Response to Comment on Elsayed et al. 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes—2023. Diabetes Care 2023;46(Suppl. 1):S68–S96

We thank Dr. Campagna and the DiaSmokeFree Working Group for their letter (1) about the tobacco cessation recommendations in the 2023 American Diabetes Association (ADA) Standards of Care in Diabetes (2). The Standards of Care is a dynamic document that is updated at least annually by the ADA Professional Practice Committee, an interprofessional group of individuals with expertise in areas relevant to diabetes care. This committee is currently reviewing the updated scientific literature to ensure the 2024 Standards of Care is based on a strong, contemporary evidence base. We are considering the feedback shared by the authors in the context of current research related to tobacco use, particularly in terms of its relevance to people with diabetes. As the authors noted, evidence from the Centers for Disease Control and Prevention, U.S. Food and Drug Administration, and others surrounding an outbreak of cases of e-cigarette, or vaping, product use–associated lung injury (EVALI) and related deaths has linked vitamin E acetate to most of the EVALI cases (3,4). As the research base regarding use of e-cigarettes grows, we will closely monitor the evidence to evaluate its relevance to promoting positive health outcomes in people with diabetes. While other organizations may recommend use of such products in their guidelines for smoking cessation, the focus of the ADA is people with diabetes, who have elevated risk for micro- and macrovascular complications. As there is evidence of cardiovascular and respiratory harms related to chemical compounds present in e-cigarettes in the general population (5,6), the ADA Professional Practice Committee is using great care in considering how these findings apply to our mission to promote optimal health outcomes in people with diabetes. We agree with the assessment that additional research is needed to guide recommendations and regulation of a largely unregulated but rapidly expanding market of products.