Discussing the Sexual Health Impacts of Electronic Cigarette Use with Youth: A Proposed Framework to Support Urologists

: The sexual health of young people during the youth age period is of utmost importance, as it sets the stage for sexual well-being over the life course. In addition to the existing challenges that youth face concerning their sexual health, electronic cigarettes may also negatively impact their sexual well-being. Speciﬁcally, through issues such as stuttering priapism, reduced sperm quality and quantity, and erectile dysfunction. Electronic cigarette use among youth is prevalent. Therefore, given the negative sexual health impacts associated with electronic cigarette use, coupled with the prevalent use of electronic cigarettes, it is necessary for youth to receive adequate support and guidance, so they understand the potential impacts that electronic cigarette use can have on their sexual well-being. Urologists are uniquely situated to play an important role in supporting the sexual health of youth, given their medical and surgical knowledge, however, it appears that they do not receive adequate training to carry out discussions about sexual health with youth. This paper aims to support urologists to have discussions with youth patients on the impact that electronic cigarettes have on their sexual health through a proposed four-step framework. This four-step framework involves: (i) establishing the relationship, (ii) assessing current electronic cigarette use, (iii) sharing research examining the impact of electronic cigarettes on sexual health, and (iv) discussing strategies to prevent/reduce or stop electronic cigarette use. It is necessary to acknowledge that this framework is only a small component of efforts to educate youth on the impacts that electronic cigarettes have on their sexual health. Moving forward, implementation and evaluation of this framework is needed.


Introduction
Electronic cigarette (e-cig) use is quite common among youth.This paper conceptualizes the youth and young people age period from the ages of 15 to 24.In 2022, data from the National Youth Tobacco Survey (NYTS) [1] on e-cig use among youth in the United States found that over 2.5 million youth in high and middle schools currently use e-cigs [1].Moreover, over a quarter of youth e-cig users in the United States (27.6%) reported using e-cigs daily [1].In Canada, 21% of youth aged 15-17 reported the use of e-cigs in the last 30 days [2].Considering the global context, Sreeramareddy et al.'s [3] study assessing e-cig use in 75 countries found that current e-cig use among youth varied greatly; in fact, e-cig use ranged from 1.2% in Togo all the way up to 35.1% in Guam.Therefore, considering the notable number of youth who use e-cigs, it is necessary that they are made aware of the risks e-cig use can carry for their sexual health.
Recent research highlights that e-cig use may have a negative impact on sexual health, namely, that e-cigs can have a negative impact on the genitourinary system [4][5][6][7][8][9].Alzahrani et al. [4] found that e-cig use was associated with stuttering priapism, which are episodes that involve repetitive prolonged erections.Specifically, the underlying mechanism is believed to be that e-cigs are able to generate reactive oxygen species (ROS), which then leads to damage to endothelial smooth muscle and unbalanced nitric oxide (NO) synthesis [4].Fertility may also be affected by e-cig use.It was reported that e-cig users have relatively low sperm counts compared to non-e-cig users (147 million vs. 91 million) [6].O'Neill et al. [7] found that e-cigs may negatively affect sperm motility and progression.A literature review by Pincus et al. [8] suggests that e-cig use may cause erectile dysfunction.Additionally, Szumilas et al.'s [9] systematic review highlights that research examining the impact of e-cigs on the female reproductive system is limited.However, studies using animal models suggest that e-cigs can harm the sexual health of females [9].
Sexual health is important for the well-being of youth.A key component of the definition of sexual health provided by the World Health Organization (WHO) [10] is: "a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity" [10].Moreover, sexual health is a broad concept that must be considered within a holistic framework.Good sexual health during adolescence has been positively related to lower rates of substance use challenges and depression [11].
Unfortunately, young people are at a high risk of contracting sexually transmitted infections, especially youth who identify as transgender [12].Moreover, for males and females in the youth age group, the rates of chlamydia, gonorrhea, and syphilis have been increasing [12].Also, youth are implicated in nearly one in every five new HIV diagnoses [12].Compounding this issue, young people may not want to access support resources for a variety of reasons [13].Additionally, in certain community contexts, appropriate resources may be unavailable for young people to access [13].This highlights the importance of supporting youth with their sexual health.Health care professionals play an important role as a support resource for youth to discuss sexual health concerns.
It is clear that discussing sexual health can be quite difficult and challenging for health care professionals [14].This is especially important because of the sensitive nature pertaining to discussions on sexual health [15], highlighting that youth may have mixed feelings on whether or not to trust physicians and other health care professionals.Key factors to develop trust include keeping patient confidentiality, being non-judgemental and providing clinically competent care [15].On the other hand, factors that contribute to mistrust include a lack of a patient-provider relationship, apprehension related to uncertainty, inadequate communication, and perceived feelings of dishonest communication [15].In today's world, it is important to acknowledge that health information is often discussed and disseminated on social media platforms [16].
Given their medical and surgical expertise, urologists play a very important role in supporting overall sexual health and wellbeing [17].As a result of urologists' specialized sexual health knowledge, youth may be more inclined to see urologists for their sexual health needs.Thus, urologists are likely among the best equipped to have discussions surrounding sexual health with youth.Urologists may see youth for a wide variety of health concerns, including, but not limited to, kidney, bladder, sexual, and fertility dysfunction [18].Moreover, some youth with complex genitourinary disease require life-long follow-up with their urologist [18].Also, some youth with chronic conditions and disabilities such as spinal abnormalities, congenital lower urinary tract abnormalities including hypospadias are seen regularly by a urologist.This could be as often as every six months.It is necessary to acknowledge that someone who is assigned female at birth is more likely to seek sexual and reproductive health care from an obstetrician-gynecologist.
Along with sexual health, urologists have been instrumental in discussing smoking with patients.Bassett et al. [19] highlight that ex-smokers who recently quit cite the advice provided by their urologist twice as often as their primary care provider's advice.Moreover, Basset et al. [19] showcase the valuable role that urologists play as diagnosticians and smoking educators, as they are able to connect a diagnosis, for example bladder cancer, to smoking.This can allow for patients to reflect on how smoking behaviour can be associated with negative health outcomes.Bjurlin et al. [20] studied the effectiveness of a urologist-led brief smoking cessation intervention.It was found that the patients who received the intervention through urologists were 2.31 times more likely to quit smoking, compared to patients who did not receive this intervention [20].Further, a study by Matulewic et al. [21] explains that a brief consultation on quitting smoking with a urologist, as compared to a primary care physician, increases the chances of quitting four-fold.Another reason for the potential success of involving urologists in these discussions is that youth may believe that the sexual health issues they are experiencing are embarrassing.However, given urologists' scope of practice, having sexual health discussions with urologists may seem less taboo for youth.Also, considering other e-cig-related genitourinary health implications, urologists can play a role in discussing the risks of bladder cancer associated with e-cig use [22].
However, it appears that urologists may not have enough training to discuss sexual health with their youth patients [17].Tsmimtsiou et al. [23] conclude that a urologist's communication role is very important in discussing sexual history and ensuring patient comfort.To enhance communication skills, Tsmimtsiou et al. [23] suggest that enrolling urologists in courses related to sexual health discussion and psychosocial orientation can help them to provide a safe environment for patients to discuss sensitive topics.According to Streur et al. [17], urologists can view sexual health discussions with youth as continuous education starting from early adolescence and gradually progressing throughout the adolescent years.Specifically, the plan may consist of establishing a long-term relationship through meaningful visits and making youth aware of the various ways urologists can support their health and well-being [17].Further, youth can be educated and prepared by their urologist during encounters about the upcoming changes in their sexual health occurring during puberty [17].Urologists may be able to bridge the important topics to communicate about the risks of e-cigarette use to sexual health among youth, however, a framework must be established.
In view of these facts, this paper aims to assist urologists when discussing the impact that e-cigs use have on the sexual health of youth through a communication framework.Specifically, this four-step framework will combine research data on e-cig use with evidence-based strategies that youth find helpful when they have a trusting relationship with a physician.

Communication Framework
The four-step communication framework was built using findings from Miller et al. [15], specifically considering factors that contribute to and detract from a trusting relationship between youth and health care professionals.The framework involves establishing a relationship, assessing current e-cig use, sharing data on the impacts that e-cigs have on sexual health, and discussing strategies to prevent e-cig use.This four-step framework is depicted in Figure 1.

Step 1: Establishing the Relationship
Given issues pertaining to trust with health care professionals [15] and a great deal of misinformation on e-cigs on social media [16], youth may be presenting to urologists with preconceived thoughts on the impact that e-cigs have on well-being.For example, information promoting false health benefits associated with e-cig use is often disseminated on social media platforms [16].Therefore, it is necessary for efforts to be made to

Step 1: Establishing the Relationship
Given issues pertaining to trust with health care professionals [15] and a great deal of misinformation on e-cigs on social media [16], youth may be presenting to urologists with preconceived thoughts on the impact that e-cigs have on well-being.For example, information promoting false health benefits associated with e-cig use is often disseminated on social media platforms [16].Therefore, it is necessary for efforts to be made to establish a safe and trusting relationship with youth from the onset, especially considering the sensitive nature of sexual health discussions.Oftentimes youth are accompanied to medical appointments by their parents or caregivers, and they may not be comfortable sharing in front of them.Youth, their caregivers, and urologists could have upfront and open conversations on the importance of ensuring that youth have alone time with their urologist.Also, it is necessary to establish a teen-friendly place where youth feel safe, comfortable, and unburdened to share what they need to with their clinician without any hesitation [24].For example, a child-friendly space for adolescents can involve having a non-intimidating waiting area, such as a space with brightly coloured walls, art supplies, novels, and space for play [24].In addition, combining a friendly environment with rewarding youth for every visit, urologists can help keep youth engaged in regular visits [24].These rewards aim to provide youth with short-term incentives to help mitigate the long-term risk of e-cig use.Rewards can be delivered in various ways, such as by providing engaging content, delving into interactive discussions, or listening to youth's personal stories.During the discussions that urologists have with youth, urologists should remind youth about confidentiality in the patient-clinician relationship and limitations to confidentiality, so youth feel able to openly share.Some of the limitations that can result in confidentiality being broken include reporting abuse of a child and thoughts of homicide or suicide.Beyond the discussions on confidentiality that urologists have with youth, it is of utmost importance that urologists and their office staff aim to provide the highest level of confidentiality, so that they avoid an unnecessary confidentiality breach, which can have devastating consequences on the youthurologist relationship.Moreover, breaches in confidentiality could have long-term impacts over the life course on the trust that youth have with health care professionals.Following this, urologists should take a patient-centered approach and ask their youth patients what brings them in.This may support youth to genuinely share their concerns and feel like they have adequate space to communicate.Fear and embarrassment for youth can make it challenging to discuss taboo topics such as sex and the use of substances [25].Furthermore, it has been explored that communication can be strengthened through establishing regular trust, emotional screening, humanistic engagement, and open-ended communication [25].Urologists can establish regular screening by making space and reassuring youth that they can be seen whenever urological issues arise or if they ever have any questions about their sexual health and well-being.

Step 2: Assessing Current E-Cig Use
As part of understanding the social history of youth patients, initiating screening on e-cig use, and engaging in open-ended communication, urologists can make it a point to ask directly about e-cig use.Specifically, Table 1 highlights screening questions that may be helpful to ask youth and outlines a rationale for the reasoning behind each question.
Through asking these questions urologists can begin to understand the context surrounding youth e-cig use.Moreover, understanding the extent to which e-cig use is intertwined with a young person's life can help set the stage to provide clinically competent, individualized care and can promote honest two-way communication.Moreover, some youth may be concerned about disclosing e-cig use because of the potential illegality associated with the behaviour.Once again, it is essential for urologists to reassure youth about confidentiality in the youth-urologist relationship and that simply disclosing e-cig use is not automatically going to result in confidentiality being broken.For example, by asking youth where they use e-cigs and whom they use e-cigs with, urologists can begin to appreciate the complex environmental and social relationships that can influence e-cig use.Social environments play an important role in smoking prevention for young people [26].For example, being friends with someone who smokes or occupying the same space-such as a room or car-as someone who smokes are social environment factors that may con-tribute to smoking behaviours.Therefore, by having a strong understanding of the social environment that youth are immersed in, urologists can have a more holistic picture when discussing smoking prevention options and strategies that are individualized and tailored to meet the needs of youth.Moreover, by appreciating the social environment that youth interact with, urologists can explore various options, such as avoiding specific triggers or seeking smokeless environments, that may help youth achieve e-cig cessation.Through asking these questions urologists can begin to understand the context surrounding youth e-cig use.Moreover, understanding the extent to which e-cig use is intertwined with a young person's life can help set the stage to provide clinically competent, individualized care and can promote honest two-way communication.Moreover, some youth may be concerned about disclosing e-cig use because of the potential illegality associated with the behaviour.again, it is essential for urologists to reassure youth about confidentiality in the youth-urologist relationship and that simply disclosing e-cig use is not automatically going to result in confidentiality being broken.For example, by asking youth where they use e-cigs and whom they use e-cigs with, urologists can begin to appreciate the complex environmental and social relationships that can influence e-cig use.Social environments play an important role in smoking prevention for young people [26].For example, being friends with someone who smokes or occupying the same space-such as a room or car-as someone who smokes are social environment factors that may contribute to smoking behaviours.Therefore, by having a strong understanding of the social environment that youth are immersed in, urologists can have a more holistic picture when discussing smoking prevention options and strategies that are individualized and tailored to meet the needs of youth.Moreover, by appreciating the social environment that youth interact with, urologists can explore various options, such as avoiding specific triggers or seeking smokeless environments, that may help youth achieve e-cig cessation.
Table 1.Pertinent screening questions to ask youth and the rationale behind these questions.

Screening Questions Question Rationale
Have After understanding current levels of e-cig use, urologists may ask youth about their perceptions of the impact that e-cigs have on sexual health.By creating space for youth to share their perspectives on how e-cigs can impact sexual help, urologists can make note of any misinformation that may need to be corrected, so that patients are aware of evidence-based information.
Following this, urologists can begin to share data from the literature with youth.It is worthwhile to share data on the sexual health impacts that e-cigs have with youth who do not currently use e-cigs, in an effort to dissuade future e-cig use because of the potential sexual health implications of them.Knowledge should be shared in a way that youth patients can understand and time should be taken to answer any questions that youth might have.By answering questions as they arise, it may be possible to reduce feelings of uncertainty that youth might have when leaving the encounter.Urologists should go over the importance of sexual health during the youth age period and its role in setting the stage for sexual health over the life course, and then dive into data from the literature.For example, urologists can define stuttering priapism and highlight that it was found to be associated with e-cig use [4].Following this, it is discussing that e-cig use is associated with lower sperm count [6], lower sperm concentration [7], lower sperm movement [7], and erectile dysfunction [8].It is necessary to acknowledge that the longterm impacts of e-cig use on sexual health are still unknown, therefore, it is possible that e-cig use can impact sexual development in the present and fertility over the life course.

Step 4: Discussing Strategies to Prevent/Reduce or Stop E-Cig Use
Finally, it is necessary to discuss strategies to either prevent or reduce e-cig use.For youth that do not currently use e-cigs, urologists can reiterate the importance of not using e-cigs and continue to encourage avoiding the use of e-cigs.While for those that use e-cigs, urologists can explore options to reduce or stop e-cig use.For example, they can ask youth directly about thoughts of quitting or reducing e-cig use.Additionally, it can be helpful to probe and see what specific resources or tools youth may find helpful to reduce e-cig use.Hieftje et al. [27] conducted a quasi-experimental study using a video game-based approach, SmokeScreen, to implement good habits and improve knowledge of the adverse outcomes of e-cig use in youth.Evaluation of this intervention showed that 76.4% of youth learned something new from playing this game.A randomized control trial (RCT) by Graham et al. [28] proposed a text message-based method to help youth quit e-cig use where participants received assessment at one and seven months, respectively.In addition, the intervention group received material on coping support and help to improve behavioral and cognitive skills.The results signified that the program had a success rate of 24.1% among youth who intended to quit smoking e-cigs.
Urologists may consider integrating these different programs as part of the support they provide youth for the cessation of e-cig use.Further, an RCT by Stead et al. [29] concluded that brief advice from a medical expert can result in an increase in the smoking cessation rate by 3%.In addition, regular follow-up has been deemed to increase the quitting rate [29].Overall, in order to launch a successful smoking cessation intervention in the clinical setting, factors such as taking a patient-centered urologist approach, healthy interactions, revising health system resources, and overcoming barriers in the process play a very significant role in bringing about improvement in urological health and coping with smoking cessation.
Ultimately, the discussion of strategies should be individually tailored to best meet the needs of specific youth patients.Through establishing a strong relationship from the onset, urologists may be able to better understand the unique needs of their patients and therefore suggest appropriate strategies that may help them reduce their e-cig use and the potential impact on their sexual health.Some patients may prefer accessing support from multiple platforms and others may choose to receive support from a single source.Therefore, it is necessary to provide youth with tailored support based on their identified preferences.Further, a patient's preference may change over time and urologists should take the opportunity when checking in with patients at subsequent follow-up appointments about the feedback they have on strategies they use and their current amount (if any) of e-cig use.

Limitations of This Framework
It is important to acknowledge that this framework has yet to be implemented or evaluated in the clinical practice of urologists.Thus, in the future, evaluating the effectiveness of this proposed communication framework through a quasi-experimental study, including a control and experimental group, with a pre-test and post-test component can allow us to observe the effectiveness of the framework.Moreover, this future research can provide short-term and long-term impacts following the clinical implementation of this framework.Also, it should be noted that evidence of the impact that e-cig use has on sexual health is still emerging, therefore, we do not know the full extent of how e-cig use impacts sexual health.Thus, it is necessary to share this with youth patients, so they recognize we are sharing the extent of data we currently have available.Further, communication on the risks associated with e-cig use should be multi-faceted and other community members, such as policymakers, educators, collaborating health care professionals, and family members also play an important role in risk communication [30].

Conclusions
conclusion, the sexual health of youth is important to their current well-being and development over their life course.There is a considerable number of youth who use e-cigs.Recent research highlights that e-cig use may have a very high negative impact on sexual health.While there may be some challenges related to training and resources, it remains evident that the urologists play a key role in sexual health discussions with youth by creating a friendly and comfortable environment.Recognizing the significance of these conversations, efforts should be made to enhance urologists' training and resources, enabling them to effectively contribute to the sexual health and well-being of their young patients.This paper outlines a four-step communication framework for urologists to discuss the impacts that e-cig use may have on the sexual health of youth.Implementation using short-term and long-term evaluation of this framework is needed to assess its efficacy.Additionally, there is a need to evaluate various interventions that may be useful for urologists to prescribe to their youth patients to achieve the cessation of e-cig use.
you used e-cigs or vaping products?To appreciate if the patient has a history of e-cig use Do you currently use e-cigs or vaping products?To understand if the patient is actively using e-cigs How often do you use e-cigs?To establish the frequency of e-cig use When did you first start using e-cigs?To appreciate the time period of e-cig use Do you use other substances when you use e-cigs?To assess if patients are using other substances in combination with e-cigs, for example, Tetrahydrocannabinol (THC) oil Where do you use e-cigs?To contextualize the environment where e-cig use is occurring Who do you use e-cigs with?To understand the social relationships that are involved with e-cig use Why did you start using e-cigs?To appreciate the underlying reason behind e-cig use 2.3.Step 3: Sharing Research Examining the Impact of E-Cig on Sexual Health