Current Response and Management Decisions of the European Union to the COVID-19 Outbreak: A Review

COVID-19 has proven to be a formidable challenge for many countries in the European Union to manage effectively. The European Union has implemented numerous strategies to face emerging issues. Member States have adopted measures such as the closure of borders and significant limitations on the mobility of people to mitigate the spread of the virus. An unprecedented crisis coordination effort between Member States has facilitated the ability to purchase equipment, personal protective equipment, and other medical supplies. Attention has also been focused on providing substantive money for research to find a vaccine and promote effective treatment therapies. Financial support has been made available to protect worker salaries and businesses to help facilitate a return to a functional economy. Lessons learned to date from COVID-19 in the European Union are many; the current crisis highlights the need to think about future pandemics from a population-based management approach and apply outside the box critical thinking. Due to the complexity, intensity, and frequency of complex disasters, global leaders in healthcare, government, and business will need to pivot from siloed approaches to decision-making to embrace multidisciplinary and transdisciplinary levels of cooperation. This cooperation requires courage and leadership to recognize that changes are necessary to avoid making the same mistakes we have planned countless times on avoiding. This study focuses on the European Union’s initial response to the COVID-19 pandemic, starting with how the European Union first learned and processed the global information arising out of China, followed by the incremental population-based medicine/management decisions made that currently are defining the European Union’s capacity and capability. The capacity to organize, deliver, and monitor care to a specific clinical population under a population-based management target includes strict social distancing strategies, contact testing and tracing, testing for the virus antigen and its antibodies, isolation, and treatment modalities such as new mitigating medications, and finally, a vaccine

Correlation between biomarkers of exposure, effect and potential harm in the urine of electronic cigarette users.

ObjectivesTo determine if urinary biomarkers of effect and potential harm are elevated in electronic cigarette users compared with non-smokers and if elevation correlates with increased concentrations of metals in urine.Study design and settingThis was a cross-sectional study of biomarkers of exposure, effect and potential harm in urine from non-smokers (n=20), electronic cigarette users (n=20) and cigarette smokers (n=13). Participant's screening and urine collection were performed at the Roswell Park Comprehensive Cancer Center, and biomarker analysis and metal analysis were performed at the University of California, Riverside.ResultsMetallothionein was significantly elevated in the electronic cigarette group (3761±3932 pg/mg) compared with the non-smokers (1129±1294 pg/mg, p=0.05). 8-OHdG (8-hydroxy-2'-deoxyguanosine) was significantly elevated in electronic cigarette users (442.8±300.7 ng/mg) versus non-smokers (221.6±157.8 ng/mg, p=0.01). 8-Isoprostane showed a significant increase in electronic cigarette users (750.8±433 pg/mg) versus non-smokers (411.2±287.4 pg/mg, p=0.03). Linear regression analysis in the electronic cigarette group showed a significant correlation between cotinine and total metal concentration; total metal concentration and metallothionein; cotinine and oxidative DNA damage; and total metal concentration and oxidative DNA damage. Zinc was significantly elevated in the electronic cigarette users (584.5±826.6 µg/g) compared with non-smokers (413.6±233.7 µg/g, p=0.03). Linear regression analysis showed a significant correlation between urinary zinc concentration and 8-OHdG in the electronic cigarette users.ConclusionsThis study is the first to investigate biomarkers of potential harm and effect in electronic cigarette users and to show a linkage to metal exposure. The biomarker levels in electronic cigarette users were similar to (and not lower than) cigarette smokers. In electronic cigarette users, there was a link to elevated total metal exposure and oxidative DNA damage. Specifically, our results demonstrate that zinc concentration was correlated to oxidative DNA damage

The time course of compensatory puffing with an electronic cigarette: Secondary analysis of real-world puffing data with high and low nicotine concentration under fixed and adjustable power settings

Introduction: In a secondary analysis of our published data demonstrating compensatory vaping behavior (increased puff number, puff duration, and device power) with e-cigarettes refilled with low versus high nicotine concentration e-liquid, here we examine 5-day time course over which compensatory behavior occurs under fixed and adjustable power settings. Aims and Methods: Nineteen experienced vapers (37.90 ± 10.66 years, eight females) vaped ad libitum for 5 consecutive days under four counterbalanced conditions (ie, 20 days in total): (1) low nicotine (6 mg/mL)/fixed power (4.0 V/10 W); (2) low nicotine/adjustable power; (3) high nicotine (18 mg/mL)/fixed power; (4) high nicotine/adjustable power (at 1.6 Ohm). Puff number, puff duration, and power settings were recorded by the device. For each day, total daily puffing time was calculated by multiplying daily puff number by mean daily puff duration. Results: A significant day × setting interaction revealed that whilst puffing compensation (daily puffing time) continued to increase over 5 days under fixed power, it remained stable when power settings were adjustable. Separate analysis for puff number and puff duration suggested that the puffing compensatory behavior was largely maintained via longer puff duration. Conclusions: Under fixed power conditions (4.0 V/10 W), vapers appear to compensate for poor nicotine delivery by taking longer puffs and this compensatory puffing appears to be maintained over time. Implications: Studies in smokers suggest that when switching to lower nicotine levels, compensation for poorer nicotine delivery is transient. Our novel findings suggest that vapers show a different pattern of compensation which is influenced by both nicotine strength and device power settings. When power is fixed (4.0 V; 10 W), compensation (via more intensive puffing) appears prolonged, persisting up to 5 days. Under adjustable settings when power is increased, puffing patterns remain stable over time. Implications of such compensatory behaviors for product safety and user satisfaction need further exploration

Comparing identity, attitudes, and indicators of effectiveness in people who smoke, vape or use heated tobacco products: a cross-sectional study

Background: There is limited long-term and independent research on heated tobacco products (HTPs). We compared people who used HTPs with those who used nicotine vaping products (NVP) or cigarettes on smoker identity, indicators of effectiveness and, among NVP/HTP users, perceptions of these products. Methods: Adults exclusive cigarette smokers (N=45) and ex-smokers with medium/long-term (>3months) NVP (N=46) or HTP use (N=45) were recruited in London, UK. Participants completed a questionnaire assessing socio-demographics, smoking characteristics, smoker identity, dependence, intention to stop and attitudes towards HTP/NVP. Results: In adjusted analysis, people who used cigarettes (Mean Difference (MD)=1.4, 95%Confidence Intervals (CI) 0.7,2.0) and HTPs (MD=0.8, 95%CI 0.1,1.5) reported stronger smoker identities than those who used NVPs. Compared with smokers, HTP/NVP users had lower cravings for cigarettes (MD=3.0, 95%CI 1.6,4.3; MD=3.1, 95%CI 1.9,4.3, respectively), and higher intention to stop product use (MD=-0.8, 95%CI -1.7,-0.01; MD=-1.2, 95%CI -2.0,-0.3, respectively). People using HTPs or NVPs reported similar perceived product satisfaction (HTP:M=3.4, 95%CI 2.8,3.9; NVP:M=3.0, 95%CI 2.5,3.5), efficacy for smoking cessation (HTP:M=4.5, 95%CI 4.2,4.9; NVP:M=4.6, 95%CI 4.3,4.9) and safety (HTP:M=2.1, 95%CI 2.0,2.2; NVP:M=2.0, 95%CI 1.8,2.1). HTP users reported greater perceived addictiveness than NVPs (MD=0.3, 95%CI 0.2,0.6). Conclusions: HTP and NVP users perceived products to be similarly acceptable and effective suggesting that HTPs, like NVPs, may support smoking cessation. However, since HTP use appears to maintain a stronger smoker identity and perceived addiction, this may suggest a more limited role of HTP for a permanent transition away from cigarettes

Daily exposure to formaldehyde and acetaldehyde and potential health risk associated with use of high and low nicotine e-liquid concentrations

Recent evidence suggests that e-cigarette users tend to change their puffing behaviors when using e-liquids with reduced nicotine concentrations by taking longer and more frequent puffs. Using puffing regimens modelled on puffing topography data from 19 experienced e-cigarette users who switched between 18 and 6 mg/mL e-liquids with and without power adjustments, differences in daily exposure to carbonyl compounds and estimated changes in cancer risk were assessed by production of aerosols generated using a smoking machine and analyzed using gas and liquid chromatography. Significant differences across conditions were found for formaldehyde and acetaldehyde (p<0.01). Switching from a higher to a lower nicotine concentration was associated with greater exposure regardless of whether power settings were fixed or adjustable which is likely due to increased liquid consumption under lower nicotine concentration settings. Daily exposure for formaldehyde and acetaldehyde was higher for 17/19 participants when using low (6mg/mL) compared with high (18mg/mL) nicotine e-liquid concentration when power was fixed. When power adjustments were permitted, formaldehyde and acetaldehyde levels were higher respectively for 16/19 and 14/19 participants with the use of 6 compared with 18 mg/mL nicotine e-liquid

Examining acute psychopharmacological effects of nicotine vaping versus heated tobacco products in a randomised crossover study of product naive adult smokers

Nicotine vaping products (NVPs) and heated tobacco products (HTPs) are designed to replicate the sensory and behavioural aspects of smoking cigarettes while avoiding combustion. The success of these products as harm reduction tools will partially depend on their ability to satisfy smokers and alleviate nicotine-related withdrawal symptoms. This study aims to compare short-term effects of NVPs (Juul and Aspire PockeX) versus HTPs (IQOS) on smoking-related withdrawal relief, product satisfaction, intention to switch to NVP/HTP, perceptions and attitudes in UK adult cigarette smokers naïve to these products. In a randomized cross-over study, 45 participants visited the lab twice, at each visit trying one of the two products (NVP/HTP) and completing a questionnaire. Responses were normalized on a 0-100% scale and mean differences (MD) between NVP and HTP scores computed, with positive and negative MD values indicating greater endorsement for NVP and HTP, respectively. Cigarette cravings were reduced similarly (~20.0%) by both products (MD=4.5%, 95%Confidence Interval (CI) -4.8, 13.8). Direct positive effects (MD=-3.5%, 95%CI -7.2, 0.2) and adverse side effects (MD=1.8%, 95%CI -0.3, 3.8) were comparable after each product use, though marginally favouring HTPs. HTPs were perceived as more satisfying overall (MD=-13.2%, 95%CI -20.3 -6.1) than NVPs but both were perceived as similarly addictive (MD=3.6%, 95%CI -4.6, 11.8), relative to cigarettes. Intention to switch to either product was comparable (MD=4.0%, 95%CI -5.7, 13.8). Comparison of acute use of NVP versus HTP in a sample of UK smokers naïve to these products suggests that HTPs are perceived as more satisfying than NVPs, though still less satisfying than cigarettes

An exploration into “do-it-yourself” (DIY) e-liquid mixing: Users' motivations, practices and product laboratory analysis

Background: E-liquids are commercially available and manufactured, however some users of e-cigarettes prefer to prepare them at home (Do-it-Yourself; DIY) using individual ingredients. To date there is a paucity of research on how and why users make their own e-liquids. Methods: Forty-one European and US based exclusive users of e-cigarettes (ex-smokers) were individually in- terviewed. Structured interviews focused on motivations for home-mixing, practices, buying habits and broader themes around reasons for long-term vaping. We also measured nicotine and solvent concentrations and ana- lysed 33 DIY e-liquids collected from 16 participants for nicotine, solvents, flavourings, and potentially harmful chemicals. Results: There were four main reasons for DIY: 1) economical (financial savings), 2) self-control over manu- facturing process, 3) novelty, fun and 4) higher nicotine concentrations. Twelve out of 16 participants achieved nicotine concentration within 20% of their intended limit. Samples from five participants were above the EU Tobacco Products Directive's (TPD) 20 mg/ml nicotine concentration upper limit. Most samples contained more vegetable glycerine (VG) than propylene glycol (PG) and the most commonly used flavourings were dessert, e.g., vanilla and caramel. Chemical analysis also revealed presence of several potentially harmful chemicals and respiratory irritants, including cinnamaldehyde, benzaldehyde, and acetoin. Conclusion: DIY may offer users of e-cigarettes a long-term affordable practical method of vaping. Recommended safety advice needs to reflect actual and fast moving user behaviour

A cross-sectional study on the flood emergency preparedness among healthcare providers in Saudi Arabia

This study used a descriptive cross-sectional methodology to measure healthcare workers’ knowledge, attitudes, perceptions, and willingness to respond to a flood scenario in Saudi Arabia. A validated survey was distributed to collect data using a convenience sampling technique through multiple social media platforms. A total of 227 participants were included in this study: 52% of them were aged between 26 to 34 years, 74% were residents from Riyadh, and 52.4% worked in nursing divisions. A significant number of respondents (73.2%) had positive perceptions towards their hospitals’ ability to provide an effective response to a flood, 89% were willing to report to work following a flood, and 90% of participants reported the need to develop both guidelines and training for flood disaster preparedness. Preparation and successful flood mitigation in the hospital setting requires staff that have both knowledge and training in emergency management. One way to obtain such readiness is through competency-based training, including both table-top and full-scale live exercises. Although the willingness to respond to such a flooding emergency was high among staff, the development of guidelines and educational programs is needed in order to develop the competencies and skills sets to improve disaster preparedness response and preparedness efforts