Risk and safety profile of electronic nicotine delivery systems (ENDS): an umbrella review to inform ENDS health communication strategies
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  • Published on:
    Comments on paper by Asfar et al. “Risk and safety profile of electronic nicotine delivery systems (ENDS): an umbrella review to inform ENDS health communication strategies”
    • K Michael Cummings, Professor, Department of Psychiatry & Behavioral Sciences Medical University of South Carolina
    • Other Contributors:
      • Tracy T Smith, Assistant Professor, Department of Psychiatry & Behavioral Sciences
      • Steve A Schroeder, Professor Emeritus, Department of Medicine
      • Kenneth E Warner, Professor Emeritus and Dean Emeritus, School of Public Health
      • Ann McNeill, Professor, Department of Addictions
      • Jamie Hartmann-Boyce, Associate Professor, Nuffield Department of Primary Care Health Sciences
      • David T Levy, Professor, Lombardi Comprehensive Cancer Center

    The paper by Asfar et al (1) had a noble objective, which was to inform ENDS health risk communications by updating the 2018 evidence review by the US. National Academies of Sciences, Engineering and Medicine (NASEM) (2). The need for improved risk communications about ENDS is reinforced by a recent study which found that only 17.4% of US smokers believe that nicotine vaping is safer than smoking (3). While ENDS use is not safe, the evidence from toxicant exposure studies does show that ENDS use is far safer than smoking cigarettes and may benefit public health by assisting those who smoke to quit smoking (4, 5).
    An important limitation of the umbrella review method utilized by the authors is that it does not directly attempt to systematically characterize new research. This is a concern because the marketplace of ENDS products used by consumers has evolved since the 2018 NASEM report (4, 5). Furthermore, the authors have included some meta-analyses of selected reviews for some domains, but these meta-analyses were not in the Prospero pre-registration (6), nor explained in the paper. It’s thus unclear how or why certain reviews were selected for meta-analysis, and also whether the comparators are the same for these reviews. More importantly, these meta-analyses risk single studies contributing multiple times to the same pooled estimate. The authors noted this as a limitation commenting inaccurately that ‘it was impossible to identify articles that were included in...

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    Conflict of Interest:
    None declared.
  • Published on:
    Response to critiques on Asfar et al. in Tobacco Control: “Risk and safety profile of electronic nicotine delivery systems (ENDS): an umbrella review to inform ENDS health communication strategies.”
    • Taghrid Asfar, Associate Professor Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, Florida, USA.
    • Other Contributors:
      • Rime Jebai, Ph.D. Candidate
      • Wei Li, Post-Doctoral Associate
      • Olusanya Joshua Oluwole, Research Analyst
      • Tarana Ferdous, Ph.D. Candidate
      • Michael Schmidt, Associate Professor
      • Seth M. Noar, Director, Communicating for Health Impact (CHI) Lab.
      • Eric Lindblom, Lawyer
      • Thomas Eissenberg, Professor
      • Zoran Bursac, Professor
      • Donna Vallone, Chief Research Officer at Truth Initiative
      • Wasim Maziak, Professor

    We thank Cummings and colleagues for their interest in and comments on our umbrella review published recently in Tobacco Control.[1] The authors criticize us for not including the latest studies. Yet, for an umbrella review, those studies need to be in a published review to be included, as we indicated in our methods and limitations. Generally, given the lengthy review and publication processes, any review will not be inclusive of all studies in a field that has as high a publication breadth and intensity as tobacco regulatory science. In addition, the authors mentioned that our meta-analysis was not available in PROSPERO pre-registration. This is because the review registration was completed in the very early stages of the review. We have updated this information in PROSPERO now to include the meta-analysis. The issue of overlap was addressed in our limitations, as we had to screen over 3,000 studies included in our selected reviews. However, given the importance of this issue for the meta-analysis, we performed a new meta-analysis that included the individual studies in each domain instead of using the odds ratio reported by the review to eliminate the effect of including the same study more than one time on our results. We confirm that the results of the new meta-analysis, which includes each study only once, are similar to the original meta-analysis (Supplement A:

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    Conflict of Interest:
    None declared.