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Abstract
Objective To identify effective policies and non-policy interventions preventing youth vaping behaviour initiation and assess their effectiveness by the level of intrusiveness and subpopulations.
Design This systematic rapid review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Data sources Searches on MEDLINE and APA-PsycINFO for studies published between January 2019 and November 2023.
Eligibility criteria Observational, intervention or mixed-method studies and quantitative systematic reviews/meta-analyses measuring the impact of interventions on youth (6–18 years) who never vaped or who had experimentally vaped.
Data extraction and synthesis A predesigned form was used to extract data. To classify interventions by levels of intrusiveness, we used the PLACE Research Lab Intervention Ladder Policy Analysis Framework. We applied PROGRESS-Plus (Place of residence, Race/ethnicity/culture/language, Occupation,Gender/sex, Religion, Education, Socioeconomic status, Social capital, and additional context-specific factors) for an equity analysis. Methodological quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool.
Results 20 studies were included: 45% were experiments or quasiexperiments, 85% reported data from the USA, 65% were non-policy interventions and 40% and 35% measured susceptibility and attitudes and behaviours related to vaping, respectively. Considering the level of intrusiveness, 45% of the studies provided information and 25% eliminated choices. Overall, the certainty of evidence was low. The effectiveness of interventions regarding their level of intrusiveness varied by each outcome. No clear pattern was found between the level of intrusiveness and intervention effectiveness, suggesting that overall, the studied interventions positively changed youth vaping behaviours. Some interventions had positive effects on multiple outcomes. Equity-related findings suggested that younger youth may be less responsive to the interventions. Recommendations for action are provided.
Conclusions We suggest that combining multiple interventions targeting different levels of intrusiveness and outcomes may be more effective in preventing youth vaping behaviours. Also important is to tailor programmes to younger youth to better meet their needs.
- Child
- Adolescents
- Primary Prevention
- Tobacco Use
- Health policy
- Schools
Data availability statement
Data are available on reasonable request. Data are available on reasonable request from the corresponding author.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This rapid review included both policy and non-policy interventions aimed at preventing vaping initiation among youth aged 6–18 years.
It analyses the effectiveness of interventions by their level of intrusiveness to individual autonomy and their equity focus and impacts.
Following the rapid review methodology, the search was restricted to only two databases and a 5-year period.
Analysis and comparisons were limited due to data heterogeneity.
Introduction
Youth vaping statistics in Canada are alarming. Data from a national, school-based survey from 2021 to 2022 report that almost one-third of grade 7–12 students have ever tried electronic cigarettes in Canada.1 In addition, 17% of grade 7–9 students have also experimented with vaping.1 2 Regular vaping with (48%) and without (21%) nicotine was perceived as being of great risk among grade 7–12 students.1
Health risks associated with vaping include pulmonary (eg, lung injury and bronchitis), cardiovascular (eg, high blood pressure and myocardial infarction)3–5 and periodontal, dental and gingival diseases.6 Ocular injuries (eg, corneal staining)7 and severe burns caused by device malfunctions8 have also been reported. Evidence also suggests that vaping may amplify mental health problems among youth.9–11 Due to their toxicity and dependence,11 vaping with nicotine or tetrahydrocannabinol has been associated with nicotine addiction, a higher risk of future cigarette smoking, increased cannabis use and problematic use of legal and illegal substances among older-aged youth.12 20% of Canadian students in grades 7–12 who vaped with nicotine in the last month reported they did so because they feel addicted to it.1
Given the rise of youth vaping and the harmful effects associated with the early onset of e-cigarette use10 in high-income countries, a number of policies and programmes have been introduced to curb vaping behaviours among the general population and youth specifically. Examples of such interventions include smoke-free public spaces; no display of vaping products in retail stores; no advertisement, promotion or sales of vaping products online; and awareness and education.13 Previous knowledge syntheses described the effectiveness of specific policies (eg, restrictions on vaping in public spaces)14 or in specific contexts (eg, the USA).15 A recent systematic review reported that regulatory strategies, such as flavour bans and taxation, were associated with positive changes in youth vaping in high-income countries.16
This rapid review adds to the growing literature on youth vaping by synthesising evidence on non-policy interventions (eg, including behavioural, educational or organisational programmes or initiatives) in addition to policies (as population-level interventions) and the inclusion of other primary outcomes beyond vaping among youth. Considering the variety of vaping prevention interventions (eg, from prohibiting access to raising awareness of health risks), there remains a knowledge gap in assessing intervention effectiveness in light of the level of restriction to public freedom each type of intervention imposes on the individual, as well as equity considerations. Therefore, the purpose of this rapid review was twofold: (1) to determine what policy and non-policy interventions were effective to prevent initiation of vaping behaviour among youth and (2) to examine their effectiveness by the level of intrusiveness and by population groups.
Methodology
This project was undertaken by researchers in the Centre for Healthy Communities (CHC) in partnership with Alberta Health Services (AHS; a provincial healthcare authority in Alberta, Canada). AHS was interested in identifying effective interventions to prevent vaping initiation among children and youth to inform their future interventions. CHC and AHS chose a rapid review methodology to systematically identify relevant recent studies in a timely manner to inform programme and policy-making. Rapid review methodology streamlines the systematic review process and engaging end-user decision-makers in the entire review process to provide results in a short timeframe while still rigorously synthesising evidence to support timely decision-making.17 We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.18 The protocol of this rapid review was not registered in any database. This rapid review did not involve patients or the public.
Search strategy
The search was structured around three main concepts: youth population, vaping and prevention. With the support of the project team, a research librarian designed the search strategy (which was independently peer reviewed by two health librarians) and conducted the searches. Literature searches were limited to the English language and for the period of January 2019–November 2023. Searches were completed in the following electronic databases: MEDLINE (via Ovid) and APA PsycINFO (via Ovid). Online supplemental table S1 provides the full search strategy used in both databases.
Supplemental material
Study selection
The study types eligible for inclusion were observational studies, intervention studies, mixed-method studies and quantitative systematic reviews/meta-analyses. The population of ‘youth’ was defined as people aged 6–18 years who never vaped or who had experimentally vaped. Vaping included any device with a power source and heating component used to inhale or exhale aerosolized nicotine, cannabis, flavoured water, liquids or chemicals; for example, vape pens, electronic nicotine delivery systems (ENDS).19 Preventive interventions measuring impact on youth vaping initiation or delay of experimentation through the following outcomes were included: youth attitudes, beliefs, knowledge and/or behaviours regarding the harms, risks and/or dependence on vaping; youth intentions or willingness to avoid experimenting or initiating vaping; or youth reactions or perceptions of the effectiveness of such interventions. Importantly, given that policies reach the entire population, the inclusion criterion for population related to vaping use was not applied. That is, studies reporting on policies may have provided combined results for users and non-users of vaping devices. The countries were limited to the Organization for Economic Co-operation and Development list and five selected United Nations developed economies. Online supplemental table S2 presents the inclusion and exclusion criteria.
Supplemental material
Screening was done through Covidence software.20 Two reviewers independently screened 10% of all included abstracts, resolving disagreements through discussion. When needed, another team member helped resolve disagreements. When 100% agreement was reached, the remaining set of the included abstracts were divided into two subsets. Each reviewer completed the screening of their subset. The same process was followed for screening of full‐text articles.
Data extraction and analysis
Two reviewers each extracted data from 50% of the included studies into a standardised data extraction form developed for this study (see online supplemental table S3 for the template used). Extracted data were verified by the second reviewer, checking for completeness and correctness. The data items included but were not limited to study design, country, duration of intervention, main outcome measures, other measures that may be relevant and outcome results. Disagreements were resolved through discussion between the two reviewers who met regularly during the data extraction process. When needed, another researcher met with the reviewers to help resolve disagreements. We conducted a qualitative synthesis of the included studies given their heterogeneity regarding study design, interventions and outcomes. In the qualitative synthesis process, periodic meetings with the team were held to discuss and compare the characteristics, measures and outcome results reported in the included studies. Some of the primary outcome measures were combined for more robust data interpretation.
Supplemental material
During the data extraction, the reviewers classified the interventions reported in the included studies according to their level of intrusiveness to individual autonomy. To do this, they applied the PLACE Research Lab Intervention Ladder Policy Analysis Framework,21 which is an adapted version of the Nuffield Council on Bioethics Intervention Ladder22 typology (eight levels) for population health interventions. The adapted version contains an additional level named reorient government action to include policy options that are more related to the way governments operate and, therefore, do not necessarily impact individuals’ autonomy. The nine levels move from low (ie, 1. reorient government action) to high levels of restriction on personal autonomy and public freedoms (ie, 9. eliminate choice). As each reviewer was responsible for 50% of the dataset for data extraction, the second reviewer verified the classification. Conflicts in the classification were resolved through discussions with the entire research team.
The focus and impacts of the interventions were examined through an equity lens. The reviewers used PROGRESS-Plus (Place of residence, Race/ethnicity/culture/language, Occupation,Gender/sex, Religion, Education, Socioeconomic status, Social capital, and additional context-specific factors)23 to identify social factors that may have been considered in the design of the intervention and social and health inequality findings that were reported by the source studies’ authors. Two reviewers independently assessed each included study for methodological limitations using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies.24 Reviewers resolved discrepancies through mutual discussion, and when required, another researcher helped to achieve consensus. Materials used in this review are available on reasonable request.
Patient and public involvement
None.
Results
The search identified 2089 studies. After removing duplicates, the titles and abstracts of 1729 studies were screened. Of 206 studies selected for full-text screening, 20 papers25–44 were included in this review (figure 1). Table 1 presents the main characteristics of the 20 included papers. Most studies used experimental and quasiexperimental designs (45%), were conducted in the USA (85%) and were non-policy interventions (65%). The most common primary outcomes studied were susceptibility to vaping (40%) and attitudes and behaviours related to vaping (35%). In the evaluation of the methodological limitations of the 20 included studies, four were rated as strong, five as moderate and 11 as weak. Regarding the intervention level of intrusiveness, interventions providing information (45%), eliminating choices (25%) and guiding choices by changing default policies (20%) were the most targeted. Online supplemental table S4 provides a detailed summary of each included study, reporting findings on outcomes of interest, levels of intrusiveness of the interventions and methodological quality. Online supplemental table S5 summarises the main characteristics of the interventions, including intervention details, who delivered it, how it was delivered, target population, data collection methods and duration of the intervention.
Supplemental material
Supplemental material
Summary of main characteristics of the 20 included papers
Preferred Reporting Items for Systematic Reviews and Meta-Analyses chart of the rapid review screening process.
Table 2 reports on the impact of the interventions among youth who have never used vaping products or devices or youth who have experimented with vaping (as defined by the source studies’ authors) by the type of policy. The positive symbol (+) indicates interventions that reported expected outcomes. For instance, the vaping prevention messages that public health organisations developed were associated with greater perceived message effectiveness among youth who had never used vaping products and devices (as expected by the source studies’ authors).35 The negative symbol (−) is used for those interventions that may have unexpectedly caused harm or had other unintended outcomes. An example is the exposure to health warning messages on cigarettes and ENDS,41 which was associated with higher ENDS initiation—a finding not expected by the source studies’ authors. The number zero (0) is applied for interventions that did not have any expected impact on the outcomes. This is exemplified in a study38 examining the introduction of excise tax on e-cigarette products that did not lead to a decrease in youth e-cigarette use over time. The analysis of findings in each column separately shows that with few exceptions (eg, household rules allowing the use of tobacco products inside the home were not effective in reducing ever-use and/or intention), most interventions had a positive impact on the specific studied outcomes.
Impact of policies and non-policy interventions on outcomes according to the level of intrusiveness*
Level of intrusiveness of the interventions
Table 3 summarises the overall effectiveness of combined policies and non-policy interventions on changing the studied outcomes under each level of intrusiveness.21 Interventions that eliminate choice effectively changed ever-use and/or initiation, susceptibility, beliefs and perceptions and attitudes and behaviours. Interventions that provide information were effective in changing all studied outcomes, except for ever-use and/or initiation for which findings were inconclusive. The interventions that guide choices by changing default policy overall showed positive impacts. For the enable choice level, the findings were mixed. For the levels of intrusiveness with only one study, those in the restrict choice and reorient government action levels were effective. The intervention that aligned with the guide choices through disincentives level was not effective. Finally, the study aligned with the do nothing or simply monitor the current situation level reported mixed findings for the two interventions analysed.
Summary of effectiveness of policies and non-policy interventions on outcomes, by the level of intrusiveness*†
Considering each outcome separately, for example, interventions that eliminate choice, restrict choice, guide choices by changing default policy, enable choice and reorient government action effectively changed youth ever-use and initiation. Positive changes in attitudes and behaviours were found in interventions that eliminate choice and provide information.
Equity-related findings
Only one study explicitly targeted a socially disadvantaged population group for participation in the intervention: Cartujano-Barrera et al’s study29 invited only black and Latino youth. Further, seven studies26 27 30 37 41–43 (of which two were studies reporting on policies)30 43 estimated the differential impacts of the interventions on specific subpopulations, defined by gender/sex, age, race/ethnicity and socioeconomic status (table 4).
Equity-related findings by social factors according to the PROGRESS-Plus
Findings were mixed on the effectiveness of interventions relative to youth’s biological sex27 41–43 and race/ethnicity.29 30 41–43 For instance, one study found an increase in intention to not use e-cigarettes in the future among female adolescents,42 while another recorded a higher initiation of e-cigarette use among female students after the interventions.27 Evidence suggested that younger youth may be less responsive to the vaping prevention interventions. The only study reporting on socioeconomic status did not find differences between groups regarding the impact of the policy on ever-use of e-cigarettes.
Discussion
This rapid review provided current evidence on effective policies and non-policy interventions to prevent youth vaping behaviours, taking into account the level of intrusiveness to individual autonomy and equity considerations. Given the multiple, complex factors behind the high prevalence of vaping among young adults (aged 18–24 years) including the co-use with cannabis and tobacco products and difficulties in quitting,45 curbing youth vaping initiation at earlier ages is critical.
A promising result from this review is that most interventions recorded positive changes in the primary outcomes studied. For instance, the reduction of ever-use and/or initiation was achieved through interventions such as comprehensive indoor air laws38 and peer-led prevention campaigns in school settings.28 Similarly, the review indicated the impacts of specific interventions on different outcomes. An example is educational presentations at school that positively changed susceptibility,32 beliefs and perceptions26 and knowledge.26 37 This disaggregated evidence may help policy-makers, public health professionals, school boards and other stakeholders to identify effective interventions that are aligned with the scope, mandate and resources of their organisation or government department.
There is no clear pattern that the more intrusive the interventions, the more effective they are. Overall, all nine levels of intrusiveness recorded interventions with a positive impact on at least one of the outcomes studied. The interventions that eliminate choice, which are the most intrusive, were effective in positively changing ever-use and/or initiation,38 susceptibility,34 beliefs and perceptions34 and attitudes and behaviours.34 Among the interventions that eliminate choice, we found that government policies banning the sale of vaping products and devices to youth younger than 21 years are shown to be overall effective in preventing youth vaping behaviour,25 30 38 which echoes findings from a previous systematic review.16 Likewise, policies that prohibit people from using vaping products and devices in public or specific private indoor (eg, hospitals, childcare facilities and workplaces) and outdoor spaces (eg, bicycle parks, playgrounds and parking areas within school properties) are effective in many ways.34 38 This is consistent with the literature indicating that these policies prevent youth from seeing others using vaping products and devices (which could otherwise contribute to the normalisation of vaping behaviour), reduce their exposure to e-cigarette secondhand aerosol and address their susceptibility to vaping in the future.13
The one study classified as guiding choices through disincentives found excise taxes had no impact on ever-use or initiation of vaping. This is different from other reviews that recorded a reduction in youth16 and adult46 vaping. Our findings suggest that excise taxes may need to be higher to increase prices enough to prevent youth from purchasing vaping products and devices. Although youth are price sensitive to vaping products and devices, it is currently unknown what level of e-cigarette tax rates can effectively reduce youth vaping initiation. Studies have advocated for federal regulations to better support statewide or province/territory-wide excise tax policies.13 46 A good example of this approach is from Canada. In 2022, the Canadian federal government introduced a vaping taxation framework and invited provinces and territories to combine the existing federal excise taxes on vaping products with additional provincial or territorial taxes to strengthen the ability to curb the increasing vaping rates.47 48 While most Canadian provinces have imposed additional taxes in the past 2 years, the impacts on youth vaping are still unknown. However, new evidence already suggests that this tax system may be undermined if a minimum price for nicotine is not implemented.49
Interventions providing information were also successful in all studied outcomes, equipping youth with knowledge, reducing their susceptibility and changing their beliefs and perceptions and attitudes and behaviours towards the health harms and social acceptability of vaping. However, their impact on reducing ever-use and/or initiation is inconclusive, suggesting that such interventions may fail to curb youth vaping ever-use and initiation. Coordinated efforts are required to help well-informed youth navigate peer pressures and social influences (eg, competitions for vaping trick performance and the creation of a collective social vaping identity)13 50 and ultimately not use vaping devices and products.
With respect to equity-related findings, our review suggested that younger youth may not respond as expected to interventions. Given evidence showing early onset of vaping,51 educational interventions should be age-appropriately tailored to younger youth to address positive attitudes towards vaping as well as poor knowledge and misperceptions of low risks of vaping, while not increasing children’s curiosity about and intention to experiment with vaping. Stricter regulations to eliminate unnecessary exposure to vaping in public spaces and marketing strategies that disguise the design of vaping products and devices and create social media advertising campaigns for children are urgently needed.13 52
Recommendations for action
Based on the evidence gathered and assessed in the rapid review and considering health promotion principles and the current public debate and policy landscape on vaping, table 5 summarises key recommendations to support policy-makers, public health researchers, school administrators and health practitioners to develop and implement their own interventions and advocate for change. While recommendations are presented by the level of intrusiveness, a comprehensive multilevel approach would be most effective in reaching a wider group of youth. Integrating multiple strategies into a more holistic approach may be more successful for tackling different but interrelated factors (eg, exposure to vaping in public spaces and access to health warning messages) that contribute to youth vaping behaviours. For instance, better results may be achieved if schools implement a combined set of strategies: in addition to smoke-free policies on the school grounds (eliminate choice), vaping prevention programmes delivered by students themselves or in partnership with health services can provide students with skills (enable choice) and knowledge (provide information) to make informed decisions on vaping; together, these may be more effective for curbing youth vaping initiation. While the elimination of choices deters vaping on school grounds, the strategies that enable choice and provide information equip the students to navigate through other settings and contexts where vaping is also present (eg, recreational facilities, shopping malls and social media).
Recommendations based on the literature review findings
Strengths and limitations
This rapid review represents one of the first literature reviews identifying both effective policy and non-policy interventions to prevent the initiation of vaping behaviour among youth (aged 6–18 years) who have never used vaping devices or who have experimentally vaped. To the best of our knowledge, this review is also innovative for analysing the interventions in light of their levels of intrusiveness. Consistent with the quick and practice-focused nature of rapid reviews,17 the search was limited to two databases and used a 5-year date limiter (2019–2023). However, the search strategy was comprehensive, using language related to only three broad concepts (age, vaping and prevention) to be more inclusive and capture a large number of studies. The date restriction was deemed appropriate to address the research question based on the rapidly evolving field of youth vaping. Notably, most of the included studies, while targeting youth in general, collected data on vaping behaviours and provided disaggregated findings for the population of interest. Given that policies are applied to the population in general, studies reporting on policies were included, which is a strength of this rapid review.
Only a very few systematic reviews or meta-analyses were found,53 which is indicative of the incipient, but growing, literature reporting separate findings for youth who have never vaped or who have experimentally vaped. Due to the heterogeneity of study designs and measures used in the included studies, analysis and comparisons were limited. This precluded us from performing a meta-analysis and creating a forest plot to summarise the effect sizes. Country-specific contextual factors should be considered when examining the review findings, as 85% of the included studies were conducted in the USA. The robustness of the findings is difficult to determine, given that 55% of the included studies were rated as being of weak methodological quality. With the low internal validity, the effectiveness of the interventions as reported by the included studies may have been overestimated. None of the included studies’ interventions were classified under the guide choices through incentives level. Caution is needed in the interpretation of findings related to the outcomes and to the levels of intrusiveness of interventions when there was only one study. For example, comparisons of the effectiveness for the restrict choice, guide choices through disincentives and reorient government action levels were not possible, given that only one study was listed under each of those levels. Due to the nature and scope of most non-policy interventions reported in the included studies, they only measured short-term effects.
While all included studies collected demographics before the intervention, most of them used statistical techniques to create models adjusting for demographic variables. This resulted in few included studies providing the differential impacts of the interventions on diverse population groups. In particular, measuring how children from different socioeconomic backgrounds responded to the interventions was rarely reported. Missing from the included studies were the focus and analysis of other important social factors that may influence the effectiveness of preventive interventions on youth vaping behaviours, such as gender (ie, sociocultural attributes to sex), place of residence (urban–rural spectrum) and religion.
Finally, the use of the PLACE Research Lab Intervention Ladder Policy Analysis Framework21 was a strength, as it allowed for a contextually sensitive interpretation of the effectiveness of interventions. From a population health perspective, this is particularly critical for intervention design and planning, as some interventions may reduce personal autonomy while seeking to achieve collective benefits.
Conclusions
This rapid review identified and assessed what interventions (as reported in the literature) are effective to prevent initiation of vaping behaviour among youth aged 6–18 years. Overall, a range of interventions at different levels of intrusiveness and targeting varied outcomes showed promising results. While an intervention may promote positive changes, combining multiple interventions for different outcomes (eg, beliefs and susceptibility) from different levels of intrusiveness (eg, eliminate choice and provide information) may be most effective for encompassing a myriad of interrelated factors that contribute to youth vaping (eg, price, desirability, access, exposure and misperceptions), as observed elsewhere with a young adult population.45 Adoption of simultaneous, varied types of interventions may be key in preventing youth vaping behaviours when other interventions may start to fail or their implementation is inconsistent (eg, non-compliance by retailers on age restrictions for purchasing vaping products and devices). Future research is needed to determine ease of replication, transferability and scalability of the interventions to different contexts. Research on preventive interventions should aim to measure the medium and long-term effects of policies and non-policy interventions, their cost-effectiveness, as well as their differential impacts on disadvantaged subpopulations (eg, socioeconomic groups) to support decision-makers to adopt the intervention(s) that can better respond to their contextual needs.
Data availability statement
Data are available on reasonable request. Data are available on reasonable request from the corresponding author.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
We are thankful for the support that Bernice Lee (Research Assistant, Centre for Healthy Communities) provided during the study screening and quality appraisal stages. We also thank the Research Librarian (Centre for Healthy Communities) for developing the search strategy and supporting the development of appendices.
References
Footnotes
X @nykiforuk_c
Contributors TA and MW conceived the review idea. All authors contributed to the design of the study. AB screened the papers and performed quality assessment. AB and LN extracted and synthesised the data. CIJN supervised the study. AB drafted the first and final version of the manuscript. All authors critically revised the manuscript for important intellectual content and approved its final version. CIJN serves as guarantor and accepts full responsibility for the work.
Funding This rapid review was funded by Alberta Health Services. Provision of funding by Alberta Health Services does not signify that this project represents the policies or views of Alberta Health Services. CIJN received support from the Canada Research Chairs Program (Grant ID: CRC-2021-00450).
Disclaimer The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.