E-cigarettes and the clinical encounter: Physician perspectives on e-cigarette safety, effectiveness, and patient educational needs

'Why do we have to be the gatekeepers?' Australian general practitioners' knowledge, attitudes and prescribing intentions on e-cigarettes as a smoking cessation aid

BACKGROUND

A significant policy change impacting the availability of nicotine for use in electronic cigarettes (e-cigarettes) in Australia took effect from October 1, 2021. This change meant that nicotine containing liquids for use with e-cigarettes would only be available by prescription from a medical practitioner as part of a smoking cessation plan. This study aimed to explore general practitioners (GPs) perceptions about the role of e-cigarettes, and understand factors informing their intentions to prescribe e-cigarettes as part of a smoking cessation plan.

METHODS

In-depth semi-structured interviews were conducted with thirteen GPs. Purposeful sampling was used to recruit participants. Interviews were audio recorded and transcribed verbatim. Thematic analysis was used to classify, describe and report themes in the data. QSR NVivo was used to aid coding, thematic analysis and retrieval of quotes.

RESULTS

Participants had diverse views on recommending and prescribing e-cigarettes as smoking cessation aids to patients. Some participants were willing to prescribe e-cigarettes to patients if other methods of smoking cessation had not worked but there were concerns, and uncertainty, about the safety and efficacy of e-cigarettes for smoking cessation. There was poor understanding of the current policy and legislation about e-cigarettes in Australia. Mostly the participants in this sample did not feel confident or comfortable to prescribe, or have discussions about e-cigarettes with patients.

CONCLUSION

The participants of this study held diverse attitudes on recommending and prescribing e-cigarettes for smoking cessation. Clarity in guidelines and consumer product information are required to enable GPs to provide consistent and accurate advice to patients that wish to use e-cigarettes as a smoking cessation aid.

General practitioners' knowledge, attitudes, beliefs and practices surrounding the prescription of e-cigarettes for smoking cessation: a mixed-methods systematic review

BACKGROUND

General practitioners (GPs) play an important role in providing patients who smoke with health information, support and treatment to encourage them to quit smoking. Despite conflicting evidence on the effectiveness of electronic cigarettes (e-cigarettes) as a smoking cessation aid, there is growing interest in the role e-cigarettes might play as an alternative to smoking tobacco. This systematic review aims to synthesise evidence from qualitative, quantitative and mixed-methods studies of the knowledge, attitudes, beliefs and social norms of GPs with respect to the use of e-cigarettes as smoking cessation aids.

METHODS

This study adhered to the PRISMA guidelines. Studies from MEDLINE, CINAHL, SCOPUS, PsycINFO, EMBASE and grey literature were searched. Two independent reviewers screened abstracts and full-text articles to identify studies that met the inclusion criteria. A data extraction form was used to extract relevant data from included papers and were quality appraised using the MMAT checklist. A PRISMA flow diagram was used to record the flow of papers and reasons for exclusion. Studies were included if they collected quantitative, qualitative or mixed methods data to determine knowledge, attitudes, beliefs and social norms of GPs for use of e-cigarettes as smoking cessation aids.

RESULTS

A total of 4056 abstracts were screened and 25 articles were included. Our findings showed that GPs had mixed views on recommending e-cigarettes as a smoking cessation aid. Some GPs were optimistic and had recommended e-cigarettes to their patients. Others were reluctant and disagreed that e-cigarettes are an effective method to quit smoking. Most GPs lacked knowledge and confidence in having discussions with patients around e-cigarette safety and efficacy as smoking cessation alternatives.

CONCLUSION

This systematic review shows there are mixed views on e-cigarettes as smoking cessation aids. Clear guidance on the role of e-cigarettes is needed to inform and upskill GPs about e-cigarettes for smoking cessation.

PROSPERO REGISTRATION

CRD42021227612.

Adult smokers' discussions about vaping with health professionals and subsequent behavior change: a cohort study

AIMS

To measure the prevalence and changes in smokers' discussions with health professionals (HPs) about nicotine vaping products (NVPs) and HPs' recommendations about NVPs between 2016 and 2020, and their associations with tobacco product use transitions.

DESIGN

Cohort study using multinomial logistic regression analyses on data from waves 1 (2016), 2 (2018) and 3 (2020) from the International Tobacco Control Four Country Smoking and Vaping Surveys.

SETTING

Four countries with varying NVP regulatory environments: 'most restrictive' (Australia), 'somewhat restrictive' (Canada) and 'less restrictive' (England and the United States).

PARTICIPANTS

Adult exclusive daily smokers who did not report NVP use at the time of their baseline survey and had visited a HP in the last 12-24 months. Prevalence data came from 4125, 4503 and 4277 respondents, respectively, for each year. Longitudinal data were from 4859 respondents who participated in at least two consecutive surveys.

MEASUREMENTS

Prevalence of self-reported discussions with HPs and recommendations from HPs about NVPs. Longitudinal transitions from smoking to vaping (either exclusively or concurrently with smoking) and quitting (regardless of NVP uptake).

FINDINGS

The prevalence of NVP discussions was low among countries with varying regulatory environments and study waves (range = 1.4-6.2%). In 2020, a low percentage of smokers who discussed NVPs with a HP reported that their HPs recommended they use NVPs in the United States (14.7%), Australia (20.2%), Canada (25.7%), with a higher percentage in England (55.7%) where clinical guidelines for smoking cessation include NVPs. Compared with 12.0% of smokers who reported no discussion, 37.0% of those whose HPs recommended NVPs transitioned to vaping at follow-up. Transition to quitting was 9.6% with HPs' recommendation of NVPs versus 13.5% without discussion, a non-significant difference.

CONCLUSIONS

In Australia, Canada, England and the United States between 2016 and 2020, health professionals' discussions with smokers about nicotine vaping products (NVPs) were infrequent. NVP discussions were associated with NVP uptake, but not with quitting smoking.

Health Care Professionals' Clinical Skills to Address Vaping and e-Cigarette Use by Patients: Needs and Interest Questionnaire Study

BACKGROUND

Widespread vaping and e-cigarette use is a relatively new phenomenon. Youth vaping peaked in 2019, with over 25% of high school students currently vaping. e-Cigarettes are used where smoking is not permitted or as an alternative smoking cessation treatment instead of Food and Drug Administration-approved options. Vaping and e-cigarette use has the potential to harm health, including causing adverse respiratory effects and nicotine addiction. Health care professionals need skills training to help their patients with this relatively new and evolving health problem.

OBJECTIVE

The aim of this study is to understand health care professionals' training needs in this subject area to determine the focus for web-based continuing education training.

METHODS

We reviewed the literature on clinical aspects of vaping and e-cigarette use. Using the results and our experience in substance use continuing education, we created a list of key clinical skills and surveyed health care professionals about their training needs. We also asked about their interest in a list of related topics. We recruited individuals who completed our web-based courses on substance use, members of health care professional-related groups, and experts who had published an article on the subject. Half of the 31 health care professionals who completed the survey were physicians and the remainder were primarily nurses, social workers, and counselors. Participants self-identified as nonexperts (n=25) and experts (n=6) on vaping.

RESULTS

Participants who were nonexperts on average agreed or strongly agreed that they needed training in each of 8 clinical skills (n=25; range 3.7-4.4 agreement out of 5). The top two skills were recommending treatments for patients (4.4 out of 5, SD 0.49) and evaluating and treating the health effects of vaping and e-cigarette use (4.4 out of 5, SD 0.50). Experts agreed on the importance of training for health care professionals in all skills but rated the need for training higher than nonexperts for each topic. Over half of the participating health care professionals (44%-80%) were interested in nearly all (9/10, 90%) vaping-related topics on a checklist. The topics participants were most interested in were the pros and cons of vaping versus smoking and the health effects of second- and third-hand vaping. Primary care physicians showed more interest in vaping-related topics than nonprimary care physicians (t13=2.17; P=.02).

CONCLUSIONS

This study confirmed gaps in health care professionals' vaping-related clinical skills identified in the literature by identifying a perceived need for training in related skills and health care professionals' interest in key topics related to vaping prevention and cessation. This study provides specific guidance on which clinical skills training is most needed and which topics are most interesting to health care professionals.

Feasibility of a primary care patient decision aid for smoking cessation with information about e-cigarettes

Decision aids can promote shared decision making and behavior change and may be effective in helping patients quit smoking. Patients are increasingly using e-cigarettes for smoking cessation; however, little is known about the impact of including e-cigarette information in smoking cessation decision aids. Our objective was to assess the feasibility and acceptability of a smoking cessation decision aid including e-cigarette information. This study was conducted at one family medicine clinic in the United States. We used a pre-post design. In Phase I, the decision aid presented information about approved cessation methods. In Phase II, current e-cigarette users and patients with no intention of quitting received additional information on switching to e-cigarettes. We assessed the impact of the decision aids on quit attempts and abstinence, confidence and readiness to quit, confidence and readiness to switch to e-cigarettes, and patient satisfaction. We enrolled 60 patients in each phase (N = 120). Patients reported higher confidence and readiness to quit after viewing the decision aids and consulting with their physician (p < 0.01). Patients reported the decision aid helped prepare them to make a decision about quitting smoking and expressed satisfaction with the decision aid and clinician consultation. We did not observe an impact of including e-cigarette information. Smoking cessation decision aids are acceptable to patients and may promote behavior change. Future studies should explore the impact of providing patients e-cigarette information using larger sample sizes and rigorous designs. Further research is needed to identify strategies to promote shared decision-making regarding e-cigarettes.

Electronic Nicotine Product Cessation and Cigarette Smoking: Analysis of Waves 3 and 4 From the PATH Study

INTRODUCTION

Identifying predictors of electronic nicotine product (ENP) cessation can inform ENP cessation interventions. High rates of cooccurring ENP and cigarette (dual) use and transitions between these products underscore the importance of considering cigarette smoking status when assessing and addressing ENP cessation.

AIMS AND METHODS

We analyzed waves 3 (W3) and 4 (W4) of the Population Assessment of Tobacco and Health (PATH) study to identify (1) W3 socio-demographics, tobacco and ENP use characteristics, and psychosocial correlates of W3 cigarette smoking status (non-smoker, former, and current) among W3 adult ENP users, and (2) W3 predictors of W4 combined ENP and cigarette smoking abstinence relative to use of one or both products.

RESULTS

At W3, 65.6% of ENP users concurrently smoked cigarettes. Adjusted multinomial regression results indicated that different W3 socio-demographics, tobacco and ENP use characteristics, and psychosocial correlates were significantly associated with distinct W3 cigarette use profiles. At W4, 9.9% of individuals were abstinent from both products. These individuals were less likely to: (1) be current smokers (vs. non-smokers) or be advised to quit using tobacco, compared with cigarette only or dual users, and (2) use ENPs daily or live in a household allowing ENP use, compared with ENP only or dual users (p < .05).

CONCLUSIONS

ENP cessation approaches need to be tailored to the distinct cigarette use profiles of ENP users. Dual users and daily ENP users may require more intensive interventions to achieve the cessation of both products. Supportive physical environments, such as home vape-free policies, may facilitate ENP cessation.

IMPLICATIONS

This analysis contributes to advancing the nascent literature on predictors of electronic nicotine product (ENP) cessation, which can guide the development of ENP cessation interventions by indicating which populations, psychosocial and environmental constructs, and cooccurring behaviors interventions should target. This research also highlights the importance of considering cigarette smoking status when designing ENP cessation interventions and defining intervention outcomes.

GP knowledge, attitudes, beliefs, and practices surrounding the prescription of e-cigarettes for smoking cessation: a protocol for a mixed-method systematic review

BACKGROUND

Electronic cigarettes (e-cigarettes) are being marketed to people who smoke (PWS) as a smoking cessation aid. GPs have an important role in providing patients with support to encourage them to quit smoking. The emergence and marketing of e-cigarettes as a smoking cessation alternative poses challenges to GPs in advising and supporting PWS to quit.

AIM

This systematic review aims to synthesise available evidence on the knowledge, attitudes, and perceptions of GPs about e-cigarettes as a smoking cessation aid.

DESIGN & SETTING

Mixed-methods study review including quantitative, qualitative, and mixed-methods studies of GPs in primary care settings.

METHOD

MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, PsycINFO, and Embase databases will be searched to identify articles published between 1 January 2003 and 30 June 2021. A Google search will be conducted to identify grey literature. Two independent reviewers will screen abstracts for relevance and full-text studies. Articles will be appraised for quality using the Mixed Methods Appraisal Tool (MMAT) and a Preferred Reporting Items for Systematic Reviews, and Meta-Analysis (PRISMA) diagram will illustrate the flow of articles and reasons for exclusion. An evidence synthesis method will be employed and guided by the Theory of Planned Behaviour (TPB). A descriptive qualitative synthesis of the findings will be reported.

CONCLUSION

Findings will provide a synthesis of current evidence regarding the knowledge, attitudes, and perceptions among GPs of e-cigarettes as a smoking cessation aid. This information will be useful to guide future research on the needs of GPs in advising and supporting patients to quit smoking. It will also assist in the development of health policy and guidelines on the role and place of e-cigarettes as a smoking cessation aid.

Primary Care Physician Perspectives on Recommending E-cigarettes to Smokers: a Best-Worst Discrete Choice Experiment

BACKGROUND

Recent clinical trials suggest that e-cigarettes may be more effective for smoking cessation than traditional cessation aids, yet primary care physician (PCP) practices regarding e-cigarette recommendations for smokers have not been studied in-depth.

OBJECTIVE

To identify factors influencing PCP recommendation of e-cigarettes for smoking cessation.

DESIGN

Discrete choice experiment and survey.

PARTICIPANTS

Florida PCPs.

MEASURES

The survey included a discrete choice experiment in which PCPs indicated whether they would recommend e-cigarettes for each of 8 hypothetical patient profiles with the following contrasting characteristics: e-cigarette use, interest in approved cessation methods, smoking intensity, prior experience with approved cessation medications, quit intention, age, and comorbidity. Responses were summarized using descriptive statistics and standardized scores (SS).

KEY RESULTS

The sample (n = 216) was predominately male (76%), white (66%), and non-Hispanic (78%), and most respondents had held their medical degree for 20+ years (77%). The response rate was 28.7%. Most PCPs thought e-cigarettes were at least somewhat effective for smoking cessation (66%) and lowering disease risk (65%); 31% perceived e-cigarettes to be equally/more effective than traditional cessation aids. PCPs were split regarding whether e-cigarettes were less (50%) or equally harmful (38%) as cigarettes. Yet, few were very confident in their ability to counsel patients on e-cigarettes risks (27%) or benefits (15%). PCPs recommended e-cigarettes in 27% of patient profiles they evaluated. The most important factors influencing the decision to recommend or not recommend e-cigarette were patients' prior use of nicotine replacement therapy with (SS = 0.22, 95% CI = 0.17-0.27) and without use of other medications for cessation (SS = 0.18, 95% CI = 0.13-0.23), and being middle age (50 years old) with chronic obstructive pulmonary disease (SS = 0.16, 95% CI = 0.10-0.23).

CONCLUSIONS

Considering the increased patient use of e-cigarettes and increasing use for cessation, this study highlights the need for guidelines and education to aid PCPs' counseling of patients about e-cigarette use.

An Evaluation of the Knowledge and Perceptions of Pharmacy Staff and Pre-Registration Students of E-Cigarettes Use: A Systematic Review

INTRODUCTION

Pharmacy staff are a trusted source of advice on the safe and appropriate use of medicines and devices. Retail pharmacies deliver smoking cessation services and sell e-cigarettes in the UK. This review asks 'what knowledge, experience and ability do staff have to support e-cigarette users to quit smoking'.

METHODS

A systematic literature search was undertaken drawn on predefined eligibility criteria and a comprehensive search strategy following the PRISMA guideline. Eligible papers reported survey-research published in English from 2015 to 2020. PubMed, Google Scholar, OVID, EMBASE and MEDLINE Databases were searched. No restrictions on study design or language were applied. Two reviewers independently screened for inclusion/exclusion and then extracted the relevant information from the articles for synthesis.

RESULTS

Of 12 potentially eligible full-text studies, 1 was a duplicate, 7 were excluded as per eligibility criteria. Four papers were finally included in this literature review. Two studies indicated that pharmacy staff are less confident in giving advice on e-cigarette use. Knowledge on the adverse effects of e-cigarettes compared to traditional smoking cessation aids remain unclear. In one study, 42% of community pharmacists did not believe that e-cigarettes could be used for smoking cessation. Three studies identified need for specific regulations and professional support. The overall certainty of the evidence is 'low' or 'very low', with moderate levels of bias.

CONCLUSION

Pharmacists may be well placed to implement e-cigarette smoking cessation interventions, but most practitioners lacked knowledge and ability to support these customers citing unclear risk of harm. Pharmacists felt secure in recommending traditional cessation tools. Further regulation, guidelines and training is needed. Findings may be less generalizable in countries where e-cigarettes are banned. Their extent of knowledge, experience and ability to support users of e-cigarettes within their community to quit smoking is lacking.

Evaluation of a smoking cessation patient decision aid that integrates information about e-cigarettes

INTRODUCTION

Smokers increasingly use e-cigarettes to try to quit smoking, even more than recommended cessation methods. However, few smokers discuss the range of cessation options with their physicians. Decision aids can inform smokers about smoking cessation options, including evidence about e-cigarettes, and encourage smokers to engage in shared decision making with their physician. This study aimed to evaluate a smoking cessation decision aid that included e-cigarette risks and benefits.

METHODS

Adult smokers were recruited from primary care clinics for two research phases: 1. usability and acceptability testing of the decision aid (n=37); and 2. pre/post study that compared usual care (n=90) with implementation of the decision aid in clinics (n=90). For the latter, outcome measures included frequency of clinical discussions of readiness to quit, methods to quit in general, and of specific cessation methods, in addition to decisional conflict, communication satisfaction, and overall patient satisfaction.

RESULTS

Smokers indicated high usability and acceptability of the decision aid. In the pre/post evaluation, decision aid implementation was associated with higher rates of smokers: being asked if they were ready to quit smoking (89% vs. 67%, respectively; p<0.001); discussing methods for smoking cessation in general (81% vs. 48%; p<0.001); and discussing specific cessation methods (NRT 55% vs. 26%, p<0.001; prescription medications 26% vs. 12%, p=0.022). Decision aid use was also associated with higher overall patient satisfaction with the physician visit.

CONCLUSIONS

Smoking cessation decision aids that incorporate information about e-cigarettes are acceptable among smokers and can lead to evidence-based clinical discussions about smoking cessation.

IMPLICATIONS

Smokers use e-cigarettes more than recommended cessation methods when they are trying to quit smoking, yet few physicians discuss the risks and benefits of e-cigarettes with their patients who smoke. This study presents preliminary findings about the feasibility and usability of a clinically based iPad-delivered smoking cessation decision aid that integrates information about e-cigarettes. Although promising, further research with randomized designs, larger samples, and longer-term follow-up is needed to determine whether this type of intervention can effectively promote cessation of all tobacco products and, for those not ready to quit smoking, the use of e-cigarettes for harm reduction.

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.

Cigarette and E-Cigarette Use and Smoking Cessation Practices among Physicians in Poland

Physicians play a key role in combating tobacco use. This study aims to evaluate the knowledge, attitude, and behaviors toward smoking cessation and vaping cessation interventions among physicians in Poland; to identify factors shaping physicians’ behaviors toward smoking and vaping cessation interventions; and to assess differences in the tobacco cessation interventions recommended for cigarette smokers and users of electronic cigarettes (e-cigarettes). A questionnaire-based survey was conducted in 2018 among physicians attending mandatory public health training courses delivered at the School of Public Health, Centre of Postgraduate Medical Education, Warsaw, Poland. The questionnaire included 25 questions related to tobacco product use and smoking cessation interventions. Data were obtained from 423 physicians (64.3% female; mean age 32.0 ± 5.8 years) with response rate of 84.6%. Current cigarette smoking was declared by 7.8% of participants; 1.9% of participants were e-cigarette users and 1.9% used heated tobacco. Smoking cessation interventions were offered more often to patients who smoked cigarettes than those who used e-cigarettes (p < 0.001). Physicians’ behaviors toward smoking cessation and vaping cessation interventions were associated with (p < 0.05) physicians’ smoking status and self-declared knowledge about smoking cessation methods. Among physicians in Poland, discussion of smoking cessation was not common behavior and limited mainly to identification of smoking status.

A narrative review evaluating the safety and efficacy of e-cigarettes as a newly marketed smoking cessation tool

Introduction:

E-cigarettes are an alternative to traditional tobacco-based cigarettes. While having considerable societal awareness, conflicting evidence exists to support their claims that they are an effective smoking cessation tool and are safe. Currently >7000 flavours exist with evidence that they exhibit detrimental cellular and tissue effects. A literature review was conducted utilising PubMed and Google Scholar Databases identifying papers between 2014 and 2019. The aims of this study were to accurately gauge the safety and efficacy of e-cigarettes as a smoking cessation tool.

Methods:

Search terms including ‘electronic cigarettes’ and ‘vaping’ were used to identify suitable references. A total of 314 articles were identified from which papers were excluded due to risk of bias, insufficient detail or were duplicate from which 58 papers were used in the final review.

Results:

Evidence shows that e-cigarettes can have detrimental effects on several cell lines and animal models with their flavourings and nicotine content implicated; this has, however, not translated into major health outcomes after 3.5 years follow-up but has been linked to chronic lung disease and cardiovascular disease. While advertised as an effective smoking cessation tool, no consensus can be made regarding their effectiveness although the first robust randomised controlled trial reports some success. This, however, is offset by the fact that the most common e-cigarette use is as a dual user and that there is evidence of threefold increased risk of future tobacco smoking.

Conclusion:

Future research is needed to evaluate the long-term health outcomes and efficacy of e-cigarettes as a smoking cessation tool with greater discussion between patients and clinicians regarding this smoking cessation tool.