Study Shows More and More Doctors Are Recommending E-Cigarettes to Patients

If you ask two different doctors about e-cigarettes, you might get two different answers.

Regardless of the device you want to learn about, whether it’s the safety of heated liquid nicotine and inhalable aerosol flavors or how to use them to quit smoking tobacco cigarettes, doctors have a wide range of responses when advising patients.

This was found in a new study by researchers at Stanford University School of Medicine, which analyzed over 500 online interactions between patients and doctors discussing e-cigarettes. The study will be published online in the American Journal of Preventive Medicine on August 26.

“Researchers have previously investigated doctors' knowledge and attitudes about e-cigarettes. In this study, we were curious about the actual behavior of providers in advising doctors during real patient interactions,” said Judith Prochaska, PhD, MPH, senior author of the study and an associate professor of medicine at the Stanford Prevention Research Center. “On a new online medical forum, we were able to observe the specific advice doctors gave to patients and see how recommendations varied by topic and clinician.”

The new observations have helped Prochaska and her colleagues develop an educational portal for doctors to inform them about what they should know regarding the health impacts of e-cigarettes and how to communicate the benefits and risks of the devices to patients. Continuing medical education credits are offered through interactive programs provided online by the Stanford Center for Continuing Medical Education.

Development Trends

While traditional cigarettes deliver nicotine to a person’s body as they inhale, e-cigarettes work by heating liquid to vaporize it without burning tobacco. The use of e-cigarettes among adults and adolescents has rapidly increased since they appeared on the market a decade ago. According to the latest estimates from the Centers for Disease Control and Prevention, 3.7% of American adults regularly use e-cigarettes. The devices are often promoted as safer than combustible cigarettes and are recommended as smoking cessation aids, but there is little long-term evidence to support any claims.

“There is rapid growth in the promotion and use of these products, while the evidence base for their safety and effectiveness in smoking cessation is lacking,” Prochaska said.

Because e-cigarettes are so new, there is little research on them, and doctors have few resources to rely on when patients inquire about the devices. For this reason, Prochaska and her colleagues wanted to know what doctors generally say and whether they communicate uncertainty.

“For me, the biggest question in smoking cessation work is how to guide patients about e-cigarettes,” said postdoctoral scholar Kaci Brown-Johnson, co-first author of the new paper.

A New Source of Data

Prochaska and Brown-Johnson teamed up with researchers at HealthTap, an online health company that allows users to submit medical questions answered by any of the 72,000 practicing physicians partnered with the site.

“Sitting back and watching years of live interactions between patients and doctors was really the best way for us to get data,” Brown-Johnson said.

When the scientists searched through the site for anonymous questions posted from July 2011 to June 2015, they identified nearly 10,000 questions related to tobacco or smoking. Among these, about 500 mentioned e-cigarettes, and the rate of questions related to e-cigarettes increased over the four-year period.

These questions ranged from simple inquiries like “Are e-cigarettes unsafe, and can they be addictive?” to more specific questions such as “Does nicotine/e-cigarettes cause hair loss?” and “Can vapor affect asthma?” Overall, about 27% of questions were about specific side effects and e-cigarettes, 19% were about general safety, and 34% were about using e-cigarettes as smoking cessation aids.

For each question and answer, the researchers analyzed what topics were mentioned by patients and doctors, whether the answers were framed in a negative or positive tone regarding e-cigarettes, and whether patients clicked a button to thank providers for their answers.

Mixed Messages

The most common topics raised by doctors matched the most common questions from patients: specific side effects and general safety. However, doctors also frequently raised topics not mentioned by patients, including the need for more research on e-cigarettes and the relative safety of e-cigarettes compared to combustible tobacco. Additionally, clinicians often mentioned nicotine more frequently than patients, who often expressed particular concern about nicotine addiction.

When it came to the overall tone of doctors' responses, there was a range: 47% of answers were considered negative by researchers regarding e-cigarettes, for example, emphasizing the risks of the devices and discouraging patients from using them. Another 20% were positive, such as encouraging the use of e-cigarettes as smoking cessation aids.

When it came to specific requests for smoking cessation, 54% of doctors mentioned e-cigarettes as a potential tool.

“Existing research, however, does not indicate that e-cigarettes help people quit combustible cigarettes,” Prochaska said. “This is an area that needs more research.”

Doctor Education

When researchers looked at how often patients thanked providers for their answers, they also found a trend: most people thanked doctors who provided positive information about e-cigarettes.

“This finding is interesting in thinking about how physicians are most likely to connect with patients,” Brown-Johnson said. “Doctors might consider delivering information about e-cigarettes in a non-judgmental way, even when discussing risks,” she said.

The research report also suggests other ways that scientists studying vaping and smoking can help doctors communicate better with patients. “This indicates the need for education for e-cigarette providers to make them aware of the so-called limitations,” Prochaska said. Future research, they said, could inform how doctors might adjust messages about e-cigarettes for different types of patients.

Andrei Berbank, MD, another co-first author and a former Stanford Health4All researcher, said the study “is an example of evidence-based medicine in the information age. With this data, we can quickly prioritize real-world concerns about e-cigarettes for decision-makers and researchers.”