Do you vape? Leveraging electronic health records to assess clinician documentation of electronic nicotine delivery system use among adolescents and adults

Current thinking about the effects of e-cigarettes on oral cancer risk

In the last decade there has been a significant increase in the appeal and popularity of e-cigarettes. Recent national news headlines outline that one million smokers will be given a free vaping starter kit to encourage them to give up tobacco products. An independent report commissioned by the UK Government has cited promotion of vaping as a critical recommendation to ensuring England is smoke-free by 2030. Undoubtedly, the dental team will now encounter many more questions from patients keen to know more regarding the safety of electronic nicotine delivery systems and their effects on the oral cavity. However, it is often difficult to answer these questions due to a lack of evidence regarding their impact. Although there are some preliminary animal and in vitro data, additional well-designed, long-term studies are required to investigate oral health outcomes of e-cigarette use.We aim to summarise the latest evidence to better inform clinicians about the effects of vaping on oral health, particularly regarding the risks of oral cancer, so they can better inform their patients.

How is nicotine vaping product (e-cigarette) use monitored in primary care electronic health records in the United Kingdom? An exploratory analysis of Clinical Practice Research Datalink (CPRD)

BACKGROUND

Electronic health records (EHRs) could identify long-term health effects of nicotine vaping. We characterised the extent to which vaping is recorded in primary care EHRs in the UK, on a population level.

METHODS

We performed descriptive analysis of Clinical Practice Research Datalink (CPRD), primary care electronic health records of 25% of the UK population (~ 16 million patients). Patients aged ≥ 18 years whose vaping status was recorded using medical codes between 2006 and 2022 were identified. We reported the frequency of vaping codes; their distribution by patient age, gender, and ethnicity; trends in vaping recording over time (including interrupted time series analyses); and transitions in patient smoking status.

RESULTS

Seven medical codes indicated current or former vaping, from 150,114 patients. When their vaping status was first recorded, mean patient age was 50.2 years (standard deviation: 15.0), 52.4% were female, and 82.1% were White. Of those recorded as currently vaping, almost all (98.9%) had records of their prior smoking status: 55.0% had been smoking, 38.3% had stopped smoking, 5.6% had never smoked. Of those who were smoking prior to being recorded as vaping, more than a year after the vaping record, over a third (34.2%) were still smoking, under a quarter (23.7%) quit smoking, 1.7% received a 'never smoked' status, and there was no smoking status for 40.4%. The 'e-cigarette or vaping product use-associated lung injury' (EVALI) outbreak was significantly associated with a declining trend in new records of current vaping between September 2019 and March 2020; and an immediate significant increase in new records of former vaping, followed by a declining trend.

CONCLUSIONS

Few patients are being asked about vaping. Most who vape had smoked, and many quit smoking after starting vaping. To enable electronic health records to provide stronger evidence on health effects, we recommend improved completeness, accuracy and consistency.

E-Cigarette Screening in Primary Care

INTRODUCTION

Primary care visits present an opportune time to assess behaviors that contribute to patient health. Smoking, alcohol use, and illicit drugs are routinely documented in electronic health records, but less is known about screening for E-cigarette use and the prevalence of E-cigarette use in primary care settings.

METHODS

Data include 134,931 adult patients who visited 1 of 41 primary care clinics within a 12-month period (June 1, 2021-June 1, 2022). Data on demographics, combustible tobacco, alcohol, illicit drug, and E-cigarette use were extracted from electronic medical records. Logistic regression was utilized to examine the variables associated with differential odds of being screened for E-cigarette use.

RESULTS

Rates of E-cigarette screening (n=46,997; 34.8%) were significantly lower than that of tobacco (n=134,196; 99.5%), alcohol (n=129,766; 96.2%), and illicit drug (n=129,766; 92.6%) use. Of those assessed for E-cigarette use, 3.6% (n=1,669) reported current use. Of those with documented nicotine use (n=7,032), 17.2% (n=1,207) used mono E-cigarettes exclusively, 76.3% (n=5,364) used combustible tobacco exclusively, and 6.6% (n=461) reported dual use (both E-cigarette use and combustible tobacco use). Those who used combustible tobacco or illicit substances as well as younger patients were more likely to have been screened for E-cigarette use.

CONCLUSIONS

Overall rates of E-cigarette screening were significantly lower than those of other substances. The use of combustible tobacco or illicit substances was associated with an increased likelihood of being screened. This finding may be because of the relatively recent proliferation of E-cigarettes, the recent addition of E-cigarette documentation to the electronic health record, or a lack of training on screening for E-cigarette use.

Understanding the habenula: A major node in circuits regulating emotion and motivation

Over the last decade, the understanding of the habenula has rapidly advanced from being an understudied brain area with the Latin name 'habena" meaning "little rein", to being considered a "major rein" in the control of key monoaminergic brain centers. This ancient brain structure is a strategic node in the information flow from fronto-limbic brain areas to brainstem nuclei. As such, it plays a crucial role in regulating emotional, motivational, and cognitive behaviors and has been implicated in several neuropsychiatric disorders, including depression and addiction. This review will summarize recent findings on the medial (MHb) and lateral (LHb) habenula, their topographical projections, cell types, and functions. Additionally, we will discuss contemporary efforts that have uncovered novel molecular pathways and synaptic mechanisms with a focus on MHb-Interpeduncular nucleus (IPN) synapses. Finally, we will explore the potential interplay between the habenula's cholinergic and non-cholinergic components in coordinating related emotional and motivational behaviors, raising the possibility that these two pathways work together to provide balanced roles in reward prediction and aversion, rather than functioning independently.

Anesthesiologists and the Other Pandemic: Tobacco Use

Tobacco use will kill a projected 1 billion people in the 21st century in one of the deadliest pandemics in history. Tobacco use disorder is a disease with a natural history, pathophysiology, and effective treatment options. Anesthesiologists can play a unique role in fighting this pandemic, providing both immediate (reduction in perioperative risk) and long-term (reduction in tobacco-related diseases) benefits to their patients who are its victims. Receiving surgery is one of the most powerful stimuli to quit tobacco. Tobacco treatments that combine counseling and pharmacotherapy (e.g., nicotine replacement therapy) can further increase quit rates and reduce risk of morbidity such as pulmonary and wound-related complications. The perioperative setting provides a great opportunity to implement multimodal perianesthesia tobacco treatment, which combines multiple evidence-based tactics to implement the four core components of consistent ascertainment and documentation of tobacco use, advice to quit, access to pharmacotherapy, and referral to counseling resources.

Impact of vaping on respiratory health

Widespread uptake of vaping has signaled a sea change in the future of nicotine consumption. Vaping has grown in popularity over the past decade, in part propelled by innovations in vape pen design and nicotine flavoring. Teens and young adults have seen the biggest uptake in use of vape pens, which have superseded conventional cigarettes as the preferred modality of nicotine consumption. Relatively little is known, however, about the potential effects of chronic vaping on the respiratory system. Further, the role of vaping as a tool of smoking cessation and tobacco harm reduction remains controversial. The 2019 E-cigarette or Vaping Use-Associated Lung Injury (EVALI) outbreak highlighted the potential harms of vaping, and the consequences of long term use remain unknown. Here, we review the growing body of literature investigating the impacts of vaping on respiratory health. We review the clinical manifestations of vaping related lung injury, including the EVALI outbreak, as well as the effects of chronic vaping on respiratory health and covid-19 outcomes. We conclude that vaping is not without risk, and that further investigation is required to establish clear public policy guidance and regulation.

Prevalence of Sensitive Terms in Clinical Notes Using Natural Language Processing Techniques: Observational Study

BACKGROUND

With the increased sharing of electronic health information as required by the US 21st Century Cures Act, there is an increased risk of breaching patient, parent, or guardian confidentiality. The prevalence of sensitive terms in clinical notes is not known.

OBJECTIVE

The aim of this study is to define sensitive terms that represent the documentation of content that may be private and determine the prevalence and characteristics of provider notes that contain sensitive terms.

METHODS

Using keyword expansion, we defined a list of 781 sensitive terms. We searched all provider history and physical, progress, consult, and discharge summary notes for patients aged 0-21 years written between January 1, 2019, and December 31, 2019, for a direct string match of sensitive terms. We calculated the prevalence of notes with sensitive terms and characterized clinical encounters and patient characteristics.

RESULTS

Sensitive terms were present in notes from every clinical context in all pediatric ages. Terms related to the mental health category were most used overall (254,975/1,338,297, 19.5%), but terms related to substance abuse and reproductive health were most common in patients aged 0-3 years. History and physical notes (19,854/34,771, 57.1%) and ambulatory progress notes (265,302/563,273, 47.1%) were most likely to include sensitive terms. The highest prevalence of notes with sensitive terms was found in pain management (950/1112, 85.4%) and child abuse (1092/1282, 85.2%) clinics.

CONCLUSIONS

Notes containing sensitive terms are not limited to adolescent patients, specific note types, or certain specialties. Recognition of sensitive terms across all ages and clinical settings complicates efforts to protect patient and caregiver privacy in the era of information-blocking regulations.

Vaping at the VA: Developing an Annotated Corpus of Electronic Cigarette Mentions in Clinical Notes at the Department of Veterans Affairs

Use of Electronic Nicotine Delivery Systems (ENDS, colloquially known as "electronic cigarettes") has increased substantially in the United States in the decade since 2010. However, currently relatively little is known regarding the documentation of ENDS use in clinical notes. With this study, we describe the development of an annotation scheme (and associated annotated corpus) consisting of 4,351 ENDS mentions derived from Department of Veterans Affairs clinical notes during the period 2010-2020. Analysis of our corpus provides important insights into ENDS documentation practices at the VA, in addition to providing a resource for the future development and validation of Natural Language Processing algorithms capable of reliably identifying ENDS-use status.

Provider documentation of electronic nicotine delivery systems use among patients prescribed contraception at an academic health center in the Southeastern United States

Purpose

Women on combined hormonal contraception (CHC) who use electronic nicotine delivery systems (ENDS) may be vulnerable to adverse cardiovascular events. To date, no study has examined whether clinicians screen for ENDS use when prescribing CHC. Therefore, we investigated documentation of ENDS screening and counseling in the electronic health record (EHR) of women prescribed CHC.

Methods

We conducted a retrospective EHR review and content analysis at an academic health center in the Southeastern United States. We randomly selected 500 records of female patients 12 years and older who had been prescribed contraception and had ENDS documented in their records identified via keyword match. Records prior to July 2020 were reviewed between June-September 2020.

Results

Of the 500 patients, 245 (49%) were ENDS users and 227 (45.4%) were non-ENDS users. Among ENDS users, there were 82 contraception-related encounters with ENDS documentation. In 55 (67.1%) of these encounters, only ENDS use status was documented. The provider counseled against ENDS use in 17 (20.7%) records. Six (7.3%) notes documented provision of patient education materials instructing patients on contraception to refrain from using ENDS. Among non-ENDS users, there were 43 contraception-related encounters with ENDS documentation; 35 (81.4%) documented the patient did not use ENDS and 3 (7%) documented provision of patient education materials.

Conclusion

ENDS use is under-documented in contraception-related encounters. Improvements in documentation may help assess long-term effects of concurrent ENDS and CHC use. These results illustrate the need to clarify EHR prompts and increase provider awareness to improve ENDS documentation.

Extracting social determinants of health from electronic health records using natural language processing: a systematic review

OBJECTIVE

Social determinants of health (SDoH) are nonclinical dispositions that impact patient health risks and clinical outcomes. Leveraging SDoH in clinical decision-making can potentially improve diagnosis, treatment planning, and patient outcomes. Despite increased interest in capturing SDoH in electronic health records (EHRs), such information is typically locked in unstructured clinical notes. Natural language processing (NLP) is the key technology to extract SDoH information from clinical text and expand its utility in patient care and research. This article presents a systematic review of the state-of-the-art NLP approaches and tools that focus on identifying and extracting SDoH data from unstructured clinical text in EHRs.

MATERIALS AND METHODS

A broad literature search was conducted in February 2021 using 3 scholarly databases (ACL Anthology, PubMed, and Scopus) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 6402 publications were initially identified, and after applying the study inclusion criteria, 82 publications were selected for the final review.

RESULTS

Smoking status (n = 27), substance use (n = 21), homelessness (n = 20), and alcohol use (n = 15) are the most frequently studied SDoH categories. Homelessness (n = 7) and other less-studied SDoH (eg, education, financial problems, social isolation and support, family problems) are mostly identified using rule-based approaches. In contrast, machine learning approaches are popular for identifying smoking status (n = 13), substance use (n = 9), and alcohol use (n = 9).

CONCLUSION

NLP offers significant potential to extract SDoH data from narrative clinical notes, which in turn can aid in the development of screening tools, risk prediction models, and clinical decision support systems.

The Impact of Vaping on Primary Spontaneous Pneumothorax Outcomes

INTRODUCTION

Cigarette smoking is associated with primary spontaneous pneumothorax (PSP). Electronic cigarettes (E-cigarettes) are touted as a healthier alternative to cigarettes; however, the impact E-cigarette use has on PSP management is not known. The goal of this study was to determine if E-cigarette use is associated with inferior outcomes after PSP, compared to never smokers and cigarette smokers.

METHODS

We conducted a retrospective cohort study of patients in a large tertiary care hospital system in an urban area who presented with PSP from September 2015 through February 2019. Primary spontaneous pneumothorax patients were identified from the institutional Society of Thoracic Surgeon (STS) database. Patients with pneumothoraces from traumatic, iatrogenic, and secondary etiologies were excluded. Baseline clinical and demographic data and outcomes including intervention(s) required, length of stay, and recurrence were evaluated.

RESULTS

Identified were 71 patients with PSP. Seventeen (24%) had unverifiable smoking history. Of the remaining, 7 (13%) currently vaped, 27(50%) currently smoked cigarettes, and 20(37%) were never smokers. Mean age was 33 years; 80% male. All vapers required tube thoracostomy vs 74% of current smokers and 75% of never smokers. Vaping was associated with increased odds of recurrence compared to never smokers (OR 2.00, 95% CI 0.35,11.44). Vapers had the shortest median time to recurrence after initial hospitalization (10 d[4,18] v 20 d[5,13] cigarette smokers v 27 d[13 275] never smokers, P < .001).

CONCLUSION

Vaping may complicate PSP outcomes. As vaping use increases, especially among adolescents, it is imperative that the manner of tobacco use is documented and considered when caring for patients, especially those with pulmonary problems.

Concordance Between Electronic Health Record and Tumor Registry Documentation of Smoking Status Among Patients With Cancer

PURPOSE

Patients with cancer who use tobacco experience reduced treatment effectiveness, increased risk of recurrence and mortality, and diminished quality of life. Accurate tobacco use documentation for patients with cancer is necessary for appropriate clinical decision making and cancer outcomes research. Our aim was to assess agreement between electronic health record (EHR) smoking status data and cancer registry data.

MATERIALS AND METHODS

We identified all patients with cancer seen at University of Florida Health from 2015 to 2018. Structured EHR smoking status was compared with the tumor registry smoking status for each patient. Sensitivity, specificity, positive predictive values, negative predictive values, and Kappa statistics were calculated. We used logistic regression to determine if patient characteristics were associated with odds of agreement in smoking status between EHR and registry data.

RESULTS

We analyzed 11,110 patient records. EHR smoking status was documented for nearly all (98%) patients. Overall kappa (0.78; 95% CI, 0.77 to 0.79) indicated moderate agreement between the registry and EHR. The sensitivity was 0.82 (95% CI, 0.81 to 0.84), and the specificity was 0.97 (95% CI, 0.96 to 0.97). The logistic regression results indicated that agreement was more likely among patients who were older and female and if the EHR documentation occurred closer to the date of cancer diagnosis.

CONCLUSION

Although documentation of smoking status for patients with cancer is standard practice, we only found moderate agreement between EHR and tumor registry data. Interventions and research using EHR data should prioritize ensuring the validity of smoking status data. Multilevel strategies are needed to achieve consistent and accurate documentation of smoking status in cancer care.

The electronic cigarette epidemic in youth and young adults: A practical review

Electronic cigarettes are the most common form of nicotine delivery used by youth and young adults, and in 2018, the US Surgeon General declared this to be an epidemic. The developing adolescent brain is vulnerable to nicotine exposure, which can lead to long-lasting cognitive and mood disorders. Screening rates for vaping are low and lack of knowledge by adolescents, clinicians, parents, and caregivers is high. This article reviews the components of vaping, prevalence, adverse reactions, regulation, treatment, and prevention strategies related to vaping in youth and young adults.

Pediatric Resident Training in Tobacco Control and the Electronic Health Record

Given the dangers posed by tobacco use and tobacco smoke exposure, pediatricians should address tobacco use and exposure with patients and parents at every opportunity, but this is not consistently done in practice. One reason may be that many medical residents do not receive education on how to address tobacco use and tobacco smoke exposure with patients and their parents. In a 2012 survey of U.S. pediatric program directors, 65% of programs reported covering tobacco control in their curricula, but most training programs focused on tobacco's health effects and not intervention strategies for clinical practice. Since that survey, electronic health records have been implemented broadly nationwide and utilized to address tobacco smoke exposure. Investigators surveyed U.S. program directors in 2018 and residents in 2019 to explore the ways in which the residents learn about tobacco use and tobacco smoke exposure, components and use of the electronic record specific to tobacco use and tobacco smoke exposure, and perceived resident effectiveness in this area. All the program directors and 85% of the residents valued training, but 21% of the residents reported receiving none. Moreover, a minority of the residents assessed themselves as effective at counseling parents (19%) or adolescents (23%), and their perceived effectiveness was related to small group learning and active learning workshops, modalities that were infrequently implemented in training. Respondents also reported infrequent use of electronic health record prompts regarding tobacco and the absence of prompts about critical issues (e.g., addressing tobacco smoke exposure in vehicles or other settings or offering treatment or referrals to parents who smoke). This paper provides recommendations about augmenting pediatric resident training in simple ways.

Not Quite the Rule, But No Longer the Exception: Multiple Tobacco Product Use and Implications for Treatment, Research, and Regulation

The patterns of tobacco product use in the United States have changed during the past several decades. Currently, a large proportion of tobacco users report using multiple tobacco products (MTPs). The prevalence of MTP use varies significantly by cigarette smoking frequency, as well: nearly half (46.9%) of all non-daily smokers report using other tobacco products within the past 30 days. Despite this, much of extant tobacco dependence treatment efforts, tobacco regulatory science research, and tobacco product research, in general, has focused largely on single product use (ie, cigarette smoking). To effectively design interventions and model the potential impact of regulations on tobacco products aimed at reducing tobacco use, as well as effectively study tobacco users, it is essential to consider actual use patterns in the population of tobacco users. Implications: MTP use is increasingly common in the United States. This commentary highlights the impact that MTP use has for efforts to treat tobacco dependence, tobacco regulatory science efforts, as well as on tobacco research, in general.

Association between vaping and health outcomes in patients with opioid use disorder: a systematic review protocol

INTRODUCTION

Vaping behaviour has increased in popularity and is particularly important to examine how it effects health outcomes in vulnerable populations, including those with opioid use disorder (OUD). With polysubstance use including cigarette and cannabis use being highly prevalent in the OUD population and cannabis/nicotine increasingly being consumed by vaping, vaping may have an important contribution to health outcomes in these individuals. The primary objective of this review is to systematically assess the literature related to patients with OUD and the effects vaping has shown on their physical and mental health.

METHOD AND ANALYSIS

A systematic search of databases including MEDLINE, Embase, PsycINFO, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Cochrane Clinical Trials Registry, the National Institutes for Health Clinical Trials Registry and the WHO International Clinical Trials Registry Platform from inception to 31 December 2020 will be conducted. Identified citations will be screened by two reviewers to determine eligibility at the title and abstract level, and then at the full text and data extraction phases. Any disagreements in inclusion will be resolved through unblinded discussion by these reviewers, with any remaining disagreements being resolved by a third reviewer. Data collection from eligible studies will be conducted according to the data extraction form tested prior to abstraction. Included studies will be examined for quality and bias and will be meta-analysed where applicable. This protocol is reported in keeping with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines.

ETHICS AND DISSEMINATION

The results for this review will be disseminated through publications in peer-reviewed journals, posters and presentations at scientific conferences. Additionally, we are collaborating with the Canadian Addiction Treatment Centre clinics to help disseminate the findings for this review. As this is a systematic review, no ethics approval is needed.

REVIEW REGISTRATION NUMBER

CRD42020178441.

Vaping: Impact of Improving Screening Questioning in Adolescent Population: A Quality Improvement Initiative

The use of Electronic Nicotine Delivery Systems (ENDS) increased dramatically over the past decade, making them the most common tobacco product used among youth. While physicians often screen for the use of tobacco, very few screen for vaping product usage. This quality improvement project aimed to increase the screening rate of ENDS use among adolescents to 85% to match the Healthy People 2020 screening target of 83.3% for smoking.

Electronic Vaping Product Use among Young Adults Who Receive Care at a Major Medical Institution

Background: National estimates of electronic vaping product (EVP) use exist, but little is known about young adult EVP users who interact with the healthcare setting. Methods: Cross-sectional survey of 18-25 year olds receiving care in our ambulatory medical practice. Population differences were evaluated with the chi square test reporting unadjusted odds ratios (ORs). Results: Response rate was 16.6% (n = 1,017/6,119). The prevalence of ever EVP use was 46.0% of whom 13.9% used every day. Each additional day of alcohol use (past 30 days) was associated with increased odds of being an EVP user (OR = 1.06, 95% CI 1.02-1.09), and cannabis use (past 30 days) was associated with a higher odds of being an EVP user compared to non-cannabis users (OR = 40.0, 95% CI 17.4 - 111.8). Observing a biological parent (OR = 2.89, 95% CI 1.98-4.24), step parent (OR = 2.03, 95% CI 1.02-4.19) and full sibling (OR = 2.31, 95% CI 1.78-3.00) using inhaled substances (past 30 days) was associated with increased odds of being an ever EVP user. Ever EVP users had lower odds than never users to report that EVPs with nicotine are "a little" or "a lot" more harmful than smoking "regular" tobacco cigarettes (OR = 0.53, 95% CI 0.37 - 0.76). Conclusion: Our survey is limited by a low response rate but confirms observed associations between EVP use and substance use and social influences. Our data also suggest that professionals should regularly screen for EVP use among young people, especially those with exposure to family members who used inhaled substances.

Tobacco-Related Counseling and Documentation in Adolescent Primary Care Practice: Challenges and Opportunities

INTRODUCTION

Primary care visits present an opportunity to reduce tobacco use and tobacco smoke exposure (TSE) among adolescents. To date, few studies have examined tobacco-related electronic health record (EHR) documentation in adolescent visits. The purpose of this study was to (1) describe tobacco-related EHR documentation practices in adolescent care clinics, including whether alternative tobacco products, parental use, and TSE were addressed; and (2) identify aspects of adolescent tobacco use that may inform EHR updates and counseling and documentation practices.

METHODS

Following a convergent mixed-methods design, we conducted an EHR review of 508 adolescent well-child visits, performed focus groups with pediatric providers and staff, and conducted in-depth interviews with adolescent patients. Record review data and interview transcripts were analyzed and interpreted concurrently.

RESULTS

In the EHR review, cigarette screening was documented in 92.3% of visits, smokeless tobacco screening in 51.4%, parental tobacco use in 23.2%, and home TSE in 33.1% of visits. Smoking status options were not mutually exclusive and did not include noncigarette products. No records documented assessment of e-cigarette use, despite nearly half of adolescent interview respondents citing these as the most popular products among adolescents. In interviews, adolescents discussed their experiences with alternative tobacco/nicotine products more than cigarettes.

CONCLUSIONS

Tobacco use status prompts should be revised for clarity and include noncigarette tobacco products and TSE. Provider education on noncigarette products and TSE assessment is needed. Improvements in EHR systems, resources, and tools can lead to better tobacco screening, prevention, and treatment practices among primary care providers.

IMPLICATIONS

Clinical guidelines call for pediatricians to assess and treat adolescent and parental tobacco use during primary care visits. The use of electronic health records (EHRs) can improve screening and counseling practices; however, few studies have examined tobacco-related EHR documentation practices in adolescent care settings. This mixed-methods study found low rates of EHR documentation related to noncigarette nicotine/tobacco products, parental tobacco use, and tobacco smoke exposure. These results demonstrate the need for increased provider training and EHR modifications to facilitate comprehensive tobacco control efforts in the adolescent population.

Improved Documentation of Electronic Cigarette Use in an Electronic Health Record

The use of electronic cigarettes (e-cigarettes) can affect patient health and clinical care. However, the current documentation of e-cigarette use in the electronic health records (EHR) is inconsistent. This report outlines how the ambulatory clinical practices of a large U.S. hospital system optimized its electronic health records (EHR) framework to better record e-cigarettes used by patients. The new EHR section for e-cigarette information was implemented for outpatient appointments. During a 30-week evaluation period post-implementation, 638,804 patients (12 yrs and older) completed ambulatory appointments within the health system; of these, the new section contained e-cigarette use information for 37,906 (6%) patients. Among these patients, 1005 (2.7%) were identified as current e-cigarette users (current every day or current some day e-cigarette use), 941 (2.5%) were reported as former e-cigarette users, and 35,960 (94%) had never used e-cigarettes. A separate EHR section to document e-cigarette use is feasible within existing clinical practice models. Utilization of the new section was modest in routine clinical practice, indicating the need for more intensive implementation strategies that emphasize the health effects of e-cigarette use, and how consistent ascertainment could improve clinical practice.

Screening for Adolescent Use of Electronic Nicotine Delivery Systems

Electronic Nicotine Delivery Systems (ENDS) are a new form of tobacco and marijuana administration that obscures the dangers of substance use and can be appealing to adolescents with a multitude of adolescent appeals and the use of electronic technology. As adolescent incidence of ENDS uses increases, health providers stand to lose ground with the past successes of tobacco- and substance-related health promotion as adolescents are initiated with the new technology. These risks identify the need for quality screening or the specific inclusion of ENDS products into our established screening methods. In addition, those who screen positive are provided quality interventions, such as motivational interviewing, that are effective and developmentally appropriate. By increasing our knowledge of ENDS, including them specifically in our regular screenings, and supporting adolescents in positive health choices, successful aversion of lifelong health risks can be overcome.

Patterns of tobacco use among smokers prior to hospitalization for an acute cardiac event: Use of combusted and non-combusted products

Use of tobacco products before or after a cardiac event increases risk of morbidity and mortality. Unlike cigarette smoking, which is generally screened in the healthcare system, identifying the use of other tobacco products remains virtually unexplored. This study aimed at characterizing the use of other non-combusted tobacco products in addition to combusted products among cardiac patients and identifying a profile of patients who are more likely to use non-combusted products. Patients (N = 168) hospitalized for a coronary event who reported being current cigarette smokers completed a survey querying sociodemographics, cardiac diagnoses, use of other tobacco products, and perceptions towards these products. Classification and regression tree (CART) analysis was used to identify which interrelationships of participants characteristics led to profiles of smoking cardiac patients more likely to also be using non-combusted tobacco products. Results showed that non-combusted tobacco product use ranged from 0% to 47% depending on patient characteristic combinations. Younger age and lower perception that cigarette smoking is responsible for their cardiac condition were the strongest predictive factors for use of non-combusted products. Tobacco product use among cardiac patients extends beyond combusted products (13.7% non-combusted product use), and consequently, screening in health care settings should be expanded to encompass other tobacco product use. This study also characterizes patients likely to be using non-combusted products in addition to combusted, a group at high-risk due to their multiple product use, but also a group that may be amenable to harm reduction approaches and evidence-based tobacco treatment strategies.

Combustible Cigarette Smoking and Alternative Tobacco Use in a Sample of Youth Transitioning from Foster Care

Among the struggles faced by youth currently in or recently exiting foster care, tobacco use remains a low priority for practitioners and researchers, alike. Indeed, despite the dramatically altered landscape of tobacco products on the market, there have been no studies evaluating the use of alternative tobacco products among this vulnerable population. The current study aimed to determine the prevalence of lifetime and current combustible and non-combustible tobacco use among youth exiting foster care, and report on the prevalence of nicotine dependence, motivation to quit, and preferred methods of tobacco cessation. Youth aged 18-24 (M = 20.13, SD = 1.16) who were transitioning from foster care (N = 154) completed a survey of tobacco product use adapted from the Population Assessment of Tobacco and Health Baseline Survey. Most participants (76%) reported lifetime use of combustible cigarettes, while almost half (42%) were current combustible cigarette smokers. Current use of electronic cigarettes was comparable to general population rates. Many participants (76%) reported interest in quitting and willingness to try through patches/gum (56%) and technology-based (61%) approaches. Youth exiting foster care are at high risk for smoking and other tobacco product use, as well as dependence, yet are rarely screened for use or advised to quit. As tobacco use remains among the most preventable causes of mortality and morbidity, future work should involve implementation of screening within child welfare and tailoring interventions to the unique needs of this population. The current results underscore a missed opportunity to promote public health in a vulnerable population.

Documentation of e-cigarette use and associations with smoking from 2012 to 2015 in an integrated healthcare delivery system

It is unclear whether use of electronic nicotine delivery systems (ENDS) precedes cigarette smoking initiation, relapse, and/or quitting. Healthcare systems with electronic health records (EHRs) provide unique data to examine ENDS use and changes in smoking. We examined the incidence of ENDS use (2012-2015) based on clinician documentation and tested whether EHR documented ENDS use is associated with twelve-month changes in patient smoking status using a matched retrospective cohort design. The sample was Kaiser Permanente Northern California (KPNC) patients aged ≥12 with documented ENDS use (N = 7926); 57% were current smokers, 35% former smokers, and 8% never-smokers. ENDS documentation incidence peaked in 2014 for current and former smokers and in 2015 for never-smokers. We matched patients with documented ENDS use to KPNC patients without documented ENDS use (N = 7926) on age, sex, race/ethnicity, and smoking status. Documented ENDS use predicted the likelihood of smoking in the following year. Among current smokers, ENDS use was associated with greater odds of quitting smoking (OR = 1.17, 95%CI = 1.05-1.31). Among former smokers, ENDS use was associated with greater odds of smoking relapse (OR = 1.53, 95%CI = 1.22-1.92). Among never-smokers, ENDS use was associated with greater odds of initiating smoking (OR = 7.41, 95%CI = 3.14-17.5). The overall number of current smokers at 12 months was slightly higher among patients with (N = 3931) versus without (N = 3850) documented ENDS use. Results support both potential harm reduction of ENDS use (quitting combustibles among current smokers) and potential for harm (relapse to combustibles among former smokers, initiation for never-smokers).