A paper published in the current issue of the Annals of the American Thoracic Society reports the results of a survey regarding physician recommendations to their patients about the use of electronic cigarettes for smoking cessation.
(See: Nickels AS, Warner DO, Jenkins SM, Tilburt J, Hays JT. Pulmonologists’ and Primary Care Physicians’ Responses to an Adult
Patient with Asthma Who Inquires about Using Electronic Cigarettes as a
Smoking Cessation Tool. Annals of the American Thoracic Society 2017; 14(3): 466-468.)
Physicians were given a clinical scenario in which a patient who smokes seeks advice about smoking cessation. Most physicians report that they would recommend the patient try FDA-approved medication before trying e-cigarettes. However, physicians who recommended against e-cigarettes initially were then given a further scenario in which the patient tells the physician that they tried other medications to quit before, that they refuse a prescription, and that they ask the physician again whether they should try e-cigarettes to quit.
Shockingly, the survey finds that in this situation, only 27% of physicians would recommend e-cigarettes. The remaining 73% of physicians would recommend against the use of e-cigarettes, even after the patient indicated that using FDA-approved medications is not an option.
The Rest of the Story
The results of this survey are truly appalling. What they tell us is that more than two-thirds of physicians are essentially counseling their patients to continue to smoke rather than to attempt to quit by switching to electronic cigarettes.
After all, those are the only options that the patient is asking about in the scenario. The patient has made it clear that using FDA-approved medications is not an option. She has explicitly refused to take a prescription, meaning that she will almost certainly not be using NRT or other drugs to quit smoking. Essentially, the only options she is presenting to the physician are continuing to smoke are giving e-cigarettes a try.
And what the physicians are saying, or at least 73% of them, is: "In that case, continue smoking."
While this is truly appalling, I do not blame the physicians. They have been misled and confused by a major campaign of deception being waged by anti-tobacco groups and some health agencies, including the FDA and the CDC. These groups have lied to physicians and deceived them about the nature of e-cigarettes, their risks, and the relative risks of smoking compared to vaping.
For example, the CDC has told physicians that e-cigarettes are simply another "form of tobacco use." The FDA has told physicians that there is no evidence that vaping is any safer than smoking. Many anti-tobacco groups have told physicians that vaping is actually worse than smoking. Several anti-tobacco researchers have told physicians that vaping poses a higher cancer risk than smoking. Recently, some anti-tobacco researchers told physicians that vaping poses a higher risk of stroke than smoking. And many organizations have told physicians that vaping causes bronchiolitis obliterans ("popcorn lung") without even a suggestion that smoking also causes this severe, progressive lung disease.
Interestingly, the Mayo Clinic itself (with which four of this paper's authors are affiliated) has been a huge part of the problem. The Mayo Clinic lied to physicians about e-cigarettes, telling them that vaping is not any safer than smoking. The Mayo Clinic even went as far as to question the sanity of electronic cigarette users.
One thing I find surprising about this paper is that it fails to point out that there is a major problem with physicians advising patients who will not use NRT or other medications not to try e-cigarettes. While the paper does not explicitly state its position with regard to the appropriateness of this physician recommendation, it appears to be suggesting that the problem is not the physicians who recommend against e-cigarettes, but those who actually support this approach. I get this sense from the way that the paper frames the major result.
Instead of describing the major finding as "73% of physicians recommend against smoking cessation using e-cigarettes for smokers not willing to quit using other methods," the paper describes the major finding as follows:
"When confronted with a patient who prefers not to use FDA-approved
medications, the majority of respondents either recommended electronic
cigarette use or at least tolerated it."
One final point is worth mention. The authors fail to disclose any conflicts of interest related to this article. However, one of the study authors is a co-author of a manuscript reporting the results of a clinical trial of Chantix in which Pfizer was a collaborator (providing the study medication free of charge). And further, that co-author acknowledged having served "as an investigator for clinical trials funded by Pfizer." I believe that this conflict of interest should have been disclosed in the paper because Pfizer clearly has a significant financial interest in the information discussed in this study. In fact, e-cigarettes and Chantix are direct competitors in the smoking cessation market.
The rest of the story is that it appears that the majority of physicians are giving misguided advice to their patients regarding smoking cessation using e-cigarettes. Apparently, the campaign of deception being waged by anti-tobacco groups and some health agencies has been quite effective. It has led to the perverse result that the majority of physicians are actually recommending that some patients continue smoking rather than attempt to quit.
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