OPINION
, London
Vapes for smoking cessation and the antiseptic properties of iodine
Cite this as: BMJ 2024;384:q298
http://dx.doi.org/10.1136/bmj.q298
Published: 08 February 2024
and chlorhexidine
Tom Nolan reviews the latest research
Tom Nolan clinical editor; sessional GP, Surrey
Does a vape a day keep the cigarettes away?
When the infamous adverts suggesting that
e-cigarettes are “95% less harmful than cigarettes”
appeared in 2015, it seemed to knock the stuffing out
of smoking cessation services: why should soon to
be bankrupt councils pay GPs and pharmacists to
help people stop smoking when they could just buy
a vape instead? Since then vapes have become a
permanent presence in corner shops and school
classrooms. But, despite their success as consumer
products, vapes are still not licensed as smoking
cessation aids. A clinical trial in China randomised
people motivated to quit smoking to receive electronic
cigarettes, varenicline, or nicotine chewing gum for
12 weeks with minimal behavioural support.
E-cigarettes came out as non-inferior to
varenicline—around 15% remaining abstinent from
smoking after six months in these groups, compared
with only 8.8% in the gum chewers.
JAMA Intern Med doi:10.1001/jamaintern-
med.2023.7846
SGLT2 inhibitor study leaves no stone
unturned
Small studies of healthy volunteers given SGLT2
inhibitors have found that the drugs can increase the
excretion of citrate—like a kind of lemon squeezer
for the kidneys. This could, in theory, help to reduce
the risk of renal stones through citrate’s reported
anti-inflammatory effects, or by forming complexes
that help to mop up some calcium. A new cohort
study followed 716 406 people in the US with type 2
diabetes who were prescribed an SGLT2 inhibitor or
a GLP-1 receptor antagonist. After a median follow-up
of 192 days, rates of kidney stones were lower in those
who were prescribed an SGLT2 inhibitor than those
prescribed a GLP-1 receptor antagonist (14.9 v 21.3
events per 1000 person-years; hazard ratio 0.69 (95%
CI 0.67 to 0.72)).
JAMA Intern Med doi:10.1001/jamaintern-
med.2023.7660
Another kick in the loin for eGFR
Calculating estimated glomerular filtration rate
(eGFR) using a combination of creatinine and cystatin
c levels (eGFRcr-cys in biochemistry lingo) is far more
accurate than using creatinine-only based
calculations eGFRcr (you add “eatinine” to the cr,
not “ap”). As covered last year on this page, eGFRcr
can be way off the mark compared with gold standard
methods of assessing GFR. It gets dealt another blow
by a new population based cohort study comparing
the accuracy of eGFRcr and eGFRcr-cys at predicting
the bmj | BMJ 2024;384:q298 | doi: 10.1136/bmj.q298
BMJ: first published as 10.1136/bmj.q298 on 8 February 2024. Downloaded from http://www.bmj.com/ on 9 March 2024 by guest. Protected by copyright.
outcomes. Stronger associations were seen with
eGFRcr-cys across the board, including for mortality
and progression to renal replacement therapy. For
instance, higher rates of all-cause mortality were
found when comparing an eGFR of 60 versus 80
2
mL/min/1.73 m when using eGFRcr-cys (hazard ratio
1.2 (95% CI 1.1 to 1.3)) but not for eGFRcr (HR 1.0 (0.9
to 1.0)).
Ann Intern Med doi:10.7326/M23-1138
A spoonful of empathy to help the complaints
go down
Empathic statements delivered as a consultation trick
rather than from a genuine interest and connection
with your situation make me cross. It’s odd then, to
see a systematic review of randomised studies of
empathy interventions, which makes empathy sound
like something that can be boxed up and delivered
to patients. It concludes that “development, testing,
and reporting of high-quality studies within
well-defined contexts is needed to optimize empathy
interventions that increase patient satisfaction.” One
issue they found from the 14 randomised trials was
heterogeneity in how empathy was delivered—long
may that continue.
Ann Intern Med doi:10.7326/M23-2168
Iodine or chlorhexidine for preoperative
antisepsis?
In 1867 Joseph Lister published a series of articles in
the Lancet describing his success in reducing rates
of infection by using carbolic acid as an antiseptic.
In one case an open fracture wound was dressed daily
with pieces of lint dipped in carbolic acid. In another
Lister described his surgical methods after a 10 year
old boy crushed his arm in the machinery while
working in a factory: “I sawed off the protruding
portion of the ulna, and the tags of muscle having
been previously clipped away, I applied carbolic acid
freely to the whole interior wound…”
A recent cluster randomised crossover trial in the
New England Journal of Medicine has a lot in common
with Lister’s work—even if the writing is a little more
sanitised and the results less dramatic. The study
compared iodine with chlorhexidine for preoperative
antisepsis in people with closed and open fractures.
A small benefit from using iodine was seen in those
with closed fractures, amounting to one infection
prevented per 100 operations. For open fractures, the
authors found no significant difference in infection
rates between the two antiseptics.
N Engl J Med doi:10.1056/NEJMoa2307679
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 OPINION

Competing interests: None declared

Provenance and peer review: Not commissioned; not peer reviewed

BMJ: first published as 10.1136/bmj.q298 on 8 February 2024. Downloaded from http://www.bmj.com/ on 9 March 2024 by guest. Protected by copyright.

2 the bmj | BMJ 2024;384:q298 | doi: 10.1136/bmj.q298