Mixed Messages Common in Physician Advice on e-Cigarettes

Nancy A. Melville

September 01, 2016

In advising patients on the use of e-cigarettes, physicians are generally negative, emphasizing concerns about their use, but many fail to convey the lack of evidence on the efficacy of e-cigarettes in smoking cessation, according to a new analysis of patient questions and physician advice in an online health forum.

"The topic for which we observed the biggest discrepancy between provider advice and the research evidence was with regard to use of e-cigarettes as an aid to quit combustible cigarettes," senior author Judith J. Prochaska, PhD, MPH, of the Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, in California, told Medscape Medical News.

"Nearly 3 of 4 doctors (74%) responding on the theme of e-cigarettes for [tobacco smoking cessation] were positive in attitude toward e-cigarettes, with 9% negative and 7% neutral," she said.

Although e-cigarettes are commonly promoted as cessation tools, only two published randomized controlled trials have evaluated e-cigarettes as cessation devices, and both showed no difference between placebo and nicotine e-cigarettes, she noted.

"A medication that fails to outperform its placebo would certainly not receive FDA [US Food and Drug Administration] approval as a therapeutic aid," she said.

The observational study published online August 26 in the American Journal of Preventive Medicine, involved evaluation of online patient-provider communications conducted between January 2011 and June 2015 on the HealthTap digital health service, an online forum in which US-licensed medical providers respond to anonymous patient questions.

Of 9723 tobacco-related questions posted by patients during the study period, 512 (5.3%) related to e-cigarettes, with the percentage increasing from 1.2% of questions in 2011 to 7.9% in 2015, reflecting an increase in the public's use of e-cigarettes.

The majority of patient questions (34%) related to side effects and harms, such as numb tongue, twitching in the ear, cancer, and chest pain.

Those concerns were followed by concerns regarding general e-cigarette safety (27%); use as an aid to quit (19%); harm reduction compared with tobacco smoking (18%); use with preexisting medical conditions (18%); and nicotine-free e-cigarettes (14%).

Other inquiries, representing fewer than 10% of questions, involved risks presented by e-cigarette chemicals, such as flavorings; use of e-cigarettes by youth; nicotine health risks; detection via drug testing; use among nonsmokers; secondhand vapor; regulatory issues; and addiction.

Among 623 responses from 366 providers included in the analysis, the most common themes generally matched topics in the inquiries, topped by harms of e-cigarettes compared with tobacco (46%), followed by general safety (34%).

Physician responses were recorded as being negative in tone regarding e-cigarettes in 46% of responses, and positive in 20%. Responses included topics not mentioned by patients, such as the need for more research on issues of safety of e-cigarettes compared with tobacco smoking.

Among 168 providers who gave advice on quitting, 31% recommended quitting cold turkey or did not identify a formal cessation method, and 54% included e-cigarettes as cessation aids.

Dr Prochaska noted that clinical practice guidelines for quitting smoking recommend counseling and use of FDA-approved cessation medications.

"It was concerning that among the 168 providers that advised quitting smoking, only 15% were consistent with the clinical practice guideline, while a majority (54%) included e-cigarettes as a cessation aid, and 31% advised quitting cold turkey," Dr Prochaska said.

Most provider responses were negative in terms of use of e-cigarettes among nonsmokers.

In further evaluating patterns of patients thanking physicians for their responses, the researchers found that most of the thankful replies were directed to physicians who gave positive messages about e-cigarettes.

"That finding is really interesting in thinking about how physicians might best connect with their patients," co–lead author Cati Brown-Johnson, PhD, a postdoctoral scholar with the department, said in a press statement.

"Doctors might consider conveying their information about e-cigarettes in a nonjudgmental way, even when conveying the risks," she said.

The US Preventive Services Task Force and other organizations have concluded that evidence is currently insufficient to determine the relative benefits vs harm of e-cigarettes for smoking cessation.

Studies show that awareness of recommendations appears lacking. In one recent study, 38.5% of smokers believed the FDA had approved e-cigarettes as a cessation aid, and 18% reported that a provider had indicated support of e-cigarettes for cessation.

A survey of North Carolina physicians conducted in 2013 showed that physicians supported the use of e-cigarettes for cessation. Two thirds of respondents considered e-cigarettes to be helpful cessation aids, and more than one third recommended them for patients who smoke.

According to Vaughan Rees, PhD, director of the Center for Global Tobacco Control at the Harvard T. H. Chan School of Public Health, in Boston, Massachusetts, such advice may be based in sound reasoning.

"Although health providers are recommending e-cigarettes as a cessation tool without supporting evidence, there may be pragmatic reasons besides a lack of awareness," he told Medscape Medical News.

"Engaging patients and encouraging and providing support for cessation efforts ― both now and in the longer term ― may be just as important as the actual strategy used to quit," he said.

In the debate over e-cigarettes, the acceptance of the cigarettes by many as a means of reducing exposure to tobacco use is countered by concerns about exposure to other toxic substances and the potential to lead to increased use of nicotine products in adolescents, Dr Rees explained.

"There may be merits to both arguments," he said.

"In time, with better information on the health risks of e-cigarettes and policies to prevent youth uptake, we may find a way to realize some benefit from these products."

The new study offers important insights into current perceptions and practices on e-cigarettes ― with some caveats, Dr Rees said.

"The study provides a helpful snapshot of patient/provider discussions on e-cigarettes, but is limited to patients enrolled in a specialized health and reflects a narrow US context," he says.

"But as a first study of its kind, it may prompt deeper inquiry into the way physicians handle e-cigarette queries, including from broader perspectives."

The US Center for Disease Control and Prevention reports that 3.7% of US adults currently use e-cigarettes regularly. Surveys show that past-month e-cigarette use is most common among current smokers (21%) in comparison with former (4%) and never (1%) smokers, according to the study.

To help inform physicians of the latest evidence on health effects of e-cigarettes and offer guidance in communicating the information to patients, Dr Prochaska and her colleagues have developed an interactive educational portal, which is scheduled to be available online through the Stanford Center for Continuing Medical Education this fall.

The study received support from the National Heart, Lung, and Blood Institute, the National Cancer Institute, and the State of California Tobacco-Related Disease Research Program. Dr Prochaska has received consulting fees from Pfizer, which makes smoking-cessation medications, and has been a paid expert in court cases against the tobacco companies. The other authors of the study have disclosed no relevant financial relationships.

Am J Prev Med. Published online August 26, 2016. Full text


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