Physicians Divided on Recommending E-Cigarettes for Quitting

Marcia Frellick

August 08, 2014

Two thirds of physicians (67%) say e-cigarettes can help patients stop smoking, and 36% recommend them to their patients, according to a study published online July 29 in PloS One.

The recommendations come despite lack of approval from the US Food and Drug Administration (FDA) for e-cigarettes as a smoking cessation tool and in light of studies that downplay their effectiveness in helping people quit.

Lead author Kelly Kandra, PhD, from the Department of Psychology and Sociology, Benedictine University, Lisle, Illinois, and colleagues sent the survey by email to a random sample of 787 North Carolina physicians, 413 of whom opened it. Of those physicians, 128 responded (31%).

Of the physicians who responded who were active in clinical practice, 64.7% had practiced 10 or more years in their field, 85.2% saw 26 or more patients in a typical week, and 56.6% lived in areas with a population greater than 100,000. The majority were white men who had never smoked.

Most (64.8%) believed that e-cigarettes lower the risk for cancer in patients who use them instead of smoking traditional cigarettes. E-cigarettes were also often part of the clinical encounter, with 48.4% of physicians saying that patients ask about e-cigarettes frequently or sometimes.

The authors note that results are limited by the small size of the study and because it surveyed physicians in only a single state.

Darl Rantz, MD, a solo family practitioner in Macon, Georgia, is among the believers. He told Medscape Medical News that he recommends e-cigarettes, or electronic devices that let smokers inhale a vaporized liquid nicotine solution, for all his smoking patients older than 18 years. He says the potential benefit, even if it can help only a percentage of smokers, is worth the risk from any toxins, which he says are a fraction of the known toxins in cigarettes.

"Nothing's perfect, but cigarettes are far from perfect because they're causing 480,000 deaths per year," he said.

"You're going to outlaw a product that doesn't help everybody quit smoking?" Dr. Rantz said. "Where's the logic in that? Even if it only works in 10% of the population, you've just saved 10% of the [smoking] population's life, and you cut my healthcare budget."

As to the studies that say they do not help people quit, he said he would like to see further studies in multisite, randomized, controlled trials with placebo comparisons. He says he knows what he sees in his practice, and he estimates that among the 10% of his patients whom he has convinced to try the e-cigarettes, about 10% have quit traditional cigarettes completely.

He says the benefit of e-cigarettes over nicotine gum and nicotine patches is that this alternative mimics the act of smoking, which makes it easier for people to accept. For his patients who chew tobacco, he recommends nicotine gum or lozenges to mimic those effects instead.

Authors Recommend Approved Treatments

However, study coauthor Leah Ranney, PhD, from the Department of Family Medicine at the University of North Carolina School of Medicine and associate director of the Tobacco Prevention and Evaluation Program at University of North Carolina, Chapel Hill, told Medscape Medical News that because the safety of e-cigarettes is unclear and because the patch and the gum are FDA-approved for smoking cessation, the latter solutions should be considered as first-line treatments in any tobacco cessation effort.

She said researchers were particularly surprised by the study's findings that 13% of physicians incorrectly thought e-cigarettes were approved by the FDA for smoking cessation.

The researchers also noted that some physicians are working against a general public perception, documented in previous reviews, that e-cigarettes are effective for quitting smoking and reducing harm.

In addition, Dr. Ranney said, the problem is not just lack of evidence that they work to help people stop smoking but also a lack of research on whether they can cause harm or entice nonsmokers to start smoking.

"Without knowing the information or having rigorous research behind it, we leave ourselves open, with making these recommendations, to being incorrect," she said.

Amount of Nicotine Not Disclosed

Ari Gilmore, MD, a family practitioner at Pacific Medical Center in Seattle, Washington, told Medscape Medical News he was "astounded" that so many physicians indicated in the survey said they would recommend e-cigarettes.

"I'm not a fan," he said, and he says that sentiment is widely shared, if not universal, among his practice of 1200 physicians.

Dr. Gilmore said in his experience, many patients are not quitting but, instead, are smoking both e-cigarettes and regular cigarettes.

There is much we do not know, he noted, because without federal regulation, manufacturers do not have to disclose how much nicotine is in the e-cigarettes, nor the amounts of other compounds.

He also said they could backfire.

"My fear is if they find it a more palatable experience, then you actually reduce the chance of quitting overall in the long term," he said.

Celebrity endorsements and marketing of appealing fruity flavors are not helping, he added, and are feeding the public perception that the e-cigarettes are "less bad."

On one point, however, physicians agree: The soaring popularity of e-cigarettes means more patients will have more questions. Meanwhile, the FDA has issued a proposed rule that would extend the agency's authority to cover e-cigarettes as a tobacco product. Short of an FDA ruling, consensus will be hard to come by.

"It takes a bit of time to collect all the research that's going on and then make determinations about the quality of research," Dr. Ranney said. "The more guidance physicians have about the long-term safety and effectiveness of the cigarettes, the more confidence they can feel in their recommendations."

This work was funded in part by the North Carolina Department of Health and Human Services and the National Cancer Institute of the National Institutes of Health. The authors, Dr. Ranney, Dr. Gilmore, and Dr. Rantz have disclosed no relevant financial relationships.

PLoS ONE. Published online July 29, 2014. Full text

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