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.
Keywords: Vaping, E-cigarettes, Cigarette smoking, Smoking cessation, Health Communication, Health professional, Health education, Health promotion, Health policy
INTRODUCTION
Smokers are increasingly using nicotine vaping products (NVPs, also known as e-cigarettes) to quit smoking (1–6), and despite some controversies over their effectiveness (7), evidence from randomized trials suggests that NVPs are more effective than nicotine-replacement therapy (8, 9). The evidence from observational studies is mixed, but several studies report that frequent vaping and tank device type are associated with greater likelihood of smoking cessation (10–12). NVPs are currently not registered as a cessation medication in any country and are not included in clinical guidelines for smoking cessation in most countries. England is the only country where recommendations were published on how to discuss the use of NVPs for quitting in adult smokers who are interested in using them (13). Nevertheless, surveys of HPs indicate that many report discussing and recommending NVPs to their patients (14, 15), although only a small percentage of smokers report discussing NVPs with their HPs (14–20). Observational studies with long-term follow-ups and in countries with contrasting NVP regulations are needed to understand the impact of these conversations.
Globally, clinical guidelines recommend that all HPs should identify smokers and help them quit (21, 22). It is well established that HP advice can motivate smokers to try to quit (16, 23). Smokers perceive HPs as a trustworthy source of information about health topics including use of NVPs (24). Thus, it is not unexpected that smokers might ask their HPs about NVPs for smoking cessation (14, 15, 19, 20, 25). The clinical setting holds potential for promoting NVPs as a harm reduction strategy (26), but many HPs lack confidence to discuss NVPs (14). Moreover, HPs hold varied opinions about the risks and benefits of NVPs (19, 27). Most of the published studies of HPs are based on cross-sectional research (15, 19, 20), making the effect of HP advice about NVPs difficult to evaluate.
Only a few studies have examined NVP discussions with HPs from smokers’ perspectives. In most countries, only a minority of current smokers reported NVP discussions, including Australia (4%), Canada (8%), England (6%), Mexico (34%), and the US (9% - 27%) (16–18, 28) despite their interest in using NVPs (29, 30). The low prevalence of NVP discussions with HPs reported by smokers in Australia may be due to its strict ban on NVPs (17). Previous research suggests differences in regulatory environments appear to explain some differences in NVP use patterns (31). Smokers’ self-reports of prior NVP discussions with their HPs are strongly and consistently associated with current NVP use in cross-sectional studies (16, 17). However, it remains unclear whether NVP use precedes or follows from these discussions. Furthermore, NVP discussions were more common among smokers who had recently attempted (16) or intended (17) to quit, suggesting smokers may use NVPs as a cessation method, as smokers increasingly use NVPs more than other approved and recommended methods (1), especially in England (6). To date, the only longitudinal study on this topic found that NVP discussions with HPs were positively associated with NVP use in a subsequent quit attempt within 4 months of follow-up in a sample of Mexican smokers (29).
This study used a large sample of representative smokers in four high-income countries, where NVP regulatory environments range broadly from the most restrictive in Australia to the least restrictive in the US and England, where HPs take a less negative view of NVPs to help smokers move away from smoking (32, 33) and where there are published recommendations on how to advise smokers using NVPs to quit with them (13). Canada is considered to land somewhere in between (31), with it being somewhat restrictive in 2016 and 2018 but less restrictive in 2020 after NVPs were legalized in May 2018. Using additional waves of data from 2018 and 2020, this study extends a prior cross-sectional study (17) to examine changes from 2016 to 2020 in the prevalence of: 1) NVP discussions between smokers and HPs; 2) HP recommendations of NVPs to smokers; and 3) HPs initiating NVP discussions. The moderating role of country in the changes was examined, as well as the longitudinal association between NVP discussions and transitions in smoking/vaping behaviors.
METHODS
Study design
Data from Waves 1 (2016), 2 (2018), and 3 (2020) were analyzed from the International Tobacco Control (ITC) Four Country Smoking and Vaping Surveys in Australia, Canada, England, and the US. Details on survey methods for each country are available via the ITC website (https://itcproject.org/methods). Briefly, Wave 1 (July to November 2016) participants included adult (aged 18+) smokers either re-contacted from the original ITC 4C cohort (34–37) or newly recruited from online panels using either probability-based sampling frames, non-probability opt-in panels, or a combination of these. Participants from Wave 2 (March to June 2018) and Wave 3 (February to June 2020) included those who were re-contacted from the previous wave and new participants who were recruited to address attrition and maintain sample size over time.
Sample
The prevalence analysis sample included those who smoked daily, used NVPs less than monthly or not at all, and reported visiting a physician or other HP in the prior year for Wave 1 participants and during the interval between surveys for the Waves 2 and 3 participants. Figure 1 summarizes how the study samples were derived from the total source population. Of the exclusive daily smokers who participated in the ITC 4CV Surveys (n=5,712, 5,822, and 5,199, respectively, for Waves 1, 2, and 3), 72.8%, 77.9%, and 82.7% reported that they visited a HP (n=4,158, 4,538, and 4,302, respectively). After excluding those who refused or provided “don’t know” responses to the NVP discussion question, the total sample for the prevalence analysis was 12,905 (n=4,125, 4,503, and 4,277, respectively, for Waves 1, 2, and 3).
Figure 1.
Study inclusion flow diagram
Note: HP=Health professionals. NVP=nicotine vaping products. “don’t know” or refused resp
The study population used for the longitudinal analysis to examine associations between NVP discussions and smoking status transitions was comprised of exclusive daily smokers from either Wave 1 or 2 who were followed up at either Wave 2 or 3 and reported visiting a HP during the follow-up period. Of 5,911 daily exclusive smokers who participated in two consecutive waves (n=3,063 for Waves 1 and 2; n=2,848 for Waves 2 and 3; See Figure 1), 82.6% reported that they visited a HP during the follow-up period (n=4,884; n=2,479 between Waves 1 and 2, n=2,405 between Waves 2 and 3). After excluding those who refused or provided “don’t know” responses, the total sample for the longitudinal analysis was 4,859. All study procedures were approved by the ethics research committee at the University of Waterloo (Ontario, Canada), and ethics committees in the US (Medical University of South Carolina), England (King’s College London) and Australia (Cancer Council Victoria).
Measures
Visit to health professionals.
Participants were asked whether they visited a doctor or other health professional, with the time frame for the question being past 12 months at Wave 1 and past 18 or 24 months at Wave 2 or 3 (i.e., the interval between waves). Responses were dichotomized to ‘yes’ or ‘no/don’t know/refused’ and only those who answered yes were included in the study sample.
NVP discussion with health professionals.
At all waves, participants were asked: (1) whether they heard of e-cigarettes; (2) whether they received any advice to quit smoking on any visit to a doctor or HP; and (3) whether the doctor or HP talked to them about e-cigarettes (if they had heard of e-cigarettes). At Waves 1 and 2, participants who had NVP discussions with HPs were asked whether HPs: recommended they use NVPs; advised against using NVPs; or neither recommended nor not recommended NVPs, with a ‘don’t know’ option which was combined with the response ‘neither recommended nor not recommended’. At Wave 3, participants who received any quit advice were asked whether their HPs recommended that they use NVPs. Participants who reported NVP discussions with HPs were asked whether they or HPs brought up NVP discussions, with a ‘don’t know’ response allowed. A dichotomous variable of HPs initiating NVP discussions was created after combining the ‘don’t know’ responses and responses indicating that participants brought up NVP discussions.
For the prevalence analysis, dichotomous variables were constructed, where ‘1’ denotes smokers’ reporting that HPs (a) discussed NVPs, regardless of giving other cessation advice; (b) brought up NVP discussions; and (c) recommended them to use NVPs; ‘0’ indicating otherwise. For the longitudinal analysis, participants were categorized into the following four groups: (1) ‘No discussion’ (i.e., those whose HPs did not give other cessation advice and did not discuss NVPs); (2) ‘NVP recommendation’ (i.e., those whose HPs discussed NVPs and recommended NVPs); (3) ‘No NVP recommendation’ (i.e., those whose HPs discussed NVPs but did not recommend NVPs); and (4) ‘Other quit advice’ (i.e., those whose HPs gave cessation advice but did not discuss NVPs or who had not heard of NVPs).
Transitions in smoking and vaping status.
To evaluate transitions between waves, the analytic sample was limited to exclusive smokers who self-reported using NVPs less than monthly or not at all at baseline (Wave 1 or 2). There was no or only a small number of baseline exclusive daily smokers who transitioned to being exclusive non-daily smokers (n=0), exclusive NVP users (n=4), or quitters who did not take up vaping (n=3) following NVP recommendations. Therefore, participants were classified into three groups at follow-up (Wave 2 or 3): (1) no transition group, comprised of exclusive smokers who smoke at least monthly and did not initiate at least monthly NVP use; (2) transition to vaping group of exclusive NVP users who smoke less than monthly or not at all (stopped smoking) and use NVPs at least monthly, or concurrent users who smoke at least monthly and use NVPs at least monthly; and (3) transition to quitting group with smokers who smoke less than monthly or not at all and did or did not initiate NVP use.
Smoking-related variables.
The Heaviness of smoking index was derived (range=0 to 6) by combining time to first cigarette of the day and cigarettes per day (38). Smokers reported any quit attempt in the prior 12, 18, 24 months (i.e., the interval between waves), as well as their intention to quit smoking within the next 6 months.
Socio-demographic variables.
Demographic variables assessed were age group (18-24, 25-39, 40-54, 55+), sex (male, female), country of residence (Australia, Canada, England, and the US), education (low [<high school], moderate, high [≥completed university], no answer), and annual household income (low [<$30,000 in Canada, US, Australia; <£15,001 in England], moderate, high [≥$60,000 in Canada, US, Australia; >£50,000 in England], no answer).
Data analysis
All analyses were conducted using Stata version 16 (39). Prevalence of NVP discussions was estimated by calculating the proportion of smokers who had NVP discussions among those who visited HPs in the past 12-24 months. To assess changes in the prevalence of reported NVP discussions with HPs, generalized estimating equation (GEE) models with an exchangeable correlation structure, robust standard errors, and logit link function, regressed NVP discussion variable on survey wave, age and sex. GEE was used to handle correlated data from the same respondents who participated in up to three survey waves. Prevalences of NVP discussion initiation and recommendations were computed by calculating the proportion of smokers whose HPs brought up NVP discussions and recommended NVPs among those who had NVP discussions. Changes in the prevalence of NVP discussion initiation and recommendations were assessed using GEE models with an independent correlation structure, robust standard errors, and logit link function. Models included sampling weights based on the characteristics of the general population in each country in terms of age, sex, education (except for Canada), geographic region, race/ethnicity (US), and language (Canada) (40). After testing the interactions between country and wave using Wald tests, the GEE models were stratified by country (See Supplementary Table 1 for the results). Prevalence for each wave and country was estimated using the post-estimation -margins- command. The estimates were adjusted for age and sex because of their usage in the weight construction. Due to small sample size, estimates were not adjusted for education and income despite differences in NVP use by these variables (41).
The longitudinal analyses pooled data across countries and included exclusive smokers at one wave (baseline) and completed a subsequent survey with complete outcome data (n=4,859). To examine associations between NVP discussion with HPs during the follow-up period (reported at the follow-up wave) and transitions in baseline smoking and vaping status, two multinomial logistic regression models were specified to estimate risk ratios for each outcome of transition to vaping and quitting. The models allowed for correlations within panels using -vce (cluster)- option. Adjusted models included covariates of country, sociodemographic variables, baseline smoking-related variables (heaviness of smoking, past quit attempts, quit intention), wave, and the number of prior surveys completed by each participant. The analysis was not pre-registered and the results should be considered exploratory.
RESULTS
Sample characteristics
Table 1 shows the unweighted study sample characteristics. There was no substantial variation in sample characteristics between surveys for the prevalence analysis. Having made a quit attempt since the last survey was approximately 10% higher at Wave 1 vs. Waves 2 and 3, likely due to question wording (“How many times, if any, have you tried to quit?” vs. “Have you tried to stop smoking?”). Approximately 30% of the sample for the longitudinal analysis reported having quit intention at baseline.
Table 1.
Sample characteristics, ITC 4-Country Smoking and Vaping Survey (4CV) Waves 1 (2016), 2 (2018), and 3 (2020), unweighted
| Sample for the prevalence analysis | Sample for the transition analysis | |||
|---|---|---|---|---|
| Wave 1 | Wave 2 | Wave 3 | Baseline exclusive daily smokers | |
| n=4,125 | n=4,503 | n=4,277 | n=4,859 | |
| %, Mean | %, Mean | %, Mean | %, Mean | |
| Country | ||||
| Canada | 28% | 28% | 30% | 28% |
| US | 20% | 21% | 21% | 23% |
| England | 32% | 31% | 28% | 27% |
| Australia | 21% | 20% | 21% | 22% |
| Age | ||||
| 18-24 | 11% | 11% | 9% | 4% |
| 25-39 | 16% | 15% | 13% | 13% |
| 40-54 | 30% | 29% | 27% | 32% |
| 55+ | 43% | 45% | 51% | 51% |
| Sex | ||||
| Male | 46% | 43% | 44% | 44% |
| Female | 54% | 57% | 56% | 56% |
| Education | ||||
| Low | 35% | 36% | 29% | 36% |
| Moderate | 42% | 42% | 47% | 41% |
| High | 22% | 21% | 23% | 23% |
| No answer | 1% | 1% | 1% | 1% |
| Income | ||||
| Low | 26% | 29% | 30% | 26% |
| Moderate | 30% | 29% | 29% | 31% |
| High | 37% | 36% | 34% | 37% |
| No answer | 7% | 6% | 6% | 6% |
| Heaviness of Smoking Index | 2.5 | 2.5 | 2.5 | 2.6 |
| Past quit attempt* | ||||
| No | 50% | 62% | 64% | 61% |
| Yes | 50% | 38% | 36% | 39% |
| Intending to quit within 6 months | ||||
| No | 66% | 68% | 68% | 70% |
| Yes | 34% | 32% | 32% | 30% |
Quit attempt in the last 12 (Wave 1)/18 (Wave 2)/24 (Wave 3) months.
Changes over time in the prevalence of NVP discussions and recommendations
Analysis of the interaction indicated no difference between countries in the prevalence of NVP discussions during 2016 through 2020 (χ26= 11.39, p=0.0770). Figure 2a shows the prevalence of NVP discussions between smokers and HPs at Waves 1, 2 and 3 by country. Of those who visited HPs in the past 12-24 months, the prevalence of NVP discussions was stable between surveys in all countries (Australia: 1.4% to 2.0%, p=0.4513; Canada: 5.4% to 3.9%, p=0.0581; England: 4.7% to 4.1%, p=0.3100; US: 5.8% to 6.2%, p=0.3403).
Figure 2.
Prevalence of NVP discussions with health professionals (HPs), HPs who initiated NVP discussions, HPs who recommended NVPs, ITC 4-Country Smoking and Vaping Survey (4CV), Wave 1 (2016) to Wave 3 (2020)
NVP=nicotine vaping products. All models adjusted for age group and sex.
†N=12,905 (Australia: 2,647, Canada: 3,672, England: 3,923, US: 2,663).
‡N=559 (Those who had NVP discussions and responded to questions on initiation of NVP discussions only; Australia: n=58, Canada: n=162, England: n=193, US: n=146).
§N=560 (Those who had NVP discussions and responded to questions on NVP recommendations only; Australia: n=58, Canada: n=163, England: n=193, US: n=146).
Bolded estimates denote significant differences in prevalence over time (Wald test p < .05).
There was no significant interaction between country and wave on NVP discussion initiation (χ26= 10.16, p=0.1180). Figure 2b shows the prevalence of HPs who initiated NVP discussions among those who reported having these discussions. The prevalence of HPs who initiated NVP discussion increased in England between 2016 and 2020 (53.3% to 72.8%; χ22=6.23, p=0.0444) but did not significantly change in other countries (Australia: 53.0% to 39.9%, p=0.9480; Canada: 39.9% to 49.9%, p=0.4908; US: 63.5% to 45.3%, p=0.3793).
There was a significant interaction between country and wave with respect to NVP recommendation (χ26= 13.37, p=0.0375). Figure 2c shows the prevalence of receiving advice to use NVPs among smokers who discussed NVPs with HPs. The prevalence of NVP recommendations significantly increased between 2016 and 2020 in England (30.4% to 55.7%; χ22=9.45, p=0.0089). Although not statistically significant, possibly owing to small sample sizes, recommending NVPs increased in Australia (8.4% to 20.2%, p=0.7445) and decreased in Canada (35.3% to 25.7%, p=0.4427) and the US (28.1% to 14.7%, p=0.0589).
Transitions in smoking and vaping status among baseline exclusive smokers
As shown in Table 2, baseline exclusive daily smokers whose HPs recommended NVPs were more likely than those who did not discuss NVPs or receive other cessation advice to become exclusive NVP users or concurrent users (Adjusted risk ratio [ARR]=3.61, 95% Confidence interval [CI] = 2.06, 6.34, p < 0.001).
Table 2.
Factors associated with transitions in smoking and vaping status among baseline exclusive daily smokers
| No transition | Transition to vaping | Transition to quitting | |||||
|---|---|---|---|---|---|---|---|
| n=3857 | n=548 | n=581 | |||||
| %, mean | %, mean | ARR (95% CI)† | p-value | %, mean | ARR (95% CI)† | p-value | |
| NVP discussion | |||||||
| No discussion | 77.7% | 12.0% | 1 (referent) | 13.5% | 1 (referent) | ||
| NVP recommended | 58.9% | 37.0% | 3.61 (2.06 - 6.34) | <0.001 | 9.6% | 0.93 (0.40 - 2.14) | 0.856 |
| NVP not recommended | 67.1% | 25.5% | 2.58 (1.69 - 3.93) | <0.001 | 16.1% | 1.27 (0.78 - 2.07) | 0.328 |
| Other cessation advice | 82.5% | 8.8% | 0.79 (0.65 - 0.97) | 0.025 | 10.3% | 0.70 (0.58 - 0.85) | <0.001 |
| Country | |||||||
| England | 75.9% | 16.3% | 1 (referent) | 11.1% | 1 (referent) | ||
| Australia | 82.8% | 8.4% | 0.49 (0.37 - 0.65) | <0.001 | 11.3% | 0.92 (0.71 - 1.20) | 0.554 |
| Canada | 97.4% | 12.4% | 0.63 (0.50 - 0.80) | <0.001 | 12.5% | 0.98 (0.77 - 1.25) | 0.877 |
| US | 38.9% | 6.6% | 0.40 (0.29 - 0.53) | <0.001 | 12.9% | 1.13 (0.87 - 1.46) | 0.361 |
| HSI | 2.6 | 2.7 | 1.11 (1.04 - 1.18) | 0.003 | 2.4 | 0.94 (0.88 - 1.00) | 0.049 |
| Quit attempt | |||||||
| No | 82.4% | 10.1% | 1 (referent) | 10.0% | 1 (referent) | ||
| Yes | 74.7% | 13.2% | 1.25 (1.00 - 1.55) | 0.048 | 15.0% | 1.28 (1.04 - 1.58) | 0.020 |
| Quit intention | |||||||
| No | 82.1% | 10.6% | 1 (referent) | 9.8% | 1 (referent) | ||
| Yes | 73.3% | 12.7% | 1.13 (0.90 - 1.41) | 0.298 | 16.9% | 1.66 (1.34 - 2.05) | <0.001 |
Transition to vaping: reported use of NVPs at least monthly, either exclusively or concurrently with cigarette smoking. Transition to quitting: reported smoking less than monthly or not at all (stopped smoking), regardless of NVP uptake.
NVP recommended/not recommended: Reported that doctor or health professional talked to them about NVPs and recommended or did not recommend NVPs. Other cessation advice: Reported that doctor or health professional did not talk to them about NVPs but received advice to quit smoking.
Models adjusted for all variables listed in the tables, age group, sex, education, income, survey wave, the number of surveys in which respondents participated.
Bolded estimates were significant at p<0.05.
When smoking abstinence was considered only, compared to baseline exclusive daily smokers who did not discuss NVPs with HPs and did not discuss other cessation methods, those whose HPs recommended NVPs were not more likely to become quitters from smoking cigarettes regardless of whether they did or did not take up NVPs at follow-up (ARR=0.93, 95% CI = 0.40, 2.14, p > 0.05). Compared to exclusive smokers who had no NVP discussions, those who had other cessation discussions (i.e., not about NVP use) with their HPs were less likely to become quitters from smoking cigarettes (ARR=0.70, 95% CI=0.58, 0.85). The mean HSI score was highest among smokers whose HPs recommended NVPs (ARR=3.21, 95% CI=2.89, 3.55), followed by smokers who had other cessation discussions (ARR=2.74, 95% CI=2.68, 2.80), and lowest among smokers who had no NVP discussions (ARR=2.44, 95% CI = 2.38, 2.50).
DISCUSSION
In our study, fewer than 10% of exclusive daily smokers reported NVP discussions with their HPs across countries and over time. Of those who discussed NVPs with their HP, less than a third reported being recommended to use NVPs for smoking cessation in the US (14.7%), Australia (20.2%), and Canada (25.7%), and over a half were recommended for NVP use in England (55.7%). The overall prevalence of exclusive daily smokers receiving such advice was low and remained low across countries between 2016 and 2020. HP recommendations to use NVP reported between surveys were associated with exclusive smokers’ uptake of NVPs over the 18- to 24-month follow-up period, with the association remaining significant after adjusting for country. However, smokers whose HPs recommended NVPs were not more likely than those who had no discussion with HPs to quit smoking. This finding coupled with that of those given other cessation advice being less likely to quit smoking suggest that HP advice itself, whether related to NVP or not, did not influence smoking cessation behavior, but rather individual characteristics might have influenced the type of advice given. The lower quit rate of those receiving other cessation advice may simply reflect the tendency for HPs to provide cessation advice to those who are most nicotine dependent. The lower quit rate of the subgroup receiving NVP recommendation reflects those who are most nicotine-dependent with the longest history of cessation failure on other products. This explanation for the latter group is consistent with studies finding a high proportion of concurrent cigarette and NVP use (42) and a low rate of complete switching to NVPs among established smokers (43). Future research should examine measures for HPs to help smokers use NVPs as a transition to become nicotine free.
Of the less than 10% of smokers who reported NVP discussions, only about half or less of those in Australia, Canada, and the US reported that HPs initiated the conversation, although 73% reported that in England. Our results contrast with that of studies of HP perspectives where they reported being frequently asked about NVPs (15, 19, 25). The lower reports of NVP discussions by smokers versus HPs may indicate the lack of meaningful discussions about NVPs in clinical settings. Consistent with this notion, HPs have reported lack of confidence in discussing NVPs (14, 20) and perceived uncertainty about the safety of NVPs (25, 44–47). NVPs are not legally designated as cessation aids and most clinical guidelines do not suggest HPs to recommend NVPs as a first-line treatment for smoking cessation (48, 49), which may have led HPs to avoid talking seriously about NVPs.
A notable finding of our study was the unexpected finding that HP cessation advice that did not include vaping discussions was associated with poorer cessation outcomes. The advice likely reflects HPs’ general lack of interest to focus on smokers’ mind and stress the importance of taking an action, which acts to demotivate the smokers. Moreover, these smokers were more nicotine dependent. In our transition analysis sample, the mean HSI score was highest among smokers who were recommended to use NVPs, followed by smokers who received cessation advice not related to NVPs. Those who did not discuss cessation at all had the lowest mean HSI. In this regard, our study suggests that those who start using NVPs are more dependent than other smokers on average, which could make them less successful in quitting. Our findings are potentially more important as they signal the need for HPs to talk about NVPs with smokers who are highly nicotine dependent. For example, smokers who already tried other cessation methods and struggled with quitting may feel hopeful and motivated to quit after NVP discussions with HPs. In line with this idea, NVPs are included in clinical guidelines in England (13, 50) and HPs take a less negative view of NVPs as a way to help smokers move away from smoking (32, 33). Additional studies are needed to explore what HPs could do to increase optimal use of NVPs for smoking cessation.
There are a few limitations to this study. First, it is possible that those who recalled NVP discussions were more likely to use NVPs. The discrepancies on reports of NVP discussions between patients and HPs may also indicate poor recall, impacting the reliability of the results. However, it may also reflect, as indicated above, weak advice which is not memorable and unlikely to call for subsequent action. Second, although we collected longitudinal data to assess transitions in smoking and vaping status, the follow-up smoking and vaping status was assessed at the same wave as measures on NVP discussions, and the temporal ordering between NVP discussions and smoking-vaping transitions is not certain. Lastly, missing data due to attrition and the ordering of question about NVP recommendation may bias the findings. Compared to the analytic sample, those who were excluded from the transition analysis due to attrition were more likely to be from England, be younger, and report past quit attempts. At Waves 1 and 2 (but not at Wave 3), those who were recommended to use NVPs may have not received quit advice. Given that NVPs are recommended as a cessation aid in England, younger smokers tend to be less nicotine-dependent and past quit attempts predict smoking cessation, together these suggest that the association between NVP discussion and quitting may have been underestimated.
Notwithstanding the limitations, this study provides evidence that NVP discussions with HPs are associated with NVP initiation among exclusive smokers and continued NVP use among concurrent users of cigarettes and NVPs. These associations persist after controlling for sociodemographic and smoking-related covariates. Our study highlights a need to provide trainings for HPs to discuss NVPs with smoking patients and to regularly update clinical guidelines to reflect recent evidence around NVP use for smoking cessation, such as the importance of completely switching to NVPs, although not necessarily suddenly.
Supplementary Material
Acknowledgments:
The authors would like to acknowledge and thank all those that contributed to the International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Survey: all study investigators and collaborators, the project staff at their respective institutions, and all respondents who took part in the surveys.
This study was supported by grants from the US National Cancer Institute (P01 CA200512), the Canadian Institutes of Health Research (FDN-148477), and by the National Health and Medical Research Council of Australia (GNT 1106451). Additional support to GTF was provided by a Senior Investigator Award from the Ontario Institute for Cancer Research and the Canadian Cancer Society O. Harold Warwick Prize.
Footnotes
Ethics: Study questionnaires and materials were reviewed and provided clearance by Research Ethics Committees at the following institutions: University of Waterloo (Canada, ORE#20803/30570, ORE#21609/30878), King’s College London, UK (RESCM-17/18-2240), Cancer Council Victoria, Australia (HREC1603), University of Queensland, Australia (2016000330/HREC1603); and Medical University of South Carolina (waived due to minimal risk). All participants provided consent to participate.
Declaration of Interests: KMC has in the past and continues to serve as a paid expert witness in litigation filed against cigarette manufacturers. GTF and JFT have served as expert witnesses or consultants for governments defending their country’s policies or regulations in litigation. GTF and SG served as paid expert consultants to the Ministry of Health of Singapore in reviewing the evidence on plain/standardized packaging. None of the other authors has any conflict of interest to declare.
Data availability statement:
The data are jointly owned by a third party in each country that collaborates with the International Tobacco Control Policy Evaluation (ITC) Project. Data from the ITC Project are available to approved researchers 2 years after the date of issuance of cleaned data sets by the ITC Data Management Centre. Researchers interested in using ITC data are required to apply for approval by submitting an International Tobacco Control Data Repository (ITCDR) request application and subsequently to sign an ITCDR Data Usage Agreement. The criteria for data usage approval and the contents of the Data Usage Agreement are described online (http://www.itcproject.org). The authors of this paper obtained the data following this procedure. This is to confirm that others would be able to access these data in the same manner as the authors. The authors did not have any special access privileges that others would not have.
REFERENCES
- 1.Caraballo RS, Shafer PR, Patel D, Davis KC, McAfee TA. Quit Methods Used by US Adult Cigarette Smokers, 2014-2016. Prev Chronic Dis. 2017;14:E32–E. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Filippidis FT, Laverty AA, Mons U, Jimenez-Ruiz C, Vardavas CI. Changes in smoking cessation assistance in the European Union between 2012 and 2017: pharmacotherapy versus counselling versus e-cigarettes. Tob Control. 2019;28(1):95–100. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.West R, Brown J, Beard E. Trends in electronic cigarette use in England. University College London, Smoking Toolkit Study. 2014;21. [Google Scholar]
- 4.Goniewicz ML, Lingas EO, Hajek P. Patterns of electronic cigarette use and user beliefs about their safety and benefits: An Internet survey. Drug and Alcohol Review. 2013;32(2):133–40. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Dawkins L, Turner J, Roberts A, Soar K. ‘Vaping’ profiles and preferences: an online survey of electronic cigarette users. Addiction. 2013;108(6):1115–25. [DOI] [PubMed] [Google Scholar]
- 6.Gravely S, Cummings KM, Hammond D, Borland R, McNeill A, East KA, et al. Self-reported quit aids and assistance used by smokers at their most recent quit attempt: Findings from the 2020 International Tobacco Control Four Country Smoking and Vaping Survey. Nicotine Tob Res. 2021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Hartmann-Boyce J, McRobbie H, Butler AR, Lindson N, Bullen C, Begh R, et al. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews. 2021(9). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal N, et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. New England Journal of Medicine. 2019;380(7):629–37. [DOI] [PubMed] [Google Scholar]
- 9.Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. The Lancet. 2013;382(9905):1629–37. [DOI] [PubMed] [Google Scholar]
- 10.Giovenco DP, Delnevo CD. Prevalence of population smoking cessation by electronic cigarette use status in a national sample of recent smokers. Addictive Behaviors. 2018;76:129–34. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.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. Nicotine & Tobacco Research. 2018;20(8):931–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Farsalinos KE, Niaura R. E-cigarettes and Smoking Cessation in the United States According to Frequency of E-cigarette Use and Quitting Duration: Analysis of the 2016 and 2017 National Health Interview Surveys. Nicotine & Tobacco Research. 2019;22(5):655–62. [DOI] [PubMed] [Google Scholar]
- 13.National Institute for Health Care Excellence. Stop smoking interventions and services. London, England: National Institute for Health and Care Excellence (NICE); 2018. [Google Scholar]
- 14.Nickels AS, Warner DO, Jenkins SM, Tilburt J, Hays JT. Beliefs, Practices, and Self-efficacy of US Physicians Regarding Smoking Cessation and Electronic Cigarettes: A National Survey. Nicotine & Tobacco Research. 2016;19(2):197–207. [DOI] [PubMed] [Google Scholar]
- 15.Steinberg MB, Giovenco DP, Delnevo CD. Patient–physician communication regarding electronic cigarettes. Preventive Medicine Reports. 2015;2:96–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Kollath-Cattano C, Thrasher JF, Osman A, Andrews JO, Strayer SM. Physician Advice for e-Cigarette Use. The Journal of the American Board of Family Medicine. 2016;29(6):741–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Gravely S, Thrasher JF, Cummings KM, Ouimet J, McNeill A, Meng G, et al. Discussions between health professionals and smokers about nicotine vaping products: results from the 2016 ITC Four Country Smoking and Vaping Survey. Addiction. 2019;114(S1). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Berg CJ, Haardoerfer R, Escoffery C, Zheng P, Kegler M. Cigarette Users’ Interest in Using or Switching to Electronic Nicotine Delivery Systems for Smokeless Tobacco for Harm Reduction, Cessation, or Novelty: A Cross-Sectional Survey of US Adults. Nicotine & Tobacco Research. 2014;17(2):245–55. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.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(7):e103462. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Sherratt FC, Newson L, Field JK. Electronic cigarettes: a survey of perceived patient use and attitudes among members of the British thoracic oncology group. Respiratory Research. 2016;17(1):55. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.The Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel L, 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(2):158–76. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.New South Wales Department of Health. Guide for the management of nicotine dependent inpatients. Summary of Evidence Sydney: NSW Health Department. 2002. [Google Scholar]
- 23.West R, Raw M, McNeill A, Stead L, Aveyard P, Bitton J, et al. Health-care interventions to promote and assist tobacco cessation: a review of efficacy, effectiveness and affordability for use in national guideline development. Addiction. 2015;110(9):1388–403. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Wackowski OA, Bover Manderski MT, Delnevo CD. Smokers’ sources of e-cigarette awareness and risk information. Preventive Medicine Reports. 2015;2:906–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Kanchustambham V, Saladi S, Rodrigues J, Fernandes H, Patolia S, Santosh S. The knowledge, concerns and healthcare practices among physicians regarding electronic cigarettes. Journal of Community Hospital Internal Medicine Perspectives. 2017;7(3):144–50. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.National Academies of Sciences, Engineering, Medicine. Public health consequences of e-cigarettes: National Academies Press; 2018. [PubMed] [Google Scholar]
- 27.Moysidou A, Farsalinos KE, Voudris V, Merakou K, Kourea K, Barbouni A. Knowledge and Perceptions about Nicotine, Nicotine Replacement Therapies and Electronic Cigarettes among Healthcare Professionals in Greece. International Journal of Environmental Research and Public Health. 2016;13(5):514. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Gallegos-Carrillo K, Barrientos-Gutiérrez I, Arillo-Santillán E, Zavala-Arciniega L, Cho YJ, Thrasher JF. Health Professionals’ Counseling about Electronic Cigarettes for Smokers and Vapers in a Country That Bans the Sales and Marketing of Electronic Cigarettes. International Journal of Environmental Research and Public Health. 2020;17(2):442. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Drouin O, McMillen RC, Klein JD, Winickoff JP. E-Cigarette Advice to Patients From Physicians and Dentists in the United States. American Journal of Health Promotion. 2018;32(5):1228–33. [DOI] [PubMed] [Google Scholar]
- 30.Chen L-S, Baker T, Brownson RC, Carney RM, Jorenby D, Hartz S, et al. Smoking Cessation and Electronic Cigarettes in Community Mental Health Centers: Patient and Provider Perspectives. Community Mental Health Journal. 2017;53(6):695–702. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Gravely S, Driezen P, Ouimet J, Quah ACK, Cummings KM, Thompson ME, et al. Prevalence of awareness, ever-use and current use of nicotine vaping products (NVPs) among adult current smokers and ex-smokers in 14 countries with differing regulations on sales and marketing of NVPs: cross-sectional findings from the ITC Project. Addiction 2019;114(6):1060–73. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.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: Public Health England; 2018. [Google Scholar]
- 33.Royal College of Physicians of London. Nicotine Without Smoke Tobacco Harm Reduction: Royal College of Physicians of London; 2016. [Google Scholar]
- 34.Thompson ME, Fong GT, Hammond D, Boudreau C, Driezen P, Hyland A, et al. Methods of the International Tobacco Control (ITC) Four Country Survey. Tob Control. 2006;15(suppl 3):iii12–iii8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Fong GT, Cummings KM, Borland R, Hastings G, Hyland A, Giovino GA, et al. The conceptual framework of the International Tobacco Control (ITC) Policy Evaluation Project. Tob Control. 2006;15:iii3–iii11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.ITC Project. ITC Four Country Wave 1 (2002) Technical Report. University of Waterloo, Waterloo, Ontario, Canada; Medical University of South Carolina, Charleston, South Carolina, United States; VicHealth Centre for Tobacco Control, Carlton, Australia; Cancer Control Victoria, Melbourne, Australia; King’s College London, London, United Kingdom; University of Stirling, Stirling, United Kingdom; the Open University, Buckinghamshire, United Kingdom.; 2004, July. [Google Scholar]
- 37.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, United States; VicHealth Centre for Tobacco Control, Carlton, Australia; Cancer Control Victoria, Melbourne, Australia; King’s College London, London, United Kingdom; University of Stirling, Stirling, United Kingdom; the Open University, Buckinghamshire, United Kingdom.; 2011, September. [Google Scholar]
- 38.Borland R, Yong H-H, O’Connor RJ, Hyland A, Thompson ME. The reliability and predictive validity of the Heaviness of Smoking Index and its two components: Findings from the International Tobacco Control Four Country study. Nicotine & Tobacco Research. 2010;12(suppl_1):S45–S50. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.StataCorp. Stata: Release 16. Statistical Software. College Station, TX: StataCorp LLC; 2019. [Google Scholar]
- 40.ITC Project. ITC Project ITC Four Country Smoking and Vaping Survey, Wave 1 (4CV1) Technical Report. University of Waterloo, Waterloo, Ontario, Canada; Medical University of South Carolina, Charleston, South Carolina, United States; Cancer Council Victoria, Melbourne, Australia; King’s College London, London, United Kingdom; 2018. [Google Scholar]
- 41.Chen R, Pierce JP, Leas EC, White MM, Kealey S, Strong DR, et al. Use of Electronic Cigarettes to Aid Long-Term Smoking Cessation in the United States: Prospective Evidence From the PATH Cohort Study. American Journal of Epidemiology. 2020;189(12):1529–37. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Patel D, Davis KC, Cox S, Bradfield B, King BA, Shafer P, et al. Reasons for current E-cigarette use among U.S. adults. Preventive Medicine. 2016;93:14–20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Anic GM, Holder-Hayes E, Ambrose BK, Rostron BL, Coleman B, Jamal A, et al. E-cigarette and Smokeless Tobacco Use and Switching Among Smokers: Findings From the National Adult Tobacco Survey. Am J Prev Med. 2018;54(4):539–51. [DOI] [PubMed] [Google Scholar]
- 44.Erku DA, Gartner CE, Do JT, Morphett K, Steadman KJ. Electronic nicotine delivery systems (e-cigarettes) as a smoking cessation aid: A survey among pharmacy staff in Queensland, Australia. Addictive Behaviors. 2019;91:227–33. [DOI] [PubMed] [Google Scholar]
- 45.Ofei-Dodoo S, Kellerman R, Nilsen K, Nutting R, Lewis D. Family Physicians’ Perceptions of Electronic Cigarettes in Tobacco Use Counseling. The Journal of the American Board of Family Medicine. 2017;30(4):448–59. [DOI] [PubMed] [Google Scholar]
- 46.Kollath-Cattano C, Dorman T, Albano AW Jr, Jindal M, Strayer SM, Thrasher JF. E-cigarettes and the clinical encounter: Physician perspectives on e-cigarette safety, effectiveness, and patient educational needs. Journal of Evaluation in Clinical Practice. 2019;25(5):761–8. [DOI] [PubMed] [Google Scholar]
- 47.Hurst S, Conway M. Exploring Physician Attitudes Regarding Electronic Documentation of E-cigarette Use: A Qualitative Study. Tobacco Use Insights. 2018;11:1179173X18782879. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.The Royal Australian College of General Practitioners. Supporting smoking cessation: A guide for health professionals. 2nd edn. East Melbourne, Vic: RACGP; 2019. [Google Scholar]
- 49.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(3):265–79. [DOI] [PubMed] [Google Scholar]
- 50.National Institute for Health Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. London: National Institute for Health and Care Excellence (NICE); 2021. [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data are jointly owned by a third party in each country that collaborates with the International Tobacco Control Policy Evaluation (ITC) Project. Data from the ITC Project are available to approved researchers 2 years after the date of issuance of cleaned data sets by the ITC Data Management Centre. Researchers interested in using ITC data are required to apply for approval by submitting an International Tobacco Control Data Repository (ITCDR) request application and subsequently to sign an ITCDR Data Usage Agreement. The criteria for data usage approval and the contents of the Data Usage Agreement are described online (http://www.itcproject.org). The authors of this paper obtained the data following this procedure. This is to confirm that others would be able to access these data in the same manner as the authors. The authors did not have any special access privileges that others would not have.