Patient-physician communication regarding electronic cigarettes

Patient-provider communication quality: Socioeconomic disparities in smoking outcomes

INTRODUCTION

Patient-provider communication quality is instrumental for healthy outcomes in patients. The objective of this study is to examine the relationships between patient-provider communication quality and participant characteristics, perception of e-cigarette harmfulness, and smoking outcomes.

METHODS

A pooled cross-sectional design was used on secondary data obtained from the Health Information National Trends Survey (HINTS) 5 from Cycle 1 through Cycle 4, from 2017-2022. Our final sample contained 3511 observations. Our outcome variable was the perception of electronic cigarette smoking status. The independent variable was patient-provider communication quality (PPCQ), measured from a series of questions with responses on a 4-item Likert scale (always, usually, sometimes, never). Demographic variables such as marital status, health insurance status, occupation status, and health-related variables were used as participant characteristics. Ordinal logistic regression models were used to examine the above relationships.

RESULTS

Compared to males, females had lower odds of being in a higher category of perception of e-cigarette harmfulness compared to other categories of e-cigarette harmfulness (AOR=0.66; 95% CI: 0.57-0.76). Respondents who were non-Hispanic Black or Hispanic had lower odds of being in a higher category of perception of e-cigarettes compared to Whites (AOR=0.52; 95% CI: 0.49-0.78, and AOR=0.51; 95% CI: 0.41-0.65, respectively). Respondents who had higher education level compared to those with less than high school had lower odds (AOR=0.30; 95% CI: 0.17-0.51), and Hispanics compared to Whites had higher odds (AOR=1.59; 95% CI: 1.05-2.40), of being former smokers rather than current smokers.

CONCLUSIONS

Providers should invest in staff training and development to target the populations that need conversations regarding e-cigarette usage.

College health providers' knowledge and confidence in addressing students' vaping: Evidence from a pilot study in New York State

Objective

This study examines the knowledge and confidence of college healthcare providers in discussing vaping with their college student populations.

Methods

This is a mixed-methods descriptive study using a sequential-explanatory approach, consisting of a cross-sectional, online survey followed by qualitative interviews. Survey data was collected from 50 college health providers located at 26 colleges in the 64-campus State University of New York system. Targeted semi-structured interviews (N = 11) were conducted by telephone with providers who completed the survey.

Results

Despite high reported levels of knowledge and confidence, few providers had participated in educational activities relative to vaping. There was evidence of misinformation about e-cigarettes, and they did not know what product (nicotine/cannabis) students typically vape.

Conclusions

Findings indicate a potential disconnect between providers' perceived and actual knowledge of college student vaping and demonstrate areas of opportunity to assist college health providers in comprehensively addressing vaping with their college student populations.

Innovation

College health providers played a key role in lowering rates of combustible cigarette smoking, but little is known about how they are now are communicating with college students about e-cigarette and cannabis vaping. This paper examines college health providers' knowledge, confidence, and training needs relative to vaping communications.

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.

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.

Tobacco Cessation Counseling and Medications Provided by Physicians to Tobacco Users During Primary Care Visits

INTRODUCTION

The established guidelines for treating tobacco use and dependency is brief provider intervention to assist those willing to quit by providing access to medication and/or behavioral counseling. The purpose of the study is to determine the extent of cessation treatment offered by providers during primary care visits by patients who are current tobacco users, and to examine associations between patient factors and treatment received.

METHODS

Using data from the 2015 to 2018 National Ambulatory Medical Care Survey (NAMCS), we examined tobacco cessation counseling and medications from 4590 visits by patients with current tobacco use. Separate multivariate logistic regressions were used to assess whether the odds of receiving tobacco cessation treatment varied by age, gender, race/ethnicity, and payment source.

RESULTS

Of visits by current tobacco users, 18.4% included cessation counseling, 5.5% included cessation medication, and 22.1% included at least 1 type of treatment. Visits by patients with Medicare had 44% greater odds of including counseling (CI = 1%-205%) and treatment (OR = 1.44; 95% CI = 1.01-2.06). Visits classified as "other payment type" had 73% greater odds of including counseling (OR = 1.73; 95% CI = 1.05-2.84). Visits by women had 86% greater odds of including medication (CI = 17%-294%).

CONCLUSIONS

Tobacco cessation treatment is underutilized by providers during primary care visits. Further research is necessary to understand and address barriers to providing routine cessation assistance.

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.

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.

The effect of a web-push survey on physician survey responses rates: a randomized experiment

Background

Achieving a high response rate for physicians has been challenging, and with response rates declining in recent years, innovative methods are needed to increase rates. An emerging concept in survey methodology has been web-push survey delivery. With this delivery method, contact is made by mail to request a response by web. This study explored the feasibility of a web-push survey on a national sample of physicians.

Methods

A total of 1,000 physicians across six specialties were randomly assigned to a mail-only or web-push survey delivery. Each mode consisted of four contacts including an initial mailing, reminder postcard, and two additional follow-ups. Response rates were calculated using the American Association for Public Opinion Research's response rate 3 calculation. Data collection occurred between Febuary and April 2018; data were analyzed March 2019.

Results

Overall reponse rates for the mail-only versus web-push survey delivery were comparable (51.2% vs. 52.8%). Higher response rates across all demographics were seen in the web-push delivery, with the exception of pulmonary/critical care and physicians over the age of 65. The web-push survey yielded a greater response after the first mailing, requiring fewer follow-up contacts resulting in a more cost-effective delivery.

Conclusions

A web-push mail survey is effective in achieving a comparable response rate to traditional mail-only delivery for physicians. The web-push survey was more efficient in terms of cost and in receiving responses in a more timely manner. Future research should explore the efficiency of a web-push survey delivery across various health care provider populations.

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.

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.

Content Analysis of Electronic Nicotine Delivery System Publications in Core Clinical Journals from 2012 to 2018

There is no consensus if electronic nicotine delivery systems (ENDS) should be used to reduce harm among the smoking population. Physicians, who represent a trusted source of health communication, are exposed to a range of often conflicting ENDS information and this information may be relayed to patients looking to quit smoking. Previous studies have examined ENDS content of various sources of media but there is a lack of knowledge about ENDS content in medical journals. We analyzed 421 ENDS publications printed between 2012 and 2018 from PubMed's Core Clinical Journal list. Publications were analyzed based on publication type, journal type, study design, geographic focus, theme, terminology, outcomes, and positive/negative statements. The number of ENDS publications grew since 2012, and peaked in 2015. Across all years, negative statements about ENDS outnumbered positive statements, though this difference decreased over time. Over time, negative statements about "toxins and carcinogens" were made less frequently, while negative statements about "gateway effects" and "youth appeal" became more prevalent. UK journals had fewer negative statements relative to US journals. Only 12.6% of publications included guidance for healthcare professionals about ENDS. As published ENDS topics change over time, physicians' communications with patients may be impacted.

Beliefs and practices regarding electronic cigarettes in smoking cessation among healthcare professionals in Slovenia

INTRODUCTION

Electronic cigarettes (ECs) have generated extensive discussion about their role in smoking cessation. The Slovenia National Institute of Public Health's recommendations state that ECs are not to be recommended for smoking cessation or reduction. The aim of this study was to explore how healthcare professionals working in the field of preventive healthcare and smoking cessation in Slovenia communicate with and counsel patients regarding electronic cigarettes and smoking cessation or reduction.

METHODS

A cross-sectional, web-based survey was conducted among healthcare professionals working in the field of preventive healthcare and smoking cessation in Slovenia. A total of 479 healthcare professionals were included in the analysis.

RESULTS

While a minority of participants (12.7%) do or would recommend electronic cigarettes for smoking cessation or reduction in general, a higher proportion of participants (33.1%) would recommend electronic cigarettes to specific groups of patients. Knowledge on electronic cigarettes was the key determinant of differences in recommendations. Only a minority of participants (9.1%) reported availability of workplace guidelines/recommendations regarding counselling about electronic cigarettes.

CONCLUSIONS

Training programmes, educational materials and existing guidelines/recommendations regarding counselling about electronic cigarette use should be provided and distributed among healthcare professionals, together with efforts to ensure compliance to official guidelines/recommendations.

Health Professionals' Counseling about Electronic Cigarettes for Smokers and Vapers in a Country That Bans the Sales and Marketing of Electronic Cigarettes

This study describes the prevalence and correlates of adult smokers’ discussions about electronic cigarettes (e-cigarettes) with health professionals (HPs), including whether these discussions may lead smokers and vapers to use e-cigarettes for smoking cessation. Methods: We analyzed data from an online survey of Mexican smokers recruited from a consumer panel for marketing research. Participants who had visited an HP in the prior four months (n = 1073) were asked about discussions of e-cigarettes during that visit and whether this led them to try to quit. Logistic models regressed these variables on socio-demographics and tobacco use-related variables. Results: Smokers who also used e-cigarettes (i.e., dual users) were more likely than exclusive smokers to have discussed e-cigarettes with their HP (adjusted odds ratio (AOR) = 3.96; 95% C.I. 2.73, 5.74), as were those who had recently attempted to quit smoking (AOR = 1.89; 95% C.I. 1.33, 2.7). Of smokers who had discussed e-cigarettes, 53.3% reported that the discussion led them to use e-cigarettes in their quit attempt. Also, dual users (AOR = 2.6; 95% C.I. 1.5, 4.5) and daily smokers (>5 cigarettes per day) (AOR = 3.62; 95% C.I. 1.9, 6.8) were more likely to report being led by their HP to use e-cigarettes in the quit attempt compared to exclusive smokers and non-daily smokers, respectively. Conclusions: Discussions between HP and smokers about e-cigarettes were relatively common in Mexico, where e-cigarettes are banned. These discussions appear driven by the use of e-cigarettes, as well as by greater smoking frequency and intentions to quit smoking.

E-Cigarette Use Among Adult Primary Care Patients: Results from a Multisite Study

BACKGROUND

Primary care settings provide opportunities to identify electronic-cigarette (e-cigarette) use and to implement strategies for changing tobacco use behavior. However, a better understanding of the extent and associated characteristics of e-cigarette use among primary care patients are needed to inform such efforts.

OBJECTIVE

To describe patient demographic and substance use characteristics by e-cigarette use status among a large sample of primary care patients. To examine the prevalence and correlates of e-cigarette use among tobacco users in the sample.

DESIGN

Cross-sectional analysis from a multisite validation study of a substance use screening instrument.

PARTICIPANTS

Adult primary care patients aged 18 and older (n = 2000) recruited across 5 primary care clinics in the Eastern USA from 2014 to 2015.

MAIN MEASURES

Patients reported past 3-month e-cigarette use, sociodemographics, tobacco use, and other substance use. Current nicotine dependence and DSM-5 criteria for past-year substance use disorders were also assessed.

KEY RESULTS

Among the total sample, 7.7% (n = 154) adults reported past 3-month e-cigarette use. Adults who reported e-cigarette use (vs. no use) were more likely to be younger, white, or have frequent tobacco use, nicotine dependence, or past-year illicit drug use/disorders. Among past 3-month tobacco users, 16.3% reported e-cigarette use. Adjusted logistic regression indicated that odds of e-cigarette use were greater among tobacco users who had some college education or more (vs. < high school) or were daily/almost daily tobacco users (vs. not); odds were lower among Blacks/African-Americans (vs. whites). E-cigarette use among tobacco users was associated with increased odds of current nicotine dependence or tobacco use disorder as well as more severe dependence/disorder.

CONCLUSIONS

Enhanced surveillance of e-cigarette use among adult tobacco users in primary care, particularly among those who use tobacco frequently, may have implications for helping patients with tobacco cessation using established approaches including behavioral support, pharmacotherapy, or referral to specialized care.

E-Cigarettes: Harmful or Harm-Reducing? Evaluation of a Novel Online CME Program for Health Care Providers

AIM

Patients are asking health care providers about e-cigarettes, vaping, and other electronic nicotine delivery systems (ENDS). Provider advice on ENDS has varied greatly, suggesting a need for evidence-based continuing medical education (CME).

SETTING

A novel free online CME course was developed on ENDS risks and benefits, product types (e.g., vape pens, pods), and screening and counseling best practices for adults, adolescents, and different smoker profiles (e.g., daily, social).

PARTICIPANTS

From January 2017 through June 2018, 1061 individuals accessed the course: 46% physicians, 7% physician assistants, 7% nurse practitioners, 15% nurses, 4% pharmacists, and 28% allied health/student/other; 41% were international.

PROGRAM DESCRIPTION

The course was built from observed online patient-provider interactions. Through video role-plays, expert interviews, and interactive activities, the course engaged learners in the evidence on ENDS. Completers earned 1.5 CME units.

PROGRAM EVALUATION

A total of 555 health care providers earned 832.5 CME units. Pre- to post-test scores significantly increased from 57 to 90%; 76% rated the course as above average (41%) or outstanding (35%); 99% indicated the course was free of commercial bias.

DISCUSSION

Addressing the growing need for balanced provider education on ENDS, this interactive online CME engaged learners and increased knowledge on devices and evidence-based cessation approaches.

Examining the effectiveness of general practitioner and nurse promotion of electronic cigarettes versus standard care for smoking reduction and abstinence in hardcore smokers with smoking-related chronic disease: protocol for a randomised controlled trial

Background

Despite the clear harm associated with smoking tobacco, many people with smoking-related chronic diseases or serious mental illnesses (SMI) are unwilling or unable to stop smoking. In many cases, these smokers have tried and exhausted all methods to stop smoking and yet clinicians are repeatedly mandated to offer them during routine consultations. Providing nicotine through electronic cigarettes (e-cigarettes) may reduce the adverse health consequences associated with tobacco smoking, but these are not currently offered. The aim of this study is to examine the feasibility, acceptability and effectiveness of general practitioners (GPs) and nurses delivering a brief advice intervention on e-cigarettes and offering an e-cigarette starter pack and patient support resources compared with standard care in smokers with smoking-related chronic diseases or SMI who are unwilling to stop smoking.

Methods/design

This is an individually randomised, blinded, two-arm trial. Smokers with a smoking-related chronic condition or SMI with no intention of stopping smoking will be recruited through primary care registers. Eligible participants will be randomised to one of two groups if they decline standard care for stopping smoking: a control group who will receive no additional support beyond standard care; or an intervention group who will receive GP or nurse-led brief advice about e-cigarettes, an e-cigarette starter pack with accompanying practical support booklet, and telephone support from experienced vapers and online video tutorials. The primary outcome measures will be smoking reduction, measured through changes in cigarettes per day and 7-day point-prevalence abstinence at 2 months. Secondary outcomes include smoking reduction, 7-day point-prevalence abstinence and prolonged abstinence at 8 months. Other outcomes include patient recruitment and follow-up, patient uptake and use of e-cigarettes, nicotine intake, contamination of randomisation and practitioner adherence to the delivery of the intervention. Qualitative interviews will be conducted in a subsample of practitioners, patients and the vape team to garner their reactions to the programme.

Discussion

This is the first randomised controlled trial to investigate whether e-cigarette provision alongside a brief intervention delivered by practitioners leads to reduced smoking and abstinence among smokers with smoking-related chronic diseases or SMI.

Trial registration

ISRCTN registry, ISRCTN59404712. Registered 28/11/17.

Discussions between health professionals and smokers about nicotine vaping products: results from the 2016 ITC Four Country Smoking and Vaping Survey

BACKGROUND AND AIMS

Debate exists about whether health professionals (HPs) should advise smokers to use nicotine vaping products (NVPs) to quit smoking. The objectives were to examine in four countries: (1) the prevalence of HP discussions and recommendations to use an NVP; (2) who initiated NVP discussions; (3) the type of HP advice received about NVPs; and (4) smoker's characteristics related to receiving advice about NVPs.

DESIGN

Cross-sectional study using multivariable logistic regression analyses on weighted data from the 2016 ITC Four Country Smoking and Vaping Survey (ITC 4CV1).

SETTING

Four countries with varying regulations governing the sale and marketing of NVPs: 'most restrictive' (Australia), 'restrictive' (Canada) or 'less restrictive' (England and United States).

PARTICIPANTS

A total of 6615 adult smokers who reported having visited an HP in the last year (drawn from the total sample of 12 294 4CV1 respondents, of whom 9398 reported smoking cigarettes daily or weekly). Respondents were from the United States (n = 1518), England (n = 2116), Australia (n = 1046), and Canada (n = 1935).

MEASUREMENTS

Participants' survey responses indicated if they were current daily or weekly smokers and had visited an HP in the past year. Among those participants, further questions asked participants to report (1) whether NVPs were discussed, (2) who raised the topic, (3) advice received on use of NVPs and (4) advice received on quitting smoking.

FINDINGS

Among the 6615 smokers who visited an HP in the last year, 6.8% reported discussing NVPs with an HP and 2.1% of smokers were encouraged to use an NVP (36.1% of those who had a discussion). Compared with Australia (4.3%), discussing NVPs with an HP was more likely in the United States [8.8%, odds ratio (OR) = 2.15, 95% confidence interval (CI) = 1.41-3.29] and Canada (7.8%, OR = 1.87, 95% CI = 1.26-2.78). Smokers in Australia were less likely to discuss NVPs than smokers in England (6.2%), although this was not statistically significant (OR = 1.47, 95% CI = 0.98-2.20). Overall, the prevalence of HPs recommending NVPs was three times more likely in the United States than in Australia (OR = 3.07, 95% CI = 1.45-6.47), and twice as likely in Canada (OR = 2.28, 95% CI = 1.06-4.87) than in Australia. Australia and England did not differ (OR = 1.76, 95% CI = 0.83-3.74). Just over half (54%) of respondents brought up NVPs themselves; there were no significant differences among countries.

CONCLUSIONS

Discussions in Australia, Canada, England, and the United States between smokers and health professionals about nicotine vaping products appear to be infrequent, regardless of the regulatory environment. A low percentage of health professionals recommended vaping products. This was particularly evident in Australia, which has the most restrictive regulatory environment of the four countries studied.

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

RATIONALE, AIMS, AND OBJECTIVES

There is limited research on how health care providers approach the topic of e-cigarettes in clinical encounters, especially in conjunction with other best-practice recommendations for smoking cessation. This qualitative study explored physician perceptions and recommendations involving e-cigarettes in the context of smoking cessation counselling, including their opinions about the implementation and content of patient educational materials that focus on e-cigarettes.

METHODS

Semistructured interviews were conducted with 15 physicians from family medicine, internal medicine, and obstetrics/gynaecology (OB/GYN).

RESULTS

Physicians did not routinely assess e-cigarette use among patients and reported that discussions were often initiated by patients. Only a minority of participants discussed e-cigarettes in conjunction with other best-practice recommendations for smoking cessation. Most others were more ambivalent about e-cigarette safety and effectiveness for cessation and did not address the topic, unless patients were already using e-cigarettes. Almost all, however, agreed that more research on e-cigarettes was needed. Physicians expressed an interest in having enhanced discussions about e-cigarettes with their patients and in using patient educational materials to accomplish this. Physicians recommended that these materials not actively promote e-cigarettes and be tailored to patients based on their demographics and motivation to quit.

CONCLUSIONS

Physicians were open to improving their smoking cessation counselling and to integrating new patient educational materials that addressed e-cigarettes. Patient educational materials that provide tailored information about e-cigarettes could potentially be used initiate e-cigarette discussions and inform smokers about what is known vs unknown about e-cigarettes.

GPs' and nurses' perceptions of electronic cigarettes in England: a qualitative interview study

BACKGROUND

Reports from royal colleges and organisations such as Public Health England suggest that GPs and nurses should advise patients to switch to electronic cigarettes (e-cigarettes) if they do not want to stop smoking using licensed medication. However, there are no data on what practitioners think, feel, or do about e-cigarettes.

AIM

To explore practitioners' perceptions and attitudes towards e-cigarettes, and their experiences of discussing e-cigarettes with patients.

DESIGN AND SETTING

A qualitative interview study was carried out with semi-structured interviews conducted with nurses and GPs across England in 2017.

METHOD

Participants were interviewed once either via telephone or face to face. Data were analysed using thematic analysis.

RESULTS

Interviews were conducted with 23 practitioners (eight nurses and 15 GPs). There were three key themes: ambivalence and uncertainty; pragmatism; and responsibility. Many practitioners had uncertainties about the safety and long-term risks of e-cigarettes. Some had ambivalence about their own knowledge and ability to advise on their use, as well as uncertainty about whether to and what to advise patients. Despite this, many sought to provide honesty in consultations by acknowledging these uncertainties about e-cigarettes with patients and taking a pragmatic approach, believing that e-cigarettes were a 'step in the right direction'. Practitioners wanted advice from healthcare regulators such as the National Institute for Health and Care Excellence to reassure them about the safety of e-cigarettes, practical tools to support the consultation, and to control their use by providing behavioural support programmes for reduction or cessation.

CONCLUSION

Current dissemination strategies for guidelines are not effective in reaching practitioners, who are offering more cautious advice about e-cigarettes than guidelines suggest is reasonable.

Source Credibility and E-Cigarette Attitudes: Implications for Tobacco Communication

As there are many conflicting sources of e-cigarette information, research is needed to determine the impact of these sources on e-cigarette attitudes to inform future communication campaigns. Source credibility is important in shaping attitudes toward other health topics; however, no study has examined its role in influencing e-cigarette attitudes. Data from the 2015 Health Information National Trends Survey-FDA (HINTS-FDA) were utilized to assess differences in trust in different sources by e-cigarette user status and to investigate the associations between trust in sources and e-cigarette attitudes (n = 3,738). Differences in trust in sources were examined using weighted linear regression. Associations between trust in sources of e-cigarette health effects and attitudes toward e-cigarettes were assessed using weighted logistic regression. Overall, e-cigarette ever users reported significantly lower trust in governmental agencies as compared to never users. Trust in e-cigarette companies was negatively associated with perceived addictiveness of e-cigarettes (AOR = 0.76, 95% CI = 0.58, 1.00), while trust in doctors/pharmacists/healthcare providers was negatively associated with harm perceptions of e-cigarettes relative to conventional cigarettes (AOR = 0.72, 95% CI = 0.55, 0.95). Trust in tobacco companies and trust in e-cigarette companies were negatively associated with absolute perceived harm of e-cigarettes (AOR = 0.70, 95% CI = 0.51, 0.95; AOR = 0.60, 95% CI = 0.46, 0.79, respectively). Results from this study indicate that the associations between trust in sources of e-cigarette health effects and e-cigarette attitudes differ both by source and specific attitude assessed. Ultimately, future campaigns should incorporate messaging to discredit industry sources of information and utilize non-governmental sources to effectively influence e-cigarette attitudes.

Exploring Physician Attitudes Regarding Electronic Documentation of E-cigarette Use: A Qualitative Study

Background:

In this article, we present qualitative work designed to explore physicians’ attitudes toward and knowledge of electronic cigarettes (or Electronic Nicotine Delivery Systems—ENDS), particularly focusing on personal attitudes held by physicians regarding ENDS use, physician beliefs regarding the relative safety of ENDS, attitudes regarding the efficacy of ENDS as a smoking cessation tool, and how physicians’ document ENDS use in the electronic health record (EHR).

Methods:

We completed a total of 17 semistructured qualitative interviews with physicians in 4 different outpatient clinic locations. Clinics were selected with the goal of reaching patient panels across a diversity of socioeconomic and local geographic locations.

Results:

The findings from our qualitative analysis suggest that physicians feel uninformed about the long-term health risks of ENDS and believe that they lack the critical medical knowledge required for discussing ENDS with their patients who smoke. Although physician responses did not endorse the view that ENDS use is a safer alternative to combustible tobacco use, approximately one-third of our physician sample did not hold strong objections to ENDS usage. Physicians placed varying degrees of importance on the issue of ENDS documentation practices.

Discussion:

Three overarching themes were revealed from our analysis. These themes included (1) physicians’ attitudes regarding the use of ENDS for smoking cessation, (2) physicians’ guidance and advisement to patients in the use of ENDS for smoking cessation, and (3) current practices of clinical documentation of ENDS use in an EHR. Our qualitative results indicate that physicians in our study rarely screen patients for ENDS use, even for those patients who are both documented smokers and recipients of physician-led tobacco cessation counseling. However, most physicians agreed that the prospect of creating a structured data field specifically for the documentation of ENDS use within the EHR would result in the likelihood of increased screening and documentation of ENDS use patterns.

Electronic cigarette use patterns and reasons for use among smokers recently diagnosed with cancer

Many patients with cancer use electronic cigarettes (e‐cigarettes), yet little is known about patterns and reasons for use. Using cross‐sectional baseline data from a randomized controlled trial, we aimed to describe prevalence and correlates of e‐cigarette use, frequency of use, and reasons for use among smokers recently diagnosed with cancer. Participants (n = 302) included adults (age ≥18 years) recently diagnosed with varied cancer types who smoked ≥1 cigarette within the past 30‐d from two US academic medical centers. Participants reported ever and current e‐cigarette use, and current e‐cigarette users reported days of e‐cigarette use and the main reason for use. We compared current, former, and never e‐cigarette users by sociodemographics, cancer type, medical comorbidities, smoking behaviors, attitudes, and emotional symptoms, and described use among current e‐cigarette users. Of smokers recently diagnosed with cancer, 49% (n = 149) reported ever e‐cigarette use and 19% (n = 56) reported current use. Of current e‐cigarette users, 29% (n = 16) reported daily use. Current e‐cigarette users did not differ from former and never e‐cigarette users by cancer type, smoking behaviors, or emotional symptoms. Women were more likely to be current users than never users, and current e‐cigarette users had less education than former users. Most current e‐cigarette users reported using them to help quit smoking (75%). One in five smokers with cancer report current e‐cigarette use, but most are not using e‐cigarettes daily. The majority report using e‐cigarettes to quit smoking. E‐cigarette use by patients with cancer appears to reflect a desire to quit smoking.

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).

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

Use of electronic nicotine delivery systems (ENDS) has increased substantially over the past decade. However, unlike smoking, which is systematically captured by clinicians through routine screening and discrete documentation fields in the electronic health record (EHR), unknown is the extent to which clinicians are documenting patients' use of ENDS. Data were gathered from medical visits with patients aged 12 and older (N=9,119; 55% male) treated in a large, integrated healthcare system. We used natural language processing to assess the incidence rates of clinician documentation of patients' ENDS use in unstructured tobacco comments in the EHR, and the words most frequently documented in relation to ENDS, from 2006-2015. ENDS documentation in the EHR increased dramatically over time (from 0.01 to 9.5 per 10,000 patients, p<0.0001), particularly among adults aged 18-24 and 25-44. Most prevalent were "e-cig," "electronic cigarettes", and "vape," with much variation in spelling and phrasing of these words. Records of adolescent and young adult patients were more likely to contain the word "vape", and less likely to have "e-cig" and "electronic cigarette" than records of adults (ps<0.0001). The relatively low observed number of patients with ENDS terms in the EHR suggested vast under documentation. While healthcare providers are increasingly documenting patients' use of ENDS in the EHR, overall documentation rates remain low. Discrete EHR fields for standard screening and documentation of ENDS that reflect the language used by patients would provide more complete longitudinal population-level surveillance of ENDS use and its association with short- and long-term health outcomes.

Worldviews and trust of sources for health information on electronic nicotine delivery systems: Effects on risk perceptions and use

Public health agencies, the news media, and the tobacco/vapor industry have issued contradictory statements about the health effects of electronic nicotine delivery systems (ENDS). We investigated the levels of trust that consumers place in different information sources and how trust is associated with cultural worldviews, risk perceptions, ENDS use, and sociodemographic characteristics using a nationally representative sample of 6051 U.S. adults in 2015. Seventeen percent of adults were uncertain about their trust for one or more potential sources. Among the rest, the Centers for Disease Control and Prevention (CDC), health experts, and the Food & Drug Administration (FDA) elicited the highest levels of trust. In contrast, tobacco and vapor manufacturers, vape shop employees, and, to a lesser extent, the news media were distrusted. Adults who had higher incomes and more education or espoused egalitarian and communitarian worldviews expressed more trust in health sources and the FDA, whereas those identifying as non-Hispanic Black or multiracial reported less trust. Current smokers, those who identified as non-Hispanic Black or other race, had lower incomes, and espoused hierarchy and individualism worldviews expressed less distrust toward the tobacco and vapor industry. Greater trust (or less distrust) toward the tobacco and vapor industry and an individualism worldview were associated with perceptions of lower risk of premature death from daily ENDS use, greater uncertainty about those risks, and greater odds of using ENDS. Public health and the FDA should consider consumer trust and worldviews in the design and regulation of public education campaigns regarding the potential health risks and benefits of ENDS.

Family Physicians' Perceived Prevalence, Safety, and Screening for Cigarettes, Marijuana, and Electronic-Nicotine Delivery Systems (ENDS) Use during Pregnancy

OBJECTIVE

Assess perceptions of prevalence, safety, and screening practices for cigarettes and secondhand smoke exposure (SHSe), marijuana (and synthetic marijuana), electronic nicotine delivery systems (ENDS; eg, e-cigarettes), nicotine-replacement therapy (NRT), and smoking-cessation medications during pregnancy, among primary care physicians (PCPs) providing obstetric care.

METHODS

A web-based, cross-sectional survey was e-mailed to 3750 US physicians (belonging to organizations within the Council of Academic Family Medicine Educational Research Alliance). Several research groups' questions were included in the survey. Only physicians who reported providing "labor and delivery" obstetric care responded to questions related to the study objectives.

RESULTS

A total of 1248 physicians (of 3750) responded (33.3%) and 417 reported providing labor and delivery obstetric care. Obstetric providers (N = 417) reported cigarette (54%), marijuana (49%), and ENDS use (24%) by "Some (6% to 25%)" pregnant women, with 37% endorsing that "Very Few (1% to 5%)" pregnant women used ENDS. Providers most often selected that very few pregnant women used NRT (45%), cessation medications (ie, bupropion or varenicline; 37%), and synthetic marijuana (23%). Significant proportions chose "Do not Know" for synthetic marijuana (58%) and ENDS (27%). Over 90% of the sample perceived that use of or exposure to cigarettes (99%), synthetic marijuana (99%), SHS (97%), marijuana (92%), or ENDS (91%) were unsafe during pregnancy, with the exception of NRT (44%). Providers most consistently screened for cigarette (85%) and marijuana use (63%), followed by SHSe in the home (48%), and ENDS (33%) and synthetic marijuana use (28%). Fewer than a quarter (18%) screened consistently for all substances and SHSe. One third (32%) reported laboratory testing for marijuana and 3% reported laboratory testing for smoking status.

CONCLUSION

This sample of PCPs providing obstetric care within academic settings perceived cigarettes, marijuana, and ENDS use to be prevalent and unsafe during pregnancy. Opportunities for increased screening during pregnancy across these substances were apparent.

Patterns of and reasons for electronic cigarette use in primary care patients

BACKGROUND

Electronic cigarette (e-cigarette) use is rising in both the general and clinical populations. Little is known about e-cigarette use in primary care, where physicians report discussing e-cigarette use with patients.

OBJECTIVE

Identify how and why smokers in primary care use e-cigarettes.

DESIGN

Cross-sectional secondary data analysis from a randomized controlled trial of a tablet intervention to deliver the 5As for smoking cessation in primary care.

PARTICIPANTS

Current smokers aged 18 and older in three primary care clinics in San Francisco, CA (N = 788).

MAIN MEASURES

Patients reported sociodemographics, cigarette smoking habits, quitting readiness, and ever and current use of e-cigarettes. We also asked reasons they have used or would use e-cigarettes. ICD-9 codes from the medical record determined comorbidities.

KEY RESULTS

Fifty-two percent (n = 408) of patients reported ever using an e-cigarette, and 20% (n = 154) reported past-30-day use. Ever e-cigarette use was associated with younger age and negatively associated with being seen at practices at a public safety-net hospital compared to a practice at University-affiliated hospital. The most common reason for having used e-cigarettes among ever e-cigarette users, and for interest in future use of e-cigarettes among never e-cigarette users, was to cut down cigarette use. The mean number of days of e-cigarette use in the past 30 increased with duration of e-cigarette use. Most current e-cigarette users did not know the nicotine content of their e-cigarettes.

CONCLUSIONS

Over half of smokers in primary care have ever used e-cigarettes, and one-fifth are currently using them. Most reported using e-cigarettes to cut down or quit cigarettes. Primary care providers should be prepared to discuss e-cigarettes with patients. Screening for e-cigarette use may help identify and treat patients interested in changing their cigarette smoking habits.

"Knowledge, recommendation, and beliefs of e-cigarettes among physicians involved in tobacco cessation: A qualitative study"

Physicians are rated the most trustworthy source of information for smokers and thus play an increasing role in disseminating information on e-cigarettes to patients. Therefore, it is important to understand what is currently being communicated about e-cigarettes between physicians and patients. This study explored the knowledge, beliefs, communication, and recommendation of e-cigarettes among physicians of various specialties. Semi-structured interviews were conducted in early 2016 with 35 physicians across five different specialties. Interviews were transcribed and coded for the following deductive themes: (1) tobacco cessation recommendation practices, (2) knowledge of e-cigarettes, (3) communication of e-cigarettes with patients, (4) recommendation of e-cigarettes, and (5) general beliefs about e-cigarettes. Physicians across all specialties reported having conversations with patients about e-cigarettes. Conversations were generally prompted by the patient inquiring about e-cigarettes as a cessation method. Overall, physicians felt there was a lack of information on the efficacy and long term health effects but despite lack of evidence, generally did not discourage patients from trying e-cigarettes as a cessation device. Although physicians did not currently recommend e-cigarettes over traditional cessation methods, they were open to recommending e-cigarettes in the future if adequate data became available suggesting effectiveness. Patients are inquiring about e-cigarettes with physicians across various specialties. Future research should continue to study physicians' perceptions/practices given their potential to impact patient behavior and the possibility that such perceptions may change over time in response to the evidence-base on e-cigarettes.

•

Physicians across specialties are having conversations with patients about ecigs.

•

Generally did not discourage patients from trying ecigs as a cessation device.

•

Physicians open to recommending ecigs for cessation in the future.

•

Adolescent use major cause of concern for physicians.

Vaporised nicotine and tobacco harm reduction for addressing smoking among people living with HIV: A cross-sectional survey of Australian HIV health practitioners' attitudes

BACKGROUND

Tobacco smoking is a major cause of morbidity and mortality among people living with HIV (PLHIV). Due to the limited success of standard abstinence-focused smoking cessation strategies in this population, there is growing interest in tobacco harm reduction (THR) approaches as an additional strategy to address these high smoking rates. This study explored the attitudes of health practitioners who provide healthcare to PLHIV towards THR.

METHODS

179 Australian health practitioners who provide healthcare to PLHIV completed an online survey that measured their attitudes towards THR approaches, including switching from cigarettes to e-cigarettes or vaporised nicotine products (VNPs).

RESULTS

Respondents supported the concept of THR but were undecided on the role of VNPs. Respondents most commonly reported 'don't know' or 'undecided' responses to statements regarding VNPs. More respondents, however, agreed than disagreed that switching from smoking to long-term vaping could reduce risk (36% and 22% respectively) and be an effective strategy to help PLHIV to quit smoking (37% agree and 17% disagree). Only a minority of respondents (20%) agreed that VNPs are too harmful to recommend to patients, however around half (53%) were undecided.

CONCLUSIONS

Despite supporting the principle of THR, health practitioners may require more evidence and knowledge about VNPs before being willing to consider them as a suitable intervention strategy.

Medical Residents' and Practicing Physicians' e-Cigarette Knowledge and Patient Screening Activities: Do They Differ?

Purpose:

The purpose of this study was to compare medical residents and practicing physicians in primary care specialties regarding their knowledge and beliefs about electronic cigarettes (e-cigarettes). We wanted to ascertain whether years removed from medical school had an effect on screening practices, recommendations given to patients, and the types of informational sources utilized.

Methods:

A statewide sample of Florida primary care medical residents (n = 61) and practicing physicians (n = 53) completed either an online or paper survey, measuring patient screening and physician recommendations, beliefs, and knowledge related to e-cigarettes. χ² tests of association and linear and logistic regression models were used to assess the differences within- and between-participant groups.

Results:

Practicing physicians were more likely than medical residents to believe e-cigarettes lower cancer risk in patients who use them as an alternative to cigarettes (P = .0003). Medical residents were more likely to receive information about e-cigarettes from colleagues (P = .0001). No statistically significant differences were observed related to e-cigarette knowledge or patient recommendations.

Conclusions:

Practicing primary care physicians are accepting both the benefits and costs associated with e-cigarettes, while medical residents in primary care are more reticent. Targeted education concerning the potential health risks and benefits associated with the use of e-cigarettes needs to be included in the current medical education curriculum and medical provider training to improve provider confidence in discussing issues surrounding the use of this product.

Motivations and Limitations Associated with Vaping among People with Mental Illness: A Qualitative Analysis of Reddit Discussions

This study aims to understand the nature and significance of online lay discussions about e-cigarettes and mental illness. We systematically searched the website Reddit.com using keywords related to e-cigarettes and mental illness. We coded relevant posts into themes under the framework of motivations for and limitations of vaping for people with mental illness. The thematic analysis included 3263 comments from 133 discussion threads. Six themes were classified as motivations to vape for people with mental illness: Self-medication; Quitting smoking; Freedom and control; Hobby; Social connectedness; and Motivation from caregivers and online communities. The limitations of vaping included: Unsatisfactory substitute for cigarettes and psychiatric medicines; Drug interactions; Nicotine addiction; Risks of e-liquid; Practical difficulties and Cost. People with mental illness; and their carers; use online discussion boards like Reddit to discuss the benefits and limitations of e-cigarettes for people with mental illness. Both positive and negative views exist. Media platforms like Reddit may shape the opinions of stakeholders and generate lay expertise about contentious health topics such as e-cigarettes. These findings have implications for policy and practice concerning assisting smokers with mental illness to reduce their health risk through switching to e-cigarettes.

Online Patient-Provider E-cigarette Consultations: Perceptions of Safety and Harm

INTRODUCTION

E-cigarettes are popular and unregulated. Patient-provider communications concerning e-cigarettes were characterized to identify patient concerns, provider advice and attitudes, and research needs.

METHODS

An observational study of online patient-provider communications was conducted January 2011-June 2015 from a network providing free medical advice, and analyzed July 2014-May 2016. Patient and provider themes, and provider attitudes toward e-cigarettes (positive, negative, or neutral) were coded qualitatively. Provider attitudes were analyzed with cumulative logit modeling to account for clustering. Patient satisfaction with provider responses was expressed via a Thank function.

RESULTS

An increase in e-cigarette-related questions was observed over time. Patient questions (N=512) primarily concerned specific side effects and harms (34%); general safety (27%); e-cigarettes as quit aids (19%); comparison of e-cigarette harms relative to combusted tobacco (18%); use with pre-existing medical conditions (18%); and nicotine-free e-cigarettes (14%). Half of provider responses discussed e-cigarettes as a harm reduction option (48%); 26% discussed them as quit aids. Overall, 47% of providers' responses represented a negative attitude toward e-cigarettes; 33% were neutral (contradictory or non-committal); and 20% were positive. Attitudes did not differ statistically by medical specialty; provider responses positive toward e-cigarettes received significantly more Thanks.

CONCLUSIONS

Examination of online patient-provider communications provides insight into consumer health experience with emerging alternative tobacco products. Patient concerns largely related to harms and safety, and patients preferred provider responses positively inclined toward e-cigarettes. Lacking conclusive evidence of e-cigarette safety or efficacy, healthcare providers encouraged smoking cessation and recommended first-line cessation treatment approaches.

Physician Advice for e-Cigarette Use

PURPOSE

To determine characteristics of smokers discussing e-cigarette use with their physician and receiving recommendations from their physician to use e-cigarettes for smoking cessation.

METHODS

US adult smokers who had visited a physician in the previous 12 months (n = 2671) were surveyed. Logistic generalized estimating equation models were used to assess the characteristics of smokers who (1) talked to a physician about e-cigarettes, and (2) received physician advice to use e-cigarettes for smoking cessation.

RESULTS

15% (n = 406) of smokers who visited a physician talked with their physician about e-cigarettes. Among those asked whether their physician recommend e-cigarettes for smoking cessation (n = 257), 61% responded affirmatively. Current e-cigarette users were more likely to talk to their physicians about e-cigarettes (nondaily users vs never users: OR, 2.70; 95% CI, 1.79-4.05; daily users vs never users: OR, 4.29; 95% CI, 2.34-7.84) and have their physician recommend e-cigarettes for smoking cessation (daily users vs never users: OR, 9.40; 95% CI, 2.54-34.71).

CONCLUSIONS

The majority of smokers who talk to their physician about e-cigarettes report that they received advice to use e-cigarettes to quit smoking, despite limited evidence for their efficacy. More studies are needed to better understand e-cigarette recommendations in clinical settings.

Beliefs, Practices, and Self-efficacy of US Physicians Regarding Smoking Cessation and Electronic Cigarettes: A National Survey

INTRODUCTION

We sought to assess physician knowledge/beliefs, self-efficacy, and experience/practice patterns surrounding smoking cessation and electronic cigarettes.

METHODS

An eight-page survey sent via US Postal service. The initial invitation included a $10 cash incentive and up to three invitations were sent. Fifteen hundred US physicians were identified with equal representation from primary care physicians (internal medicine and family practice), surgical care physicians (general surgeons and anesthesiologists), and pulmonologists.

RESULTS

Two hundred fourteen were not included in the analysis (183 non-deliverable, one deceased, 30 not practicing). 561/1286 (44%) remaining surveys were returned for analysis. Greater than 90% agreed that advising and assisting with smoking cessation is their responsibility; 86% advise and 65% assist their patients with smoking cessation more than 75% of the time. Approximately two-thirds of respondents report that their patients ask them about electronic cigarettes at least some of the time (≥25%); 58.4% report that they ask their patients about electronic cigarette use at least some of the time. Overall, 37.9% have at some point recommended electronic cigarettes to their patients that smoke, with 11.5% reporting recommending them at least 25% of the time. Surgical care providers appear less confident and less self-efficacious with smoking cessation, as well as with electronic cigarettes and appear less likely to endorse use of electronic cigarettes.

DISCUSSION

US physicians are frequently discussing electronic cigarettes in a clinical context and a substantial proportion of US physicians have recommended electronic cigarettes to their patients.

IMPLICATIONS

This study documents several important previously poorly characterized aspects of the role of electronic cigarettes in clinical care. The majority of US physicians are discussing electronic cigarettes in clinical contexts and a substantial proportion of US physicians have recommended electronic cigarettes to their patients. The extent of physician engagement on the topic of electronic cigarettes should be met with increased efforts to better characterize electronic cigarettes' appropriate role in smoking cessation and reduction.

Health professionals in Flanders perceive the potential health risks of vaping as lower than those of smoking but do not recommend using e-cigarettes to their smoking patients

Background

Many misperceptions of both risks and opportunities of e-cigarettes (e-cigs) exist among the general population and among physicians, although e-cigs could be a valuable harm reduction tool for current smokers.

Methods

Two groups in Flanders, namely general practitioners (GPs; family doctors) and tobacco counselors filled out an online questionnaire with regard to their attitudes and risk perceptions concerning e-cigs. Statements included were on the safety and the addictive properties of e-cigs in absolute terms, whereas other items compared e-cigs with regular tobacco cigarettes. Statements about possible “gateway” and “renormalization” effects, selling to minors, and use in public places and on the potential of e-cigs as a smoking cessation aid were also included. Respondents were also asked for the rate at which their patients asked information about e-cigs, if they would recommend e-cigs to their smoking patients, and whether they had information brochures on e-cigs.

Results

About 70 % believed that e-cigs are harmful to vapers, and about half to two thirds believed that e-cigs are carcinogenic, increase cardiovascular risk, and increase the risk of chronic lung disease. Also, a substantial minority incorrectly believed these risks to be no less than those resulting from regular smoking. Ten to almost 20 % disagreed that e-cigs are healthier and represent less risk for the main serious smoking-related diseases than conventional cigarettes. More than half of the respondents disagreed that e-cigs are an effective smoking cessation aid. None (0 %) offered the strongest level of agreement for recommending e-cigs to their clients/patients, but GPs agreed to a lesser degree a bit more often than tobacco counselors. Almost none had information leaflets for potentially interested patients. Finally, the majority of our sample also believed that e-cigs will cause renormalization of smoking and that e-cigs will lead to an uptake of conventional smoking and disagreed with allowing vaping in enclosed public places.

Conclusions

Health professionals in Flanders perceive the potential health risks of vaping as lower than those of smoking but do not recommend using e-cigs to their smoking patients.

Knowledge and Perceptions about Nicotine, Nicotine Replacement Therapies and Electronic Cigarettes among Healthcare Professionals in Greece

Introduction. The purpose of this study was to evaluate the knowledge and perceptions of Greek healthcare professionals about nicotine, nicotine replacement therapies and electronic cigarettes. Methods. An online survey was performed, in which physicians and nurses working in private and public healthcare sectors in Athens-Greece were asked to participate through email invitations. A knowledge score was calculated by scoring the correct answers to specific questions with 1 point. Results. A total of 262 healthcare professionals were included to the analysis. Most had daily contact with smokers in their working environment. About half of them considered that nicotine has an extremely or very important contribution to smoking-related disease. More than 30% considered nicotine replacement therapies equally or more addictive than smoking, 76.7% overestimated their smoking cessation efficacy and only 21.0% would recommend them as long-term smoking substitutes. For electronic cigarettes, 45.0% considered them equally or more addictive than smoking and 24.4% equally or more harmful than tobacco cigarettes. Additionally, 35.5% thought they involve combustion while the majority responded that nicotine in electronic cigarettes is synthetically produced. Only 14.5% knew about the pending European regulation, but 33.2% have recommended them to smokers in the past. Still, more than 40% would not recommend electronic cigarettes to smokers unwilling or unable to quit smoking with currently approved medications. Cardiologists and respiratory physicians, who are responsible for smoking cessation therapy in Greece, were even more reluctant to recommend electronic cigarettes to this subpopulation of smokers compared to all other participants. The knowledge score of the whole study sample was 7.7 (SD: 2.4) out of a maximum score of 16. Higher score was associated with specific physician specialties. Conclusions. Greek healthcare professionals appear to overestimate the adverse effects of nicotine, and many would not recommend any nicotine-containing product as a long-term smoking substitute. Additionally, they have poor knowledge about the function and characteristics of electronic cigarettes.

Primary Care Physicians' Beliefs and Practices Regarding E-Cigarette Use by Patients Who Smoke: A Qualitative Assessment

We explored primary care physicians’ (PCPs’) beliefs and practices about e-cigarettes. Cross-sectional, semi-structured interviews with PCPs in 2014 were conducted and audio-recorded. Participants were 15 general internal and family medicine physicians practicing in two settings in Virginia, USA. Interview recordings were transcribed, and the content analyzed using the Constant Comparative Method to identify key themes regarding PCPs’ reported current practices and beliefs. Five themes were identified: (1) existing clinic processes do not include mechanisms to screen for noncombustible tobacco products (such as e-cigarettes); (2) e-cigarette discussions are becoming commonplace with patients initiating the discussions and seeking physician guidance regarding e-cigarette use; (3) a lack of knowledge regarding the potential harms and benefits of e-cigarettes, yet a willingness to support their patients’ desire to use e-cigarettes (4) believing e-cigarettes are a safer alternative to smoking combustible tobacco products; and (5) abandoning concerns regarding the potential harms of e-cigarettes in the context of highly addicted patients and those with extensive comorbidities. Despite acknowledging limited knowledge regarding e-cigarettes, findings suggest that some PCPs are currently recommending e-cigarettes to their patients for smoking cessation and relative harm reduction, often personalizing recommendations based on the patient’s perceived addiction level and current health status. Physicians need to be informed about the evolving evidence regarding the risks and benefits of e-cigarettes.

Physicians' Counseling of Adolescents Regarding E-Cigarette Use

PURPOSE

Electronic cigarette (e-cigarette) use now surpasses the use of conventional cigarettes among U.S. adolescents. Given the important role of physicians in preventing adolescent risk behaviors, we sought to understand how physicians communicate about e-cigarettes when counseling adolescent patients and their parents. We also explored physicians' support for regulations aimed at discouraging adolescents' e-cigarette use.

METHODS

A national U.S. sample of 776 pediatricians and family medicine physicians who provide primary care to adolescent patients completed an online survey in Spring 2014.

RESULTS

Many physicians (41%) would, if asked, tell their patients that e-cigarettes are less harmful than cigarettes, and a substantial minority (24%) would recommend e-cigarettes to adolescents for smoking cessation. Most physicians reported routinely screening adolescent patients for cigarette smoking but few routinely screened for e-cigarette use (86% vs. 14%; p < .001). Routine counseling was similarly more common for avoiding cigarette smoking than for avoiding e-cigarette use (79% vs. 18%; p < .001). Support for government regulation of e-cigarettes was high, with 91% of physicians endorsing policies that prevent minors from buying e-cigarettes.

CONCLUSIONS

Physicians infrequently screen or counsel their adolescent patients about e-cigarette use, although e-cigarettes often come up during visits. Additional efforts by physicians could help prevent future use by adolescents. Recommending e-cigarettes as a smoking cessation aid to adolescent patients is inadvisable given the lack of evidence for efficacy in that population. As federal regulation of e-cigarettes remains in limbo, pediatricians and family medicine physicians can offer a powerful voice for informing regulations aimed at reducing use by adolescents.

Smokers' sources of e-cigarette awareness and risk information

INTRODUCTION

Few studies have explored sources of e-cigarette awareness and peoples' e-cigarette information needs, interests or behaviors. This study contributes to both domains of e-cigarette research.

METHODS

Results are based on a 2014 e-cigarette focused survey of 519 current smokers from a nationally representative research panel.

RESULTS

Smokers most frequently reported seeing e-cigarettes in stores (86.4%) and used in person (83%). Many (73%) had also heard about e-cigarettes from known users, broadcast media ads (68%), other (print, online) advertisements (71.5%), and/or from the news (60.9%); sources of awareness varied by e-cigarette experience. Most smokers (59.9%) believed e-cigarettes are less harmful than regular cigarettes, a belief attributed to "common sense" (76.4%), the news (39.2%) and advertisements (37.2%). However, 79.5% felt e-cigarette safety information was important. Over one-third said they would turn to a doctor first for e-cigarette safety information, though almost a quarter said they would turn to the Internet or product packaging first. Most (59.6%) ranked doctors as the most trustworthy risk source, and 6.8% had asked a health professional about e-cigarettes.

CONCLUSIONS

Future research should explore the content of e-cigarette information sources, their potential impact, and ways they might be strengthened or changed through regulatory and/or educational efforts.