Comment
to the need to standardise and certify training and skills in point-of-care ultrasonography for physicians in the emergency department. Hopefully, Laursen will be able to disseminate his knowledge in ultrasound and potentially improve care in the emergency department for patients with respiratory symptoms. Another limitation of the study, inherent to its design, in which only one investigator did the pointof-care ultrasonography, is that the inclusion of patients in the trial was not truly consecutive and this might lead to subsequent bias. The results of Laursen and colleagues’ study show the usefulness of point-of-care ultrasonography in obtaining an early diagnosis in the emergency department in patients with specific respiratory signs and symptoms. Probably, it is now time for specialists in emergency medicine and pulmonologists to learn or improve their knowledge and skills of ultrasonography. Is point-of-care ultrasonography the 21st century stethoscope?
Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Instituto de Salud Carlos III, Villarroel 170, 08036 Barcelona, Spain (PR) [email protected]
Paula Ramirez, *Antoni Torres
9
Critical Care Department, Hospital Universitario y Politécnico la Fe (PR), and Pneumology Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS (AT), Centro de Investigación
We declare no competing interests. 1
2
3
4
5 6
7
8
Volpicelli G, Elbarbary M, Blaivas M, et al. International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 2012; 38: 577–91. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008; 134: 117–25. Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest 2011; 139: 1140–47. Parlamento S, Copetti R, Di Bartolomeo S. Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED. Am J Emerg Med 2009; 27: 379–84. Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med 2011; 37: 224–32. Crisp JG, Lovato LM, Jang TB. Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med 2010; 56: 601–10. Ahern M, Mallin MP, Weitzel S, Madsen T, Hunt P. Variability in ultrasound education among emergency medicine residencies. West J Emerg Med 2010; 11: 314–18. Counselman FL, Sanders A, Slovis CM, Danzl D, Binder LS, Perina DG. The status of bedside ultrasonography training in emergency medicine residency programs. Acad Emerg Med 2003; 10: 37–42. Laursen CB, Sloth E, Lassen AT, et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir Med 2014; published online July 4. http://dx.doi.org/10.1016/S2213-2600(14)70135-3.
Happy wheezers, happy parents, and happy doctors? Wheeze is common in young children.1 In this Comment, we summarise a practical approach to three recent papers on the topic.2–4 We also explore the extent to which doctors keep themselves and the families happy by treating a symptom without necessarily considering the scientific evidence. The most frequent picture of wheeze in young children is episodic viral wheeze, characterised by acute episodes of wheeze, cough, and breathlessness in association with a clinically diagnosed viral respiratory tract infection, with few or no interval symptoms. A few children have multiple trigger wheeze, which resembles asthma, with interval symptoms between acute episodes, triggered by cold air, activity, crying, and often with an atopic personal and family history. Overlaps can occur in individual children, which is indicative of the multifactorial nature of wheeze. Rarer specific disorders need to be excluded in the diagnostic approach. 600
Several approaches have been used to categorise wheeze in children less than 5 years of age: epidemiological (transient early wheeze vs persistent wheeze,1 and more sophisticated classifications);5–7 atopic versus non-atopic wheeze;8 and symptom pattern (as described above).9 A cardinal error is to conflate duration and severity of symptoms with temporal pattern. The first two approaches, although of scientific importance, are not useful in guiding of treatment. The European Respiratory Society classification begs the question as to whether multiple trigger wheeze is the same as childhood asthma. The answer depends on the definition of asthma. If it includes airway eosinophilia, the airway pathology in children with at least severe multiple trigger wheeze is similar to that in childhood asthma.10 The correct treatment of a disease should be preceded as far as possible by an accurate diagnosis. www.thelancet.com/respiratory Vol 2 August 2014
Clearly, neither the assumption that every wheezy child has a unique phenotype nor the placement of all wheezy children in the same disease entity of asthma is useful for treatment. Unfortunately, physicians continue a faith-based—and sometimes uncritical— behaviour in prescribing medication, especially inhaled corticosteroids and antibiotics, to children with respiratory symptoms.11,12 When we treat a wheezy infant, how much are we in fact treating the parents who want something done about the respiratory sounds made by their child? Illness perception is well known to affect the way in which patients with asthma cope and self-manage their illness. How should we manage wheeze in children? First, it is important to consider whether the child really needs treatment. Unfortunately, other respiratory sounds are often mislabelled by parents as wheeze, and confirmation of parental reports of wheeze by an experienced doctor is essential.13 Exposure to tobacco smoke and air pollution is associated with triggering of early wheeze. Environmental exposures are a major and entirely avoidable health risk, but attention to environmental measures continues to be largely overlooked. In principle, intermittent symptoms should be treated with intermittent treatment. A therapeutic trial of bronchodilators, either β2-agonists or anticholinergics delivered by a metered-dose inhaler and spacer, is the treatment of choice for acute episodes of wheezing.2–4 Physicians should not be coerced into prescribing antibiotics or corticosteroids. Oral corticosteroids are indicated only for really severe acute episodes in the hospital setting.14 Some so-called happy wheezers only make noises when they are active; these children are not distressed, develop normally, and might not need treatment. However, the parents might be upset by the wheeze and disturbed by their frequent sleepless nights, and are typically unhappy to accept the idea that nothing can be done to relieve this annoying noise. If symptoms are not controlled with bronchodilators, intermittent treatment with either high-dose inhaled corticosteroids or montelukast starting at the first sign of a respiratory tract infection and continued for an arbitrary time period (eg, 7–10 days), could be a useful approach. The one-size-fits-all mindset, whereby wheeze mandates a prescription for inhaled corticosteroids, must be avoided. Physicians should be www.thelancet.com/respiratory Vol 2 August 2014
Amelie-Benoist/Bsip/Science Photo Library
Comment
reasonably reluctant to prescribe a regular controller therapy in a young child with recurrent wheeze. Some experts believe that both the frequency of symptoms and their severity are the main reasons for initiation of controller therapy, irrespective of the phenotype.2–4 The scientific evidence is scarce; in particular, no published trial supports the use of regular inhaled corticosteroids in children younger than 5 years with episodic viral wheeze. Whatever the clinical context and the chosen medication, important principles should be followed. The fact that even low-dose inhaled corticosteroids can lead to growth suppression in young children should be discussed with parents.15 Any therapeutic trial should always be given for a fixed time period (eg, 6–8 weeks) and then discontinued to see whether symptoms recur or have disappeared and treatment has therefore become unnecessary. Children should be reviewed regularly to assess their response to treatment and any changes in symptom pattern. Education of parents in the correct use of inhalers should be repeated at each visit. If an inhaled drug does not seem to be effective, checking of the correct technique of administration rather than escalation of treatment is mandatory. Finally, physicians (and families) should be aware that no drug strategy can reduce the future risk of asthma, and that failure to initiate regular treatment will not prejudice the future respiratory health of the child. When approaching a child with wheeze, physicians should bear both science and ethics in mind. Wheeze is a symptom and not a disease. Scientific progress (and the 601
Comment
pressure of pharmaceutical companies) should not allow us to forget that treatment of the patient—in this case a child—and not a disease remains the main principle of the art of medicine.
6
7
8
*Fernando Maria de Benedictis, Andrew Bush Department of Mother and Child Health, Salesi Children’s Hospital, 11 via Corridoni, Ancona, 60123, Italy (FMdB); Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, and National Heart and Lung Institute, Imperial School of Medicine, London, UK (AB) [email protected]
9
10
11
We declare no competing interests. 1
2
3 4 5
Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan WJ. Asthma and wheezing in the first six years of life. N Engl J Med 1995; 332: 133–38. Brand PL, Caudri D, Eber E, et al. Classification and pharmacological treatment of preschool wheezing: changes since 2008. Eur Respir J 2014; 43: 1172–77. Bush A, Grigg J, Saglani S. Managing wheeze in preschool children. BMJ 2014; 348: g15. Ducharme FM, Tse SM, Chauhan B. Diagnosis, management, and prognosis of preschool wheeze. Lancet 2014; 383: 1593–604. Spycher BD, Silverman M, Brooke AM, Minder CE, Kuehni CE. Distinguishing phenotypes of childhood wheeze and cough using latent class analysis. Eur Respir J 2008; 31: 974–81.
12 13 14 15
Henderson J, Granell R, Heron J, et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung function and airway hyperresponsiveness in mid-childhood. Thorax 2008; 63: 974–80. Savenije OE, Granell R, Caudri D, et al. Comparison of childhood wheezing phenotypes in 2 birth cohorts: ALSPAC and PIAMA. J Allergy Clin Immunol 2011; 127: 1505–12. Illi S, von Mutius E, Lau S, et al. Perennial allergen sensitisation early in life and chronic asthma in children: a birth cohort study. Lancet 2006; 368: 763–70. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J 2008; 32: 1096–110. Saglani S, Payne DN, Zhu J, et al. Early detection of airway wall remodelling and eosinophilic inflammation in preschool wheezers. Am J Respir Crit Care Med 2007; 176: 858–64. Klok T, Kaptein AA, Duiverman E, Oldenhof FS, Brand PL. General practitioners’ prescribing behaviour as a determinant of poor persistence with inhaled corticosteroids in children with respiratory symptoms: mixed methods study. BMJ Open 2013; 3: e002310. Bisgaard H, Szefler S. Prevalence of asthma-like symptoms in young children. Pediatr Pulmonol 2007; 42: 723–28. Lowe L, Murray CS, Martin L, et al. Reported versus confirmed wheeze and lung function in early life. Arch Dis Child 2004; 89: 540–43. de Benedictis FM, Bush A. Corticosteroids in respiratory diseases in children. Am J Respir Crit Care Med 2012; 185: 12–23. Fuhlbrigge AL, Kelly HW. Inhaled corticosteroids in children: effects on bone mineral density and growth. Lancet Respir Med 2014; 2: 487–96.
B. Boissonnet Bsip/Science Photo Library
Should Australia reconsider its ban on the sale of electronic nicotine delivery systems?
See Editorial Lancet Respir Med 2014; 2: 429; Comment Lancet Respir Med 2013; 1: 429; Comment Lancet Respir Med 2013; 1: 431 and Correspondence Lancet Respir Med 2013; 1 e26
602
In the past 30 years, steep increases in tobacco taxes, advertising bans, and bans on smoking in public places have reduced the daily smoking rate in Australian adults from 35% in 1983 to 13% in 2013.1,2 Australia was an early adopter of graphic health warnings on cigarette packs and mandatory plain packaging of cigarettes.2 In 2011, Australia joined Brazil, Canada, and several European countries in banning the sale of e-cigarettes or electronic nicotine delivery systems.3 By contrast with other areas of substance use, harm reduction strategies have never had a role in Australian tobacco policy. These strategies aim to reduce tobacco-related toxicity by encouraging smokers to use less harmful ways to obtain nicotine, such as smokeless tobacco or electronic nicotine delivery systems. Australia’s national tobacco strategy includes major legal and regulatory obstacles to tobacco harm reduction,4 including a ban on the sale of smokeless tobacco since 1991.5
The Australian laws covering electronic nicotine delivery systems are complex and vary between the different states but they effectively ban their sale. Since 2011, personal importation of electronic nicotine delivery systems as an unapproved cessation aid has only been allowed on medical prescription. State drugs and poisons legislations prevent the retail sale, possession, or use of non-therapeutic nicotine preparations without a licence, approval, or permit.6 Some states have also banned the sale of vaporising devices that do not contain nicotine. They have extended laws that were originally designed to prevent the sale of cigarette-like confectionary and toys to children to prohibit the sale of any products that resemble tobacco products.6 The national tobacco control strategy indicates that consideration is being given to “whether there is a need to increase restrictions on their availability and use”.4 Despite these laws, the percentage of Australian smokers who have ever tried electronic nicotine delivery www.thelancet.com/respiratory Vol 2 August 2014
to the need to standardise and certify training and skills in point-of-care ultrasonography for physicians in the emergency department. Hopefully, Laursen will be able to disseminate his knowledge in ultrasound and potentially improve care in the emergency department for patients with respiratory symptoms. Another limitation of the study, inherent to its design, in which only one investigator did the pointof-care ultrasonography, is that the inclusion of patients in the trial was not truly consecutive and this might lead to subsequent bias. The results of Laursen and colleagues’ study show the usefulness of point-of-care ultrasonography in obtaining an early diagnosis in the emergency department in patients with specific respiratory signs and symptoms. Probably, it is now time for specialists in emergency medicine and pulmonologists to learn or improve their knowledge and skills of ultrasonography. Is point-of-care ultrasonography the 21st century stethoscope?
Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Instituto de Salud Carlos III, Villarroel 170, 08036 Barcelona, Spain (PR) [email protected]
Paula Ramirez, *Antoni Torres
9
Critical Care Department, Hospital Universitario y Politécnico la Fe (PR), and Pneumology Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS (AT), Centro de Investigación
We declare no competing interests. 1
2
3
4
5 6
7
8
Volpicelli G, Elbarbary M, Blaivas M, et al. International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 2012; 38: 577–91. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008; 134: 117–25. Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest 2011; 139: 1140–47. Parlamento S, Copetti R, Di Bartolomeo S. Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED. Am J Emerg Med 2009; 27: 379–84. Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med 2011; 37: 224–32. Crisp JG, Lovato LM, Jang TB. Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med 2010; 56: 601–10. Ahern M, Mallin MP, Weitzel S, Madsen T, Hunt P. Variability in ultrasound education among emergency medicine residencies. West J Emerg Med 2010; 11: 314–18. Counselman FL, Sanders A, Slovis CM, Danzl D, Binder LS, Perina DG. The status of bedside ultrasonography training in emergency medicine residency programs. Acad Emerg Med 2003; 10: 37–42. Laursen CB, Sloth E, Lassen AT, et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir Med 2014; published online July 4. http://dx.doi.org/10.1016/S2213-2600(14)70135-3.
Happy wheezers, happy parents, and happy doctors? Wheeze is common in young children.1 In this Comment, we summarise a practical approach to three recent papers on the topic.2–4 We also explore the extent to which doctors keep themselves and the families happy by treating a symptom without necessarily considering the scientific evidence. The most frequent picture of wheeze in young children is episodic viral wheeze, characterised by acute episodes of wheeze, cough, and breathlessness in association with a clinically diagnosed viral respiratory tract infection, with few or no interval symptoms. A few children have multiple trigger wheeze, which resembles asthma, with interval symptoms between acute episodes, triggered by cold air, activity, crying, and often with an atopic personal and family history. Overlaps can occur in individual children, which is indicative of the multifactorial nature of wheeze. Rarer specific disorders need to be excluded in the diagnostic approach. 600
Several approaches have been used to categorise wheeze in children less than 5 years of age: epidemiological (transient early wheeze vs persistent wheeze,1 and more sophisticated classifications);5–7 atopic versus non-atopic wheeze;8 and symptom pattern (as described above).9 A cardinal error is to conflate duration and severity of symptoms with temporal pattern. The first two approaches, although of scientific importance, are not useful in guiding of treatment. The European Respiratory Society classification begs the question as to whether multiple trigger wheeze is the same as childhood asthma. The answer depends on the definition of asthma. If it includes airway eosinophilia, the airway pathology in children with at least severe multiple trigger wheeze is similar to that in childhood asthma.10 The correct treatment of a disease should be preceded as far as possible by an accurate diagnosis. www.thelancet.com/respiratory Vol 2 August 2014
Clearly, neither the assumption that every wheezy child has a unique phenotype nor the placement of all wheezy children in the same disease entity of asthma is useful for treatment. Unfortunately, physicians continue a faith-based—and sometimes uncritical— behaviour in prescribing medication, especially inhaled corticosteroids and antibiotics, to children with respiratory symptoms.11,12 When we treat a wheezy infant, how much are we in fact treating the parents who want something done about the respiratory sounds made by their child? Illness perception is well known to affect the way in which patients with asthma cope and self-manage their illness. How should we manage wheeze in children? First, it is important to consider whether the child really needs treatment. Unfortunately, other respiratory sounds are often mislabelled by parents as wheeze, and confirmation of parental reports of wheeze by an experienced doctor is essential.13 Exposure to tobacco smoke and air pollution is associated with triggering of early wheeze. Environmental exposures are a major and entirely avoidable health risk, but attention to environmental measures continues to be largely overlooked. In principle, intermittent symptoms should be treated with intermittent treatment. A therapeutic trial of bronchodilators, either β2-agonists or anticholinergics delivered by a metered-dose inhaler and spacer, is the treatment of choice for acute episodes of wheezing.2–4 Physicians should not be coerced into prescribing antibiotics or corticosteroids. Oral corticosteroids are indicated only for really severe acute episodes in the hospital setting.14 Some so-called happy wheezers only make noises when they are active; these children are not distressed, develop normally, and might not need treatment. However, the parents might be upset by the wheeze and disturbed by their frequent sleepless nights, and are typically unhappy to accept the idea that nothing can be done to relieve this annoying noise. If symptoms are not controlled with bronchodilators, intermittent treatment with either high-dose inhaled corticosteroids or montelukast starting at the first sign of a respiratory tract infection and continued for an arbitrary time period (eg, 7–10 days), could be a useful approach. The one-size-fits-all mindset, whereby wheeze mandates a prescription for inhaled corticosteroids, must be avoided. Physicians should be www.thelancet.com/respiratory Vol 2 August 2014
Amelie-Benoist/Bsip/Science Photo Library
Comment
reasonably reluctant to prescribe a regular controller therapy in a young child with recurrent wheeze. Some experts believe that both the frequency of symptoms and their severity are the main reasons for initiation of controller therapy, irrespective of the phenotype.2–4 The scientific evidence is scarce; in particular, no published trial supports the use of regular inhaled corticosteroids in children younger than 5 years with episodic viral wheeze. Whatever the clinical context and the chosen medication, important principles should be followed. The fact that even low-dose inhaled corticosteroids can lead to growth suppression in young children should be discussed with parents.15 Any therapeutic trial should always be given for a fixed time period (eg, 6–8 weeks) and then discontinued to see whether symptoms recur or have disappeared and treatment has therefore become unnecessary. Children should be reviewed regularly to assess their response to treatment and any changes in symptom pattern. Education of parents in the correct use of inhalers should be repeated at each visit. If an inhaled drug does not seem to be effective, checking of the correct technique of administration rather than escalation of treatment is mandatory. Finally, physicians (and families) should be aware that no drug strategy can reduce the future risk of asthma, and that failure to initiate regular treatment will not prejudice the future respiratory health of the child. When approaching a child with wheeze, physicians should bear both science and ethics in mind. Wheeze is a symptom and not a disease. Scientific progress (and the 601
Comment
pressure of pharmaceutical companies) should not allow us to forget that treatment of the patient—in this case a child—and not a disease remains the main principle of the art of medicine.
6
7
8
*Fernando Maria de Benedictis, Andrew Bush Department of Mother and Child Health, Salesi Children’s Hospital, 11 via Corridoni, Ancona, 60123, Italy (FMdB); Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, and National Heart and Lung Institute, Imperial School of Medicine, London, UK (AB) [email protected]
9
10
11
We declare no competing interests. 1
2
3 4 5
Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan WJ. Asthma and wheezing in the first six years of life. N Engl J Med 1995; 332: 133–38. Brand PL, Caudri D, Eber E, et al. Classification and pharmacological treatment of preschool wheezing: changes since 2008. Eur Respir J 2014; 43: 1172–77. Bush A, Grigg J, Saglani S. Managing wheeze in preschool children. BMJ 2014; 348: g15. Ducharme FM, Tse SM, Chauhan B. Diagnosis, management, and prognosis of preschool wheeze. Lancet 2014; 383: 1593–604. Spycher BD, Silverman M, Brooke AM, Minder CE, Kuehni CE. Distinguishing phenotypes of childhood wheeze and cough using latent class analysis. Eur Respir J 2008; 31: 974–81.
12 13 14 15
Henderson J, Granell R, Heron J, et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung function and airway hyperresponsiveness in mid-childhood. Thorax 2008; 63: 974–80. Savenije OE, Granell R, Caudri D, et al. Comparison of childhood wheezing phenotypes in 2 birth cohorts: ALSPAC and PIAMA. J Allergy Clin Immunol 2011; 127: 1505–12. Illi S, von Mutius E, Lau S, et al. Perennial allergen sensitisation early in life and chronic asthma in children: a birth cohort study. Lancet 2006; 368: 763–70. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J 2008; 32: 1096–110. Saglani S, Payne DN, Zhu J, et al. Early detection of airway wall remodelling and eosinophilic inflammation in preschool wheezers. Am J Respir Crit Care Med 2007; 176: 858–64. Klok T, Kaptein AA, Duiverman E, Oldenhof FS, Brand PL. General practitioners’ prescribing behaviour as a determinant of poor persistence with inhaled corticosteroids in children with respiratory symptoms: mixed methods study. BMJ Open 2013; 3: e002310. Bisgaard H, Szefler S. Prevalence of asthma-like symptoms in young children. Pediatr Pulmonol 2007; 42: 723–28. Lowe L, Murray CS, Martin L, et al. Reported versus confirmed wheeze and lung function in early life. Arch Dis Child 2004; 89: 540–43. de Benedictis FM, Bush A. Corticosteroids in respiratory diseases in children. Am J Respir Crit Care Med 2012; 185: 12–23. Fuhlbrigge AL, Kelly HW. Inhaled corticosteroids in children: effects on bone mineral density and growth. Lancet Respir Med 2014; 2: 487–96.
B. Boissonnet Bsip/Science Photo Library
Should Australia reconsider its ban on the sale of electronic nicotine delivery systems?
See Editorial Lancet Respir Med 2014; 2: 429; Comment Lancet Respir Med 2013; 1: 429; Comment Lancet Respir Med 2013; 1: 431 and Correspondence Lancet Respir Med 2013; 1 e26
602
In the past 30 years, steep increases in tobacco taxes, advertising bans, and bans on smoking in public places have reduced the daily smoking rate in Australian adults from 35% in 1983 to 13% in 2013.1,2 Australia was an early adopter of graphic health warnings on cigarette packs and mandatory plain packaging of cigarettes.2 In 2011, Australia joined Brazil, Canada, and several European countries in banning the sale of e-cigarettes or electronic nicotine delivery systems.3 By contrast with other areas of substance use, harm reduction strategies have never had a role in Australian tobacco policy. These strategies aim to reduce tobacco-related toxicity by encouraging smokers to use less harmful ways to obtain nicotine, such as smokeless tobacco or electronic nicotine delivery systems. Australia’s national tobacco strategy includes major legal and regulatory obstacles to tobacco harm reduction,4 including a ban on the sale of smokeless tobacco since 1991.5
The Australian laws covering electronic nicotine delivery systems are complex and vary between the different states but they effectively ban their sale. Since 2011, personal importation of electronic nicotine delivery systems as an unapproved cessation aid has only been allowed on medical prescription. State drugs and poisons legislations prevent the retail sale, possession, or use of non-therapeutic nicotine preparations without a licence, approval, or permit.6 Some states have also banned the sale of vaporising devices that do not contain nicotine. They have extended laws that were originally designed to prevent the sale of cigarette-like confectionary and toys to children to prohibit the sale of any products that resemble tobacco products.6 The national tobacco control strategy indicates that consideration is being given to “whether there is a need to increase restrictions on their availability and use”.4 Despite these laws, the percentage of Australian smokers who have ever tried electronic nicotine delivery www.thelancet.com/respiratory Vol 2 August 2014
