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 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.”


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