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Adult smokers’ discussions about vaping with health professionals and subsequent behavior change: a cohort study
Abstract
Aims:
To measure the prevalence and changes in smokers' discussions with health professionals (HPs) about nicotine vaping products (NVPs) and HPs' recommendations about NVPs between 2016 and 2020, and their associations with tobacco product use transitions.
Design:
Cohort study using multinomial logistic regression analyses on data from Waves 1 (2016), 2 (2018), and 3 (2020) from the International Tobacco Control Four Country Smoking and Vaping Surveys.
Setting:
Four countries with varying NVP regulatory environments: 'most restrictive' (Australia), 'somewhat restrictive' (Canada), and 'less restrictive' (England and the US).
Participants:
Adult exclusive daily smokers who did not report NVP use at the time of their baseline survey and had visited a HP in the last 12-24 months. Prevalence data came from 4,125, 4,503, and 4,277 respondents respectively for each year. Longitudinal data were from 4,859 respondents who participated in at least two consecutive surveys.
Measurements:
(1) Prevalence of self-reported discussions with HPs and recommendations from HPs about NVPs and (2) longitudinal transitions from smoking to vaping (either exclusively or concurrently with smoking) and quitting (regardless of NVP uptake).
Findings:
The prevalence of NVP discussions was low across countries with varying regulatory environments and study waves (range=1.4%-6.2%). In 2020, a low percentage of smokers who discussed NVPs with a HP reported that their HPs recommended they use NVPs in the US (14.7%), Australia (20.2%), Canada (25.7%), with a higher percentage in England (55.7%) where clinical guidelines for smoking cessation include NVPs. Compared with 12.0% of smokers who reported no discussion, 37.0% of those whose HPs recommended NVPs transitioned to vaping at follow-up. Transition to quitting was 9.6% with HPs' recommendation of NVPs versus 13.5% without discussion, a non-significant difference.
Conclusions:
In Australia, Canada, England, and the United States between 2016 and 2020, health professionals' discussions with smokers about nicotine vaping products (NVPs) were infrequent. NVP discussions were associated with NVP uptake, but not with quitting smoking.
... HPs rarely discuss NVPs with patients who smoke: in 2016 among people who smoked who visited a HP, only 6.8% of survey respondents from Australia, Canada, England, and the US reported their HP discussing NVPs with them 15 . A cohort study found that the prevalence of NVP discussions were low and remained relatively unchanged between 2016, 2018 and 2020 25 . Further, among respondents who discussed NVPs with HPs, only about one-third (37.8%) reported that their HP recommended that they use them 15 . ...
... Further, among respondents who discussed NVPs with HPs, only about one-third (37.8%) reported that their HP recommended that they use them 15 . The likelihood of receiving NVP recommendations from HPs in England was higher and increased significantly between 2016 and 2020, but did not change significantly in Australia, Canada or the US 25 . ...
... Regarding NVP discussions with HPs, consistent with existing studies which used survey data from Australia, Canada, England, and US from 2016 15 and 2016-2020 25 , we found that a very low proportion of respondents who visited their HP reported their HP discussing NVPs with them. However, we found some evidence that those with both depression and anxiety had higher odds of their HPs discussing NVPs, compared to respondents with no depression/ anxiety. ...
Introduction:
People with mental health conditions are disproportionately affected by smoking-related diseases and death. The aim of this study was to assess whether health professional (HP) interactions regarding smoking cessation and nicotine vaping products (NVPs) differ by mental health condition.
Methods:
The cross-sectional 2018 International Tobacco Control Four Country (Australia, Canada, England, United States) Smoking and Vaping Survey data included 11040 adults currently smoking or recently quit. Adjusted weighted logistic regressions examined associations between mental health (self-reported current depression and/or anxiety) and visiting a HP in last 18 months; receiving advice to quit smoking; discussing NVPs with a HP; and receiving a recommendation to use NVPs.
Results:
Overall, 16.1% self-reported depression and anxiety, 7.6% depression only, and 6.6% anxiety only. Compared with respondents with no depression/anxiety, those with depression (84.7%, AOR=2.65; 95% CI: 2.17-3.27), anxiety (82.2%, AOR=2.08; 95% CI: 1.70-2.57), and depression and anxiety (87.6%, AOR=3.74; 95% CI: 3.19-4.40) were more likely to have visited a HP. Among those who had visited a HP, 47.9% received advice to quit smoking, which was more likely among respondents with depression (AOR=1.58; 95% CI: 1.34-1.86), and NVP discussions were more likely among those with depression and anxiety (AOR=1.63; 95% CI: 1.29-2.06). Of the 6.1% who discussed NVPs, 33.5% received a recommendation to use them, with no difference by mental health.
Conclusions:
People with anxiety and/or depression who smoke were more likely to visit a HP than those without, but only those with depression were more likely to receive cessation advice, and only those with depression and anxiety were more likely to discuss NVPs. There are missed opportunities for HPs to deliver cessation advice. NVP discussions and receiving a positive recommendation to use them were rare overall.
Introduction:
This study retrospectively describes smoking cessation aids, cessation services, and other types of assistance used by current and ex-smokers at last quit attempt (LQA) in four high-income countries.
Methods:
Data are from the Wave 3 (2020) International Tobacco Control Four Country Smoking and Vaping Survey in Australia, Canada, England, and the US. Eligible respondents were daily smokers or past-daily recent ex-smokers who made a quit attempt/quit smoking in the last 24-months, resulting in 3614 respondents. Self-reported quit aids/assistance included: nicotine vaping products (NVPs), nicotine replacement therapy (NRT), other pharmacological therapies (OPT: varenicline/bupropion/cytisine), tobacco (non-combustible: heated tobacco product/smokeless tobacco), cessation services (quitline/counseling/doctor), other cessation support (e.g., mobile apps/website/pamphlets etc.), or no aid.
Results:
Among all respondents, at LQA, 28.8% used NRT, 28.0% used an NVP, 12.0% used OPT, 7.8% used a cessation service, 1.7% used a tobacco product, 16.5% other cessation support, and 38.6% used no aid/assistance. Slightly more than half of all smokers and ex-smokers (57.2%) reported using any type of pharmacotherapy (NRT or OPT) and/or an NVP, half used NRT and/or an NVP (49.9%), and 38.4% used any type of pharmacotherapy (NRT and/or OPT). A quarter of smokers/ex-smokers used a combination of aids. NVPs and NRT were the most prevalent types of cessation aids used in all four countries; however, NRT was more commonly used in Australia relative to NVPs, and in England, NVPs were more commonly used than NRT. The use of NVPs or NRT was more evenly distributed in Canada and the US.
Conclusions:
It appears that many smokers are still trying to quit unassisted, rather than utilizing cessation aids or other forms of assistance. Of those who did use assistance, NRT and NVPs were the most common method, which appears to suggest that nicotine substitution is important for smokers when trying to quit smoking.
E-cigarettes are the preferred smoking-cessation aid in the US, however there is little evidence regarding long-term effectiveness among those who use them. We used the Population Assessment of Tobacco and Health Study to compare long-term abstinence between matched US smokers who tried to quit with and without use of e-cigarettes as a cessation aid. We identified a nationally representative cohort of 2,535 adult US smokers in 2014-15 (baseline assessment), who in 2015-2016 (exposure assessment) reported a past-year quit attempt and the cessation aids used, and reported smoking status in 2016-17 (outcome assessment; self-reported 12+ months continuous abstinence). We used propensity-score methods to match each e-cigarette user with similar non-users. We found that, among US smokers who used e-cigarettes to help quit, 12.9% (95% CI: 9.1%,16.7%) successfully attained long-term abstinence. However, there was no difference compared to matched non-e-cigarette-users (cigarette abstinence difference: 2%; 95% CI: -3%, 7%). Furthermore, fewer e-cigarette users were long-term abstinent from nicotine products (nicotine abstinence difference: -4%; 95% CI: -7%, -1%); about two-thirds of e-cigarette users who successfully quit smoking continued to use e-cigarettes. These results suggest that e-cigarettes may not be an effective cessation aid for adult smokers, and instead may contribute to continuing nicotine dependence.
This study describes the prevalence and correlates of adult smokers' discussions about electronic cigarettes (e-cigarettes) with health professionals (HPs), including whether these discussions may lead smokers and vapers to use e-cigarettes for smoking cessation.
Methods:
We analyzed data from an online survey of Mexican smokers recruited from a consumer panel for marketing research. Participants who had visited an HP in the prior four months (n = 1073) were asked about discussions of e-cigarettes during that visit and whether this led them to try to quit. Logistic models regressed these variables on socio-demographics and tobacco use-related variables.
Results:
Smokers who also used e-cigarettes (i.e., dual users) were more likely than exclusive smokers to have discussed e-cigarettes with their HP (adjusted odds ratio (AOR) = 3.96; 95% C.I. 2.73, 5.74), as were those who had recently attempted to quit smoking (AOR = 1.89; 95% C.I. 1.33, 2.7). Of smokers who had discussed e-cigarettes, 53.3% reported that the discussion led them to use e-cigarettes in their quit attempt. Also, dual users (AOR = 2.6; 95% C.I. 1.5, 4.5) and daily smokers (>5 cigarettes per day) (AOR = 3.62; 95% C.I. 1.9, 6.8) were more likely to report being led by their HP to use e-cigarettes in the quit attempt compared to exclusive smokers and non-daily smokers, respectively.
Conclusions:
Discussions between HP and smokers about e-cigarettes were relatively common in Mexico, where e-cigarettes are banned. These discussions appear driven by the use of e-cigarettes, as well as by greater smoking frequency and intentions to quit smoking.
Aims
This paper presents updated prevalence estimates of awareness, ever‐use, and current use of nicotine vaping products (NVPs) from 14 International Tobacco Control Policy Evaluation Project (ITC Project) countries that have varying regulations governing NVP sales and marketing.
Design, setting, participants and measurements
A cross‐sectional analysis of adult (≥18 years) current smokers and ex‐smokers from 14 countries participating in the ITC Project. Data from the most recent survey questionnaire for each country were included, which spanned the period 2013 to 2017. Countries were categorized into four groups based on regulations governing NVP sales and marketing (allowable or not), and level of enforcement (strict or weak where NVPs are not permitted to be sold): (1) most restrictive policies (MRPs): not legal to be sold or marketed with strict enforcement: Australia, Brazil, Uruguay; (2) restrictive policies (RPs): not approved for sale or marketing with weak enforcement: Canada, Malaysia, Mexico, New Zealand (NZ); (3) less restrictive policies (LRPs): legal to be sold and marketed with regulations: England, Netherlands, Republic of Korea, United States (US); (4) no regulatory policies (NRPs): Bangladesh, China, Zambia. Countries were also grouped by World Bank Income Classifications. Country‐specific weighted logistic regression models estimated adjusted NVP prevalence estimates for: awareness, ever/current use, and frequency of use (daily vs. non‐daily).
Findings
NVP awareness and use were lowest in NRP countries. Generally, ever‐ and current use of NVPs were lower in MRP countries [ever‐use: 7.1% to 48.9%; current use: 0.3% to 3.5%] relative to LRP countries [ever‐use: 38.9% to 66.6%; current use: 5.5% to 17.2%] and RP countries [ever‐use: 10.0% to 62.4%; current use: 1.4% to 15.5%]. NVP use was highest among high income countries, followed by upper‐middle income countries, and then by lower‐middle income countries.
Conclusions
With a few exceptions, awareness and use of nicotine vaping products (NVPs) varies by the strength of national regulations governing NVP sales/marketing, and by country income. In countries with no regulatory policies, use rates were very low, suggesting that there was little availability, marketing and/or interest in NVPs in these countries where smoking populations are predominantly poorer. The higher awareness and use of NVPs in high income countries with moderately (e.g., Canada, NZ) and less (e.g., England, US) restrictive policies, is likely due to the greater availability and affordability of NVPs.
Objectives:
This study examined views of pharmacy staff regarding the safety of e-cigarettes compared to nicotine replacement therapies (NRTs) and conventional cigarettes, as well as views on their regulation in Australia.
Methods:
We conducted a cross-sectional survey among pharmacy staff (64 pharmacists and 76 pharmacy assistants) from the greater Brisbane region, Queensland, Australia. The self-administered questionnaire included closed- and open-ended questions that explores pharmacy staff perception on harms of e-cigarettes versus NRT and traditional cigarettes, knowledge of current e-cigarette regulations, views on how they should be regulated and information needs regarding e-cigarettes. Pearson's chi-square test was employed for computing differences between variables. A content analysis of responses to open-ended questions was also performed.
Results:
Over 90% of pharmacy staff regarded e-cigarettes without nicotine and NRTs as less harmful than regular tobacco cigarettes. This reduced to 72% for e-cigarettes containing nicotine, with 24% of respondents believing they are equally as harmful as conventional cigarettes. Moreover, few respondents were confident about the short and long term safety of e-cigarettes containing nicotine (36% and 15% respectively) whereas pharmacy staff were more comfortable with the safety of NRTs for short (88%) and long term (35%) use. The majority of respondents believed that e-cigarettes with nicotine should be regulated as a medicine, either requiring a prescription (24%) or sold only by pharmacies (22%), though many believed that they should be regulated in the same way as regular tobacco cigarettes (27%). Some pharmacy staff (39%) reported having been asked about e-cigarettes by customers and 75% believed that their customers would be interested in using e-cigarettes as a smoking cessation aid.
Conclusions:
There is a need to provide evidence-based and customised education for pharmacists regarding e-cigarettes to help them guide their clients.
Background
In this article, we present qualitative work designed to explore physicians’ attitudes toward and knowledge of electronic cigarettes (or Electronic Nicotine Delivery Systems—ENDS), particularly focusing on personal attitudes held by physicians regarding ENDS use, physician beliefs regarding the relative safety of ENDS, attitudes regarding the efficacy of ENDS as a smoking cessation tool, and how physicians’ document ENDS use in the electronic health record (EHR).
Methods
We completed a total of 17 semistructured qualitative interviews with physicians in 4 different outpatient clinic locations. Clinics were selected with the goal of reaching patient panels across a diversity of socioeconomic and local geographic locations.
Results
The findings from our qualitative analysis suggest that physicians feel uninformed about the long-term health risks of ENDS and believe that they lack the critical medical knowledge required for discussing ENDS with their patients who smoke. Although physician responses did not endorse the view that ENDS use is a safer alternative to combustible tobacco use, approximately one-third of our physician sample did not hold strong objections to ENDS usage. Physicians placed varying degrees of importance on the issue of ENDS documentation practices.
Discussion
Three overarching themes were revealed from our analysis. These themes included (1) physicians’ attitudes regarding the use of ENDS for smoking cessation, (2) physicians’ guidance and advisement to patients in the use of ENDS for smoking cessation, and (3) current practices of clinical documentation of ENDS use in an EHR. Our qualitative results indicate that physicians in our study rarely screen patients for ENDS use, even for those patients who are both documented smokers and recipients of physician-led tobacco cessation counseling. However, most physicians agreed that the prospect of creating a structured data field specifically for the documentation of ENDS use within the EHR would result in the likelihood of increased screening and documentation of ENDS use patterns.
Background
The landscape of smoking cessation may have changed in Europe recently.
Objectives
To identify changes in use of smoking cessation assistance in the European Union (EU) and factors associated with use of cessation assistance.
Methods
Data from the 2012 (n=9921) and 2017 (n=9489) waves of the Eurobarometer survey were used. Self-reported use of smoking cessation assistance was assessed among smokers who had ever tried to quit and former smokers. Changes in use of each type of assistance were assessed using logistic regression.
Results
Among current and former smokers, those who had ever attempted to quit without assistance increased from 70.3% (2012) to 74.8% (2017). Current smokers were more likely to have used any assistance compared with former smokers (P<0.001). Use of e-cigarettes for smoking cessation assistance increased (3.7% to 9.7%)%), while use of pharmacotherapy (14.6% to 11.1%)%) and smoking cessation services (7.5% to 5.0%)%) declined. Younger people were more likely to have reported e-cigarette use for smoking cessation but less likely to have used a cessation service. Individuals living in countries with comprehensive smoking cessation policies were more likely to have used any cessation assistance (adjusted OR (aOR)=1.78; 95% CI 1.15 to 2.76), pharmacotherapy (aOR=3.44; 95% CI 1.78 to 6.66) and smoking cessation services (aOR=2.27; 95% CI 1.27 to 4.06) compared with those living in countries with weak smoking cessation policies.
Conclusions
These findings highlight the need for approaches that ensure that smokers get support to quit smoking across the EU. The question of whether the availability of e-cigarettes will displace other methods, and the impact of such a displacement, should be closely evaluated.
Background:
Recent support has been shown for physicians to recommend e-cigarettes to patients who are trying to quit smoking. Supporters of this recommendation argue that e-cigarettes are not combustible products and are less harmful and more effective cessation products than regular cigarettes, with less inherent risk. Those who oppose this idea argue that little reliable evidence suggests that e-cigarettes are better cigarette cessation devices than currently available nicotine replacement therapies, and that they pose as much risk as cigarettes. This study was conducted to explore family physicians' perceptions of recommending e-cigarettes as smoking cessation aids to patients who smoke cigarettes.
Methods:
The study used a mixed-methods approach whereby a 12-item survey was sent to 154 family physicians throughout the state of Kansas. Data were collected from 117, a 76% response rate. A multidisciplinary team used an immersion-crystallization approach to analyze the content of respondents' qualitative data; contingency table analysis was used to evaluate the quantitative data.
Results:
The results showed that family physicians have negative perceptions of e-cigarettes and do not recommend them for smoking cessation. Family physicians are concerned about the effectiveness of e-cigarettes and the uncertainty regarding safety.
Conclusions:
The results suggest that most family physicians do not recommend e-cigarettes for smoking cessation, citing lack of evidence on effectiveness and uncertainty regarding short- and long-term safety.
Background: Electronic cigarettes (e-cigarettes) are battery-powered devices that deliver aerosolized nicotine. With easy access and over-the-counter availability, many patients consider using electronic cigarettes for smoking cessation. Few studies have looked at long-term safety/efficacy and physician knowledge/attitudes toward e-cigarettes. Physicians have insufficient guidelines for advising their patients about e-cigarettes.
Objective: 1) To identify knowledge and attitude of health care practitioners toward electronic cigarettes. 2) To identify the effect of level of training, experience and speciality on knowledge and practice of electronic cigarettes. 3) To identify factors influencing electronic cigarettes advise/prescribing practice.
Methods: An anonymous online questionnaire was sent to residents, fellows, and faculty in pre-selected specialties at Saint Louis University (SLU) Hospital.
Results: We received 115 responses. Nine percent reported being ‘very familiar’ with e-cigarettes, while 25% reported no familiarity; 18% of physicians would advise e-cigarettes as nicotine-replacement therapy if asked by patients; 91% were aware of the nicotine content of e-cigarettes, but only 20% and 39%, respectively, were aware of the presence of carcinogens and polyethylene glycol. Only 63% of respondents knew what ‘vape’ meant. Lack of evidence regarding long-term safety (76%), e-cigarettes as starter products for nonsmokers (50%), absence of Food and Drug Administration (FDA) regulations (51%) and marketing to youth (42%) were major concerns. Stricter regulations (54%), warning labels similar to tobacco products (53%), restricting advertising (36%), banning sales to minors (34%), and banning use in public spaces (25%) were favored as regulatory measures. More than 50% of physicians see a role for e-cigarettes as part of ‘harm-reduction strategy’.
Conclusions: Further research is needed to assess whether e- cigarettes could be an effective smoking-cessation tool. There is an apparent knowledge deficit among physicians and an urgent need for evidence-based guidelines to aid with advising patients enquiring about e-cigarettes.
Purpose:
To report on adults' recall of discussion by physicians and dentists about e-cigarettes.
Design:
A nationally representative cross-sectional survey (Internet and random digit dialing) in the United States.
Participants:
Adults who ever used e-cigarettes.
Measures:
Participant-reported discussion about the potential benefits and harms of e-cigarettes with their doctor, dentist, or child's doctor in the past 12 months.
Analysis:
Fisher exact test for the analysis between benefits and harms for each type of provider and for rates of advice between provider types.
Results:
Among the 3030 adults who completed the survey, 523 (17.2%) had ever used e-cigarettes. Of those who had seen their doctor, dentist, or child's doctor in the last year, 7.3%, 1.7%, and 10.1%, respectively, reported discussing potential harms of e-cigarettes. Conversely, 5.8%, 1.7%, and 9.3% of patients who had seen their doctor, dentist, or child's doctor in the last year reported that the clinician discussed the potential benefits of e-cigarettes. Each clinician type was as likely to discuss harms as benefits. Rates of advice were similar between doctors and child's doctors but lower for dentists. Rates were comparable when the analysis was limited to current e-cigarette users, participants with children, or those who reported using both e-cigarettes and combusted tobacco.
Conclusions:
Few physicians and dentists discuss either the harms or benefits of e-cigarettes with their patients. These data suggest an opportunity to educate, train, and provide resources for physicians and dentists about e-cigarettes and their use.
To quantify the prevalence of 10 quit methods commonly used by adult cigarette smokers, we used data from a nationally representative longitudinal (2014–2016) online survey of US adult cigarette smokers (n = 15,943). Overall, 74.7% of adult current cigarette smokers used multiple quit methods during their most recent quit attempt. Giving up cigarettes all at once (65.3%) and reducing the number of cigarettes smoked (62.0%) were the most prevalent methods. Substituting some cigarettes with e-cigarettes was used by a greater percentage of smokers than the nicotine patch, nicotine gum, or other cessation aids approved by the US Food and Drug Administration. Further research into the effectiveness of e-cigarettes as a cessation aid is warranted.
Purpose:
To determine characteristics of smokers discussing e-cigarette use with their physician and receiving recommendations from their physician to use e-cigarettes for smoking cessation.
Methods:
US adult smokers who had visited a physician in the previous 12 months (n = 2671) were surveyed. Logistic generalized estimating equation models were used to assess the characteristics of smokers who (1) talked to a physician about e-cigarettes, and (2) received physician advice to use e-cigarettes for smoking cessation.
Results:
15% (n = 406) of smokers who visited a physician talked with their physician about e-cigarettes. Among those asked whether their physician recommend e-cigarettes for smoking cessation (n = 257), 61% responded affirmatively. Current e-cigarette users were more likely to talk to their physicians about e-cigarettes (nondaily users vs never users: OR, 2.70; 95% CI, 1.79-4.05; daily users vs never users: OR, 4.29; 95% CI, 2.34-7.84) and have their physician recommend e-cigarettes for smoking cessation (daily users vs never users: OR, 9.40; 95% CI, 2.54-34.71).
Conclusions:
The majority of smokers who talk to their physician about e-cigarettes report that they received advice to use e-cigarettes to quit smoking, despite limited evidence for their efficacy. More studies are needed to better understand e-cigarette recommendations in clinical settings.
E-cigarette use has increased rapidly among U.S. adults. However, reasons for use among adults are unclear. We assessed reasons for e-cigarette use among a national sample of U.S. adults. Data were collected via online surveys among U.S. adults aged 18 or older from April through June 2014. Descriptive and multivariate regression analyses were conducted to assess reasons for e-cigarette use among 2448 current e-cigarette users, by sociodemographic characteristics and product type. Assessed reasons included cessation/health, consideration of others, convenience, cost, curiosity, flavoring, and simulation of conventional cigarettes. Among current e-cigarette users, 93% were also current cigarette smokers. The most common reasons for e-cigarette use were cessation/health (84.5%), consideration of others (71.5%), and convenience (56.7%). The prevalence of citing convenience (adjusted prevalence ratio [aPR]=1.49) and curiosity (aPR=1.54) as reasons for e-cigarette use were greater among current cigarette smokers than nonsmokers (P<0.05). The prevalence of citing flavoring as a reason for use was greater among adults aged 18 to 24 (aPR=2.02) than 55 or older (P<0.05). Tank use was associated with greater prevalence of citing every assessed reason except convenience and curiosity. Cessation- and health-related factors are primary reasons cited for e-cigarette use among adults, and flavorings are more commonly cited by younger adults. Efforts are warranted to provide consumers with accurate information on the health effects of e-cigarettes and to ensure that flavoring and other unregulated features do not promote nicotine addiction, particularly among young adults.
Introduction. The purpose of this study was to evaluate the knowledge and perceptions of Greek healthcare professionals about nicotine, nicotine replacement therapies and electronic cigarettes. Methods. An online survey was performed, in which physicians and nurses working in private and public healthcare sectors in Athens-Greece were asked to participate through email invitations. A knowledge score was calculated by scoring the correct answers to specific questions with 1 point. Results. A total of 262 healthcare professionals were included to the analysis. Most had daily contact with smokers in their working environment. About half of them considered that nicotine has an extremely or very important contribution to smoking-related disease. More than 30% considered nicotine replacement therapies equally or more addictive than smoking, 76.7% overestimated their smoking cessation efficacy and only 21.0% would recommend them as long-term smoking substitutes. For electronic cigarettes, 45.0% considered them equally or more addictive than smoking and 24.4% equally or more harmful than tobacco cigarettes. Additionally, 35.5% thought they involve combustion while the majority responded that nicotine in electronic cigarettes is synthetically produced. Only 14.5% knew about the pending European regulation, but 33.2% have recommended them to smokers in the past. Still, more than 40% would not recommend electronic cigarettes to smokers unwilling or unable to quit smoking with currently approved medications. Cardiologists and respiratory physicians, who are responsible for smoking cessation therapy in Greece, were even more reluctant to recommend electronic cigarettes to this subpopulation of smokers compared to all other participants. The knowledge score of the whole study sample was 7.7 (SD: 2.4) out of a maximum score of 16. Higher score was associated with specific physician specialties. Conclusions. Greek healthcare professionals appear to overestimate the adverse effects of nicotine, and many would not recommend any nicotine-containing product as a long-term smoking substitute. Additionally, they have poor knowledge about the function and characteristics of electronic cigarettes.
Background
Smoking cessation following lung cancer diagnosis has been found to improve several patient outcomes. Electronic cigarette (e-cigarette) use is now prevalent within Great Britain, however, use and practice among patients with lung cancer has not as yet been explored. The current study aims to explore e-cigarette use among patients and examine current practice among clinicians. The results have important implications for future policy and practice.
Methods
Members of The British Thoracic Oncology Group (BTOG) were contacted via several e-circulations (N = 2,009), requesting them to complete an online survey. Of these, 7.7 % (N = 154) completed the survey, which explored participant demographics and smoking history, perceptions of patient e-cigarette use, practitioner knowledge regarding sources of guidance pertaining to e-cigarettes, and practitioner advice.
Results
Practitioners frequently observed e-cigarette use among patients with lung cancer. The majority of practitioners (81.4 %) reported responding to patient queries pertaining to e-cigarettes within the past year; however, far fewer (21.0 %) felt confident providing patients with e-cigarette advice. Practitioner confidence was found to differentiate by gender (p = 0.012) and employment speciality (p = 0.030), with nurses reporting particularly low levels of confidence in advising. The results also demonstrate extensive variability regarding the practitioner advice content.
Conclusions
The results demonstrate that patients refer to practitioners as a source of e-cigarette guidance, yet few practitioners feel confident advising. The absence of evidence-based guidance may have contributed towards the exhibited inconsistencies in practitioner advice. The findings highlight that training should be delivered to equip practitioners with the knowledge and confidence to advise patients effectively; this could subsequently improve smoking cessation rates and patient outcomes.
Introduction:
Few studies have explored sources of e-cigarette awareness and peoples' e-cigarette information needs, interests or behaviors. This study contributes to both domains of e-cigarette research.
Methods:
Results are based on a 2014 e-cigarette focused survey of 519 current smokers from a nationally representative research panel.
Results:
Smokers most frequently reported seeing e-cigarettes in stores (86.4%) and used in person (83%). Many (73%) had also heard about e-cigarettes from known users, broadcast media ads (68%), other (print, online) advertisements (71.5%), and/or from the news (60.9%); sources of awareness varied by e-cigarette experience. Most smokers (59.9%) believed e-cigarettes are less harmful than regular cigarettes, a belief attributed to "common sense" (76.4%), the news (39.2%) and advertisements (37.2%). However, 79.5% felt e-cigarette safety information was important. Over one-third said they would turn to a doctor first for e-cigarette safety information, though almost a quarter said they would turn to the Internet or product packaging first. Most (59.6%) ranked doctors as the most trustworthy risk source, and 6.8% had asked a health professional about e-cigarettes.
Conclusions:
Future research should explore the content of e-cigarette information sources, their potential impact, and ways they might be strengthened or changed through regulatory and/or educational efforts.
AimsThis paper provides a concise review of the efficacy, effectiveness and affordability of healthcare interventions to promote and assist tobacco cessation, in order to inform national guideline development and assist countries in planning their provision of tobacco cessation support.Methods
Cochrane reviews of randomised controlled trials (RCTs) of major healthcare tobacco cessation interventions were used to derive efficacy estimates in terms of percentage-point increases relative to comparison conditions in 6–12 month continuous abstinence rates. This was combined with analysis and evidence from ‘real world’ studies to form a judgement on the likely effectiveness of each intervention in different settings. The affordability of each intervention was assessed for exemplar countries in each World Bank income category (low, lower middle, upper middle, high). Based on WHO criteria, an intervention was judged as affordable for a given income category if the estimated extra cost of saving a life-year was less than or equal to the per-capita Gross Domestic Product for that category of country.ResultsBrief advice from a healthcare worker given opportunistically to smokers attending healthcare services can promote smoking cessation and is affordable for countries in all World Bank income categories (i.e., globally). Proactive telephone support, automated text messaging programmes, and printed self-help materials can assist smokers wanting help with a quit attempt and are affordable globally. Multi-session, face-to-face behavioural support can increase quit success for cigarettes and smokeless tobacco and is affordable in middle and high income countries. Nicotine replacement therapy, bupropion, nortriptyline, varenicline and cytisine can all aid quitting smoking when given with at least some behavioural support; of these cytisine and nortriptyline are affordable globally.Conclusions
Brief advice from a healthcare worker, telephone helplines, automated text messaging, printed self-help materials, cytisine and nortriptyline are globally affordable healthcare interventions to promote and assist smoking cessation. Evidence on smokeless tobacco cessation suggests that face-to-face behavioural support and varenicline can promote cessation. This article is protected by copyright. All rights reserved.
Introduction:
Smokers are likely asking their physicians about the safety of e-cigarettes and their potential role as a cessation tool; however, the research literature on this communication is scant. A pilot study of physicians in the United States was conducted to investigate physician-patient communication regarding e-cigarettes.
Methods:
A total of 158 physicians were recruited from a direct marketing e-mail list and completed a short, web-based survey between January and April 2014. The survey addressed demographics, physician specialty, patient-provider e-cigarette communication, and attitudes towards tobacco harm reduction.
Results:
Nearly two-thirds (65%) of physicians reported being asked about e-cigarettes by their patients, and almost a third (30%) reported that they have recommended e-cigarettes as a smoking cessation tool. Male physicians were significantly more likely to endorse a harm reduction approach.
Discussion:
Physician communication about e-cigarettes may shape patients' perceptions about the products. More research is needed to explore the type of information that physicians share with their patients regarding e-cigarettes and harm reduction.
Introduction
Electronic cigarettes (e-cigarettes) are not currently approved or recommended by the Food and Drug Administration (FDA) or various medical organizations; yet, they appear to play a substantial role in tobacco users’ cessation attempts. This study reports on a physician survey that measured beliefs, attitudes, and behavior related to e-cigarettes and smoking cessation. To our knowledge this is the first study to measure attitudes toward e-cigarettes among physicians treating adult smokers.
Methods
Using a direct marketing company, a random sample of 787 North Carolina physicians were contacted in 2013 through email, with 413 opening the email and 128 responding (response rate = 31%). Physicians’ attitudes towards e-cigarettes were measured through a series of close-ended questions. Recommending e-cigarettes to patients served as the outcome variable for a logistic regression analysis.
Results
Two thirds (67%) of the surveyed physicians indicated e-cigarettes are a helpful aid for smoking cessation, and 35% recommended them to their patients. Physicians were more likely to recommend e-cigarettes when their patients asked about them or when the physician believed e-cigarettes were safer than smoking standard cigarettes.
Conclusions
Many North Carolina physicians are having conversations about e-cigarettes with their patients, and some are recommending them. Future FDA regulation of e-cigarettes may help provide evidence-based guidance to physicians about e-cigarettes and will help ensure that patients receive evidence-based recommendations about the safety and efficacy of e-cigarettes in tobacco cessation.
To characterize e-cigarette use, users and effects in a sample of Electronic Cigarette Company (TECC) and Totally Wicked E-Liquid (TWEL) users.
Online survey hosted at the University of East London with links from TECC/TWEL websites from September 2011 to May 2012.
Online questionnaire.
One thousand three hundred and forty-seven respondents from 33 countries (72% European), mean age 43 years, 70% male, 96% Causacian, 44% educated to degree level or above.
Seventy-four percent of participants reported not smoking for at least a few weeks since using the e-cigarette and 70% reported reduced urge to smoke. Seventy-two percent of participants used a ‘tank’ system, most commonly, the eGo-C (23%). Mean duration of use was 10 months. Only 1% reported exclusive use of non-nicotine (0 mg) containing liquid. E-cigarettes were generally considered to be satisfying to use; elicit few side effects; be healthier than smoking; improve cough/breathing; and be associated with low levels of craving. Among ex-smokers, ‘time to first vape’ was significantly longer than ‘time to first cigarette’ (t1104 = 11.16, P < 0.001) suggesting a lower level of dependence to e-cigarettes. Ex-smokers reported significantly greater reduction in craving than current smokers (χ21 = 133.66, P < 0.0007) although few other differences emerged between these groups. Compared with males, females opted more for chocolate/sweet flavours (χ21 = 16.16, P < 0.001) and liked the e-cigarette because it resembles a cigarette (χ23 = 42.65, P < 0.001).
E-cigarettes are used primarily for smoking cessation, but for a longer duration than nicotine replacement therapy, and users believe them to be safer than smoking.
There is increasing recognition that the two measures in the Heaviness of Smoking Index (HSI), time to first cigarette of the day (TTFC) and daily consumption (cigarettes per day [CPD]), are strong predictors of quitting behavior.
Use of Waves 1-4 of International Tobacco Control cohort with around 8,000 respondents per wave and 6,000 for prediction of quit outcomes at the next wave. We measured TTFC and CPD at each wave and quit outcomes at the next wave. We also looked at the relative utility of the standard categorical scoring compared with a continuous score using the square root of CPD minus the natural log of TTFC in minutes.
We found considerable consistency of the measures across years with a small decrease as duration between measurements increased. For a 3-year gap, the correlations were .72 and .70 for the continuous and categorical composite HSI measures, respectively, and were at least .63 for the individual components. Both TTFC and CPD independently predicted maintenance of quit attempts (for at least 1 month) in each of the three wave-to-wave replications, and these effects were maintained when controlling for demographic factors. CPD also predicted making attempts consistently, but the results for TTFC was not consistently significant.
Both TTFC and CPD are fairly reliable over time and are important predictors of quitting. There are only small effects of mode of computing the scores, and the two items can be used either individually or combined as the HSI.
This paper describes the conceptual model that underlies the International Tobacco Control Policy Evaluation Project (ITC Project), whose mission is to measure the psychosocial and behavioural impact of key policies of the Framework Convention on Tobacco Control (FCTC) among adult smokers, and in some countries, among adult non-smokers and among youth. The evaluation framework utilises multiple country controls, a longitudinal design, and a pre-specified, theory-driven conceptual model to test hypotheses about the anticipated effects of specific policies. The ITC Project consists of parallel prospective cohort surveys of representative samples of adult smokers currently in nine countries (inhabited by over 45% of the world's smokers), with other countries being added in the future. Collectively, the ITC Surveys constitute the first-ever international cohort study of tobacco use. The conceptual model of the ITC Project draws on the psychosocial and health communication literature and assumes that tobacco control policies influence tobacco related behaviours through a causal chain of psychological events, with some variables more closely related to the policy itself (policy-specific variables) and other variables that are more downstream from the policy, which have been identified by health behaviour and social psychological theories as being important causal precursors of behaviour (psychosocial mediators). We discuss the objectives of the ITC Project and its potential for building the evidence base for the FCTC.
This paper outlines the design features, data collection methods and analytic strategies of the International Tobacco Control (ITC) Four Country Survey, a prospective study of more than 2000 longitudinal respondents per country with yearly replenishments. This survey possesses unique features that sets it apart among surveys on tobacco use and cessation. One of these features is the use of theory-driven conceptual models. In this paper, however, the focus is on the two key statistical features of the survey: longitudinal and "quasi-experimental" designs. Although it is often possible to address the same scientific questions with a cross-sectional or a longitudinal study, the latter has the major advantage of being able to distinguish changes over time within individuals from differences among people at baseline (that is, differences between age and cohort effects). Furthermore, quasi-experiments, where countries not implementing a given new tobacco control policy act as the control group to which the country implementing such a policy will be compared, provide much stronger evidence than observational studies on the effects of national-level tobacco control policies. In summary, application of rigorous research methods enables this survey to be a rich data resource, not only to evaluate policies, but also to gain new insights into the natural history of smoking cessation, through longitudinal analyses of smoker behaviour.
Background:
Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, although some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review.
Objectives:
To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence.
Search methods:
We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 July 2022, and reference-checked and contacted study authors. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and randomized cross-over trials, in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report abstinence from cigarettes at six months or longer or data on safety markers at one week or longer, or both.
Data collection and analysis:
We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included the proportion of people still using study product (EC or pharmacotherapy) at six or more months after randomization or starting EC use, changes in carbon monoxide (CO), blood pressure (BP), heart rate, arterial oxygen saturation, lung function, and levels of carcinogens or toxicants, or both. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in meta-analyses.
Main results:
We included 78 completed studies, representing 22,052 participants, of which 40 were RCTs. Seventeen of the 78 included studies were new to this review update. Of the included studies, we rated ten (all but one contributing to our main comparisons) at low risk of bias overall, 50 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There was high certainty that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (RR 1.63, 95% CI 1.30 to 2.04; I2 = 10%; 6 studies, 2378 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6). There was moderate-certainty evidence (limited by imprecision) that the rate of occurrence of AEs was similar between groups (RR 1.02, 95% CI 0.88 to 1.19; I2 = 0%; 4 studies, 1702 participants). SAEs were rare, but there was insufficient evidence to determine whether rates differed between groups due to very serious imprecision (RR 1.12, 95% CI 0.82 to 1.52; I2 = 34%; 5 studies, 2411 participants). There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.94, 95% CI 1.21 to 3.13; I2 = 0%; 5 studies, 1447 participants). In absolute terms, this might lead to an additional seven quitters per 100 (95% CI 2 to 16). There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 1840 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 8 studies, 1272 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.66, 95% CI 1.52 to 4.65; I2 = 0%; 7 studies, 3126 participants). In absolute terms, this represents an additional two quitters per 100 (95% CI 1 to 3). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was some evidence that (non-serious) AEs were more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 1.03, 95% CI 0.54 to 1.97; I2 = 38%; 9 studies, 1993 participants). Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons, hence evidence for these is limited, with CIs often encompassing clinically significant harm and benefit.
Authors' conclusions:
There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the effect size. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates, but further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.
Background:
Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol formed by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, but some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit and if they are safe to use for this purpose. This is an update conducted as part of a living systematic review.
Objectives:
To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence.
Search methods:
We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 May 2021, and reference-checked and contacted study authors. We screened abstracts from the Society for Research on Nicotine and Tobacco (SRNT) 2021 Annual Meeting. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and randomized cross-over trials, in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report abstinence from cigarettes at six months or longer or data on safety markers at one week or longer, or both.
Data collection and analysis:
We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included the proportion of people still using study product (EC or pharmacotherapy) at six or more months after randomization or starting EC use, changes in carbon monoxide (CO), blood pressure (BP), heart rate, arterial oxygen saturation, lung function, and levels of carcinogens or toxicants or both. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in meta-analyses.
Main results:
We included 61 completed studies, representing 16,759 participants, of which 34 were RCTs. Five of the 61 included studies were new to this review update. Of the included studies, we rated seven (all contributing to our main comparisons) at low risk of bias overall, 42 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (risk ratio (RR) 1.53, 95% confidence interval (CI) 1.21 to 1.93; I2 = 0%; 4 studies, 1924 participants). In absolute terms, this might translate to an additional three quitters per 100 (95% CI 1 to 6). There was low-certainty evidence (limited by very serious imprecision) that the rate of occurrence of AEs was similar (RR 0.98, 95% CI 0.80 to 1.19; I2 = 0%; 2 studies, 485 participants). SAEs were rare, but there was insufficient evidence to determine whether rates differed between groups due to very serious imprecision (RR 1.30, 95% CI 0.89 to 1.90: I2 = 0; 4 studies, 1424 participants). There was moderate-certainty evidence, again limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.94, 95% CI 1.21 to 3.13; I2 = 0%; 5 studies, 1447 participants). In absolute terms, this might lead to an additional seven quitters per 100 (95% CI 2 to 16). There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 3 studies, 601 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 1.06, 95% CI 0.47 to 2.38; I2 = 0; 5 studies, 792 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.61, 95% CI 1.44 to 4.74; I2 = 0%; 6 studies, 2886 participants). In absolute terms this represents an additional six quitters per 100 (95% CI 2 to 15). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was some evidence that non-serious AEs were more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants), and again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 1.51, 95% CI 0.70 to 3.24; I2 = 0%; 7 studies, 1303 participants). Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued use. Very few studies reported data on other outcomes or comparisons, hence evidence for these is limited, with CIs often encompassing clinically significant harm and benefit.
Authors' conclusions:
There is moderate-certainty evidence that ECs with nicotine increase quit rates compared to NRT and compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the effect size. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs. Overall incidence of SAEs was low across all study arms. We did not detect evidence of harm from nicotine EC, but longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates, but further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is now a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.
Importance
Tobacco use is the leading preventable cause of disease, disability, and death in the US. In 2014, it was estimated that 480 000 deaths annually are attributed to cigarette smoking, including second hand smoke exposure. Smoking during pregnancy can increase the risk of numerous adverse pregnancy outcomes (eg, miscarriage and congenital anomalies) and complications in the offspring (including sudden infant death syndrome and impaired lung function in childhood). In 2019, an estimated 50.6 million US adults (20.8% of the adult population) used tobacco; 14.0% of the US adult population currently smoked cigarettes and 4.5% of the adult population used electronic cigarettes (e-cigarettes). Among pregnant US women who gave birth in 2016, 7.2% reported smoking cigarettes while pregnant.
Objective
To update its 2015 recommendation, the USPSTF commissioned a review to evaluate the benefits and harms of primary care interventions on tobacco use cessation in adults, including pregnant persons.
Population
This recommendation statement applies to adults 18 years or older, including pregnant persons.
Evidence Assessment
The USPSTF concludes with high certainty that the net benefit of behavioral interventions and US Food and Drug Associated (FDA)–approved pharmacotherapy for tobacco smoking cessation, alone or combined, in nonpregnant adults who smoke is substantial. The USPSTF concludes with high certainty that the net benefit of behavioral interventions for tobacco smoking cessation on perinatal outcomes and smoking cessation in pregnant persons is substantial. The USPSTF concludes that the evidence on pharmacotherapy interventions for tobacco smoking cessation in pregnant persons is insufficient because few studies are available, and the balance of benefits and harms cannot be determined. The USPSTF concludes that the evidence on the use of e-cigarettes for tobacco smoking cessation in adults, including pregnant persons, is insufficient, and the balance of benefits and harms cannot be determined. The USPSTF has identified the lack of well-designed, randomized clinical trials on e-cigarettes that report smoking abstinence or adverse events as a critical gap in the evidence.
Recommendations
The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and FDA-approved pharmacotherapy for cessation to nonpregnant adults who use tobacco. (A recommendation) The USPSTF recommends that clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco. (A recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant persons. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of e-cigarettes for tobacco cessation in adults, including pregnant persons. The USPSTF recommends that clinicians direct patients who use tobacco to other tobacco cessation interventions with proven effectiveness and established safety. (I statement)
Rationale, aims, and objectives
There is limited research on how health care providers approach the topic of e‐cigarettes in clinical encounters, especially in conjunction with other best‐practice recommendations for smoking cessation. This qualitative study explored physician perceptions and recommendations involving e‐cigarettes in the context of smoking cessation counselling, including their opinions about the implementation and content of patient educational materials that focus on e‐cigarettes.
Methods
Semistructured interviews were conducted with 15 physicians from family medicine, internal medicine, and obstetrics/gynaecology (OB/GYN).
Results
Physicians did not routinely assess e‐cigarette use among patients and reported that discussions were often initiated by patients. Only a minority of participants discussed e‐cigarettes in conjunction with other best‐practice recommendations for smoking cessation. Most others were more ambivalent about e‐cigarette safety and effectiveness for cessation and did not address the topic, unless patients were already using e‐cigarettes. Almost all, however, agreed that more research on e‐cigarettes was needed. Physicians expressed an interest in having enhanced discussions about e‐cigarettes with their patients and in using patient educational materials to accomplish this. Physicians recommended that these materials not actively promote e‐cigarettes and be tailored to patients based on their demographics and motivation to quit.
Conclusions
Physicians were open to improving their smoking cessation counselling and to integrating new patient educational materials that addressed e‐cigarettes. Patient educational materials that provide tailored information about e‐cigarettes could potentially be used initiate e‐cigarette discussions and inform smokers about what is known vs unknown about e‐cigarettes.
Introduction
The study purpose was to examine the association between electronic cigarette (e-cigarette) use and smoking cessation among United States (US) adults. Duration of smoking cessation was taken into consideration since e-cigarette awareness and use were low in the US before 2010.
Methods
Pooled analysis of the 2016 and 2017 National Health Interview Surveys on current (N=9935) and former smokers (N=14754) was performed. Adjusted prevalence ratios (aPRs), adjusted for sociodemographic factors, were calculated.
Findings
Current e-cigarette use was reported by 10.5% (95%CI:9.8-11.3%) of current smokers and 4.5% (95%CI:4.0-5.0%) of former smokers. Prevalence was high in former smokers of <1 year (16.8%, 95%CI:13.9-20.2%), 1-3 years (15.0%, 95%CI:13.0-17.3%) and 4-6 years (10.5%, 95%CI:8.6-12.7%) and very low in former smokers of >6 years (0.7%, 95%CI:0.5-0.9%). Similar patterns were observed for daily e-cigarette use. Current e-cigarette use was negatively associated with being a former smoker when quit duration was ignored (aPR:0.64, 95%CI:0.59-0.69) but was positively associated with being a former smoker of <1 year (aPR:1.44, 95%CI:1.12-1.84) and 1-3 years (aPR:1.21, 95%CI:1.03-1.42). Daily e-cigarette use was not associated with being a former smoker when quit duration was ignored but was positively associated with being a former smoker of <1 year (aPR:3.44, 95%CI:2.63-4.49), 1-3 years (aPR:2.51, 95%CI:2.13-2.95) and 4-6 years (aPR:1.84, 95%CI:1.49-2.26).
Conclusions
Daily e-cigarette use is strongly associated with recent smoking cessation (< 6 years) among US adults. Frequency of e-cigarette use and smoking cessation duration are important parameters when analyzing the effects of e-cigarettes in population surveys.
Background
E-cigarettes are commonly used in attempts to stop smoking, but evidence is limited regarding their effectiveness as compared with that of nicotine products approved as smoking-cessation treatments.
Methods
We randomly assigned adults attending U.K. National Health Service stop-smoking services to either nicotine-replacement products of their choice, including product combinations, provided for up to 3 months, or an e-cigarette starter pack (a second-generation refillable e-cigarette with one bottle of nicotine e-liquid [18 mg per milliliter]), with a recommendation to purchase further e-liquids of the flavor and strength of their choice. Treatment included weekly behavioral support for at least 4 weeks. The primary outcome was sustained abstinence for 1 year, which was validated biochemically at the final visit. Participants who were lost to follow-up or did not provide biochemical validation were considered to not be abstinent. Secondary outcomes included participant-reported treatment usage and respiratory symptoms.
Results
A total of 886 participants underwent randomization. The 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group (relative risk, 1.83; 95% confidence interval [CI], 1.30 to 2.58; P<0.001). Among participants with 1-year abstinence, those in the e-cigarette group were more likely than those in the nicotine-replacement group to use their assigned product at 52 weeks (80% [63 of 79 participants] vs. 9% [4 of 44 participants]). Overall, throat or mouth irritation was reported more frequently in the e-cigarette group (65.3%, vs. 51.2% in the nicotine-replacement group) and nausea more frequently in the nicotine-replacement group (37.9%, vs. 31.3% in the e-cigarette group). The e-cigarette group reported greater declines in the incidence of cough and phlegm production from baseline to 52 weeks than did the nicotine-replacement group (relative risk for cough, 0.8; 95% CI, 0.6 to 0.9; relative risk for phlegm, 0.7; 95% CI, 0.6 to 0.9). There were no significant between-group differences in the incidence of wheezing or shortness of breath.
Conclusions
E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support. (Funded by the National Institute for Health Research and Cancer Research UK; Current Controlled Trials number, ISRCTN60477608.)
Background and Aims
Debate exists about whether health professionals (HPs) should advise smokers to use nicotine vaping products (NVPs) to quit smoking. The objectives were to examine in four countries: (1) prevalence of HP discussions and recommendation to use an NVP; (2) who initiated NVP discussions; (3) the type of HP advice received about NVPs; and (4) smoker's characteristics related to receiving advice about NVPs.
Design
Cross‐sectional study using multivariable logistic regression analyses on weighted data from the 2016 ITC Four Country Smoking and Vaping Survey (ITC 4CV1).
Setting
Four countries with varying regulations governing the sale and marketing of NVPs: “most restrictive” (Australia), “restrictive” (Canada) or “less restrictive” (England and US).
Participants
6,615 adult smokers who reported having visited an HP in the last year (drawn from the total sample of 12,294 4CV1 respondents, of whom 9,398 reported smoking cigarettes daily or weekly). Respondents were from the United States (US, n=1,518), England (n=2,116), Australia (n=1,046), and Canada (n=1,935).
Measurements
Participants' survey responses indicated if they were current daily or weekly smokers and had visited an HP in the past year. Among those participants, further questions asked participants to report 1) whether e‐cigarettes were discussed, 2) who raised the topic, 3) advice received on use of e‐cigarettes, and 4) advice received on quitting smoking.
Methods
Data were from the 2016 ITC Four Country Smoking and Vaping Survey (ITC 4CV1), consisting of 6,615 adult smokers who reported having visited an HP in the last year (drawn from the total sample of 12,294 4CV1 respondents, of whom 9,398 reported smoking cigarettes daily or weekly). Respondents were from the United States (US, n=1,518), England (n=2,116), Australia (n=1,046), and Canada (n=1,935), Multivariable logistic regression analyses were conducted on weighted data.
Findings
Among the 6,615 smokers who visited an HP in the last year, 6.8% reported discussing NVPs with an HP, and 2.1% of smokers were encouraged to use an NVP (36.1% of those who had a discussion). Compared with Australia (4.3%), discussing NVPs with an HP was more likely in the US (8.8%, OR=2.15, 95% CI=1.41‐3.29) and Canada (7.8%, OR=1.87, 95% CI=1.26‐2.78). Smokers in Australia were less likely to discuss NVPs than smokers in England (6.2%), although this was not statistically significant (OR=1.47, 95% CI=0.98‐2.20). Overall, the prevalence of HPs recommending NVPs was three‐times more likely in the US than in Australia (OR=3.07, 95% CI= 1.45‐6.47), and twice as likely in Canada (OR=2.28, CI=1.06‐4.87) than in Australia. Australia and England did not differ (OR=1.76, 95% CI=0.83‐3.74). Just over half (54%) of respondents brought up NVPs themselves; there were no significant differences among countries.
Conclusions
Discussions in Australia, Canada, England, and the US between smokers and health professionals about nicotine vaping products appear to be infrequent, regardless of the regulatory environment. A low percentage of health professionals recommended vaping products. This is particularly evident in Australia, which has the most restrictive regulatory environment of the four countries studied.
Introduction:
Assessing the extent that cigarette smokers use or switch to e-cigarettes and smokeless tobacco can help inform the population health impact of these products. This study estimated the prevalence of e-cigarette and smokeless tobacco use and switching among current and recent former adult cigarette smokers.
Methods:
Data from the 2012-2013 (n=8,891) and 2013-2014 (n=11,379) National Adult Tobacco Survey were analyzed in 2016. Response rates for this telephone survey were 44.9% and 36.1%, respectively. Tobacco product use was assessed by smoking status.
Results:
Current e-cigarette use increased for all groups, with a greater increase among recent quitters, 9.1% (95% CI=7.1%, 11.1%) in 2012-2013 and 15.8% (95% CI=13.7%, 17.9%) in 2013-2014, than smokers with an unsuccessful quit attempt, 10.4% (95% CI=9.1%, 11.7%) in 2012-2013 and 14.8% (95% CI=13.5%, 16.1%) in 2013-2014, or smokers with no quit attempt, 5.9% (95% CI=4.8%, 6.9%) in 2012-2013 and 10.7% (95% CI=9.4%, 12.0%) in 2013-2014. Between 2012-2013 and 2013-2014, current use of smokeless tobacco remained steady for recent quitters (4.6% to 4.7%, p=0.92) and smokers with no quit attempt (4.0% to 4.3%, p=0.97), and decreased in smokers with an unsuccessful quit attempt (5.7% to 3.8%, p=0.004). More recent quitters completely switched to e-cigarettes in the past year (15.3% in 2012-2013, 25.7% in 2013-2014) than to smokeless tobacco (4.6% in 2012-2013, 4.5% in 2013-2014).
Conclusions:
Current and recent former adult smokers are more likely to use e-cigarettes than smokeless tobacco. Current e-cigarette use was most prevalent among unsuccessful quitters and recent quitters, who were substantially more likely to report complete switching to e-cigarettes than smokeless tobacco.
Objectives:
While cessation from cigarettes is a top priority for public health, controversy surrounds the role of e-cigarettes for quitting cigarettes. This study examines the role of e-cigarettes in quit attempts and 3-month cigarette abstinence using a large, recent nationally representative US sample.
Methods:
Data from the 2014/15 Tobacco Use Supplement-Current Population Survey (TUS-CPS) on cigarette and e-cigarette use and individual characteristics were supplemented with information on state tobacco control policies. We estimated frequencies and multivariate logistic equations for making a quit attempt among those who smoked 1 year earlier and for remaining abstinent at least 3 months among those making a quit attempt. These two outcomes were related to demographic characteristics, tobacco control policies and different frequency measures of e-cigarette use (ever, at least 1, 5, 20 of the last 30 days, a continuous measure of days use).
Results:
Having made a quit attempt was more likely among smokers using e-cigarettes than non-users. Among those making at least one quit attempt, quit success was lower among ever users, but higher among those with at least 5 days use of e-cigarettes in the last month. Both quit attempts and quit success were linearly related to the frequency of e-cigarette use.
Conclusions:
Consistent with randomized trials and those observational studies that measure frequency of e-cigarette use, both quit attempts and quit success were positively associated with increased frequency of e-cigarette use. Frequency of e-cigarette use was important in gauging the nature of these relationships.
Implications:
Previous studies have obtained mixed results regarding the relationship of e-cigarette use to cigarette smoking cessation. This study provides a more precise methodology for considering the relationship of e-cigarette use to quit attempts and to quit success, and finds that quit attempts and quit success increase with the number of days use in the past month.
Introduction:
Amid decreasing rates of cigarette smoking and a rise in e-cigarette use, there is a need to understand population patterns of use to inform tobacco control efforts and evaluate whether e-cigarettes may play a role in tobacco harm reduction.
Methods:
This study merged data from the 2014 and 2015 National Health Interview Survey (NHIS) and restricted the sample to recent smokers [i.e., current smokers and former smokers who quit in 2010 or later (n=15,532)]. Log-binomial regression estimated adjusted prevalence ratios (aPR) for being quit by e-cigarette use status (i.e., daily, some day, former trier, never). All analyses controlled for factors traditionally correlated with smoking cessation.
Results:
A quarter of the sample (25.2%) were former smokers. The prevalence of being quit was significantly higher among daily e-cigarette users compared to those who had never used e-cigarettes [52.2% vs. 28.2%, aPR: 3.15 (2.66, 3.73)]. Those who used e-cigarettes on some days were least likely to be former smokers (12.1%). These relationships held even after accounting for making a quit attempt and use of other tobacco products.
Conclusions:
Among those with a recent history of smoking, daily e-cigarette use was the strongest correlate of being quit at the time of the survey, suggesting that some smokers may have quit with frequent e-cigarette use or are using the products regularly to prevent smoking relapse. However, the low prevalence of cessation among infrequent e-cigarette users highlights the need to better understand this subgroup, including the individual factors and/or product characteristics that may inhibit cessation.
Little is known about patients’ electronic cigarette use, interest in and use of smoking cessation treatments, and providers’ attitude towards such treatment. We assessed patients (N = 231) and providers (45 psychiatrists, 97 case workers) in four Community Mental Health Centers. Interestingly, 50% of smokers reported interest in using electronic cigarettes to quit smoking, and 22% reported current use. While 82% of smokers reported wanting to quit or reduce smoking, 91% of psychiatrists and 84% of case workers reported that patients were not interested in quitting as the lead barrier, limiting the provision of cessation interventions. Providers’ assumption of low patient interest in treatment may account for the low rate of smoking cessation treatment. In contrast, patients report interest and active use of electronic cigarettes to quit smoking. This study highlights the need for interventions targeting different phases of smoking cessation in these patients suffering disproportionately from tobacco dependence.
Introduction
We sought to assess physician knowledge/beliefs, self-efficacy, and experience/practice patterns surrounding smoking cessation and electronic cigarettes.
Methods
An eight-page survey sent via US Postal service. The initial invitation included a $10 cash incentive and up to three invitations were sent. Fifteen hundred US physicians were identified with equal representation from primary care physicians (internal medicine and family practice), surgical care physicians (general surgeons and anesthesiologists), and pulmonologists.
Results
Two hundred fourteen were not included in the analysis (183 non-deliverable, one deceased, 30 not practicing). 561/1286 (44%) remaining surveys were returned for analysis. Greater than 90% agreed that advising and assisting with smoking cessation is their responsibility; 86% advise and 65% assist their patients with smoking cessation more than 75% of the time. Approximately two-thirds of respondents report that their patients ask them about electronic cigarettes at least some of the time (≥25%); 58.4% report that they ask their patients about electronic cigarette use at least some of the time. Overall, 37.9% have at some point recommended electronic cigarettes to their patients that smoke, with 11.5% reporting recommending them at least 25% of the time. Surgical care providers appear less confident and less self-efficacious with smoking cessation, as well as with electronic cigarettes and appear less likely to endorse use of electronic cigarettes.
Discussion
US physicians are frequently discussing electronic cigarettes in a clinical context and a substantial proportion of US physicians have recommended electronic cigarettes to their patients.
Implications
This study documents several important previously poorly characterized aspects of the role of electronic cigarettes in clinical care. The majority of US physicians are discussing electronic cigarettes in clinical contexts and a substantial proportion of US physicians have recommended electronic cigarettes to their patients. The extent of physician engagement on the topic of electronic cigarettes should be met with increased efforts to better characterize electronic cigarettes’ appropriate role in smoking cessation and reduction.
Objective: To summarize the recently published US Public Health Service report Treating Tobacco Use and Dependence: A Clinical Practice Guideline, which provides recommendations for brief clinical interventions, intensive clinical interventions, and system changes to promote the treatment of tobacco dependence. Participants: An independent panel of 18 scientists, clinicians, consumers, and methodologists selected by the US Agency for Healthcare Research and Quality. A consortium of 7 governmental and nonprofit organizations sponsored the update. Evidence: Approximately 6000 English- language, peer-reviewed articles and abstracts, published between 1975 and 1999 were reviewed for data that addressed assessment and treatment of tobacco dependence. This literature served as the basis for more than 50 meta-analyses. Consensus Process: One panel meeting and numerous conference calls and staff meetings were held to evaluate meta-analytic and other results, to synthesize the results, and to develop recommendations. The updated guideline was then externally reviewed by more than 70 experts and revised. Conclusions: This evidence-based, updated guideline provides specific recommendations regarding brief and intensive tobacco cessation interventions as well as system-level changes designed to promote the assessment and treatment of tobacco use. Brief clinical approaches for patients willing and unwilling to quit are described. Major conclusions and recommendations include: (1) Tobacco dependence is a chronic condition that warrants repeated treatment until long-term or permanent abstinence is achieved. (2) Effective treatments for tobacco dependence exist and all tobacco users should be offered those treatments. (3) Clinicians and health care delivery systems must institutionalize the consistent identification, documentation, and treatment of every tobacco user at every visit. (4) Brief tobacco dependence treatment is effective, and every tobacco user should be offered at least brief treatment. (5) There is a strong dose-response relationship between the intensity of tobacco dependence counseling and its effectiveness. (6) Three types of counseling were found to be especially effective - practical counseling, social support as part of treatment, and social support arranged outside of treatment. (7) Five first-line pharmacotherapies for tobacco dependence - sustained-release bupropion hydrochloride, nicotine gum, nicotine inhaler, nicotine nasal spray, and nicotine patch - are effective, and at least 1 of these medications should be prescribed in the absence of contraindications. (8) Tobacco dependence treatments are cost-effective relative to other medical and disease prevention interventions; as such, all health insurance plans should include as a reimbursed benefit the counseling and pharmacotherapeutic treatments identified as effective in the updated guideline.
Introduction:
We examined: (a) current (past 30-day) smokers' interest in using or switching to electronic nicotine delivery systems (ENDS) or smokeless tobacco for various reasons; (b) correlates of interest in these products; and (c) subgroups of current smokers in relation to interest in these products.
Methods:
We conducted a cross-sectional survey assessing sociodemographics, tobacco use, interest in ENDS and smokeless tobacco among smokers, and knowledge about ENDS among 2,501 US adults recruited through an online consumer panel. We oversampled tobacco users (36.7% current cigarette smokers), ethnic minorities, and southeastern US state residents.
Results:
On average, participants were more interested in ENDS than smokeless tobacco across all reasons provided. Additionally, they were less interested in either product because of their potential use in places prohibiting smoking or due to curiosity and more interested in reducing health risk or cigarette consumption or to aid in cessation. We documented high rates (27.9%) of misbeliefs about Food and Drug Administration approval of ENDS for cessation, particularly among current smokers (38.5%). Also, 27.2% of current smokers had talked with a health care provider about ENDS, with 18.0% reporting that their provider endorsed ENDS use for cessation. Furthermore, cluster analyses revealed 3 groups distinct in their interest in the products, sociodemographics, and smoking-related characteristics.
Conclusions:
This study highlights higher interest in ENDS versus smokeless tobacco and greater interest in both for harm reduction and cessation than due to novelty or smoking restrictions. Developing educational campaigns and informing practitioners about caveats around ENDS as cessation or harm reduction aids are critical.
Electronic cigarettes (e-cigarettes) can deliver nicotine and mitigate tobacco withdrawal and are used by many smokers to assist quit attempts. We investigated whether e-cigarettes are more effective than nicotine patches at helping smokers to quit.
We did this pragmatic randomised-controlled superiority trial in Auckland, New Zealand, between Sept 6, 2011, and July 5, 2013. Adult (≥18 years) smokers wanting to quit were randomised (with computerised block randomisation, block size nine, stratified by ethnicity [Māori; Pacific; or non-Māori, non-Pacific], sex [men or women], and level of nicotine dependence [>5 or ≤5 Fagerström test for nicotine dependence]) in a 4:4:1 ratio to 16 mg nicotine e-cigarettes, nicotine patches (21 mg patch, one daily), or placebo e-cigarettes (no nicotine), from 1 week before until 12 weeks after quit day, with low intensity behavioural support via voluntary telephone counselling. The primary outcome was biochemically verified continuous abstinence at 6 months (exhaled breath carbon monoxide measurement <10 ppm). Primary analysis was by intention to treat. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12610000866000.
657 people were randomised (289 to nicotine e-cigarettes, 295 to patches, and 73 to placebo e-cigarettes) and were included in the intention-to-treat analysis. At 6 months, verified abstinence was 7·3% (21 of 289) with nicotine e-cigarettes, 5·8% (17 of 295) with patches, and 4·1% (three of 73) with placebo e-cigarettes (risk difference for nicotine e-cigarette vs patches 1·51 [95% CI -2·49 to 5·51]; for nicotine e-cigarettes vs placebo e-cigarettes 3·16 [95% CI -2·29 to 8·61]). Achievement of abstinence was substantially lower than we anticipated for the power calculation, thus we had insufficient statistical power to conclude superiority of nicotine e-cigarettes to patches or to placebo e-cigarettes. We identified no significant differences in adverse events, with 137 events in the nicotine e-cigarettes group, 119 events in the patches group, and 36 events in the placebo e-cigarettes group. We noted no evidence of an association between adverse events and study product.
E-cigarettes, with or without nicotine, were modestly effective at helping smokers to quit, with similar achievement of abstinence as with nicotine patches, and few adverse events. Uncertainty exists about the place of e-cigarettes in tobacco control, and more research is urgently needed to clearly establish their overall benefits and harms at both individual and population levels.
Health Research Council of New Zealand.
Introduction and aims:
As the popularity of electronic cigarettes (e-cigarettes) increases, it is becoming important to find out more about the characteristics of e-cigarette users, why and how they use the product and whether e-cigarettes are used exclusively or in combination with conventional cigarettes. The objective of this study was to investigate patterns and effects of e-cigarette use and user beliefs about e-cigarette safety and benefits.
Design and methods:
E-cigarette users in Poland were recruited online and asked to participate in a web-based survey. The participants provided information on their smoking history, patterns of e-cigarette use, beliefs and attitudes regarding the product and information on concurrent use of conventional cigarettes.
Results:
The survey was completed by 179 e-cigarette users. Almost all participants used e-cigarettes daily. E-cigarettes were primarily used to quit smoking or to reduce the harm associated with smoking (both 41%), and were successful in helping the surveyed users to achieve these goals with 66% not smoking conventional cigarettes at all and 25% smoking under five cigarettes a day. Most participants (82%) did not think that e-cigarettes were completely safe, but thought that they were less dangerous than conventional cigarettes. Sixty percent believed that e-cigarettes were addictive, but less so than conventional cigarettes.
Discussion and conclusions:
The participants primarily used e-cigarettes as a stop-smoking aid or as an alternative to conventional cigarettes, and the majority reported that they successfully stopped smoking. More data on e-cigarette safety and its efficacy in harm-reduction and smoking cessation are needed.
The relationship of E-cigarette use to cigarette quit attempts and cessation: Insights from a large
- D T Levy
- Z Yuan
- Y Luo
- D B Abrams
Levy DT, Yuan Z, Luo Y, Abrams DB. The relationship of E-cigarette
use to cigarette quit attempts and cessation: Insights from a large,
nationally representative U.S. Survey Nic Tobacco Res. 2018;20:
931-9.
Physicians' attitudes and use of E-cigarettes as cessation devices, North Carolina
- K L Kandra
- L M Ranney
- Jgl Lee
- A O Goldstein
Kandra KL, Ranney LM, Lee JGL, Goldstein AO. Physicians' attitudes
and use of E-cigarettes as cessation devices, North Carolina, 2013.
PLoS ONE. 2014;9:e103462.
The Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel Liaisons and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report
The Clinical Practice Guideline Treating Tobacco Use and
Dependence 2008 Update Panel Liaisons and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008
update. A U.S. Public Health Service report. Am J Prev Med. 2008;
35:158-76.
Evidence Review of E-Cigarettes and Heated Tobacco Products 2018. A report commissioned by Public Health England London
- A Mcneill
- L Brose
- R Calder
- L Bauld
- D Robson
McNeill A, Brose L, Calder R, Bauld L, Robson D. Evidence Review of
E-Cigarettes and Heated Tobacco Products 2018. A report commissioned by Public Health England London, UK: Public Health England;
2018.
VicHealth Centre for Tobacco Control
International Tobacco Control (ITC) Project. ITC Four Country Wave
1 (2002) Technical Report. University of Waterloo, Waterloo,
Ontario, Canada; Medical University of South Carolina, Charleston,
South Carolina, USA; VicHealth Centre for Tobacco Control, Carlton,
Australia; Cancer Control Victoria, Melbourne, Australia; King's College London, London, United Kingdom; University of Stirling, Stirling,
UK; the Open University, Buckinghamshire, UK; 2004, July.
37. International Tobacco Control (ITC) Project. ITC Four Country Waves
2 to 8 (2003-2011) Technical Report. University of Waterloo,
Waterloo, Ontario, Canada; Medical University of South Carolina,
Charleston, South Carolina, USA; VicHealth Centre for Tobacco Control, Carlton, Australia; Cancer Control Victoria, Melbourne, Australia;
US Preventive Services Task Force. Interventions for tobacco smoking cessation in adults, including pregnant persons: US preventive services task force recommendation statement
US Preventive Services Task Force. Interventions for tobacco smoking cessation in adults, including pregnant persons: US preventive
services task force recommendation statement. Jama. 2021;325:
265-79.