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HomeHarm ReductionUS study finds many physicians have misconceptions about e-cigarettes

US study finds many physicians have misconceptions about e-cigarettes

Many physicians in the United States incorrectly believe that all tobacco products are equally harmful and thus are less likely to recommend e-cigarettes for people seeking to quit smoking or those being treated for a tobacco-caused disease, according to a study by Rutgers University.

The following story by Patti Verbanas was published by Rutgers University on 15 April 2022:

About 480,000 people die each year in the United States from smoking tobacco. Although the Food and Drug Administration has not approved e-cigarettes as a cessation device, many people ask their physicians about using them as an alternative to tobacco cigarettes or as a way to help them stop smoking. E-cigarettes use a heated liquid containing nicotine.

“As the evidence grows showing e-cigarettes as potentially effective for smoking cessation, they may play a pivotal role in reducing use of cigarettes and subsequently tobacco-caused disease,” said study author Michael Steinberg, medical director of the Rutgers Tobacco Dependence Programme and division chief in the Department of Medicine at the Rutgers Robert Wood Johnson Medical School.

“It’s important to understand physicians’ perspectives on e-cigarettes as a means for harm reduction.”

The study, published in JAMA Network Open, asked 2,058 US physicians in 2018 and again in 2019 about their communication with patients about e-cigarettes.

The researchers asked how they would advise two different patients who wanted to quit smoking: a young woman who is a lighter smoker and had not yet tried to quit and an older man who smoked heavily and had tried to quit many times using different methods.

The study found that physicians were significantly more likely to recommend e-cigarettes for the heavy smoker while recommending FDA-approved medications, like nicotine gum or lozenges, for the light smoker.

Nearly 70% of the physicians reported that patients have asked them about e-cigarettes, and one-third said they were asked in the past 30 days. More than 60% of the doctors incorrectly believed that all tobacco products are equally harmful.

“These findings show it is critical to address physicians’ misperceptions and educate them on e-cigarettes’ efficacy, particularly correcting their misperceptions that all tobacco products are equally harmful, as opposed to the fact that combusted tobacco is by far the most dangerous,” said lead author Professor Cristine Delnevo, director of the Rutgers Centre for Tobacco Studies and professor of health behaviour, society and policy at the Rutgers School of Publish Health.

The study also found that pulmonologists, cardiologists and physicians who used the US Public Health Service Clinical Practice Guidelines treating tobacco use and dependence were more likely to recommend e-cigarettes to patients as were those who endorsed a harm-reduction perspective and had themselves smoked cigarettes.

Physicians were also more likely to recommend e-cigarettes, however, if a patient asked about them first.


Study details

Communication Between US Physicians and Patients Regarding Electronic Cigarette Use

Cristine D Delnevo, Michelle Jeong, Arjun Teotia et al, Michelle M Bover Manderski, Binu Singh, Mary Hrywna, Olivia A Wackowski and Michael B Steinberg

Author Affiliations: Rutgers University in the United States.

First published by JAMA Network Open on 15 April 2022.


Physicians play a primary role in patient smoking cessation, yet their communication regarding e-cigarettes is not well understood.


To assess physician-patient communication regarding e-cigarettes.

Design, setting and participants

A national cross-sectional survey in 2018 and 2019 was conducted. Participants were invited by mail; surveys were completed online. Respondents were 2,058 board-certified physicians from family medicine, internal medicine, obstetrics and gynaecology, cardiology, pulmonary and oncology. Data were analysed from August to September 2021.


Physician demographic characteristics, tobacco use, medical specialty and harm-reduction beliefs (that is, not all tobacco products are equally harmful) applied within two hypothetical clinical scenarios.

Main outcomes and measures  

Physicians’ self-reported e-cigarette communication (being asked about e-cigarettes by patients and recommending e-cigarettes to patients) and hypothetical e-cigarette communication in two clinical scenarios.


Among 2,058 physicians, the mean (SD) age was 51.6 (10.5) years, and 1,173 (58.5%) were male. More than 60% of physicians believed all tobacco products to be equally harmful.

Overall, 69.8% of physicians reported ever being asked about e-cigarettes by their patients (35.9% in the past 30 days), and 21.7% reported ever recommending e-cigarettes to a patient (9.8% in the past 30 days).

Pulmonologists (adjusted odds ratio [aOR], 2.14, 95% CI, 1.10-4.16) and cardiologists (aOR, 2.04; 95% CI, 1.03-4.05), as well as physicians who implemented the US Public Health Service Clinical Practice Guidelines (aOR, 1.77; 95% CI, 1.12-2.80), had greater odds of recommending e-cigarettes to patients.

Physicians who endorsed a harm-reduction perspective (aOR, 3.04, 95% CI, 2.15-4.31) and had ever smoked cigarettes (aOR, 1.98; 95% CI, 1.27-3.08) were significantly more likely to recommend e-cigarettes. Physicians who reported being asked about e-cigarettes had greater odds of recommending e-cigarettes (aOR, 16.60; 95% CI, 10.33-26.68).

In clinical scenarios, physicians were overall more likely to recommend e-cigarettes for cessation to an older heavy smoker with multiple unsuccessful quit attempts (49.3%; 95% CI, 47.1%-51.4%) than a younger light smoker with no prior cessation treatments (15.2%; 95% CI, 13.6%-16.7%) (P < .001).

Conclusions and relevance

In this survey study of physicians, findings suggest that physicians may recommend switching to e-cigarettes for some patients who smoke cigarettes under certain circumstances, presumably for cessation.

The belief that all tobacco products are equally harmful was associated with lower rates of recommending e-cigarettes. As the evidence base grows for e-cigarette efficacy for smoking cessation, there is need for physician education regarding e-cigarette efficacy.


Rutgers University story – Many Physicians Have Misconceptions About E-Cigarettes (Open access)


JAMA Network Open article – Communication Between US Physicians and Patients Regarding Electronic Cigarette Use (Open access)


See also from the MedicalBrief archives


Australian GPs willing to prescribe e-cigarettes to help patients quit


Don’t offer e-cigarettes as an 'official' alternative to smoking, French doctors advised


In world first, NHS may prescribe e-cigarettes for smoking cessation


E-cigarettes: What we know and what we don’t – Cancer Research UK


WHO versus Public Health England over e-cigarettes




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