Background Use of the electronic cigarette for nicotine delivery has increased dramatically in recent years. Information continues to emerge on its role as a smoking cessation aid, but little is known about resident physician use of the device in clinical practice.
Methods In 2015, an electronic survey was administered to resident physicians in one healthcare system in Columbus, Ohio. The survey included questions about personal smoking exposure, knowledge, beliefs, attitudes about electronic cigarettes and early adoption of electronic cigarettes with patients. Data were dichotomised based on a ‘stages of change’ model that assessed resident physician adoption of electronic cigarettes for therapeutic use. Data were analysed through χ2 tests and logistic regression using ORs and 95% CIs.
Results Of 338 residents, 142 (42%) responded. Of all residents, 25 (17.7%) reported that they have been recommending electronic cigarettes to their patients for the past 6 months or longer. In the multivariate model, residents ≥postgraduate year (PGY)-3 (OR=3.68, 95% CI 1.20 to 11.29), peer-reviewed article exposure (OR=6.65, 95% CI 1.56 to 28.38) and the view that addictive potential is definitely or somewhat less than traditional cigarettes (OR=5.05, 95% CI 1.48 to 17.24) were associated with recommendation of electronic cigarettes.
Conclusions Few residents report recommending electronic cigarettes to patients who smoke. These residents consider the electronic cigarette less addicting than traditional cigarettes, supporting harm reduction strategies over strict abstinence. Most residents require further evidence-based education on efficacy and long-term safety of electronic cigarettes before recommending to their patients.
- GENERAL MEDICINE (see Internal Medicine)
- MEDICAL EDUCATION & TRAINING
- PRIMARY CARE
- PREVENTIVE MEDICINE
- PUBLIC HEALTH
- RESPIRATORY MEDICINE (see Thoracic Medicine)
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- GENERAL MEDICINE (see Internal Medicine)
- MEDICAL EDUCATION & TRAINING
- PRIMARY CARE
- PREVENTIVE MEDICINE
- PUBLIC HEALTH
- RESPIRATORY MEDICINE (see Thoracic Medicine)
Electronic cigarette use has increased dramatically since first introduced in 2007. Between 2010 and 2013, electronic cigarette use in the USA more than doubled among adults1 with sales approaching 1 billion dollars in 2013.2 It is predicted that during the next decade, electronic cigarette use will surpass that of conventional cigarettes.3
There has been a sharp increase in electronic cigarette use among smokers who have previously attempted to quit smoking.4 A survey of 5939 current and former smokers across four countries found that almost 80% of device users considered electronic cigarettes less harmful and less addicting than traditional cigarettes; 85% reported using these devices to quit or reduce smoking, although only 11% had quit.5 In England, electronic cigarettes are the most common smoking cessation aid, having replaced other nicotine replacement therapies (NRTs).2
Though significant work has evaluated public use of electronic cigarettes,5–9 limited research has examined resident physician attitudes towards the electronic cigarette. Therefore, we aimed to evaluate resident physicians' personal use, perceived knowledge and use of electronic cigarettes as a smoking cessation aid for their patients and to determine factors associated with resident physician stage of adoption of electronic cigarettes in clinical practice.
A cross-sectional, electronic survey (through SurveyMonkey) was sent to all residents in three teaching hospitals within OhioHealth, a large community-based healthcare system in Columbus, Ohio, USA.
We surveyed residents and fellows in all years of residency and from all disciplines (n=338). Non-surgical residents included internal medicine, family medicine, preliminary and transitional medicine, cardiology, otolaryngology, emergency medicine, sports medicine, palliative medicine and pulmonary critical care. Surgical residents included neurosurgery, plastic surgery, general surgery, obstetrics and gynaecology, anaesthesia, orthopaedics and ophthalmology. Residents from all disciplines were chosen because the investigators believed that all physicians should question patients about smoking and provide options for smoking reduction and cessation.
The development team (one attending teaching physician, one postgraduate year (PGY)-2 internal medicine resident and a biostatistician with a doctorate degree in social work) submitted questions that each felt pertinent to this topic. Terminology was carefully reviewed for language and understanding, and content was revised on six separate occasions to help establish face and preliminary content validity.
The final survey consisted of 19 questions (see online supplementary appendix 1) in seven domains: (1) demographics, (2) personal tobacco exposure, (3) sources of information about electronic cigarettes, (4) knowledge base, (5) beliefs about risks, addictive potential and costs of electronic cigarettes, (6) stages of adoption of electronic cigarettes in clinical practice and (7) attitudes about harm reduction as a prevention strategy. Questions on harm reduction were modified from a study examining social workers’ views on harm reduction in substance-abusing clients.10
The transtheoretical model11 was used to assess respondents' recommendation of electronic cigarettes to patients. The five stages were defined as precontemplation “I have never thought about recommending electronic cigarettes to my patients”, contemplation “I have thought about recommending electronic cigarettes to my patients but am waiting for more evidence”, preparation “I am planning to recommend electronic cigarettes in the next 6 months”, action “I have been recommending electronic cigarettes over the past 6 months” and maintenance “I have already been recommending electronic cigarettes to patients for more than 6 months”.
The transtheoretical model is frequently used as part of stage-matched interventions for smoking cessation and improving health behaviours,11 but has not been previously validated for assessing clinician adoption of new technology (ie, electronic cigarettes). Previous research on clinicians has generally utilised the theory of planned behaviour,12 which focuses on intentions leading to behaviour. However, given our interest in self-reported stage of behaviour regarding clinical use of the electronic cigarette, the transtheoretical model of behaviour was the best fit for the goals of our study.
Email invitations, with an electronic link, were sent to eligible participants through SurveyMonkey in 2015 on 5 January. Reminder emails were sent at 2 weeks and 1 month. A unique study-specific identifier was assigned to ensure anonymity of responses. Data were imported into a Microsoft Excel spreadsheet secured through a password-protected computer.
Survey questions were dichotomised prior to the analysis. Those who identified themselves as having smoked greater than 100 cigarettes in their lifetime and responded ‘daily use’, ‘frequent use’, ‘some use’ or ‘occasional/rare use’ were coded as ‘Currently smokes cigarettes’. Those who identified as having smoked greater than 100 cigarettes in their lifetime and reported that they had quit smoking were recoded as ‘Smoked previously but quit’. Participants who reported never smoking were coded as ‘Never smoked’. These categories are consistent with the US Centers for Disease Control and Prevention definitions of smoking used in epidemiological research.13
Current use of an electronic cigarette was assessed by the question ‘Do you currently smoke an electronic cigarette?’ with answers ranging from every day, most days, some days, occasional/rare day and never smoked. Participants who reported smoking electronic cigarettes between ‘every day’ and ‘occasional/rare day’ were recoded as ‘Currently smokes electronic cigarettes’.
To examine factors associated with early adoption of electronic cigarettes, we dichotomised respondents (action/maintenance vs precontemplation/contemplation/preparation). The residents in action/maintenance stages were termed ‘early adopters’ of electronic cigarettes as opposed to ‘non-adopters’ who identified as being in the precontemplation/contemplation/preparation stages.
Univariate comparisons were made using independent samples t-tests and χ2 tests. A multivariate logistic regression model, reporting ORs and 95% CIs, was used to examine the factors associated with self-reported recommendation of electronic cigarettes to patients. Only variables with p values <0.10 in the univariate analyses were included in the logistic model. Statistical significance was based on traditional two-sided tests with the α error set at 5%. Statistical analyses were conducted using IBM SPS Statistics V.19.0 (Armonk, New York, USA) and STATA V.12 (College Station, Texas, USA).
Of the 338 residents, 142 submitted complete surveys, for a response rate of 42%. One respondent completed only the demographic section of the survey and was dropped from all analyses. More non-surgical residents responded: 102 (71.8%) versus 40 (28.2%), see table 1.
Of all residents, 25 (17.7%) reported that they have been recommending electronic cigarettes to patients for the past 6 months or longer (action/maintenance), see figure 1. Fourteen (9.9%) were in the action stage and 11 (7.7%) were in the maintenance stage.
Univariate analysis found that residents were more likely to recommend e-cigarettes if they reported having a strong knowledge base, had encountered print advertisement or read a peer-reviewed article, reported current smoking and were less likely to report that abstinence should be the primary goal of smoking cessation treatment, see table 2.
In the multivariate logistic regression model, recommendation of electronic cigarettes was associated with residents ≥PGY-3 (OR=3.68, 95% CI 1.20 to 11.29), peer-reviewed article exposure (OR=6.65, 95% CI 1.56 to 28.38) and the view that addictive potential is less than with traditional cigarettes, (OR=5.05, 95% CI 1.48 to 17.24), see table 3. Belief that abstinence should be the primary goal of treatment was negatively associated with recommendation of e-cigarettes (OR=0.15, 95% CI 0.02 to 0.97). This model accounts for a moderate amount of variance in early adoption status (R2=28.7%, p<0.001).
Factors associated with early adoption of electronic cigarette use include more years in training, exposure to peer-reviewed literature on the topic, belief that electronic cigarettes are less addictive than traditional cigarettes and belief that harm reduction is an important goal when addressing smoking cessation with patients.
The majority of our surveyed residents were not currently recommending electronic cigarettes to patients (precontemplation/contemplation/preparation stages) though many were contemplating use. Most residents reported that they required more evidence before using electronic cigarettes in clinical practice. Resident non-adopters were less likely to report strong personal knowledge of electronic cigarettes compared with early adopters and additionally reported little exposure to peer-reviewed articles. Non-adopters were also more likely to report that abstinence should be the primary goal of smoking cessation treatment compared with residents in the adoption phase who valued harm reduction.
Our findings mirror the few studies that have examined attitudes of practicing physicians towards the electronic cigarette. Pepper et al evaluated practitioners' perceptions about electronic cigarette use and implications for preventive counselling in adolescents. They found that 83% of providers reported that they knew ‘little or nothing at all’ about electronic cigarettes, with the majority expressing need for additional education.14 However, a survey of practicing physicians in North Carolina found that 67% of respondents viewed e-cigarettes as helpful for smoking cessation, and 35% reported recommending electronic cigarettes to patients and belief that risk of cancer from the electronic cigarette was lower than with use of traditional cigarettes.15 Early adopters of the electronic cigarette in our study reported similar views on addiction and safety.
A recent Public Health England report estimated that electronic cigarettes are 95% safer than traditional smoking,7 which has prompted significant discourse and concerns about tobacco industry influence.16 Conversely, several studies suggest that long-term health effects of electronic cigarettes are not known, adding to uncertainty about risk versus benefit.17 ,18 Research suggests that in addition to concerns about the safety of the electronic cigarette to the current user, there is concern about risks to non-smokers from second-hand exposure.4 Because of these uncertainties, policymakers and medical organisations have proposed regulations on electronic cigarette sale and usage and some countries have banned public use of these devices.3 ,9 ,17 ,19
In May 2016, the US Food and Drug Administration (FDA) finalised a rule regulating all tobacco products, including electronic cigarettes, which are not currently FDA-approved as a smoking cessation aid.13 Currently, the US Preventive Service Task Force has concluded that the evidence on harms versus benefits is insufficient to recommend electronic nicotine delivery systems for tobacco cessation and recommends that clinicians counsel patients about ‘cessation interventions with established effectiveness and safety’.20 However, a 2016 report from the Royal College of Physicians addressed electronic cigarette use and concluded that ‘the availability of e-cigarettes has been beneficial to UK public health’ and further, ‘in the interests of public health it is important to promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK’.9
Though general agreement exists that complete smoking cessation ultimately provides best tobacco harm reduction, it is important to consider that residents who are early adopters were more likely to consider harm reduction as a primary endpoint. Two possible explanations for this include the following: (1) early adopters may consider that electronic cigarettes is a step towards abstinence for patients recalcitrant to complete cessation, and (2) belief that any reduction in number of cigarettes smoked allows for harm reduction from both nicotine and other components of inhaled tobacco smoke.
We found that increased years of training was associated with adoption of the electronic cigarette in clinical practice. As residents progress through clinical training, they may experience increasing numbers of patients who remain ambivalent about smoking cessation or are unwilling to quit completely. Early adopters may view use of the electronic cigarette as a compromise to strict abstinence. In other words, using the electronic cigarette allows implementation of a harm reduction approach and continuation of a physician–patient therapeutic relationship. Meta-analysis suggests moderate effects with the use of motivational interviewing strategy for smoking cessation.21 Motivational interviewing, a stage of change intervention, builds the therapeutic alliance by acknowledging patient ambivalence in a non-confrontational manner with recognition that strict adherence to an abstinence model may have a negative impact on the therapeutic relationship between patient and physician.
Support for smoking reduction as a harm reduction strategy without complete abstinence has been published.9 ,22 In 2007, the Royal College of Physicians suggested that the majority of harm from smoking arises ‘not from nicotine, but from other components of tobacco smoke’. Nine years later, an updated statement from this organisation reviewed several studies addressing harms from the electronic cigarette, and stated that ‘hazard from long-term electronic cigarette use is unlikely to exceed 5% of the harm from traditional tobacco smoking’; the organisation promotes the electronic cigarette as a tobacco harms reduction tool.9 The National Institute for Health and Care Excellence suggests that harm reduction strategies, which include smoking reduction as well as smoking cessation, with or without use of licensed nicotine-containing products for as long as needed, are important for patients who are highly dependent on nicotine and in groups with a high smoking prevalence.23
Finally, current licensed or medically approved smoking cessation therapies have associated significant failure rates. Studies suggest that 25% to 33% of smokers who use standard pharmacologic therapy for smoking cessation remain smoke-free in 6 months.24 For patients who have failed established treatment, early adopters may view the electronic cigarette as an additional strategy to assist in smoking reduction and possibly cessation, and thereby allow harm reduction from conventional cigarette use. It has been suggested that for every one million adults who switch to electronic cigarettes from conventional smoking, roughly 6000 premature deaths could be prevented;25 however, it is important to remember that this figure is an estimate, and long-term safety and harm reduction are uncertain.
The reported success rates for smoking reduction and cessation with use of electronic cigarettes are mixed. Several studies note significant success with decreased cigarette consumption and abstinence,2 ,7 ,22 ,26 ,27 while others describe only modest or no effect in attaining abstinence.5 ,28–30 The most recent systematic review and meta-analysis found that the odds of quitting cigarettes were 28% lower in those who used e-cigarettes compared with those who did not use e-cigarettes (OR 0.72, 95% CI 0.57 to 0.91).31 A recent report from the 2014 US National Health Interview Survey found that among current smokers, 22% of individuals who report quitting smoking within 1 year continue to use electronic cigarettes every day or some days and further, 15.9% report daily use/some use of electronic cigarettes (dual use).8
There is concern that dual use and/or prolonged exposure to low levels of nicotine from electronic cigarette use alone may be associated with increases in individual risk for malignancy and cardiovascular disease.17
The information on safety and risks is often conflicting and continues to evolve, yet a majority of both non-adopters and early adopters expressed opinion that morbidity and mortality were definitely or somewhat better when using electronic versus conventional cigarettes. It is unclear how these opinions were formed, and whether resident physicians were concerned about dual use (both traditional and electronic cigarettes), but it is important to note that few residents in either group reported that they were actively seeking information. Thus, they may be unaware of new or evolving information.
Given the rapid growth in public use of the electronic cigarette, it is likely that resident physicians will see increased numbers of electronic cigarette users in their clinical practice. Among residents who have adopted electronic cigarette use, only slightly more than half reported strong personal knowledge of these devices while 25% of non-users reported strong knowledge base. Significant numbers of both groups (early adopters and non-adopters) report little or no exposure to peer-reviewed articles on electronic cigarette safety and clinical use and few report actively seeking information. The majority of residents have gained their information through printed or media advertisements or by word of mouth. When providing smoking cessation education, efforts should ensure that residents are exposed to current peer-reviewed literature on safety of electronic cigarettes, both pros and cons, for best informed discussion and decision-making with their patients. It is important that resident physician clinical decisions are formulated on evidence-based study and/or guidelines.
Our findings suggest that improved resident physician education is greatly needed. Previous studies have found that medical school curricula do not adequately cover the treatment of nicotine dependence32 though recent studies report an encouraging increase in the extent of teaching on tobacco.33 We did not evaluate resident education about the electronic cigarette during medical school. However, as information about biologic effects and clinical efficacy of the electronic cigarette continues to evolve, educators should incorporate evidence-based instruction on both harms and benefits of the electronic cigarette into smoking cessation curricula.
Although the insights gained into resident's knowledge and viewpoints about electronic cigarettes are novel, there are limitations to our study. We surveyed resident physicians from one healthcare system within a small geographical area, making our results vulnerable to selection bias and limiting generalisability. The cross-sectional design only allows for insight into current perspectives about electronic cigarettes.
As a relatively new phenomenon, literature about electronic cigarette continues to be published. Consequently, physician attitudes may change. Importantly, the transtheoretical model represents the temporal dimensions of change and assumes a unidirectional movement in the change process. This limits the ability to measure future changes in residents' attitudes either towards or against electronic cigarettes that might occur based on the evolving literature.
In terms of measurement bias, sections of our survey were created de novo, so reliability and validity have not been established. Our study involved self-report measures, which are subject to social desirability bias. Formal chart review is needed to assess actual practice patterns.
This study adds to the literature providing information on resident physicians' early adoption of electronic cigarettes in the clinical setting. Use is associated with views that these devices are less addicting than traditional cigarettes and that harm reduction strategies are important when caring for patients who smoke. However, most resident physicians surveyed do not recommend electronic cigarettes in clinical practice. Most residents report knowledge deficits regarding safety and use of the electronic cigarette, and primary sources of information are from advertisements or word of mouth. Additional research on the harms and benefits of these devices is needed as well as dispersion of evidence-based information on use and efficacy if physicians are to consider electronic cigarettes as a therapeutic strategy for tobacco cessation efforts in larger numbers.
Despite increased public use of electronic cigarettes, few residents report recommending electronic cigarettes to patients who smoke.
Residents who adopt a risk reduction strategy consider the electronic cigarette less addicting than traditional cigarettes, supporting harm reduction strategies over strict abstinence.
Resident non-adopters were less likely to report strong personal knowledge of electronic cigarettes compared with early adopters and reported little exposure to peer-reviewed articles.
Residents require further evidence-based education on efficacy and long-term safety of electronic cigarettes before recommending to their patients.
Current research questions
Using the transtheoretical model what is the stage of adoption breakdown for resident's clinical use of electronic cigarette?
What factors are associated with residents' reported early adoption of electronic cigarettes for patient care?
Previous presentations This research was presented at the American College of Physicians Ohio Chapter meeting in Columbus, Ohio in October 2015 and the American College of Physicians National meeting in Washington, DC in May 2016.
Contributors All authors were involved in the planning, conducting and reporting of the work. All authors are guarantors and accept full responsibility for the work and/or the conduct of the study, had access to the data and controlled the decision to publish.
Funding This research was funded and supported by the OhioHealth Research Institute resident research fund.
Competing interests None declared.
Ethics approval This human subjects research received expedited approval (IRB #: OH1-14-00546) under the Riverside/Grant Institutional Review Board on 18 September 2014.
Provenance and peer review Not commissioned; externally peer reviewed.
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