Educating physicians on nicotine and the risk continuum.
By Cheryl K. Olson
In an earlier edition of Tobacco Reporter, I described the globally widespread, misplaced fears about the health risks of nicotine—and the critical need for credible messengers to counter those fears (see “Watch Your Mouth,” Tobacco Reporter, March 2022). People generally trust their doctors for health information. Smokers do too.1 The limited data available suggest smokers trust their doctors over other sources of information on e-cigarettes2 and that most patients using e-cigarettes would appreciate at least a brief discussion or handout.3
Are physicians positioned to take advantage of that trust? Can they effectively guide patients who can’t or won’t quit nicotine toward lifesaving alternatives to smoking? Getting patients to stop smoking is top priority. Cigarettes are still the leading preventable cause of illness and death in the U.S. and many other nations. Smoking rates are stagnant among vulnerable populations, including those who are older, low-income or struggling with chronic physical or mental illness.4 Thanks in part to media-driven fears of vaping lung injuries and to e-cigarette flavor bans, cigarette sales are actually on the rise.5, 6
Before doctors can help, they must be armed with accurate information and believe that taking action is necessary.
Physicians are Confused About Nicotine
One huge obstacle is a widespread physician perception that nicotine is dangerous. The first sentence in a 2021 survey report from the Journal of General Internal Medicine states, “Nicotine is responsible for the highly addictive nature of tobacco products, but most tobacco-caused disease is not directly caused by nicotine but rather by other chemicals present in tobacco or tobacco smoke.”7 Stunningly, four of five physicians in this U.S. survey strongly agreed (incorrectly!) that nicotine causes cancer, cardiovascular disease and chronic obstructive pulmonary disease. There were only minor variations across medical specialties. Recent surveys across countries have similar findings.
What effects might these beliefs have on physician willingness to recommend nicotine-replacement therapies to patients who smoke? And what about recreational nicotine products?
Physicians Don’t Understand the Continuum of Risk
Another barrier is ignorance about or fear of reduced-harm products that aren’t pharmaceuticals. I couldn’t locate any studies on what, if anything, doctors know about the full range of novel recreational nicotine products. However, a 2020 review from the University of Queensland8 found 45 qualitative and quantitative studies internationally that looked at what physicians believe and do regarding electronic nicotine-delivery systems (ENDS). Doctors were aware of ENDS but far from experts in their health effects and use for smoking cessation. Most of what they knew came from media stories or patients. “This lack of knowledge and feeling of being ‘uninformed’ was reported consistently by [healthcare professionals] across and within studies.”
The latest and largest U.S. study of what doctors say to patients about vaping appeared in the April 2022 issue of JAMA Network Open.9 The Rutgers University authors surveyed a national cross-section of 2,058 board-certified physicians. The conclusion? “More than half of the physicians believed that all tobacco products are equally harmful, and this belief was associated with lower rates of recommending e-cigarettes.” The authors argue that “it is critical to address physician nicotine misperceptions and to correct misperceptions regarding the relative harm of various tobacco products,” as the “FDA authorization process” introduces more modified-risk products.
What Might Start to Open Minds?
I asked a young physician friend (a third-year resident at Virginia Commonwealth University) what he and his fellow doctors would want to know about reduced-harm nicotine products that their patients might be using. He immediately mentioned wanting to see results from randomized controlled trials (RCTs) on “products that will help patients quit harmful tobacco products but also data regarding health outcomes. For example, what are the rates of lung cancer in a patient who smokes cigarettes for 10 years versus someone who vapes for 10 years?”
This is the sort of response we expect and was consistent with the JAMA Network Open survey findings. But can data alone change beliefs?
An earlier study from the Rutgers researchers involving structured interviews with doctors gives reason for doubt.10 Most doctors they talked to were at least neutral about attempts to switch to e-cigarettes for patients who had failed with traditional smoking cessation methods. But five of the 35 doctors were adamantly opposed; they would not recommend vaping to patients even if future RCTs found e-cigarettes to be equal or superior to other quit methods. One oncologist said, “Based on what I’ve heard and read about them, I don’t think so. It seems like they’re actually, like I said, kind of dangerous.”
A careful read suggests that physicians who believed e-cigarettes could be effective switching tools—about half of those interviewed—were so persuaded by a combination of stories and data. Patients, friends or family members had cut down or quit cigarettes through vaping. And, perhaps sensitized to the issue by these stories, the doctors recalled seeing one or more studies that backed up their personal observations. Interestingly, 11 of the doctors who doubted e-cigarette effectiveness cited the hand-to-mouth behavior similarities to smoking as a negative rather than a positive for switching. This suggests they don’t know smokers.
Physician Harm Reduction
During his postdoctoral training as a primary care physician, Sudhanshu Patwardhan grew increasingly concerned about the ineffectiveness of the advice and treatments given to patients who smoked combustible cigarettes. Since then, he’s focused his clinical and research career on harm reduction for addicted smokers. He’s currently based in Great Britain, where he’s the director of the Centre for Health Research and Education.
Patwardhan has researched physicians and nicotine in the U.K., Sweden, Greece and India. For the past year, he and I have been talking about the clinical and public policy challenges that come with shifting toward a harm reduction approach to smoking cessation.
“Consistently, between 65 [percent and] 80 percent of surveyed physicians across all these countries harbor misperceptions about nicotine,” he said. “It’s no wonder that, universally, ‘Why replace one addiction with another?’ is one of the commonest attitudes [among physicians] for nicotine-replacement therapy for tobacco cessation using a harm reduction approach.
“Doctors forget that in addition to its long-term effects, inhaling the smoke from burning tobacco induces the breakdown of many drugs, thus making those treatments ineffective. Many psychiatrists I interact with admit to simply increasing the dose of the administered medications to compensate for the loss of effectiveness due to smoke-induced breakdown but don’t offer cessation support simultaneously. This, of course, leads to higher side effects and poorer patient outcomes—all because physicians are not sensitized to and empowered about tobacco cessation and harm reduction.
“Most freshly minted doctors would know how to recognize the most esoteric heart murmur but have no practical experience in the basics of behavioral intervention or the role of medications for tobacco cessations. Pharmacology and clinical medicine barely touch on nicotine-replacement therapy and give no clues to trainee doctors on what to prescribe, for how long and how to manage cravings and withdrawal symptoms effectively. Most noncommunicable diseases have tobacco use as a risk factor. Yet doctors simply do not address it along with the presenting complaint.
“Our center’s strategy focuses on the root of the issue: We’re developing and conducting peer-based education of healthcare providers in a safe and nonjudgmental environment. Our approach and materials are country specific. For example, in the U.K., e-cigarettes are a part of the suite of potential harm reduction tools offered by the National Health Service. In India, however, e-cigarettes are currently banned and not licensed for smoking cessation. There, we focus on approved approaches, such as nicotine-replacement therapy, bupropion and varenicline.”
“We need to start overhauling the medical education curriculum in this area. We’re conducting pilot programs at some medical schools with exciting results and will publish those data. Practicing physicians also need training to increase their effectiveness. Finally, scaling up of nicotine education for healthcare providers can be a significant challenge, especially for countries as wide as the U.S. or as populated as India. Digital tech tools, such as cessation apps, short media presentations, including online videos and smart print campaigns designed for social media, can all help.”–C.K.O.
1 Nelms E et al. Trust in physicians among rural Medicaid-enrolled smokers. Journal of Rural Health, 2014: 30(2), 214–220. doi:10.1111/jrh.12046.
2 Wackowski OA et al. Smokers’ sources of e-cigarette awareness and risk information. Preventive Medicine Reports, 2015: 906–910, http://dx.doi.org/10.1016/j.pmedr.2015.10.006.
3 Doescher MP et al. Patient perspectives on discussions of electronic cigarettes in primary care. Journal of the American Board of Family Medicine, 2018, doi: 10.3122/jabfm.2018.01.170206.
4 Zhu S-H et al. Smoking prevalence in Medicaid has been declining at a negligible rate. PLoS One, 2017, https://doi.org/10.1371/journal.pone.0178279.
5 Xu Y et al. The impact of banning electronic nicotine-delivery systems on combustible cigarette sales: Evidence from U.S. state-level policies. Value in Health, 2022, doi: 10.1016/j.jval.2021.12.006.
6 Federal Trade Commission. FTC report finds annual cigarette sales increased for the first time in 20 years. October 2021. www.ftc.gov/news-events/news/press-releases/2021/10/ftc-report-finds-annual-cigarette-sales-increased-first-time-20-years.
7 Steinberg MB et al. Nicotine risk perceptions among U.S. physicians. Journal of General Internal Medicine, 2020, doi: 10.1007/s11606-020-06172-8.
8 Erku DA et al. Beliefs and self-reported practices of healthcare professionals regarding electronic nicotine-delivery systems (ENDS): a mixed-methods systematic review and synthesis. Nicotine & Tobacco Research, 2020 https://doi.org/10.1093/ntr/ntz046.
9 Delnevo CD et al. Communication between U.S. physicians and patients regarding electronic cigarette use. JAMA Network Open, 2022, doi:10.1001/jamanetworkopen.2022.6692.
10 Singh B et al. Knowledge, recommendation and beliefs of e-cigarettes among physicians involved in tobacco cessation: A qualitative study. Preventive Medicine Reports, 2017 http://dx.doi.org/10.1016/j.pmedr.2017.07.012.