Practice Patterns and Perceptions of Chest Health Care Providers on Electronic Cigarette Use: An In-Depth Discussion and Report of Survey Results

Communication Between US Physicians and Patients Regarding Electronic Cigarette Use

IMPORTANCE

Physicians play a primary role in patient smoking cessation, yet their communication regarding e-cigarettes is not well understood.

OBJECTIVE

To assess physician-patient communication regarding e-cigarettes.

DESIGN, SETTING, AND PARTICIPANTS

A national cross-sectional survey in 2018 and 2019 was conducted. Participants were invited by mail; surveys were completed online. Respondents were 2058 board-certified physicians from family medicine, internal medicine, obstetrics and gynecology, cardiology, pulmonary, and oncology. Data were analyzed from August to September 2021.

EXPOSURES

Physician demographic characteristics, tobacco use, medical specialty, and harm-reduction beliefs (ie, not all tobacco products are equally harmful) applied within 2 hypothetical clinical scenarios.

MAIN OUTCOMES AND MEASURES

Physicians' self-reported e-cigarette communication (being asked about e-cigarettes by patients and recommending e-cigarettes to patients) and hypothetical e-cigarette communication in 2 clinical scenarios.

RESULTS

Among 2058 physicians, the mean (SD) age was 51.6 (10.5) years, and 1173 (58.5%) were male. More than 60% of physicians believed all tobacco products to be equally harmful. Overall, 69.8% of physicians reported ever being asked about e-cigarettes by their patients (35.9% in the past 30 days), and 21.7% reported ever recommending e-cigarettes to a patient (9.8% in the past 30 days). Pulmonologists (adjusted odds ratio [aOR], 2.14, 95% CI, 1.10-4.16) and cardiologists (aOR, 2.04; 95% CI, 1.03-4.05), as well as physicians who implemented the US Public Health Service Clinical Practice Guidelines (aOR, 1.77; 95% CI, 1.12-2.80), had greater odds of recommending e-cigarettes to patients. Physicians who endorsed a harm-reduction perspective (aOR, 3.04, 95% CI, 2.15-4.31) and had ever smoked cigarettes (aOR, 1.98; 95% CI, 1.27-3.08) were significantly more likely to recommend e-cigarettes. Physicians who reported being asked about e-cigarettes had greater odds of recommending e-cigarettes (aOR, 16.60; 95% CI, 10.33-26.68). In clinical scenarios, physicians were overall more likely to recommend e-cigarettes for cessation to an older heavy smoker with multiple unsuccessful quit attempts (49.3%; 95% CI, 47.1%-51.4%) than a younger light smoker with no prior cessation treatments (15.2%; 95% CI, 13.6%-16.7%) (P < .001).

CONCLUSIONS AND RELEVANCE

In this survey study of physicians, findings suggest that physicians may recommend switching to e-cigarettes for some patients who smoke cigarettes under certain circumstances, presumably for cessation. The belief that all tobacco products are equally harmful was associated with lower rates of recommending e-cigarettes. As the evidence base grows for e-cigarette efficacy for smoking cessation, there is need for physician education regarding e-cigarette efficacy.

Electronic Cigarettes: Past, Present, and Future: What Clinicians Need to Know

Electronic cigarettes (EC) are battery-operated devices that heat and aerosolize a liquid solution that typically contains nicotine. ECs have become commonly used among youth and may pose substantial risks of future addiction and health problems in this population. However, ECs are far less toxic per puff compared with combustible cigarettes, and as a result, might present an important harm reduction opportunity for cigarette smokers who cannot stop smoking by traditional means. The long-term health effects of ECs on individuals and the net effect on public health will remain unknown for many years.

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline

Background: Current tobacco treatment guidelines have established the efficacy of available interventions, but they do not provide detailed guidance for common implementation questions frequently faced in the clinic. An evidence-based guideline was created that addresses several pharmacotherapy-initiation questions that routinely confront treatment teams.

Methods: Individuals with diverse expertise related to smoking cessation were empaneled to prioritize questions and outcomes important to clinicians. An evidence-synthesis team conducted systematic reviews, which informed recommendations to answer the questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to rate the certainty in the estimated effects and the strength of recommendations.

Results: The guideline panel formulated five strong recommendations and two conditional recommendations regarding pharmacotherapy choices. Strong recommendations include using varenicline rather than a nicotine patch, using varenicline rather than bupropion, using varenicline rather than a nicotine patch in adults with a comorbid psychiatric condition, initiating varenicline in adults even if they are unready to quit, and using controller therapy for an extended treatment duration greater than 12 weeks. Conditional recommendations include combining a nicotine patch with varenicline rather than using varenicline alone and using varenicline rather than electronic cigarettes.

Conclusions: Seven recommendations are provided, which represent simple practice changes that are likely to increase the effectiveness of tobacco-dependence pharmacotherapy.

Beliefs and Self-reported Practices of Health Care Professionals Regarding Electronic Nicotine Delivery Systems: A Mixed-Methods Systematic Review and Synthesis

AIMS

This review explores the (1) beliefs and attitudes of health care professionals (HCPs) toward electronic nicotine delivery systems (ENDS) including use as a smoking cessation aid and/or harm reduction, safety and regulation, and (2) the extent and content of patient-HCP communication about ENDS.

METHODS

PubMed, Embase, CINAHL, and PsycINFO were searched to identify articles published since 2003. The Mixed Methods Appraisal Tool and Strengthening the Reporting of Observational Studies in Epidemiology checklists were used to assess the quality of studies. Thematic synthesis was used to analyze qualitative data.

RESULTS

A total of 45 articles (32 quantitative, 12 qualitative, and 1 mixed) were included. There was wide variation regarding beliefs about the efficacy of ENDS as a cessation aid. Although the majority of HCPs believes that ENDS are safer than combustible cigarettes, they also have concern about the short and long-term safety of ENDS, uptake by adolescents, and the potential for ENDS to act as a "gateway" to smoking cigarettes. Beliefs about ENDS are influenced by media stories and experiences provided by patients. Although most HCPs do not proactively recommend ENDS, they are more likely to support ENDS use among patients with smoking related comorbidities, heavy smokers with previous unsuccessful quit attempts, or patients who express interest in trying them.

CONCLUSIONS

Overall, HCPs hold diverse views about the efficacy of ENDS and expressed wariness over their potential health effects. HCP endorsement of ENDS use seems to depend largely on patient health status, the presence of other competing risk factors and patient preferences.

IMPLICATION

Although evidence on safety and efficacy of ENDS is emerging, HCPs should be honest with their clients, stating that the long-term safety is not yet established but what is known is that they appear to be a lower risk alternative to cigarettes. Our review highlights a need for further training and support for HCPs regarding ENDS use, which would enable them to guide their clients in making evidence-based decisions.

Adult E-Cigarettes Use Associated with a Self-Reported Diagnosis of COPD

The use of electronic cigarettes (e-cigarettes) has increased in the US, but little is known about the effects of these products on lung health. The main purpose of this study was to examine the association between e-cigarette use and a participant's report of being diagnosed with chronic obstructive pulmonary disease (COPD) in a nationally representative sample of adults. Methods: The first wave of the Population Assessment of Tobacco and Health (PATH) survey adult data was used (N = 32,320). Potential confounders between e-cigarette users and non-users were balanced using propensity score matching. Odds ratios (OR) were calculated to examine the association between e-cigarette use and COPD in the propensity-matched sample, the entire sample, different age groups, and in nonsmokers. Replicate weights and balanced repeated replication methods were utilized to account for the complex survey design. Results: Of the 3642 participants who met the criteria for e-cigarette use, 2727 were propensity matched with 2727 non e-cigarette users. In the propensity-matched sample, e-cigarette users were more likely to report being diagnosed with COPD (OR 1.43, 95% confidence interval [CI] 1.12-1.85) than non-e-cigarette users after adjusting for confounders. The result was similar in the entire sample and in the different age subgroups. Among nonsmokers, the odds of reporting a COPD diagnosis were even greater among e-cigarette users (OR 2.94, 95% CI 1.73-4.99) compared to non-e-cigarette users. Conclusion: Our findings demonstrate that e-cigarette use was associated with a reported diagnosis of COPD among adults in the US. Further research is necessary to characterize the nature of this association and on the long-term effects of using e-cigarettes.

Electronic Cigarettes and Smoking Cessation in the Perioperative Period of Cardiothoracic Surgery: Views of Australian Clinicians

For patients who smoke, electronic cigarettes may offer a pathway to achieve tobacco abstinence and reduce the risk of postoperative complications. Clinicians have a pivotal role in supporting smoking cessation by patients with lung cancer and coronary artery disease throughout the perioperative period of cardiothoracic surgery. However, the views of Australian cardiothoracic clinicians on electronic cigarettes and smoking cessation are unknown. Semi-structured interviews were conducted with 52 cardiothoracic surgeons, anaesthetists, nurses and physiotherapists in six hospitals in Sydney and thematically analysed. Clinicians’ knowledge about electronic cigarettes and the regulatory environment surrounding them was limited. Clinicians believed that: electronic cigarettes, though unlikely to be safe, were safer than tobacco cigarettes; electronic cigarettes may have a harm reduction role in public health; and electronic cigarettes were a potential smoking cessation tool for the extraordinary circumstances of surgery. The professional role of a clinician and their views about electronic cigarettes as a perioperative smoking cessation aid had an influence on future clinician-patient interactions. Electronic cigarette use is increasing in Australia and clinicians are likely to receive more frequent questions about electronic cigarettes as a cessation aid. Stronger guidance for clinicians is needed on the topic of electronic cigarettes and cardiothoracic surgery.