Delphi consensus me hodology
o gauge expe pe spec i es on
smoking p e en ion, cessa ion
and ha m educ ion in I aly
Pasquale Caponne o
1,2
*, Vincenzo Con u si
3
,
F ancesco Fedele
4
, Fabio Lugoboni
5
and Sal a o e No o
6
1
Depa men o Educa ional Sciences, Sec ion o Psychology, Uni e si y o Ca ania, Ca ania, I aly,
2
Cen e o Excellence o he Accele a ion o Ha m Reduc ion (CoEHAR), Uni e si y o Ca ania,
Ca ania, I aly,
3
Ca dio ascula A ea, I alian In e disciplina y Socie y o P ima y Ca e, Ba i, I aly,
4
Depa men o Ca dio ascula , Respi a o y, Neph ological and Ge ia ic Sciences, Is i u o Nazionale
pe le Rice che Ca dio ascola i (INRC), Bologna, I aly,
5
Depa men o Medicine, Uni e si y Hospi al o
Ve ona, Ve ona, I aly,
6
Depa men PROMISE, Uni e si y o Pale mo, Pale mo, I aly
The ole o smoke- ee al e na i es o ciga e es o obacco ha m educ ion
emains con o e sial. This s udy was conduc ed o unde s and he pe spec i es
o a panel o I alian expe s on his opic. Using Delphi consensus me hodology,
expe opinions on he use o smoke- ee al e na i es, obacco ha m educ ion
and an i-smoking legisla ion we e ga he ed and analyzed. In July 2022, a
Scien ific Commi ee, including fi e membe s, p oposed 38 s a emen s
spanning h ee a eas: (1) ha m om obacco smoking and s a egies o ha m
educ ion; (2) smoke- ee al e na i es o ciga e es; and (3) an i-smoking
legisla ion. Be ween Augus and No embe 2022, he Expe Panel, including
membe s o he Scien ific Commi ee and 15 o he key opinion leade s, o ed on
he s a emen s in wo ounds. Consensus was achie ed on 24 o 38 s a emen s.
The esul s emphasized he pe sis en na ional heal h h ea posed by obacco
smoking in I aly, wi h a smoking p e alence o 20–24% be ween 2007 and 2022.
Emphasizing ha m educ ion as a pi o al public heal hca e s a egy, he Expe
Panel ag eed on 10 s a emen s ela ed o smoke- ee al e na i es, bu unde lined
he need o u he esea ch despi e p omising ini ial findings. The Expe Panel
also eached consensus on six s a emen s ega ding an i-smoking legisla ion,
s essing he impo ance o c a ing and upholding igo ous an i-smoking laws
ha a e consis en wi h Wo ld Heal h O ganiza ion guidelines. This pionee ing
Delphi consensus s a emen illumina es he complica ed deba e ega ding he
ole o smoke- ee al e na i es o obacco ha m educ ion in I aly. The findings
highligh he e ol ing na u e and ad oca e he need o ongoing discussions and
u he esea ch on his impo an issue.
KEYWORDS
Delphi consensus, elec onic ciga e es, hea ed obacco p oduc s, I aly, public heal h,
smoke- ee p oduc s, smoking cessa ion s a egies, obacco ha m educ ion
F on ie s in Psychia y on ie sin.o g01
OPEN ACCESS
EDITED BY
Sco J. Moelle ,
S ony B ook Medicine, Uni ed S a es
REVIEWED BY
Jannie Hugo,
Uni e si y o P e o ia, Sou h A ica
Kishan Ka iippanon,
The Uni e si y o Sydney, Aus alia
Knu K oege ,
Helios Hospi al K e eld, Ge many
*CORRESPONDENCE
Pasquale Caponne o
[email p o ec ed]
RECEIVED 07 Decembe 2023
ACCEPTED 06 Janua y 2025
PUBLISHED 31 Janua y 2025
CITATION
Caponne o P, Con u si V, Fedele F,
Lugoboni F and No o S (2025) Delphi
consensus me hodology o gauge expe
pe spec i es on smoking p e en ion,
cessa ion and ha m educ ion in I aly.
F on . Psychia y 16:1349265.
doi: 10.3389/ psy .2025.1349265
COPYRIGHT
© 2025 Caponne o, Con u si, Fedele,
Lugoboni and No o. This is an open-access
a icle dis ibu ed unde he e ms o he
C ea i e Commons A ibu ion License (CC BY).
The use, dis ibu ion o ep oduc ion in o he
o ums is pe mi ed, p o ided he o iginal
au ho (s) and he copy igh owne (s) a e
c edi ed and ha he o iginal publica ion in
his jou nal is ci ed, in acco dance wi h
accep ed academic p ac ice. No use,
dis ibu ion o ep oduc ion is pe mi ed
which does no comply wi h hese e ms.
TYPE Re iew
PUBLISHED 31 Janua y 2025
DOI 10.3389/ psy .2025.1349265
1 In oduc ion
The p e alence o smoking has dec eased in some coun ies
du ing he pas 30 yea s; howe e , he o e all numbe o smoke s
wo ldwide has inc eased om 0.99 billion in 1990 o 1.14 billion in
2019 due o popula ion g ow h (1). As a esul , obacco smoking
con inues o pose a significan heal h challenge, leading o subs an ial
mo bidi y and mo ali y, as well as con ibu ing o nega i e socie al
consequences, such as inc eased heal hca e cos s (1,2). In 2019,
obacco smoking was esponsible o an es ima ed 8 million dea hs
globally and was he leading cause o dea h and disabili y among men
(1). In I aly, he p e alence o obacco smoking emains high, a
app oxima ely 20.5% in 2023, despi e declining om he ecen peaks
o 24.2% in 2022 and 22.0% in 2019 (3,4).
The cu en obacco con ol measu es all sho and a e unlikely
o lead o he achie emen o he Wo ld Heal h O ganiza ion
(WHO) objec i e o a 30% educ ion in he p e alence o
smoking by 2030 (5). A undamen al change is needed o
p omo e subs an ial p og ess in his a ea.
Tobacco ha m educ ion is commonly defined as a public heal h
s a egy ha seeks o p e en o educe he damage caused by he oxins
gene a ed by obacco combus ion o people who wish o con inue
smokingo whoa eunable oqui , a he han aiming a comple e
abs inence om nico ine use (6–8). The use o obacco esul s in nico ine
addic ion and, he e o e, ha m educ ion s a egies ha e he po en ial o
imp o e ou comes in hose who do no gi e up obacco smoking (6,9,10).
O e he pas decade, smoke- ee al e na i es o obacco,
including elec onic ciga e es, hea ed obacco de ices and o ally
adminis e ed obacco- o nico ine-based p oduc s ha e become
popula , ye con o e sial subs i u es o obacco ciga e es among
smoke s wo ldwide (11–17). Compa ed wi h con en ional ciga e es,
smoke- ee al e na i es o e a subs an ial educ ion in exposu e o
oxic chemicals; o his eason, hese al e na i es can be used o
educe he ha m caused by ciga e e smoke and as aids o smoking
cessa ion (6,7,18–22). One e iew ound ha he p e alence o
obacco smoking is lowe , pa icula ly among young people, in
coun ies ha ha e highe a es o adop ion o smoke- ee obacco
al e na i es, such as he Uni ed Kingdom, Sweden, No way, New
Zealand and Japan, compa ed wi h o he coun ies (23).
Despi e hei g owing use, he ole o smoke- ee al e na i es o
obacco ha m educ ion emains a subjec o deba e. The scien ificand
medical communi ies ha e add essed he o e all po en ial benefi and
ha m o hese al e na i es, wi h di e gen opinions on hei e ficacy,
sa e y and socie al implica ions (24–28). This con o e sy unde sco es
he need o consensus on he ole o smoke- ee al e na i es in
educing he bu den caused by obacco smoking. Gi en his con ex ,
he objec i e o his s udy was o o mula e a consensus on he ole o
smoke- ee p oduc s in educing he ha m caused by obacco.
2 Me hods
2.1 S udy design
This s udy was unded by Philip Mo is I alia, a subsidia y o
Philip Mo is In e na ional, a obacco company ha has in es ed
mo e han $12.5 billion in he de elopmen o al e na i e, less
ha m ul p oduc s aimed a educing he ha m caused by obacco
use (h ps://www.pmi.com/, accessed Decembe 3, 2024). The s udy
employed a Delphi consensus me hodology, consis ing o wo
ounds o o ing. In July 2022, a i ual mee ing o a Scien ific
Commi ee ha consis ed o fi e specialis s in a ious he apeu ic
a eas (see Supplemen a y Me hods o he lis o membe s) was
con ened o d a a lis o s a emen s.
The s a emen s co e ed h ee gene al a eas: ha m om obacco
smoking and s a egies o ha m educ ion, smoke- ee al e na i es
o ciga e es, and an i-smoking legisla ion. Each s a emen
exp essed an opinion ega ding a ques ion o impo ance in
smoking ha m educ ion, on which he e was disag eemen o no
s ong ag eemen among membe s o he Scien ific Commi ee. The
s a emen s we e o mula ed o be clea and specific(e.g.,by
a oiding double nega i es) o ully exp ess all he dimensions o
he p oblem.
The s a emen s we e submi ed o online o ing o an Expe
Panel, which, in addi ion o membe s o he Scien ific Commi ee,
included 15 key opinion leade s who we e membe s o se e al
I alian scien ific socie ies. Thus, he Expe Panel comp ised a o al
o 20 membe s (see Supplemen a y Me hods o he ull lis ).
To ensu e he anonymi y o he online o ing p ocess, a
compu e ool was used in which clinicians ecei ed a
ques ionnai e ia email con aining only he ques ions wi hou
indica ing he name o he esponden . In no way was i possible
o ace he iden i y o he esponden . This p ocedu e gua an eed
ha expe s could exp ess hei genuine opinions wi hou ex e nal
p essu e o influence.
2.2 Selec ion o he Expe Panel
The selec ion o he Scien ific Commi ee and he key opinion
leade s was conduc ed h ough he in ol emen o I alian scien ific
socie ies om a ious disciplines ele an o he p ojec . These
socie ies we e in i ed o pa icipa e, and hose who accep ed he
in i a ion designa ed ei he hei p esiden o ano he ep esen a i e
knowledgeable abou he opic o ac as p ojec con ac s. F om his
pool, he fi e membe s o he Scien ific Commi ee we e selec ed
based on hei ex ensi e expe ience and ecognized expe ise on he
subjec , as e idenced by hei scien ific publica ions and ini ia i es
unde aken wi hin he coun y. Simila ly, he 15 key opinion leade s
we e chosen o hei demons a ed expe ise and con ibu ions o he
field o smoking p e en ion, cessa ion, and ha m educ ion. The
Delphi panel was o med wi h no inpu om he sponso . The
selec ion o a di e se g oup o 20 expe s helped ensu e a wide ange
o pe spec i es, educing he likelihood o bias.
Wo king independen ly, he Scien ific Commi ee ensu ed a
balanced and comp ehensi e se o s a emen s, ocusing on a eas
whe e he e was disag eemen o no s ong ag eemen among
membe s. To ensu e in eg i y and objec i i y, all phases o he
s udy, including da a collec ion, analysis, and in e p e a ion, we e
independen ly execu ed by he membe s o he Expe Panel.
The igo ous na u e o he Delphi consensus me hodology,
combined wi h addi ional sa egua ds, minimizes any po en ial
Caponne o e al. 10.3389/ psy .2025.1349265
F on ie s in Psychia y on ie sin.o g02
influence on he panel while ensu ing a balanced agg ega ion o
expe opinion.
Membe s o he Expe Panel we e asked o a e each s a emen
on a 9-poin Like scale, in which 1 indica ed maximum
disag eemen and 9 indica ed maximum ag eemen . The 9-poin
scale was chosen because he odd numbe o choices would educe
unce ain y while p o iding he op imum le el o p ecision.
Membe s o he Expe Panel we e encou aged o a e all
s a emen s. Responses we e collec ed online and we e
anonymous, o u he mi iga e po en ial biases. This anonymi y
allowed expe s o exp ess hei genuine opinions wi hou ex e nal
p essu e o influence.
Responses o he membe s o he Expe Panel we e analyzed by
an independen me hodologis . This independen analysis added an
addi ional laye o objec i i y o he p ocess, ensu ing ha da a
in e p e a ion was ee om sponso influence.
The le el o ag eemen was ca ego ized as low (Like scale
sco es 1–3), mode a e (sco es 4–6), o high (sco es 7–9). Consensus
was conside ed o ha e been eached on a s a emen i o e 85% o
esponden s exp essed le els o ag eemen ha ell in o one o he
h ee ca ego ies (low, mode a e, o high). These s a emen s would
be included in he final lis o ecommenda ions. Membe s o he
Expe Panel we e conside ed o ha e no eached consensus
ega ding a s a emen i he p opo ion o esponden s who
exp essed high o low ag eemen and he p opo ion o
esponden s who exp essed mode a e ag eemen collec i ely
exceeded 90%. The Scien ific Commi ee would hen discuss and
e ise such s a emen s be o e submi ing hem o he Expe Panel
o he second ound o o ing. I esponden s exp essed an e en
wide ange o ag eemen le els on a s a emen , ha s a emen was
conside ed unlikely o each consensus and was wi hd awn om
he subsequen s eps. Du ing he fi s ound o o ing, membe s o
he Expe Panel could p opose addi ional s a emen s.
The fi s ound o o ing ook place be ween Augus and
Sep embe 2022, and he second ound o o ing was in
No embe 2022. A he end o No embe 2022, he Scien ific
Commi ee me o discuss he second ound o o ing and o
p epa e he Expe Opinion s a emen .
In May 2023, he PubMed da abase was sea ched o ele an
a icles (see Supplemen a y Me hods o he li e a u e sea ch
s a egy). All he expe s we e p o ided wi h he scien ific
li e a u e on he subjec o consul be o e he o ing p ocess.
3 Resul s
In o al, 38 s a emen s we e de eloped ac oss he h ee a eas o
in e es : 11 s a emen s in A ea 1 (ha m om obacco smoking and
s a egies o ha m educ ion), 19 in A ea 2 (smoke- ee al e na i es
o ciga e es) and eigh in A ea 3 (an i-smoking legisla ion).
Du ing he fi s ound o o ing, consensus was eached
ega ding 17 s a emen s, while membe s o he Expe Panel did
no each consensus ega ding 19 s a emen s (Supplemen a y
Figu e 1). In addi ion, opinions di e ged on wo s a emen s o
such an ex en ha consensus was conside ed unlikely. These
s a emen s we e wi hd awn om he second ound o o ing.
Following he fi s ound o o ing, membe s o he Scien ific
Commi ee discussed and e ised he 19 s a emen s on which
esponden s did no each consensus.
Du ing he second ound o o ing, consensus was eached
ega ding se en addi ional s a emen s (Supplemen a y Figu e 1).
Membe s o he Expe Panel did no each consensus ega ding
12 s a emen s.
The final e sion o he s a emen s is p esen ed in Table 1.In
A ea 1, consensus was eached o eigh s a emen s (S a emen s 1
and 3–9). In A ea 2, consensus was eached on 10 s a emen s
(S a emen s 19–21, 23–26 and 28–30). In A ea 3, he panel eached
a consensus on six s a emen s (S a emen s 31–34, 37 and 38).
3.1 A ea 1: ha m om obacco smoking
and s a egies o ha m educ ion
Membe s o he Expe Panel ag eed ha ciga e e smoking is a
na ional heal h eme gency ha equi es u gen a en ion. The
p e alence o smoking in I aly has emained ela i ely s able
be ween 2007 and he p esen (3,27,29). Be ween 2007 and
2016, 20% and 22% o he I alian popula ion we e ciga e e
smoke s (27,29), wi h he p e alence o smoking inc easing om
22% in 2019 o 24% in 2022 (3). As discussed abo e, he p e alence
o smoking appea s o ha e declined in 2023; howe e , i s ill
emains abo e 20% (4). These da a highligh he g a i y o he
obacco smoking p oblem in I aly.
In addi ion, he membe s o he Expe Panel ag eed ha ha m
educ ion can be a aluable public heal h s a egy o educing he
nega i e impac o damaging beha io s in indi iduals who a e
unable o unwilling o e ain om such beha io s, and ha he
Minis y o Heal h o I aly should in es in p omo ing awa eness o
ha m educ ion among smoke s, including he use o smoke- ee
al e na i es. The e ec i eness o he ha m educ ion app oach has
been demons a ed wi h ega d o o he damaging beha io s, such
as alcohol and d unk d i ing, as well as d ugs and injec ion- ela ed
ha m (30).
3.2 A ea 2: smoke- ee al e na i es
o ciga e es
The Expe Panel concu ed ha cu en scien ific e idence
while p omising equi es u he s udies o es ablish he isk-
educ ion po en ial o smoke- ee p oduc s in compa ison o
adi ional ciga e es. A sys ema ic e iew o 56 s udies, 29 o
which we e andomized con olled ials, concluded ha nico ine-
con aining elec onic ciga e es inc eased obacco smoking qui
a es compa ed wi h nico ine eplacemen he apy (31). The
e iew also de ec ed no e idence o ha m om nico ine-
con aining elec onic ciga e es, a finding ha was limi ed by he
ela i ely sho du a ion o ollow-up (31). A subsequen analysis
showed ha he use o nico ine-con aining elec onic ciga e es was
associa ed wi h a educ ion in he le els o bioma ke s o po en ial
ha m, including exhaled ca bon monoxide, ni osamines,
polya oma ic hyd oca bon me aboli es and o he known
Caponne o e al. 10.3389/ psy .2025.1349265
F on ie s in Psychia y on ie sin.o g03
TABLE 1 Final s a emen s and he ou come o he wo- ound Delphi p ocess.
No. S a emen Ou come
A ea 1: Ha m om obacco smoking and s a egies o ha m educ ion Ag eemen ,
%
1 Ciga e e smoking ep esen s a na ional heal h eme gency which mus be con on ed wi h high p io i y h oughou
ou coun y.
Consensus 100
2The inc ease in dea hs due o ciga e e smoking and he g ow h o smoking- ela ed mo bidi ies a e p incipally caused
by subs ances p oduced du ing he combus ion p ocess.
No eached consensus 76.5
3The Minis y o Heal h o I aly should in es mo e ime and esou ces in p og ams aimed a helping smoke s qui
(e.g., an ismoking cen e s, oll- ee ho lines, e c.).
Consensus 94.1
4 The Minis y o Heal h o I aly mus in es ime and esou ces in p og ams aimed a sp eading he awa eness and
inc easing he knowledge o he concep o ha m educ ion as i ela es o smoking.
Consensus 100
5The Minis y o Heal h o I aly should in es ime and esou ces in in o ma ion p og ams aimed a inc easing he
awa eness o smoke- ee al e na i es o adul smoke s unable o unwilling o qui smoking.
Consensus 88.2
6 Public hea h can be imp o ed ia he implemen a ion o poli ical s a egies, p og ams, se ices and ini ia i es wi h
he goal o educing he e ec s o damaging beha io s o a minimum, despi e he likelihood ha such beha io s
may no be elimina ed.
Consensus 100
7 Reduc ion o he isks o smoking is a medical s a egy, and no o any o he na u e, on he same le el as p e ious
humani a ian app oaches adop ed success ully by he scien ific communi y in he p e en ion o ce ain diseases
(e.g., low-sal , low- a and low-suga die s, e c.).
Consensus 100
8The educ ion in he isks o smoking is a medical s a egy, equally impo an as he me hods used in he figh
agains and in he p e en ion o o he chemical dependencies.
Consensus 88.2
9 Ha m educ ion is an app oach which has he objec i e o educing o he lowes possible le els any impac s on
heal h caused by damaging beha io s, e en i such beha io s canno be en i ely elimina ed.
Consensus 100
10 Ha m educ ion can be an adequa e app oach o con on he p oblem o ciga e e smoking in adul smoke s who
a e unwilling o unable o qui .
No eached consensus 76.5
11 Assis ing smoke s o ansi ion om ypical ciga e es o less-damaging op ions (such as hose ha supply nico ine
wi hou a ) ep esen s a alid public heal h s a egy (bo h on a pe sonal and on a public le el).
No eached consensus 52.9
A ea 2: Smoke- ee al e na i es o ciga e es
12 Smoke ee al e na i es o ciga e es (such as elec onic ciga e es, hea ed obacco de ices o o ally adminis e ed
obacco- o nico ine-based p oduc s) may play a ole in he educ ion o ha m associa ed wi h smoking adi ional
ciga e es o bo h he indi idual and o he socie y.
No eached consensus 56.8
13 The exclusi e use o smoke- ee al e na i es (such as elec onic ciga e es, hea ed obacco de ices o o ally
adminis e ed obacco- o nico ine-based p oduc s) o e s a p ac ical and accep able al e na i e o adul smoke s who
would o he wise con inue o smoke ciga e es.
No eached consensus 76.5
14 As s a ed by he FDA, he cu en scien ific e idence ega ding he dec eased le els o damaging o po en ially
damaging chemicals p oduced by elec onic ciga e es in compa ison wi h adi ional ciga e es is su ficien o
conside hem p oduc s o educed isk.
No eached consensus 70.6
15 Real-wo ld e idence has e ealed ha elec onic ciga e es a e equally e ec i e as he d ugs used o smoking
cessa ion (31).
No eached consensus 64.7
16 The dual use o bo h adi ional ciga e es and smoke- ee al e na i es mus be a oided, as i is an ine ec i e and
useless in he long e m.
No eached consensus 82.4
17 T ansi ioning om smoking adi ional ciga e es o he exclusi e use o smoke- ee p oduc s is equi alen o
qui ing smoking.
Wi hd awn 100
18 Fo emale smoke s du ing p egnancy, ansi ioning om smoking adi ional ciga e es o he exclusi e use o
smoke- ee p oduc s is a much sa e app oach, which may help he woman o comple ely qui smoking and may
o p o ec he om possible elapse.
Wi hd awn 100
19 Cu en scien ific e idence mus be confi med by su ficien ly long- e m s udies in o de o e i y whe he smoke- ee
al e na i es a e associa ed wi h a g ea e educ ion in smoking- ela ed pa hologies compa ed wi h
adi ional ciga e es.
Consensus 88.2
20 The cessa ion o he use o any nico ine- o obacco-based p oduc s emains he gold-s anda d o which bo h
doc o s and pa ien s mus aim, ese ing he use o al e na i e p oduc s o adul smoke s who wish o con inue
smoking as a ha m educ ion s a egy.
Consensus 100
(Con inued)
Caponne o e al. 10.3389/ psy .2025.1349265
F on ie s in Psychia y on ie sin.o g04
TABLE 1 Con inued
No. S a emen Ou come
A ea 2: Smoke- ee al e na i es o ciga e es
21 P o iding accu a e in o ma ion ega ding smoke- ee al e na i es (such as elec onic ciga e es, hea ed obacco
de ices o o ally adminis e ed obacco- o nico ine-based p oduc s) o adul smoke s who would o he wise
con inue smoking is a s ep in he igh di ec ion o socie y as a whole and should be ega ded as in eg al o public
heal h policy.
Consensus 100
22 Fo adul smoke s who would o he wise con inue smoking, he go e nmen should os e he sha ing o scien ific
in o ma ion ega ding smoke- ee p oduc s in o de o a o in o med decision making.
No eached consensus 76.5
23 Scien ific o ganiza ions should use hei ac i i ies (as well as cong esses) in o de o p omo e in o ma ion and
aining o heal hca e p o essionals on smoking- ela ed issues and smoking cessa ion s a egies.
Consensus 100
24 Scien ific o ganiza ions should use hei ac i i ies (as well as cong esses) in o de o p omo e in o ma ion and
aining o heal hca e p o essionals ega ding al e na i e op ions a ailable o adul s who decide o no
qui smoking.
Consensus 100
25 I would be use ul o heal hca e p o essionals o ecei e addi ional in o ma ion on he ha m educ ion s a egies
and on he al e na i e smoke- ee p oduc s, based on he mos up- o da e scien ificfindings a ailable.
Consensus 100
26 I would be use ul o heal hca e p o essionals o ecei e addi ional in o ma ion on how o he na ions ha e
e alua ed he isks o smoke- ee p oduc s ela i e o adi ional ciga e es.
Consensus 100
27 Con a y o he guidelines sugges ed by he FDA and he NHS, some public heal h o ganiza ions end o emphasize
he po en ial isks o smoke- ee p oduc s, while o e looking hei benefi s. This app oach can ha e nega i e
epe cussions on public heal h.
No eached consensus 70.6
28 The e is a lo o disin o ma ion coming om he media ega ding he subjec o po en ial isks o smoke-
ee al e na i es.
Consensus 100
29 The scien ific e idence on he s a egy o obacco ha m educ ion and on ciga e e al e na i es ha comes om
bo h independen and indus y sou ces should be discussed and e iewed anspa en ly a app op ia e scien ific
mee ings by egula o y au ho i ies based on e idence-based medical p inciples and wi hou p io p econcep ions.
Consensus 100
30 The scien ific e idence on he s a egy o obacco ha m educ ion and on ciga e e al e na i es ha comes om
bo h independen and indus y sou ces should be discussed and e iewed anspa en ly, a app op ia e scien ific
mee ings by he medical-scien ific communi y based on e idence-based medical p inciples and wi hou
p io p econcep ions.
Consensus 100
A ea 3: An i-smoking legisla ion
31 Policies ough o con inue o de e people om beginning o smoke any ype o p oduc and o encou age hem
o qui .
Consensus 100
32 An adequa e egula o y amewo k should be used o moni o he undesi able consequences and o educe as
much as possible he ini ia ion o smoking in adolescen s and young adul s.
Consensus 100
33 In e en ions should be p opo ional o he isk/damage o obacco and smoke- ee al e na i es (such as elec onic
ciga e es, hea ed obacco de ices and o ally adminis e ed obacco- o nico ine-based p oduc s).
Consensus 100
34 In e en ions should ollow a common sense-based app oach: mo e damaging p oduc s, such as ciga e es, should be
subjec ed o mo e es ic i e egula ions.
Consensus 94.1
35 In I aly, housands o adul s will likely con inue o smoke, despi e he a ailabili y o exis ing he apies; hese people
should ha e he oppo uni y o ansi ion o less isky al e na i es. An adequa e egula o y amewo k should
ecognize ha no all obacco p oduc s ha e he same isk p ofile.
No eached consensus 76.5
36 An adequa e egula o y amewo k should o e adul smoke s access o less damaging smoke- ee p oduc s and he
necessa y in o ma ion o allow hem o make in o med decisions ega ding hei heal h.
No eached consensus 82.4
37 An adequa e egula o y amewo k should c ea e a way o he igo ous scien ific e alua ion o no el smoke- ee
p oduc s and hei ela i e heal h isks.
Consensus 88.2
38 An adequa e egula o y amewo k should allow consume s o ecei e scien ifically subs an ia ed in o ma ion
ega ding new p oduc s wi h he objec i e o a oiding misleading claims.
Consensus 88.2
S a emen s in i alics we e modified a e he fi s ound o o ing.
Ag eemen indica es he pe cen age o esponden s whose a ings ell in o he same ag eemen ca ego y, i.e. low ag eemen (Like scale sco es 1–3), mode a e ag eemen (sco es 4–6), high
ag eemen (sco es 7–9).
FDA, The Uni ed S a es Food and D ug Adminis a ion; NHS, The Na ional Heal h Se ice o G ea B i ain.
Caponne o e al. 10.3389/ psy .2025.1349265
F on ie s in Psychia y on ie sin.o g05
ca cinogens, compa ed wi h con en ional ciga e es and he
combined use o elec onic and con en ional ciga e es (32).
The benefi s o long- e m use o smoke- ee p oduc s e sus
con en ional ciga e es we e demons a ed in a s udy o pa ien s
wi h ch onic obs uc i e pulmona y disease (COPD) who we e
smoke s (33). In he s udy, objec i e and subjec i e ou comes we e
compa ed be ween 20 COPD pa ien s who used elec onic
ciga e es and 19 age- and sex-ma ched con ols who con inued
o smoke. A e 5 yea s o ollow-up, he sel - epo ed mean numbe
o con en ional ciga e es smoked pe day was significan ly lowe in
pa ien s who used elec onic ciga e es han in hose who con inued
o smoke (1.4 s 18.3; p<0.001). Fu he mo e, in he elec onic
ciga e e g oup, he mean annual COPD exace ba ion a e and
mean COPD assessmen ool (CAT) sco es (highe sco es indica e
g ea e impac o COPD) we e significan ly dec eased compa ed
wi h baseline (p<0.001 and p=0.020, espec i ely), and he mean 6-
minu e walk dis ance (6MWD) had significan ly inc eased om
baseline (p=0.005). In con as , o pa ien s who con inued o
smoke, he changes in hese pa ame e s om baseline we e no
s a is ically significan (33).
Ano he s udy subsequen ly compa ed ou comes a e 3 yea s o
ollow-up in 19 pa ien s wi h COPD who used hea ed obacco
p oduc s and 19 age- and sex-ma ched con ols who con inued o
smoke (34). Simila o he p e ious s udy, hea ed obacco p oduc s
we e associa ed wi h a significan educ ion om baseline o he
mean numbe o ciga e es smoked pe day, annual exace ba ion
a e, CAT sco e and 6MWD a 3 yea s, bu hese ou comes we e no
significan ly di e en in pa ien s who con inued o smoke (34).
Fu he suppo ing he benefi o smoke- ee al e na i es e sus
ciga e e smoking is he obse a ion ha a es o obacco smoking
a e lowe in coun ies wi h highe adop ion a es o smoke- ee
al e na i es han in coun ies wi h lowe adop ion a es (23).
Howe e , he e a e se e al unanswe ed ques ions ega ding
smoke- ee al e na i es o obacco (35). Fo example, he e is a
need o u he esea ch o e alua e he long- e m e ec s o smoke-
ee p oduc s on gene al heal h. In addi ion, as comple e smoking
cessa ion emains he p e e ed app oach, he abili y o e ec i ely
iden i y pa ien s who a e able o qui smoking e sus hose who
would benefi om ha m educ ion, would be use ul. Las ly, he
numbe o smoke- ee p oduc s has inc eased conside ably in
ecen yea s, and he con en s, quali y and ela i e sa e y o some
o hese p oduc s a e unknown, highligh ing he need o u he
esea ch and app op ia e egula ion (35).
I is impo an o no e ha obacco companies comple ely o
pa ially own many o he leading elec onic ciga e e
manu ac u e s and ha e in es ed hea ily in he p omo ion o he
obacco ha m educ ion app oach (36). In ligh o his, an edi o ial
by D s Koh and Fio e has sugges ed h ee p inciples ha could help
o e come disag eemen s among he a ious s akeholde s and
p omo e p og ess in his a ea: (i) he need o de alue ciga e es
and o he combus ibles; (ii) use o app o ed cessa ion medica ions
and legally ma ke ed ha m educ ion p oduc s in adul s; and (iii)
p e en ion o exposu e o obacco in child en, adolescen s and
young adul s (36).
The Expe Panel a fi med he impo ance o p omo ing
anspa en discussion o he scien ific e idence ega ding ha m
educ ion s a egies and ciga e e smoking al e na i es om bo h
independen and indus y sou ces. Howe e , he Expe Panel
emphasized ha he cessa ion o all nico ine- o obacco-based
p oduc s emains he ‘gold s anda d’ owa ds which heal hca e
p o essionals and pa ien s should aim, and unde sco ed he
necessi y o scien ifically subs an ia ed in o ma ion abou smoke-
ee al e na i es o ciga e e smoke s who wish o con inue
smoking. This in o ma ion should de i e om Heal h
Au ho i ies, Medical and Scien ificSocie ies,and heMedical
Communi y a la ge.
3.3 A ea 3: an i-smoking legisla ion
The consensus s a emen s ega ding an i-smoking legisla ion
highligh ed he need o con inuing policies ha de e people om
s a ing ciga e e smoking and encou age hem o qui , consis en
wi h WHO guidelines (2). The Expe Panel also ag eed ha
cessa ion in e en ions should be p opo ional o he isks posed
by obacco smoking and smoke- ee al e na i es, and ha an
adequa e egula o y amewo k should acili a e he igo ous
scien ific e alua ion o and dissemina ion o in o ma ion abou
no el smoke- ee p oduc s and hei ela i e heal h isks.
The Expe Panel did no each consensus on he s a emen ha
a egula o y amewo k should be de eloped o o e all smoke s he
op ion o ansi ion o smoke- ee p oduc s, o o allow access o
hese p oduc s o all smoke s (wi h he necessa y in o ma ion
p o ided o allow in o med decision-making).
4 Discussion
The p esen Delphi s udy acili a ed igo ous discussion and
consensus-building among a panel o expe s in a ious he apeu ic
a eas on he issue o using smoke- ee al e na i es o ciga e es o
obacco ha m educ ion in I aly. P o ound di e ences o opinion
a e known o exis wi hin he medical p o ession on he ques ion o
obacco ha m educ ion, as confi med du ing his s udy. This
highligh s he need o inc eased e o s o p omo e dialogue and
consensus-building. The Delphi me hod is a aluable ool o
na iga ing con o e sies and unce ain ies in a ious scien ific
fields by p o iding a s uc u ed app oach o collec ing and
syn hesizing expe opinions. Impo an ly, o ou knowledge, his
is he fi s Delphi consensus s a emen o examine he ole o
smoke- ee p oduc s in educing he ha m caused by obacco. The
use o he Delphi me hod in he p esen s udy acili a ed he
delinea ion o common g ound and spo ligh ed a eas o
di e gence, p edominan ly hose ela ed o obacco ha m
educ ion. Gi en he con o e sial na u e o his field, i was no
su p ising ha a clea consensus could no be eached on
se e al s a emen s.
Caponne o e al. 10.3389/ psy .2025.1349265
F on ie s in Psychia y on ie sin.o g06
While ce ain key s a emen s did no achie e consensus in he
Delphi p ocess, his disag eemen should be iewed as an in e p e i e
oppo uni y a he han a limi a ion. Conside ing he lack o
consensus in he b oade con ex o he en i e s udy, i becomes
clea ha some disc epancies may be due o misin e p e a ions o
inco ec wo ding o specific ques ions. This highligh s he
impo ance o clea ques ion aming in u u e s udies. A he same
ime, he exis ence o disag eemen s eflec s he complexi y o he
issue and unde sco es he alue o he Delphi me hod in os e ing
nuanced discussions and na iga ing con o e sies.
The lack o consensus on s a emen 12 is balanced by he
consensus eached in s a emen 19. This highligh s he
impo ance o long- e m s udies o confi m he educ ion o
ha m wi h smoke- ee al e na i es, despi e he significan
educ ion in exposu e o oxican s.
The lack o consensus on s a emen 13 can be a ibu ed o he
wo ding o he ques ion. I appea s ha some panelis s (23%) may
ha e in e p e ed “exclusi e use”as he only op ion, wi hou any
cessa ion a emp s (e.g., NRT use), a he han a comple e ansi ion
o smoke- ee al e na i es wi hou dual use wi h combus ible
obacco p oduc s. This indica es ha clea e o mula ion o
ques ions is c ucial o a oid po en ial misin e p e a ions.
The lack o consensus on s a emen 14 likely s ems om an
inco ec o mula ion o he ques ion ega ding he FDA s a emen .
The FDA used “modified le els”ins ead o “dec eased le els”o
Ha m ul and Po en ially Ha m ul Cons i uen s (HPHC). This
sugges s ha some panelis s highligh ed his o e sigh a he han
disag eeing wi h he FDA’s opinion.
The lack o consensus on s a emen s 35 and 36 is in con as
wi h he consensus eached o s a emen s 33 and 34. This
inconsis ency, whe e he consensus and lack o consensus eached
o hose s a emen s a e in s a k con as o each o he , has no
explana ion o he han some panelis s could ha e misin e p e ed
he ele an ques ions. I should be no ed ha he lack o consensus
is he esul o he peculia wo ding used in s a emen s 35 and 36
(whe e, a any a e, he e was an a e age consensus o 80%) as hey
e e ed o “all smoke s”and no o “adul smoke s who would
o he wise con inue smoking.”When compa ing such a esul o he
one o s a emen 21 (100% consensus), he Expe Panel did ag ee
abou making smoke- ee al e na i es accessible o adul smoke s
who would o he wise con inue smoking (wi h in o ma ion o
enable in o med decision-making). Howe e , he ake-home
message om he cumula i e in e p e a ion o such s a emen s is
ha no all obacco p oduc s ha e he same isk p ofile (con inuum
o he isk concep ) and ha mo e es ic i e egula ions should be
applied o p oduc s which a e po en ially mo e damaging.
The lack o consensus on s a emen s 10 and 11 is appa en ly in
con as wi h he consensus eached o s a emen 20.
On one hand, e idence om ecen s udies by Qu eshi and
colleagues (37), Rose and colleagues (38), La Rosa and colleagues
(39), and Ansa i and colleagues (40) highligh s he benefi s o
smoke- ee al e na i es in educing exposu e o oxican s and
imp o ing heal h ou comes. On he o he hand, findings by
se e al au ho s unde sco e un esol ed isks, such as he impac o
smoke- ee p oduc s on small ai way unc ion (41), umo
me as asis (42), hype ension (43) and ca dio espi a o y fi ness
(44). This duali y unde sco es he con en ious na u e o obacco
ha m educ ion and he need o ongoing esea ch and deba e o
guide e idence-based policies.
Howe e , when in e p e ed cumula i ely, he Panel consensus
was clea : bo h he Ha m Reduc ion app oach and assis ing adul
smoke s who would o he wise con inue smoking o ansi ion om
ciga e es o less damaging op ions a e s a egies o be
ecommended and adop ed jus in he la e popula ion, whils
cessa ion emains he gold s anda d o pu sue in all
ciga e e smoke s.
In o al, 24 s a emen s (S a emen s 1, 3–9, 19–21, 23–26, 28–34,
37 and 38) eached consensus a e wo ounds o o ing, indica ing
subs an ial ag eemen on a ange o issues wi hin h ee b oad a eas
(1): ha m om obacco smoking and s a egies o ha m educ ion,
(2) smoke- ee al e na i es o ciga e es and (3) an i-
smoking legisla ion.
Despi e eaching a consensus on se e al s a emen s, he Expe
Panel emained di ided on se e al issues. Fo example, di e gen
opinions we e exp essed on s a emen s ega ding he ole o smoke-
ee al e na i es o ha m educ ion. These disag eemen s a e
eflec ed in he deba e ha con inues o un old in he scien ific
li e a u e (6,23,24,27,45–47). P oponen s o he use o smoke-
ee al e na i es o obacco ha m educ ion end o emphasize ha
mos o he ha m associa ed wi h obacco use comes om
combus ion, which is absen in smoke- ee al e na i es (48).
O he s ha e aised conce ns abou he sa e y o he chemicals
con ained in elec onic ciga e es and abou he possibili y ha
smoke- ee obacco al e na i es may se e as a ga eway o
adi ional ciga e es o cause obacco smoke s who ha e
p e iously qui o elapse (24,27,49). Howe e , he mos ecen
da a om he Global You h Tobacco Su ey, which was ca ied ou
in I aly o e he 2021–2022 school yea and ques ioned 2,069
adolescen s aged 13–15 yea s, has indica ed ha he use o
ciga e es and nico ine p oduc s o e all has dec eased o e he
pas 8 yea s (50). Fu he , as o he in e en ions and policies ha e
hus a ailed o elimina e smoking, despi e subs an ial public
policy e o s, i may be ha commi men o he goal o comple e
abs inence on he pa o hose who a e conce ned abou smoke- ee
obacco al e na i es p e en s hem om seeing he alue o
in e media e solu ions (6).
Ul ima ely, his Delphi s udy ep esen s a c i ical app oach o
unde s anding expe pe spec i es ha is consis en wi h he
p inciples o scien ific esea ch. Ra he han seeking unanimous
ag eemen , he p ocess illumina ed di e se iewpoin s and os e ed
nuanced discussion, which is equi ed o add essing he di e se
challenges o obacco ha m educ ion.
The concep o abs inence as he only possible s a egy in
obacco con ol needs o be c i ically e iewed. Undoub edly,
comple e cessa ion o smoking is he bes possible ou come.
Howe e , his ocus necessa ily o e looks he needs o hose who
Caponne o e al. 10.3389/ psy .2025.1349265
F on ie s in Psychia y on ie sin.o g07
a e unwilling o unable o qui en i ely. Fo hese indi iduals, he
use o smoke- ee p oduc s may p o ide a sui able, i no he only,
s a egy o subs an ially educe hei heal h isks, and ha m
educ ion measu es should be ecognized as an essen ial
componen o public heal h s a egy.
Hesi ancy in adop ing ha m educ ion s a egies has also been
obse ed in o he a eas o public heal h, such as he opioid c isis,
whe e ha m educ ion s a egies ha e shown subs an ial benefi s in
educing opioid use, lowe ing he isk o o e dose, and p e en ing
he ansmission o in ec ious diseases. Howe e , despi e clea
e idence o he benefi s o ha m educ ion measu es, many
expe s and policymake s con inue o a o abs inence-only
app oaches, o en sidelining he benefi s o non-abs inence
s a egies (51,52).
This example p o ides a clea pa allel o obacco con ol:
ailing o ecognize he alue o ha m educ ion may limi ou
abili y o e ec i ely educe he bu den o smoking- ela ed diseases.
This s udy was unded by Philip Mo is I alia, a subsidia y o
Philip Mo is In e na ional. The unding eflec s a con inued
commi men by he obacco indus y o de elop less ha m ul
al e na i es o consume s, indica ing a clea pa adigm shi
owa d a ha m educ ion app oach, simila o e o s seen in he
au omo i e indus y o imp o e p oduc sa e y.
While ou s udy was unded by a obacco company, se e al s eps
we e aken o ensu e he esea ch’s objec i i y and in eg i y. The
independence o he esea ch eam, he anonymous o ing p ocess,
and he in ol emen o an independen me hodologis in da a
analysis we e c ucial measu es aken o mi iga e po en ial conflic s
o in e es . T anspa ency in ou me hodology and ull disclosu e o
he unding sou ce ha e been pa amoun , and we belie e hese s eps
main ain high s anda ds o scien ific igo . Addi ionally, we
acknowledge he conce n ha some po en ial collabo a o s migh
ha e op ed ou due o he sou ce o unding, which could ha e
influenced he o e all composi ion o he Scien ific Commi ee.
Howe e , he igo ous na u e o he DELPHI consensus
me hodology inhe en ly minimizes he po en ial impac o any
selec ion bias on ou wo k. E en i significan selec ion bias we e o
occu a he Scien ific Commi ee le el, he i e a i e p ocedu al s eps
o he DELPHI consensus allow o ag eemen s/disag eemen s om
many key opinion leade s. Impo an ly, he key opinion leade s we e
selec ed om a pool o 20 scien ific socie ies, comp ising heal h
p o essionals wi h a di e se ange o iews on obacco ha m
educ ion. This di e si y enhances he balance and in eg i y o
ou analysis.
These ongoing disag eemen s eflec he complexi ies and
challenges inhe en in o ming a consensus on a apidly e ol ing
and con en ious field like obacco ha m educ ion. The e o e, he
findings o his consensus s udy unde sco e he need o u he
esea ch, dialogue and expe discussions o guide policy and
p ac ice in his impo an public heal h a ea. In pa icula , u u e
wo k should ocus on he s a emen s whe e consensus was no
eached, o examine hese a eas in mo e dep h, and o p o ide
u he e idence o guide policy and p ac ice in obacco ha m
educ ion in I aly. Indeed, he au ho s sugges ha ano he
consensus s udy be conduc ed wi hin he nex 2 yea s, gi en he
la ge amoun o scien ific e idence likely o be published in he nea
u u e in he field o p e en able diseases.
While his esea ch cen e s a ound he I alian con ex , he
findings can be applied o any na ion acing a significan
p e alence o smoking. The concep s o educing obacco- ela ed
ha m and he collabo a i e consensus-building p ocess discussed
a e uni e sally applicable, o e ing a amewo k ha can be ailo ed
o add ess obacco use as a public heal h issue in di e en coun ies.
The p esen consensus s udy had se e al limi a ions. Fi s ly,
consensus was based on he opinions o a selec g oup o 20
specialis s, which may no encompass he b oade pe spec i es o
he la ge scien ific communi y. Secondly, as he s udy was limi ed
o he opinions o I alian expe s, he p esen consensus may no be
eadily gene alizable o specialis s in o he coun ies. Howe e , one
o he s eng hs o he p esen s udy was he use o a much highe
h eshold o consensus (>85%) han is commonly used in
Delphi s udies.
To ensu e he in eg i y and objec i i y o ou esea ch, he
Expe Panel main ained s ic independence om he sponso
wo king independen ly h oughou all s ages o he esea ch
p ocess. All he conclusions p esen ed in his s udy eflec he
opinions o he au ho s and ha e no been influenced by he
sponso . We ha e ully disclosed ou unding sou ce and a e
commi ed o anspa ency, making ou me hodology and da a
a ailable o pee e iew.
In conclusion, his Delphi consensus s udy ep esen s an
impo an s ep in es ablishing expe consensus on he ole o
smoke- ee p oduc s in educing he ha m caused by obacco
smoking in I aly. I p o ides a amewo k o ongoing dialogue
and ac ion, wi h he ul ima e aim o educing he significan heal h
bu den posed by obacco smoking.
Au ho con ibu ions
PC: Concep ualiza ion, Me hodology, Supe ision, W i ing –
e iew & edi ing. VC: Concep ualiza ion, Me hodology,
Supe ision, W i ing – e iew & edi ing. FF: Concep ualiza ion,
Me hodology, Supe ision, W i ing – e iew & edi ing. FL:
Concep ualiza ion, Me hodology, Supe ision, W i ing – e iew &
edi ing. SN: Concep ualiza ion, Me hodology, Supe ision, W i ing
– e iew & edi ing.
Funding
The au ho (s) decla e financial suppo was ecei ed o he
esea ch, au ho ship, and/o publica ion o his a icle. This wo k
was suppo ed by Phillip Mo is I alia S. .l. The unde was no
in ol ed in he s udy design, collec ion, analysis, in e p e a ion o
da a, w i ing o his a icle, o he decision o submi i o publica ion.
Caponne o e al. 10.3389/ psy .2025.1349265
F on ie s in Psychia y on ie sin.o g08
Acknowledgmen s
Edi o ial suppo was p o ided by Geo gii Fila o on behal o
Sp inge Heal hca e Communica ions. This Delphi consensus was
commissioned and financed by Philip Mo is I alia S. .l.; howe e ,
all opinions and s a emen s epo ed in he p esen pape a e
exclusi ely hose o he au ho s. The au ho s hank all he
membe s o he Expe Panel o hei con ibu ion, and
Alessand o U bani o wo k as a mode a o and me hodologis .
Conflic o in e es
The au ho s decla e ha he esea ch was conduc ed in he
absence o any comme cial o financial ela ionships ha could be
cons ued as a po en ial conflic o in e es .
Publishe ’s no e
All claims exp essed in his a icle a e solely hose o he au ho s
and do no necessa ily ep esen hose o hei a filia ed
o ganiza ions, o hose o he publishe , he edi o s and he
e iewe s. Any p oduc ha may be e alua ed in his a icle, o
claim ha may be made by i s manu ac u e , is no gua an eed o
endo sed by he publishe .
Supplemen a y ma e ial
The Supplemen a y Ma e ial o his a icle can be ound online
a : h ps://www. on ie sin.o g/a icles/10.3389/ psy .2025.1349265/
ull#supplemen a y-ma e ial
Re e ences
1. GBD 2019 Tobacco Collabo a o s. Spa ial, empo al, and demog aphic pa e ns in
p e alence o smoking obacco use and a ibu able disease bu den in 204 coun ies and
e i o ies, 1990-2019: A sys ema ic analysis om he global bu den o disease s udy 2019.
Lance (London England). (2021) 397:2337–60. doi: 10.1016/s0140-6736(21)01169-7
2. Wo ld Heal h O ganiza ion. Tobacco (2022). A ailable online a : h ps://www.
who.in /news- oom/ ac -shee s/de ail/ obacco (Accessed June 16, 2024).
3. Is i u o Supe io e di Sani à. P ess Release N°39/2022 - Smoking: I aly Repo s
Almos 800,000 Smoke s Mo e Than in 2019 and he Consump ion o Hea ed Tobacco
P oduc s Has T ipled (2022). A ailable online a : h ps://www.iss.i /en/-/no- obacco-
day-2022-iss-en#:~: ex =The e%20a e%2012.4%20million%20smoke s,non%
2Dsmoke s%20 o%2060.9%25 (Accessed June 16, 2024).
4. Is i u o Supe io e di Sani à. Comunica o S ampa N°39/2023 Gio na a Mondiale
Senza Tabacco: I Da i Sui Fuma o i in I alia (2023). A ailable online a : h ps://www.iss.
i /web/gues /comunica i-s ampa/-/asse _publishe / jTKmjJgSgdK/con en /id/8743826
(Accessed June 16, 2024).
5. Beaglehole R, Boni a R. Tobacco con ol: ge ing o he finish line. Lance (London
England). (2022) 399:1865. doi: 10.1016/s0140-6736(22)00835-2
6. Polosa R, Rodu B, Caponne o P, Maglia M, Raci i C. A esh look a obacco ha m
educ ion: he case o he elec onic ciga e e. Ha m educ ion J. (2013) 10:19.
doi: 10.1186/1477-7517-10-19
7. Ha sukami DK, Ca oll DM. Tobacco ha m educ ion: pas his o y, cu en
con o e sies and a p oposed app oach o he u u e. P e Med. (2020) 140:106099.
doi: 10.1016/j.ypmed.2020.106099
8. O’Lea y R, Polosa R. Tobacco ha m educ ion in he 21s cen u y. D ugs Alcohol
Today. (2020) 20:219–34. doi: 10.1108/DAT-02-2020-0007
9. Benowi z NL. Nico ine addic ion. New Engl J Med. (2010) 362:2295–303.
doi: 10.1056/NEJM a0809890
10. Roh S. Scien ific e idence o he addic i eness o obacco and smoking cessa ion
in obacco li iga ion. J P e Med Public Heal h = Yebang Uihakhoe chi. (2018) 51:1–5.
doi: 10.3961/jpmph.16.088
11. Ho i A, Tabuchi T, Kunugi a N. Rapid inc ease in hea ed obacco p oduc
(H p) use om 2015 o 2019: om he Japan 'Socie y and new obacco' In e ne
su ey (Jas is). Tobacco con ol. (2020) 30:474–5. doi: 10.1136/ obaccocon ol-2020-
055652
12. Ra ajczak A, Jankowski P, S us P, Feleszko W. Hea no bu n obacco p oduc -a
new global end: impac o hea -no -bu n obacco p oduc s on public heal h, a
sys ema ic e iew. In J En i on Res Public Heal h. (2020) 17:409. doi: 10.3390/
ije ph17020409
13. McNeill A, B ose L, Calde R, Simona icius E, Robson D. Vaping in England: an
e idence upda e including aping o smoking cessa ion, Feb ua y 2021: A epo
commissioned by Public Heal h England London: Public Heal h England (2021).
A ailable online a : h ps://www.go .uk/go e nmen /publica ions/ aping-in-england-
e idence-upda e- eb ua y-2021 (Accessed June 16, 2024).
14. Eu opean Commission. Special Eu oba ome e 506: A i udes o Eu opeans
Towa ds Tobacco and Elec onic Ciga e es (2021). A ailable online a : h p://da a.
eu opa.eu/euodp/en/da a/da ase /S2240_506_ENG (Accessed June 16, 2024).
15. Je zynski T, S imson GV, Shapi o H, K ol G. Es ima ion o he global numbe o E-
ciga e e use s in 2020. Ha m educ ion J. (2021) 18:109. doi: 10.1186/s12954-021-00556-7
16. Mille CR, Su an o E, Smi h DM, Hi chman SC, G a ely S, Yong HH, e al.
Cha ac e izing hea ed obacco p oduc use among adul ciga e e smoke s and nico ine
aping p oduc use s in he 2018 I c ou coun y smoking & Vaping su ey. Nico ine
obacco Res. (2022) 24:493–502. doi: 10.1093/n /n ab217
17. Mina di V, As a F, Con oli B, Masocco M. Gy s 2022: I Da i Nazionali (2023).
A ailable online a : h ps://www.epicen o.iss.i /gy s/Indagine-2022-da i-nazionali
(Accessed June 16, 2024).
18. Fa salinos KE, Polosa R. Sa e y e alua ion and isk assessmen o elec onic
ciga e es as obacco ciga e e subs i u es: A sys ema ic e iew. The Ad D ug Sa .
(2014) 5:67–86. doi: 10.1177/2042098614524430
19. Haziza C, de la Bou donnaye G, Me le S, Benzim a M, Ance ewicz J, Donelli A,
e al. Assessmen o he educ ion in le els o exposu e o ha m ul and po en ially
ha m ul cons i uen s in Japanese subjec s using a no el obacco hea ing sys em
compa ed wi h con en ional ciga e es and smoking abs inence: A andomized
con olled s udy in confinemen . Regul Toxicol pha macology: RTP. (2016) 81:489–
99. doi: 10.1016/j.y ph.2016.09.014
20. Dayna d R. Public heal h consequences o E-ciga e es: A consensus s udy epo
o he na ional academies o sciences, enginee ing, and medicine. J Pub Heal h Pol.
(2018) 39:379–81. doi: 10.1057/s41271-018-0132-1
21. Gale N, McEwan M, Eld idge AC, Fea on IM, She wood N, Bowen E, e al.
Changes in bioma ke s o exposu e on swi ching om a con en ional ciga e e o
obacco hea ing p oduc s: A andomized, con olled s udy in heal hy Japanese subjec s.
Nico ine obacco Res. (2019) 21:1220–7. doi: 10.1093/n /n y104
22. Ha mann-Boyce J, Lindson N, Bu le AR, McRobbie H, Bullen C, Begh R, e al.
Elec onic ciga e es o smoking cessa ion. Coch ane Da abase sys ema ic Re . (2022)
11:CD010216. doi: 10.1002/14651858.CD010216.pub7
23. Fage s öm K. Can al e na i e nico ine p oduc s pu he final nail in he smoking
co fin? Ha m educ ion J. (2022) 19:131. doi: 10.1186/s12954-022-00722-5
24. Bha JM, Ramphul M, Bush A. An upda e on con o e sies in E-ciga e es.
Pedia Respi Re . (2020) 36:75–86. doi: 10.1016/j.p .2020.09.003
25. Polosa R, Fa salinos K, P isco D. A double-edged swo d: E-ciga e es, and o he
elec onic nico ine deli e y sys ems (Ends): eply. In e nal Eme gency Med. (2020)
15:1119–21. doi: 10.1007/s11739-019-02228-8
26. Bal ou DJK, Benowi z NL, Colby SM, Ha sukami DK, Lando HA, Leischow SJ,
e al. Balancing conside a ion o he isks and benefi s o E-ciga e es. Am J Public
Heal h. (2021) 111:1661–72. doi: 10.2105/ajph.2021.306416
27. Gallus S, Bo oni E, Odone A, an den B and PA, Go ini G, Spizzichino L, e al.
The ole o no el (Tobacco) p oduc s on obacco con ol in I aly. In J En i on Res
Public Heal h. (2021) 18:1895. doi: 10.3390/ije ph18041895
28. Cohen JE, K ishnan-Sa in S, Eissenbe g T, Gould TJ, Be man ML, Bha naga A,
e al. Balancing isks and benefi s o E-ciga e es in he eal wo ld. Am J Public Heal h.
(2022) 112:e1–2. doi: 10.2105/ajph.2021.306607
29. Lugo A, Asciu o R, Pacifici R, Colombo P, La Vecchia C, Gallus S. Smoking in
I aly 2013-2014, wi h a ocus on he young. Tumo i. (2015) 101:529–34. doi: 10.5301/
j.5000311
30. Ri e A, Came on J. A e iew o he e ficacy and e ec i eness o ha m educ ion
s a egies o alcohol, obacco and illici d ugs. D ug Alcohol Re . (2006) 25:611–24.
doi: 10.1080/09595230600944529
Caponne o e al. 10.3389/ psy .2025.1349265
F on ie s in Psychia y on ie sin.o g09
