Electronic cigarettes as a harm reduction strategy among patients with COPD: protocol for an open-label two arm randomized controlled pilot trial

Background Smoking cessation is the most effective means of slowing the decline of lung function associated with chronic obstructive pulmonary disease (COPD). While effective smoking cessation treatments are available, they are underutilized and nearly half of people with COPD continue to smoke. By addressing both nicotine and behavioral dependence, electronic cigarettes (EC) could help people with COPD reduce the harm of combustible cigarettes (CC) through reductions in number of Cigarettes per Day (CPD) or quitting CC completely. The purpose of this pilot study is to identify barriers and facilitators to the use of and assess the preliminary effectiveness of EC as a harm reduction strategy among people with COPD. Methods In an open-label two-arm randomized controlled trial pilot study, 60 patients identified as smokers with a COPD diagnosis via electronic health records from a large urban health center are randomized in a 1:1 ratio to either standard care [counseling + nicotine replacement therapy (NRT)] or counseling + EC. The NRT arm will receive nicotine patches and nicotine lozenges for 12 weeks. The EC arm will receive EC for 12 weeks. Both cohorts will receive counseling from a licensed mental health counselor. Using ecological momentary assessment, participants will report their use of CC in both arms and EC use in the EC arm daily via text message. Primary outcomes will be feasibility and acceptability of intervention, and secondary outcomes will be reduction in CPD and change in COPD symptoms as measured by COPD Assessment Tool (CAT) score at 12-weeks. EC displacement of CC. To explore attitudes towards the use of EC as a harm-reduction strategy for patients with COPD, interviews will be performed with a sample of participants from both study arms. Discussion Despite decades of availability of smoking cessation medications, nearly half of people with COPD still smoke. This study aims to address the unmet need for feasible and effective strategies for reducing CC use among those with COPD, which has the potential to significantly improve the health of people with COPD who smoke. Trial Registration ClinicalTrials.gov Identifier: NCT04465318.

Performance-Enhancing Substances in Sports

Given that the current strategies focusing on deterrence and punishment are increasingly ineffective worldwide, is there a radically different approach to ensuring a level playing field? This essay explores the growing discourse on alternate approaches to controlling the use of performance enhancing substances (PES) in sports and reflects on the fact that social and cultural behaviour patterns, plus a lack of ethics in the practice of medicine are the issues that need to be tackled urgently in this eagerness to ensure a level playing field in sports. Kaveri Prakash cautiously argues for adopting a relatively new approach, under wide discussion, centring on a harm reduction strategy, that would allow performance enhancing substances to be administered under supervision. However, this will only be successful if regulatory and ethical frameworks in related areas are strengthened and current practices are systematically reviewed and either discarded or reformed. Moreover, India needs to pay serious attention to its sporting population, on and off the field, in order to gauge its response to regulation.

“Anything that looks like smoking is bad”: Moral opposition and support for harm reduction policies.

One dilemma faced by policy makers is the choice between banning a harmful behavior and allowing the behavior to continue but with mitigated harm. This latter approach––a harm reduction strategy––is often efficacious, yet policies of this sort can be unpopular if people morally oppose the target behavior (MacCoun, 2013). This raises interesting questions for understanding how judgments of harmfulness relate to moral opposition. In four studies (N = 1,088), including one U.S. representative sample, we found that increased moral opposition to cigarette smoking, risky sex, and gun ownership, was associated with less support for e-cigarette use, pre-exposure prophylaxis, and gun safety training, respectively—with one critical exception. When news broke of “vaping sickness” in 2019, we no longer observed this relationship. Interestingly, judgments of harmfulness of both gun ownership and risky sexual behavior, though correlated with moral opposition, positively predict policy support, suggesting that it is possible to judge a behavior as harmful but otherwise acceptable, and in that case harm-reduction policy is also acceptable. Together, these results highlight the multi-faceted nature of moral opposition and its implications for real-world policy.

Turning Over a New Leaf: A Subnational Analysis of ‘Coca Yes, Cocaine No’ in Bolivia

International pressure to suppress cocaine trafficking sustained decades of harsh drug laws in Bolivia against cocaleros (coca producers), thus affecting coca production for traditional consumption and for manufacturing illicit cocaine. These harsh drug laws caused social unrest in cocalero communities outside traditional coca zones. President Evo Morales, leader of the Movimiento al Socialismo (Movement toward Socialism, MAS) party, implemented ‘Coca Yes, Cocaine No’ (CYCN), a harm-reduction strategy that authorised ‘non-traditional’ farmers to cultivate legal coca and self-police production. This article compares CYCN outcomes in Bolivia's traditional and non-traditional coca regions and finds that strong cocalero organisations were vital to CYCN success in non-traditional areas. In contrast, organised resistance in traditional zones restricted CYCN success and added to regime instability in the lead-up to Morales’ forced resignation in 2019. Hence, while Morales harnessed state power to change drug policy, he was constrained by the rural grassroots organisations that brought him to power.

SARS-CoV-2 safer infection sites: moral entitlement, pragmatic harm reduction strategy or ethical outrage?

The pandemic of SARS-CoV-2 has led to unprecedented changes to society, causing unique problems that call for extraordinary solutions. We consider one such extraordinary proposal: ‘safer infection sites’ that would offer individuals the opportunity to be intentionally infected with SARS-CoV-2, isolate, and receive medical care until they are no longer infectious. Safer infection could have value for various groups of workers and students. Health professionals place themselves at risk of infection daily and extend this risk to their family members and community. Similarly, other essential workers who face workplace exposure must continue their work, even if have high-risk household members and live in fear of infecting. When schools are kept closed because of the fear that they will be sites of significant transmission, children and their families are harmed in multiple ways and college students who are living on campus, whether or not they are attending classes in person, are contributing to high rates of transmission and experiencing high rates of exposure. We consider whether offering safer infection sites to these groups could be ethically defensible and identify the empirical unknowns that would need to resolve before reaching definitive conclusions. This article is not an endorsement of intentional infection with the coronavirus, but rather is meant to spark conversation on the ethics of out-of-the-box proposals. Perhaps most meaningfully, our paper explores the value of control and peace of mind for those among us most impacted by the pandemic: those essential workers risking the most to keep us safe.

The Ethics of Tobacco Harm Reduction: An Analysis of E-Cigarette Availability From the Perspectives of Utilitarianism, Bioethics, and Public Health Ethics

Much evidence suggests e-cigarettes are substantially less harmful than combustible cigarettes. Assuming this is true, we analyze the ethical case for a policy of e-cigarette availability (ECA) as a tobacco harm reduction strategy. ECA involves making e-cigarettes available to allow smokers to switch to them, and informing smokers of the lower risks of e-cigarettes vis-à-vis smoking. After suggesting that utilitarian/consequentialist considerations do not provide an adequate ethical analysis, we analyze ECA using two other ethical frameworks. First, ECA is supported by a public health ethics framework. ECA is a population-level intervention consistent with respecting individual autonomy by using the least restrictive means to accomplish public health goals, and it supports equity and justice. Second, ECA is supported by four principles that form a biomedical ethics framework. By reducing smokers’ health risks and not harming them, ECA fulfills principles of beneficence and non-maleficence. Because ECA allows smokers to make informed health decisions for themselves, it fulfills the principle requiring respect for persons and their autonomy. Here, we consider whether nicotine addiction and thus ECA undermine autonomy, and also discuss the ethical warrant for special protections for youth. Finally, ECA can also advance justice by providing a harm reduction alternative for disadvantaged groups that disproportionately bear the devastating consequences of smoking. Policies of differential taxation of cigarettes and e-cigarettes can facilitate adoption of less harmful alternatives by those economically disadvantaged. We conclude that public health and biomedical ethics frameworks are mutually reinforcing and supportive of ECA as a tobacco harm reduction strategy. Implications Making e-cigarettes and information about them available is supported as ethical from multiple ethical perspectives.

104 House Rules and Clean Kids: The down-low on Tobacco

Background Despite multiple published guidelines outlining the potential health risks caused by tobacco smoke, young children continue to be exposed to the detrimental effects of household smoking. Environmental factors also have the potential to influence levels of tobacco exposure in children. Many factors such as comfort can influence the decisions of smoking parents to smoke indoors, increasing potential harm for children. Understanding the correlation between various locations within the household and tobacco exposure is helpful in informing a harm reduction strategy for smokers. This project compared the location of reported tobacco use to detection of the nicotine byproduct cotinine in children’s urine samples. Objectives To determine the impact of smoking location on unintentional tobacco exposure in children. Design/Methods This prospective cross-sectional study focused on children under age ten, since 13% of Canadian children in grades 6 and up have tried a cigarette at least once. Of 286 parents approached during a pediatrician visit, 231 agreed to complete an exposure questionnaire and 132 children were able to provide a urine sample during the visit. A standard ELISA assay was used to measure urine cotinine. Results About half of the 31% of households that reported smoking had an indoor smoking ban. Some indoor smokers isolated their activity to the garage (56%). Of the 84 children with detectable urine cotinine, 62 lived in homes that reported smoking. This suggests that some children were exposed to tobacco smoke through other sources or the underestimation of potential tobacco exposure. Fifteen percent of children from smoking homes had cotinine levels similar to nonsmoking homes. Children of indoor smokers were more likely to have detectable cotinine than those of outdoor smokers. Conclusion Roughly 50% of smokers with children have an indoor smoking ban as a harm reduction strategy. In our study, children of smokers with an indoor smoking ban were less likely to have detectable urine cotinine. Although not smoking is the best strategy, limiting smoking to outside is an optimal harm mitigation strategy. For families with indoor smokers, encouraging them to isolate smoking to a single space like the garage may decrease unintentional pediatric exposure.

Association Between Harm Reduction Strategies and Healthcare Utilization and Outcomes in Patients on Long-term Prescribed Opioid Therapy Presenting to Acute Healthcare Settings: A Systematic Review and Meta-analysis

BackgroundLong-term prescription of opioids by healthcare professionals has been linked to poor individual patient outcomes and high resource utilization. Harm reduction strategies in this population in regard to acute healthcare settings may have substantial impact.MethodsWe performed a systematic review and meta-analysis of primary studies. The studies were included according to the following criteria: 1) age 18 and older; 2) long-term/chronic prescribed opioid therapy; 3) acute healthcare setting presentation from a complication of opioid therapy; 4) evaluating a harm reduction strategy; 5) comparing the effectiveness of different interventions; 6) addressing patient or healthcare related outcomes. We performed a qualitative analysis of harm reduction strategies identified. We pooled patient and system related outcome data for each harm reduction strategy.ResultsA total of 5664 studies were screened and 21 studies were included. A total of 11 broad categories of harm reduction strategies were identified. Meta-analysis was performed for the “supports for patients in pain” harm reduction strategy on two system-related outcomes using a ratio of means. The number of emergency department (ED) visits were significantly reduced for cohort studies (n=6, 0.36, 95% CI [0.20-0.62], I2 = 87%) and randomized controlled trials (RCTs) (n=3, 0.71, 95% CI [0.61-0.82], I2 = 0%). The number of opioid prescriptions at ED discharge was significantly reduced for RCTs (n=3, 0.34, 95% CI [0.14-0.82], I2 = 78%).InterpretationFor patients presenting to acute healthcare settings with complications related to long-term opioid therapy, the intervention with the most robust data is “supports for patients in pain”.Study registrationCRD42018088962