Research on e-Cigarettes Lacking but Needed by Clinicians

Kate Johnson

October 24, 2016

LOS ANGELES — Healthcare providers are fielding a growing number of questions from patients about e-cigarettes, but they have widely different opinions on their use as a tool for smoking cessation, according to results from a new survey.

"The division of opinion on e-cigarette effectiveness for smoking cessation was surprising and striking," said investigator Stephen Baldassarri, MD, a fellow in pulmonary and critical care medicine at the Yale School of Medicine in New Haven, Connecticut.

"It suggests that two different doctors could give the same patient opposite advice," he told Medscape Medical News.

Therefore, "it is important that we continue to generate high-quality research on the risks of these products and determine whether they can provide benefit by reducing harm among traditional cigarette smokers," he said.

Some major questions need to be answered, Dr Baldassarri added. Do e-cigarettes reduce harm in tobacco smokers who switch? Are e-cigarettes a gateway to tobacco products for adolescents and other nonsmokers? Can e-cigarettes serve as an exit from cigarettes?

Results from the survey were presented here at CHEST 2016: American College of Chest Physicians Annual Meeting.

The use of e-cigarettes is rising in the United States, according to the Centers for Disease Control and Prevention. In 2013, 2.5 million middle-school and high-school students used e-cigarettes; this rose to 3 million in 2015. The pattern in adults is similar.

Dr Baldassarri and his team conducted a survey to determine what healthcare providers are telling patients who want to use using e-cigarettes for smoking cessation.

Of the 994 clinicians who responded (5.5% response rate), 77% practiced in the United States. The majority of respondents were pulmonary or critical care specialists.

Although 69% of respondents said they consider e-cigarettes intrinsically harmful to human health, opinions about their use as smoking-cessation aids were evenly split, with about one third agreeing they are effective, one third disagreeing, and one third having no opinion.

"Even health organizations differ in their current opinions," Dr Baldassarri noted.

"The Forum of International Respiratory Societies, which includes both the American College of Chest Physicians and the American Thoracic Society, has taken the position that e-cigarettes represent a threat to some of the progress made in tobacco control over the past 50 years and should therefore be viewed with caution," he reported.

In contrast, "the British Royal College of Physicians has broadly recommended the use of e-cigarettes for its smoking population as a means to reduce smoking-related harms," he said.

Patients Asking Providers

The survey showed that patients are asking providers about e-cigarettes. "Here, the results were very clear," said Dr Baldassarri.

Of the survey respondents, 88% reported having at least some patients who asked about e-cigarettes, and 80% said at least some of their patients were using electronic cigarettes specifically for the purpose of smoking cessation.

Concern that e-cigarettes could increase the risk for relapse by those who had quit smoking was expressed by 48% of respondents.

The team looked at how e-cigarettes compare with first-line treatments for smoking cessation approved by the US Food and Drug Administration (FDA), such as nicotine replacement, varenicline, or bupropion.

Fifty-three percent of respondens considered e-cigarettes less effective than FDA-approved treatments. Still, 35% said they agree that patients who have failed one or more quit attempts should use e-cigarettes, whereas 36% said they disagree.

"I always want to encourage any attempt at quitting smoking. I try to emphasize that we have proven effective treatments, and I make it a point to make sure patients have had at least some attempts using standard therapy," said Dr Baldassarri. "But if a patient comes to me and says they've tried everything and nothing worked, but e-cigarettes helped them stop, I congratulate them. I don't necessarily tell them that's a bad thing, but I do say we don't know fully what the effects are of these products."

The results of this survey are not surprising, said session moderator Melissa Tukey, MD, assistant professor of medicine at Brown University and director of the Interventional Pulmonology at Comprehensive Cancer Center at Rhode Island Hospital in Providence.

"It's something we're hearing a lot about, and it's very challenging for us as clinicians because the adoption of these products happened long before much information about their safety profile was provided," she told Medscape Medical News.

"The studies haven't been done because the products are so new, and a lot of the health concerns that we're worrying about are things that happen after exposure to toxins over a long period of time," she pointed out.

"Early studies on e-cigarettes have looked at absolute toxin content, and that does seem to be quite a bit lower than conventional cigarettes, so our gut reaction is it's the lesser of two evils," Dr Tukey explained. "But we've all seen things in medical practice considered conventional wisdom for decades but later proven to have unintended consequences."

"As clinicians, we have to have honest and upfront conversations with our patients about what we do know and what we don't know. But whether to encourage patients to switch from something that we know is so toxic to an alternative product that we don't know that much about — it's challenging to know if that's the right thing to do," she said.

In my opinion, e-cigarettes are not a smoking-cessation device. Dr John Studdard

A more definitive statement came from John Studdard, MD, a critical care physician in private practice at Jackson Pulmonary Associates in Mississippi, who is president-designate of CHEST.

"In my opinion, e-cigarettes are not a smoking-cessation device," he told Medscape Medical News.

"It concerns me that more healthcare providers are not asking if patients are using e-cigarettes and that so many don't feel comfortable discussing health effects. This speaks to the need for more education of healthcare providers and the public," he said. "Certainly, more research is also needed."

Dr Baldassarri, Dr Tukey, and Dr Studdard have disclosed no relevant financial relationships.

CHEST 2016: American College of Chest Physicians Annual Meeting. Presented October 23, 2016.

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