Letters sion that adolescents using e-cigarettes are transitioning to smoking is clearly not appropriate.
COMMENT & RESPONSE
Youth Tobacco Use and Electronic Cigarettes To the Editor In their study, Dutra and Glantz1 reported the results of a cross-sectional sample of adolescents interviewed in 2011 and 2012 in the National Youth Tobacco Survey and concluded that electronic cigarette (e-cigarette) use does not discourage and may encourage conventional cigarette use among US adolescents. However, their conclusions are not justified by the data presented. In a cross-sectional study, the observed relationship between e-cigarette use and higher and more sustained levels of smoking does not imply causation. Moreover, such studies do not take into account other population characteristics, which may play a crucial role when determining potential causation.2,3 Although the authors acknowledged this limitation in the text, they ended up drawing a conclusion that misleads the public into thinking e-cigarettes are leading to smoking initiation and addiction among adolescents. The 2011 National Youth Tobacco Survey included a question about whether participants used any interventions to quit smoking in the past 12 months. We analyzed the association between these interventions and smoking status, abstinence, frequency of smoking in the past 30 days, and number of cigarettes smoked during the days of smoking in the group of cigarette experimenters (ever smoked in the past 12 months, even 1 puff). Interventions were coded as pharmacologic (ie, nicotine gums, patches, or any medication) and nonpharmacologic (ie, attending a program in the school or the community, calling a quitline, visiting an Internet website, getting help from family or friends, using any other method such as hypnosis or acupuncture, or trying to independently quit). Logistic regression analysis was performed introducing age (continuous variable), sex, and race/ ethnicity as covariates. According to this analysis, use of pharmacologic intervention was consistently associated with a higher chance of ever being a smoker and being a current smoker, higher cigarette use frequency and consumption (with odds ratios ranging from 2.07-3.04), and a lower chance of 30-day and 6-month abstinence from cigarettes (odds ratios ranging from 0.390.43). Similar results were observed with the use of nonpharmacologic intervention. All results were statistically significant. Despite these results, it would be inappropriate to conclude that the use of pharmacologic or nonpharmacologic smoking-cessation interventions do not discourage and probably encourage smoking among US adolescents. However, this is exactly what Dutra and Glantz have done in their article on e-cigarettes, using similar analysis as herein. Their conclu-
Konstantinos E. Farsalinos, MD Riccardo Polosa, MD, PhD Author Affiliations: Onassis Cardiac Surgery Center, Kallithea, Greece (Farsalinos); Centro per la Prevenzione e Cura del Tabagismo, Institute of Internal Medicine, Azienda Policlinico-V Emanuele, Dipartimento di Biomedicina Clinica e Molecolare, Università di Catania, Catania, Italy (Polosa). Corresponding Author: Riccardo Polosa, MD, PhD, Centro per la Prevenzione e Cura del Tabagismo, Institute of Internal Medicine, Azienda, Dipartimento di Biomedicina Clinica e Molecolare, Via S Sofia 78, Catania, CT 95125, Italy (polosa @unict.it). Conflict of Interest Disclosures: Dr Farsalinos has performed studies for institutions that have received unrestricted funds from electronic cigarette companies. Dr Polosa has received lecture and research funding from GlaxoSmithKline and Pfizer and has served as a consultant for Pfizer and Arbi Group Srl, manufacturerers that distribute electronic cigarettes. Funding/Support: Dr Farsalinos’ salary is paid for by a scholarship grant from the Greek Society of Cardiology and Dr Polosa’s research is supported by Lega Italiana AntiFumo. Role of the Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. 1. Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among US adolescents: a cross-sectional study [published online March 6, 2014]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.5488. 2. Lee CW, Kahende J. Factors associated with successful smoking cessation in the United States: 2000. Am J Public Health. 2007;97(8):1503-1509. 3. Zhou X, Nonnemaker J, Sherrill B, Gilsenan AW, Coste F, West R. Attempts to quit smoking and relapse: factors associated with success or failure from the ATTEMPT cohort study. Addict Behav. 2009;34(4):365-373.
To the Editor The article by Dutra and Glantz1 focused on electronic cigarettes (e-cigarettes) as an emerging tobacco product among youth and explored the relationship between ecigarette trials and established smoking. Despite the significance of their findings, the study explored e-cigarette use in a vacuum and did not recognize that youth tobaccouse behaviors are complex and experimentation with multiple tobacco products is common. As noted in the 2012 Surgeon General’s report on youth, concurrent use of multiple tobacco products is prevalent among youth most notably among adolescent boys, white individuals, and older youth.2 Using 2012 National Youth Tobacco Survey data, we modeled established smoking, defined by Dutra and Glantz1 as having smoked 100 cigarettes in a lifetime and having smoked in the past 30 days, among experimenters (n = 6361) controlling for age, race/ethnicity, and sex as well as use of cigars, smokeless tobacco, and hookah. Additionally, we estimated the adjusted odds ratio (AOR) for each tobacco product separately. Current use of e-cigarettes was indeed associated with higher odds of current established cigarette smoking in the 2012 National Youth Tobacco Survey1; however, additional analy-
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sis found similar relationships for current use of cigars (AOR, 4.5; 95% CI, 3.7-5.5), smokeless tobacco (AOR, 5.4; 95% CI, 4.27.0), and hookah (AOR,3.3; 95% CI, 2.6-4.0). Moreover, the strength of the relationship between current e-cigarette use and current cigarette smoking diminished when the use of all other tobacco products was included in the analysis (AOR, 5.4; 95% CI, 3.8-7.8). While cigarettes are the most common tobacco product youth had tried and used in the past 30 days (26.3% and 9.4%, respectively), cigar use is also common (21.2% and 8.4%), followed by smokeless tobacco (9.6% and 4.4%) and hookah (8.6% and 3.5%). The e-cigarette ever (6.5%) and current prevalences (2.0%) were lower compared with all other tobacco products. Dutra and Glantz1 also highlighted the more than doubling of total e-cigarette use among teenagers between 2011 and 2012 (1.1% to 2.0%); however, the same increase of 0.9% was also observed for current hookah use (2.6% to 3.5%). Similar trends were noted by Arrazola and colleagues3 who reported significant increases for current use of ecigarettes and hookah among high school students between 2011 and 2012. Although Dutra and Glantz highlighted an important trend in e-cigarette use among our nation’s youth, failing to consider e-cigarette use in the context of other tobacco products may place undue emphasis on e-cigarettes, overshadowing the importance of the current use of multiple tobacco products as well as experimentation with cigars, smokeless tobacco, and hookah in this population. Cristine D. Delnevo, PhD, MPH Michelle T. Bover Manderski, MPH Gary A. Giovino, PhD, MS Author Affiliations: Center for Tobacco Studies, Rutgers School of Public Health, New Brunswick, New Jersey (Delnevo, Bover Manderski); Community Health and Health Behavior, University at Buffalo School of Public Health and Health Professions, Buffalo, New York (Giovino). Corresponding Author: Cristine D. Delnevo, PhD, MPH, Center for Tobacco Studies, Rutgers School of Public Health, 335 George St, Ste 2100, New Brunswick, NJ 08901 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among US adolescents: a cross-sectional study [published online March 6, 2014]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.5488. 2. US Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. 3. Arrazola RA, Dube SR, King BA; Centers for Disease Control and Prevention. Tobacco product use among middle and high school students: United States, 2011 and 2012. MMWR Morb Mortal Wkly Rep. 2013;62(45):893-897.
In Reply While our analysis1 of the National Youth Tobacco Survey focused on electronic cigarettes (e-cigarettes), we agree with Delnevo et al that e-cigarettes are not the only alternative nicotine product youth are using, either alone or with cigarettes. The Delnevo et al finding that e-cigarettes remained significantly associated with cigarette smoking even after adjusting for use of other tobacco products indicates that the relationship between e-cigarette use and smoking holds true 776
even after adjusting for dual use of other tobacco products (besides e-cigarettes). Contrary to the Farsalinos and Polosa letter, our crosssectional study made no claims about causation; drawing such conclusions requires longitudinal data. Our conclusion that the “[u]se of e-cigarettes does not discourage, and may encourage, conventional cigarette use among US adolescents” is based on observations that among teens who had ever tried a cigarette, even a puff, ever e-cigarette users were more likely than never e-cigarette users to have become regular cigarette smokers (smoked 100 cigarettes) and e-cigarette use was positively associated with cigarette smoking and smoking intensity and negatively associated with smoking abstinence among adolescents. If e-cigarettes were helping youth stop smoking, we would have found the opposite. Farsalinos and Polosa reported that in the 2011 National Youth Tobacco Survey, use of smoking-cessation aids was associated with lower odds of abstinence from smoking, higher odds of ever and current smoking, and higher smoking frequency and intensity; they used these associations to argue that “[d]espite these results, it would be inappropriate to conclude that use of pharmacologic or nonpharmacologic smokingcessation interventions do not discourage and probably encourage smoking among US adolescents…[Dutra and Glantz’s] conclusion that adolescents using e-cigarettes are transitioning to smoking is clearly not appropriate.” Farsalinos and Polosa assume that nicotine-replacement therapy is beneficial for teens despite the fact that pharmacological cessation aids are not approved for adolescents by the US Food and Drug Administration2 owing to the lack of efficacy evidence for teens.2-4 Farsalinos and Polosa simply confirm that the Food and Drug Administration acted appropriately. Both nicotine-replacement therapy and e-cigarettes are more likely to be used by regular youth smokers. This result does not diminish our findings of a significant positive association between e-cigarette use and becoming an established cigarette smoker among youth who had ever tried smoking (cigarette experimenters) or the negative association between e-cigarette use and smoking abstinence. Our findings are precisely what one would expect to find given that ecigarette advertising targets youth frequently and models and glamorizes smoking behavior, not abstinence.5-7 Lauren M. Dutra, ScD Stanton A. Glantz, PhD Author Affiliations: University of California, San Francisco (Dutra); Center for Tobacco Research and Education, University of California, San Francisco (Glantz). Corresponding Author: Stanton A. Glantz, PhD, Center for Tobacco Research and Education, University of California, San Francisco, 530 Parnassus Ave, Ste 366, San Francisco, CA 94143-1390 ([email protected]). Conflict of Interest Disclosures: None reported. Funding/Support: This work was supported by grants CA-113710 and CA-060121 from the National Cancer Institute. Role of the Sponsor: The funder had no role in the preparation, review, or approval of the manuscript, and the decision to submit the manuscript for publication. 1. Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among US adolescents a cross-sectional study [published online March 6, 2014]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.5488.
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2. Karpinski JP, Timpe EM, Lubsch L. Smoking cessation treatment for adolescents. J Pediatr Pharmacol Ther. 2010;15(4):249-263.
Author Affiliations: Student Research Committee, Babol University of Medical Sciences, Babol, Iran.
3. Adelman WP. Nicotine replacement therapy for teenagers: about time or a waste of time? Arch Pediatr Adolesc Med. 2004;158(3):205-206.
Corresponding Author: Amin Zarghami, Student Research Committee, Babol University of Medical Sciences, Ganjafrouz Ave, Babol, Mazandaran, Iran ([email protected]).
4. Stanton A, Grimshaw G. Tobacco cessation interventions for young people. Cochrane Database Syst Rev. 2013;8:CD003289. 5. Grana RA, Ling PM. “Smoking revolution”: a content analysis of electronic cigarette retail websites. Am J Prev Med. 2014;46(4):395-403. 6. Cho JH, Shin E, Moon SS. Electronic-cigarette smoking experience among adolescents. J Adolesc Health. 2011;49(5):542-546. 7. Yamin CK, Bitton A, Bates DW. E-cigarettes: a rapidly growing Internet phenomenon. Ann Intern Med. 2010;153(9):607-609.
Sexuality Talk: Still a Great Dilemma in Many Countries To the Editor We read with the great interest the editorial by Boeckeloo1 in JAMA Pediatrics. This editorial addressed the low frequency of physicians’ discussions with adolescents about issues around sexuality and related topics in primary care based on the study by Alexander et al,2 which is probably the first study of sexuality talk between physicians and adolescents documented by direct observation. The author mentioned the hesitancy of adolescents discussing sexuality with physicians depends on several reasons including that adolescents do not understand the purpose or do not feel confident that the doctor can be trusted to keep the discussion confidential. This seems to be directly related to the intrinsic viewpoints and previous judgments of adolescents about their physicians and the critical role physicians play in the management of adolescents’ problems. Family members, particularly parents, and schools are the 2 principal resources capable of solving these problems. Which one plays the more pivotal role? In developed countries, schools hold most of this responsibility by initiating sexual education beginning in elementary school. This policy has had a great impact in enhancing the quality of the knowledge of sexual health so far. But in developing countries, particularly religious countries such as Iran, the circumstances are very different. There is no specific curriculum in schools that focuses on this important issue. Moreover, most families do not mention adolescent sexual health at home because talking about these topics seems to be taboo. Altogether, these reasons lead to poor knowledge and, to some extent, misconceptions surrounding issues of sexual health. According to the authors’ knowledge, there have been no studies published on this vital issue in Islamic countries, such as Iran and neighboring areas, because surveying on such topics is thought to be beyond the red lines in these countries. Given today’s wide range of advanced technology and progress in multimedia, it is time to develop a new model of comprehensive adolescent sexual primary health care and design and implement certain programs about sexual health in schools. We also need a new primary care policy to cover different aspects of sexual health topics and promote education at varying stages of adolescent life. Amin Zarghami Amirhossein Zarghami, BSc
Conflict of Interest Disclosures: None reported. 1. Boekeloo BO. Will you ask? will they tell you? are you ready to hear and respond? barriers to physician-adolescent discussion about sexuality. JAMA Pediatr. 2014;168(2):111-113. 2. Alexander SC, Fortenberry D, Pollak KI, et al. Sexuality talk during adolescent health maintenance visits. JAMA Pediatr. 2014;168(2):163-169.
Prophylactic Use of a Probiotic in the Prevention of Colic To the Editor In their study, Indrio et al1 argued that prophylactic use of L reuteri during the first 3 months of life reduced not only the onset of functional gastrointestinal disorders but also the associated private and public management costs. Their study was a placebo-controlled trial. They used oil as placebo; however, the type of the oil used was not mentioned. Oils can change gut behavior and result in enhanced or decreased colic frequency based on their constituents. Furthermore, maternal diet has also been known as an influential factor in changing colic frequency.2-4 One might wonder if this was considered throughout the Indrio et al study. Moreover, to promote uniform documentation by parents and confirm that the infants were correctly given the study products, 1 investigator at each center was always available by telephone to help parents. In most studies, medical records are used as the source of information for many purposes including evaluation of the quality of care provided. In the study by Indrio et al, however, despite their reliance on the medical records, there were no reports to validate recorded content against the interaction between patient and physician, questioning the accuracy and validity of the information provided by parents, especially on some subjective measurements for variables such as regurgitation. Improvement in patient care crucially depends on the availability of high-quality, validated health information in clinical practice. Sarvin Sanaie, MD, PhD Ata Mahmoodpoor, MD Samad E. J. Golzari, MD Author Affiliations: Nutrition Research Center, Faculty of Nutrition, Tabriz University of Medical Sciences, Tabriz, Iran (Sanaie); Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran (Mahmoodpoor); Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran (Golzari). Corresponding Author: Ata Mahmoodpoor, MD, General Intensive Care Unit, Imam Reza Hospital, Daneshgah St, 5166614756, Tabriz, Iran (amahmoodpoor @yahoo.com). Conflict of Interest Disclosures: None reported. 1. Indrio F, Di Mauro A, Riezzo G, et al. Prophylactic use of a probiotic in the prevention of colic, regurgitation, and functional constipation: a randomized clinical trial. JAMA Pediatr. 2014;168(3):228-233. 2. Lust KD, Brown JE, Thomas W. Maternal intake of cruciferous vegetables and other foods and colic symptoms in exclusively breast-fed infants. J Am Diet Assoc. 1996;96(1):46-48.
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COMMENT & RESPONSE
Youth Tobacco Use and Electronic Cigarettes To the Editor In their study, Dutra and Glantz1 reported the results of a cross-sectional sample of adolescents interviewed in 2011 and 2012 in the National Youth Tobacco Survey and concluded that electronic cigarette (e-cigarette) use does not discourage and may encourage conventional cigarette use among US adolescents. However, their conclusions are not justified by the data presented. In a cross-sectional study, the observed relationship between e-cigarette use and higher and more sustained levels of smoking does not imply causation. Moreover, such studies do not take into account other population characteristics, which may play a crucial role when determining potential causation.2,3 Although the authors acknowledged this limitation in the text, they ended up drawing a conclusion that misleads the public into thinking e-cigarettes are leading to smoking initiation and addiction among adolescents. The 2011 National Youth Tobacco Survey included a question about whether participants used any interventions to quit smoking in the past 12 months. We analyzed the association between these interventions and smoking status, abstinence, frequency of smoking in the past 30 days, and number of cigarettes smoked during the days of smoking in the group of cigarette experimenters (ever smoked in the past 12 months, even 1 puff). Interventions were coded as pharmacologic (ie, nicotine gums, patches, or any medication) and nonpharmacologic (ie, attending a program in the school or the community, calling a quitline, visiting an Internet website, getting help from family or friends, using any other method such as hypnosis or acupuncture, or trying to independently quit). Logistic regression analysis was performed introducing age (continuous variable), sex, and race/ ethnicity as covariates. According to this analysis, use of pharmacologic intervention was consistently associated with a higher chance of ever being a smoker and being a current smoker, higher cigarette use frequency and consumption (with odds ratios ranging from 2.07-3.04), and a lower chance of 30-day and 6-month abstinence from cigarettes (odds ratios ranging from 0.390.43). Similar results were observed with the use of nonpharmacologic intervention. All results were statistically significant. Despite these results, it would be inappropriate to conclude that the use of pharmacologic or nonpharmacologic smoking-cessation interventions do not discourage and probably encourage smoking among US adolescents. However, this is exactly what Dutra and Glantz have done in their article on e-cigarettes, using similar analysis as herein. Their conclu-
Konstantinos E. Farsalinos, MD Riccardo Polosa, MD, PhD Author Affiliations: Onassis Cardiac Surgery Center, Kallithea, Greece (Farsalinos); Centro per la Prevenzione e Cura del Tabagismo, Institute of Internal Medicine, Azienda Policlinico-V Emanuele, Dipartimento di Biomedicina Clinica e Molecolare, Università di Catania, Catania, Italy (Polosa). Corresponding Author: Riccardo Polosa, MD, PhD, Centro per la Prevenzione e Cura del Tabagismo, Institute of Internal Medicine, Azienda, Dipartimento di Biomedicina Clinica e Molecolare, Via S Sofia 78, Catania, CT 95125, Italy (polosa @unict.it). Conflict of Interest Disclosures: Dr Farsalinos has performed studies for institutions that have received unrestricted funds from electronic cigarette companies. Dr Polosa has received lecture and research funding from GlaxoSmithKline and Pfizer and has served as a consultant for Pfizer and Arbi Group Srl, manufacturerers that distribute electronic cigarettes. Funding/Support: Dr Farsalinos’ salary is paid for by a scholarship grant from the Greek Society of Cardiology and Dr Polosa’s research is supported by Lega Italiana AntiFumo. Role of the Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. 1. Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among US adolescents: a cross-sectional study [published online March 6, 2014]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.5488. 2. Lee CW, Kahende J. Factors associated with successful smoking cessation in the United States: 2000. Am J Public Health. 2007;97(8):1503-1509. 3. Zhou X, Nonnemaker J, Sherrill B, Gilsenan AW, Coste F, West R. Attempts to quit smoking and relapse: factors associated with success or failure from the ATTEMPT cohort study. Addict Behav. 2009;34(4):365-373.
To the Editor The article by Dutra and Glantz1 focused on electronic cigarettes (e-cigarettes) as an emerging tobacco product among youth and explored the relationship between ecigarette trials and established smoking. Despite the significance of their findings, the study explored e-cigarette use in a vacuum and did not recognize that youth tobaccouse behaviors are complex and experimentation with multiple tobacco products is common. As noted in the 2012 Surgeon General’s report on youth, concurrent use of multiple tobacco products is prevalent among youth most notably among adolescent boys, white individuals, and older youth.2 Using 2012 National Youth Tobacco Survey data, we modeled established smoking, defined by Dutra and Glantz1 as having smoked 100 cigarettes in a lifetime and having smoked in the past 30 days, among experimenters (n = 6361) controlling for age, race/ethnicity, and sex as well as use of cigars, smokeless tobacco, and hookah. Additionally, we estimated the adjusted odds ratio (AOR) for each tobacco product separately. Current use of e-cigarettes was indeed associated with higher odds of current established cigarette smoking in the 2012 National Youth Tobacco Survey1; however, additional analy-
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sis found similar relationships for current use of cigars (AOR, 4.5; 95% CI, 3.7-5.5), smokeless tobacco (AOR, 5.4; 95% CI, 4.27.0), and hookah (AOR,3.3; 95% CI, 2.6-4.0). Moreover, the strength of the relationship between current e-cigarette use and current cigarette smoking diminished when the use of all other tobacco products was included in the analysis (AOR, 5.4; 95% CI, 3.8-7.8). While cigarettes are the most common tobacco product youth had tried and used in the past 30 days (26.3% and 9.4%, respectively), cigar use is also common (21.2% and 8.4%), followed by smokeless tobacco (9.6% and 4.4%) and hookah (8.6% and 3.5%). The e-cigarette ever (6.5%) and current prevalences (2.0%) were lower compared with all other tobacco products. Dutra and Glantz1 also highlighted the more than doubling of total e-cigarette use among teenagers between 2011 and 2012 (1.1% to 2.0%); however, the same increase of 0.9% was also observed for current hookah use (2.6% to 3.5%). Similar trends were noted by Arrazola and colleagues3 who reported significant increases for current use of ecigarettes and hookah among high school students between 2011 and 2012. Although Dutra and Glantz highlighted an important trend in e-cigarette use among our nation’s youth, failing to consider e-cigarette use in the context of other tobacco products may place undue emphasis on e-cigarettes, overshadowing the importance of the current use of multiple tobacco products as well as experimentation with cigars, smokeless tobacco, and hookah in this population. Cristine D. Delnevo, PhD, MPH Michelle T. Bover Manderski, MPH Gary A. Giovino, PhD, MS Author Affiliations: Center for Tobacco Studies, Rutgers School of Public Health, New Brunswick, New Jersey (Delnevo, Bover Manderski); Community Health and Health Behavior, University at Buffalo School of Public Health and Health Professions, Buffalo, New York (Giovino). Corresponding Author: Cristine D. Delnevo, PhD, MPH, Center for Tobacco Studies, Rutgers School of Public Health, 335 George St, Ste 2100, New Brunswick, NJ 08901 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among US adolescents: a cross-sectional study [published online March 6, 2014]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.5488. 2. US Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. 3. Arrazola RA, Dube SR, King BA; Centers for Disease Control and Prevention. Tobacco product use among middle and high school students: United States, 2011 and 2012. MMWR Morb Mortal Wkly Rep. 2013;62(45):893-897.
In Reply While our analysis1 of the National Youth Tobacco Survey focused on electronic cigarettes (e-cigarettes), we agree with Delnevo et al that e-cigarettes are not the only alternative nicotine product youth are using, either alone or with cigarettes. The Delnevo et al finding that e-cigarettes remained significantly associated with cigarette smoking even after adjusting for use of other tobacco products indicates that the relationship between e-cigarette use and smoking holds true 776
even after adjusting for dual use of other tobacco products (besides e-cigarettes). Contrary to the Farsalinos and Polosa letter, our crosssectional study made no claims about causation; drawing such conclusions requires longitudinal data. Our conclusion that the “[u]se of e-cigarettes does not discourage, and may encourage, conventional cigarette use among US adolescents” is based on observations that among teens who had ever tried a cigarette, even a puff, ever e-cigarette users were more likely than never e-cigarette users to have become regular cigarette smokers (smoked 100 cigarettes) and e-cigarette use was positively associated with cigarette smoking and smoking intensity and negatively associated with smoking abstinence among adolescents. If e-cigarettes were helping youth stop smoking, we would have found the opposite. Farsalinos and Polosa reported that in the 2011 National Youth Tobacco Survey, use of smoking-cessation aids was associated with lower odds of abstinence from smoking, higher odds of ever and current smoking, and higher smoking frequency and intensity; they used these associations to argue that “[d]espite these results, it would be inappropriate to conclude that use of pharmacologic or nonpharmacologic smokingcessation interventions do not discourage and probably encourage smoking among US adolescents…[Dutra and Glantz’s] conclusion that adolescents using e-cigarettes are transitioning to smoking is clearly not appropriate.” Farsalinos and Polosa assume that nicotine-replacement therapy is beneficial for teens despite the fact that pharmacological cessation aids are not approved for adolescents by the US Food and Drug Administration2 owing to the lack of efficacy evidence for teens.2-4 Farsalinos and Polosa simply confirm that the Food and Drug Administration acted appropriately. Both nicotine-replacement therapy and e-cigarettes are more likely to be used by regular youth smokers. This result does not diminish our findings of a significant positive association between e-cigarette use and becoming an established cigarette smoker among youth who had ever tried smoking (cigarette experimenters) or the negative association between e-cigarette use and smoking abstinence. Our findings are precisely what one would expect to find given that ecigarette advertising targets youth frequently and models and glamorizes smoking behavior, not abstinence.5-7 Lauren M. Dutra, ScD Stanton A. Glantz, PhD Author Affiliations: University of California, San Francisco (Dutra); Center for Tobacco Research and Education, University of California, San Francisco (Glantz). Corresponding Author: Stanton A. Glantz, PhD, Center for Tobacco Research and Education, University of California, San Francisco, 530 Parnassus Ave, Ste 366, San Francisco, CA 94143-1390 ([email protected]). Conflict of Interest Disclosures: None reported. Funding/Support: This work was supported by grants CA-113710 and CA-060121 from the National Cancer Institute. Role of the Sponsor: The funder had no role in the preparation, review, or approval of the manuscript, and the decision to submit the manuscript for publication. 1. Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among US adolescents a cross-sectional study [published online March 6, 2014]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.5488.
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2. Karpinski JP, Timpe EM, Lubsch L. Smoking cessation treatment for adolescents. J Pediatr Pharmacol Ther. 2010;15(4):249-263.
Author Affiliations: Student Research Committee, Babol University of Medical Sciences, Babol, Iran.
3. Adelman WP. Nicotine replacement therapy for teenagers: about time or a waste of time? Arch Pediatr Adolesc Med. 2004;158(3):205-206.
Corresponding Author: Amin Zarghami, Student Research Committee, Babol University of Medical Sciences, Ganjafrouz Ave, Babol, Mazandaran, Iran ([email protected]).
4. Stanton A, Grimshaw G. Tobacco cessation interventions for young people. Cochrane Database Syst Rev. 2013;8:CD003289. 5. Grana RA, Ling PM. “Smoking revolution”: a content analysis of electronic cigarette retail websites. Am J Prev Med. 2014;46(4):395-403. 6. Cho JH, Shin E, Moon SS. Electronic-cigarette smoking experience among adolescents. J Adolesc Health. 2011;49(5):542-546. 7. Yamin CK, Bitton A, Bates DW. E-cigarettes: a rapidly growing Internet phenomenon. Ann Intern Med. 2010;153(9):607-609.
Sexuality Talk: Still a Great Dilemma in Many Countries To the Editor We read with the great interest the editorial by Boeckeloo1 in JAMA Pediatrics. This editorial addressed the low frequency of physicians’ discussions with adolescents about issues around sexuality and related topics in primary care based on the study by Alexander et al,2 which is probably the first study of sexuality talk between physicians and adolescents documented by direct observation. The author mentioned the hesitancy of adolescents discussing sexuality with physicians depends on several reasons including that adolescents do not understand the purpose or do not feel confident that the doctor can be trusted to keep the discussion confidential. This seems to be directly related to the intrinsic viewpoints and previous judgments of adolescents about their physicians and the critical role physicians play in the management of adolescents’ problems. Family members, particularly parents, and schools are the 2 principal resources capable of solving these problems. Which one plays the more pivotal role? In developed countries, schools hold most of this responsibility by initiating sexual education beginning in elementary school. This policy has had a great impact in enhancing the quality of the knowledge of sexual health so far. But in developing countries, particularly religious countries such as Iran, the circumstances are very different. There is no specific curriculum in schools that focuses on this important issue. Moreover, most families do not mention adolescent sexual health at home because talking about these topics seems to be taboo. Altogether, these reasons lead to poor knowledge and, to some extent, misconceptions surrounding issues of sexual health. According to the authors’ knowledge, there have been no studies published on this vital issue in Islamic countries, such as Iran and neighboring areas, because surveying on such topics is thought to be beyond the red lines in these countries. Given today’s wide range of advanced technology and progress in multimedia, it is time to develop a new model of comprehensive adolescent sexual primary health care and design and implement certain programs about sexual health in schools. We also need a new primary care policy to cover different aspects of sexual health topics and promote education at varying stages of adolescent life. Amin Zarghami Amirhossein Zarghami, BSc
Conflict of Interest Disclosures: None reported. 1. Boekeloo BO. Will you ask? will they tell you? are you ready to hear and respond? barriers to physician-adolescent discussion about sexuality. JAMA Pediatr. 2014;168(2):111-113. 2. Alexander SC, Fortenberry D, Pollak KI, et al. Sexuality talk during adolescent health maintenance visits. JAMA Pediatr. 2014;168(2):163-169.
Prophylactic Use of a Probiotic in the Prevention of Colic To the Editor In their study, Indrio et al1 argued that prophylactic use of L reuteri during the first 3 months of life reduced not only the onset of functional gastrointestinal disorders but also the associated private and public management costs. Their study was a placebo-controlled trial. They used oil as placebo; however, the type of the oil used was not mentioned. Oils can change gut behavior and result in enhanced or decreased colic frequency based on their constituents. Furthermore, maternal diet has also been known as an influential factor in changing colic frequency.2-4 One might wonder if this was considered throughout the Indrio et al study. Moreover, to promote uniform documentation by parents and confirm that the infants were correctly given the study products, 1 investigator at each center was always available by telephone to help parents. In most studies, medical records are used as the source of information for many purposes including evaluation of the quality of care provided. In the study by Indrio et al, however, despite their reliance on the medical records, there were no reports to validate recorded content against the interaction between patient and physician, questioning the accuracy and validity of the information provided by parents, especially on some subjective measurements for variables such as regurgitation. Improvement in patient care crucially depends on the availability of high-quality, validated health information in clinical practice. Sarvin Sanaie, MD, PhD Ata Mahmoodpoor, MD Samad E. J. Golzari, MD Author Affiliations: Nutrition Research Center, Faculty of Nutrition, Tabriz University of Medical Sciences, Tabriz, Iran (Sanaie); Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran (Mahmoodpoor); Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran (Golzari). Corresponding Author: Ata Mahmoodpoor, MD, General Intensive Care Unit, Imam Reza Hospital, Daneshgah St, 5166614756, Tabriz, Iran (amahmoodpoor @yahoo.com). Conflict of Interest Disclosures: None reported. 1. Indrio F, Di Mauro A, Riezzo G, et al. Prophylactic use of a probiotic in the prevention of colic, regurgitation, and functional constipation: a randomized clinical trial. JAMA Pediatr. 2014;168(3):228-233. 2. Lust KD, Brown JE, Thomas W. Maternal intake of cruciferous vegetables and other foods and colic symptoms in exclusively breast-fed infants. J Am Diet Assoc. 1996;96(1):46-48.
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