We wish to congratulate the Professional Practice Committee of the American Diabetes Association (ADA) for their recent update of the ADA Standards of Care in Diabetes (1). In particular, it is reassuring to see that the ADA is expanding its mission “to improve the lives of all people affected by diabetes” by addressing the problem of continued smoking (1). Smoking/tobacco cessation in diabetes is largely neglected, and it is important to bolster confidence in diabetes education programs across the world to help health professionals maximize the chances of their patients stopping smoking or using tobacco.
Obviously, we agree that people with diabetes who smoke should be offered smoking cessation counseling and treatment of tobacco addiction as a routine component of diabetes care (1). Nevertheless, the solid bond with cigarette smoking creates a huge obstacle even for those who have a strong desire to quit. Little success with standard cessation interventions has been shown in smokers with diabetes (2). For those who are having difficulty stopping smoking or who do not intend to quit, the alternative of lessening the negative health effects of smoking by switching to combustion-free technologies for nicotine delivery (e.g., oral nicotine pouches or electronic nicotine delivery systems [ENDS], otherwise known as electronic cigarettes and heated tobacco products) should be considered. Compared with conventional cigarettes, ENDS can play a role in smoking cessation and can offer substantial reductions in exposures to toxic chemicals. For these reasons, they are proposed for harm reduction from cigarette smoke and for stopping smoking (3,4). Notably, governments in the U.K. and in New Zealand have included ENDS in their official evidence-based guidance on quitting smoking.
We also noticed the following statement in the ADA Standards of Care (1): “In recent years, e-cigarettes have gained public awareness and popularity because of perceptions that e-cigarette use is less harmful than regular cigarette smoking. However, in light of recent Centers for Disease Control and Prevention evidence of deaths related to e-cigarette use, no individuals should be advised to use e-cigarettes, either as a way to stop smoking tobacco or as a recreational drug.” This statement is incorrect and at discordance with the evidence provided by the Centers for Disease Control and Prevention and many others. It is now well-known that those deaths have nothing to do with legally marketed nicotine vaping products; rather, they were linked to the use of unregulated tetrahydrocannabinol (THC) vaping products contaminated with vitamin E acetate (5).
On the basis of the evidence provided above, and considering that many people with diabetes will continue to smoke despite the well-known health risks, we believe that the statement that “no individuals should be advised to use e-cigarettes, either as a way to stop smoking tobacco or as a recreational drug” should be corrected to “currently there is not enough evidence to recommend use of e-cigarettes as a tobacco cigarette substitute among people with diabetes who smoke, and more research is needed.”
A complete list of DiaSmokeFree Working Group Members can be found in the Appendix.
See accompanying article, p. e214.
Appendix
Members of the DiaSmokeFree Working Group include Davide Campagna (Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy), Agostino Di Ciaula (Clinica Medica “A. Murri,” Department of Precision and Regenerative Medicine and Ionian Area [DiMePre-J], University “Aldo Moro” Medical School, Bari, Italy), Tabinda Dugal (Royal Cornwall Hospital NHS Trust, Treliske, Truro, U.K.), Andre Kengne (Non-Communicable Diseases Research Unit, South African Medical Research Council and University of Cape Town, Cape Town, South Africa; Department of Biological and Environmental Science, Faculty of Science, Walter Sisulu University, Mthatha, South Africa), Anoop Misra (Diabetes Foundation [India], New Delhi, India; National Diabetes, Obesity and Cholesterol Foundation [N-DOC], New Delhi, India; Fortis C-DOC Centre for Excellence for Diabetes, Metabolic Disease, and Endocrinology, New Delhi, India), Riccardo Polosa (Center of Excellence for the Acceleration of HArm Reduction [CoEHAR], University of Catania, Catania, Italy; Centre for the Prevention and Treatment of Tobacco Addiction [CPCT], Catania, Italy; Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy), Syed Abbas Raza (Shaukat Khanum Cancer Hospital and Research Center, Peshawar, Pakistan), Cristina Russo (Ashford and Saint Peter’s Hospitals NHS Foundation Trust, Chertsey, U.K.), Roberta Sammut (Faculty of Health Sciences, University of Malta, Valletta, Malta; id-Dar tal-Providenza, Siggiewi, Malta), Noel Somasundaram (Diabetes and Hormone Center, Colombo, Sri Lanka; South Asian Federation of Endocrine Societies, Colombo, Sri Lanka; National Hospital of Sri Lanka, Colombo, Sri Lanka; Endocrine Society of Sri Lanka, Colombo, Sri Lanka), and Magdalena Walicka (Department of Human Epigenetics, Mossakowski Medical Research Institute, Polish Academy of Sciences, Warsaw, Poland; Department of Internal Diseases, Endocrinology, and Diabetology, The National Institute of Medicine of the Ministry of Interior and Administration, Warsaw, Poland).
Article Information
Duality of Interest. D.C. is supported through the Fellowship RTD-A PON REACT-EU 2021 GREEN Bando 3411/2021 by Ministero dell’Università e della Ricerca (MUR). R.P. has received grants from U-BIOPRED and AIR-PROM, Integral Rheumatology & Immunology Specialists Network (IRIS), Foundation for a Smoke Free World, Pfizer, GlaxoSmithKline, CV Therapeutics, NeuroSearch A/S, Sandoz, Merck Sharp & Dohme, Boehringer Ingelheim, Novartis, Arbi Group Srl., Duska Therapeutics, Forest Laboratories, Ministero dell Universita’e della Ricerca (MUR) Bando PNRR 3277/2021 (CUP E63C22000900006) and 341/2022 (CUP E63C22002080006), funded by NextGenerationEU of the European Union (EU), and the ministerial grant PON REACT-EU 2021 GREEN-Bando 3411/2021 by Ministero dell Universita’e (MUR)–PNRR EU Community. He is founder of the Center for Tobacco Prevention and Treatment at the University of Catania and of the Center of Excellence for the Acceleration of Harm Reduction at the same university. He receives consultancy fees from Pfizer, Boehringer Ingelheim, Duska Therapeutics, Forest Laboratories, CV Therapeutics, Sermo Inc., GRG Health, Clarivate Analytics, Guidepoint Expert Network, and GLG Group. He receives textbooks royalties from Elsevier. He is also involved in a patent application for ECLAT Srl. He is a pro bono scientific advisor for Lega Italiana Anti Fumo and the International Network of Nicotine Consumers Organizations, and he is Chair of the European Technical Committee for Standardization on “Requirements and test methods for emissions of electronic cigarettes” (CEN/TC 437, WG4). M.W. has received honoraria for lectures from Sanofi and AstraZeneca and has received support for attending meetings from Sanofi, Novo Nordisk, and Berlin Chemie. No other potential conflicts of interest relevant to this article were reported.
