type of chemicals in tobacco smoke to which an indi- higher dependenceuse on nicotine than healthy smokers (Lundback et vidual is exposed (Conrad, 2011). Importantly, it is likely that it is al., 2003). However, despite COPD being considered as a smok- not just a single compound or a compound class, such as oxidants, ing-related lung disorder, not all traditional cigarette smokers but rather a highly complex and changing mixture of compounds develop this disease. Faner et al. (2014) showed that some smokers that is responsible for disease initiation, progression, and cardio- may develop
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