Key Points Question How do physicians communicate with their patients about e-cigarettes? Findings In this cross-sectional survey of 2058 respondents, physicians who were asked about e-cigarettes by their patients, endorsed a harm-reduction perspective, or had ever smoked were more likely to recommend e-cigarettes to patients. In hypothetical clinical scenarios, physicians were more likely to recommend e-cigarettes for an older heavy smoker with prior unsuccessful quit attempts and use of pharmacotherapy for a younger light smoker with no prior cessation treatments. Meaning Results of this survey study suggest that physicians are recommending e-cigarettes for cessation or harm reduction under certain risk-based circumstances, such as treating patients with tobacco-related disease.
Although cigars pose health risks similar to cigarettes, their packaging/marketing is not subject to commensurate regulation in the US. In a 2000 agreement with the Federal Trade Commission, seven major manufacturers agreed to use some form of cigar warning. In 2016, the Food and Drug Administration passed a rule requiring larger standardized warnings, but the requirement was successfully challenged in court. Here, we examined U.S. population-level trends in noticing existing cigarillo, traditional and filtered cigar warnings. We analyzed Wave 5 Population Assessment of Tobacco and Health adult data to assess prevalence of past-30 day warning noticing and associations with socio-demographic and tobacco use variables. Noticing was higher among current users of cigarillos (27%), filtered (34%) and traditional cigars (21%), than non-users (8% for each product, p’s < 0.0001), and among every-day vs. some-day users, established vs. experimental users, and past-30 day users vs. those without past-30 day use. Results varied by product, but generally indicated lower noticing among non-Hispanic Whites and dual cigarette users, but higher noticing among those purchasing cigars by the box/pack (vs. not purchasing for themselves). Low overall noticing but higher prevalence among frequent users underscores a need for a stronger, uniform cigar warning label policy in the US.
ImportanceEmpirical evidence is needed on how a capitated, risk-based county plan performs as a viable public option in the Affordable Care Act (ACA) Marketplace in California.ObjectiveTo estimate whether LA Care—a capitated, county-based public option and California’s largest public insurer—was associated with health insurance premium growth in the Los Angeles (LA) regions of Covered California (CC), the ACA exchange in California.Design, Setting, and ParticipantsThis economic evaluation used ACA silver plan premium data within the 19 CC regions. Difference-in-differences and event study models used data on plan-level premiums from Health Insurance Exchange Compare for years 2014 to 2022 to estimate the association between LA Care and ACA premium growth in LA.ExposuresThe intervention was LA Care becoming the lowest-cost health plan on the ACA exchange in 2018. The treatment group included the East and West LA regions, and the control group included the remaining 17 CC regions.Main Outcomes and MeasuresThe main outcome variable was annual premium growth of plans on CC from 2014 to 2022.ResultsUsing 504 plan-level observations for 2014 to 2022, ACA premium growth in LA declined by 4.8% after LA Care became the lowest-cost health plan on the exchange in 2018 (coefficient estimate, −0.048; SE, 0.022; 95% CI, −0.093 to −0.002). Savings due to lower premium growth from 2019 to 2022 were calculated to be $345 million, with approximately 70% of the savings ($242 million) going to the federal government.Conclusions and RelevanceIn this economic evaluation, LA Care was associated with lower premium growth of other health insurance plans in the LA regions of CC, with the majority of savings going to the federal government. California could have captured these savings if it had applied for and received a State Innovation Waiver under section 1332 of the ACA. LA Care may be a viable public option with the potential to be expanded across California through the state’s 16 other county-based health plans.
ImportancePhysicians play a primary role in smoking cessation, and their communication regarding e-cigarettes needs to be understood.ObjectiveTo examine physician-patient communication regarding e-cigarettes.DesignA national, repeated cross-sectional survey in 2018 and 2019 was conducted.SettingParticipants were invited by mail; surveys were completed online.ParticipantsResponse rates were 51.8% (2018) and 59.1% (2019), resulting in 2,058 board-certified physicians from family medicine, internal medicine, obstetrics/gynecology, cardiology, pulmonary/critical care, and hematology/oncology.ExposuresPhysician demographics, tobacco use, medical specialty, and harm-reduction beliefs (i.e., not all tobacco products equally harmful); two hypothetical clinical scenarios.Main outcomes and measuresPhysicians’ self-reported e-cigarette communication behaviors (being asked about e-cigarettes by patients and recommending e-cigarettes to patients), and hypothetical e-cigarette communication in two clinical scenarios.ResultsAmong 2,058 physicians, the mean age was 51.6 years and 41.5% were female. Over 60% of physicians believed all tobacco products are equally harmful. Overall, 69.8% of physicians reported ever being asked about e-cigarettes by their patients (35.9% in the past 30 days), while 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. Being asked about e-cigarettes by patients was a strong predictor of physicians’ recommending (AOR,16.6; 95% CI, 10.3-26.7). In clinical scenarios, physicians were overall more likely to recommend e-cigarettes for cessation to an older, heavy smoker with multiple unsuccessful quit attempts than a younger, light smoker with no prior cessation treatments (49.3% vs. 15.2%, p<.001).Conclusions and relevanceFindings suggest physicians may recommend e-cigarettes for cessation under certain circumstances. Given the role of e-cigarettes in FDA’s comprehensive nicotine policy, there is need for continued physician education regarding e-cigarette efficacy, particularly correcting misperceptions regarding harm reduction.Key PointsQuestionHow do physicians communicate with their patients about e-cigarettes?FindingsIn this repeated cross-sectional survey of 2,058 respondents, physicians who were asked about e-cigarettes by their patients, endorsed a harm-reduction perspective, or had ever smoked were significantly more likely to recommend e-cigarettes to patients. Clinical scenarios showed physicians were significantly more likely to recommend e-cigarettes for an older, heavy smoker with prior unsuccessful quit attempts, and use of FDA-approved pharmacotherapy for a younger, light smoker with no prior cessation treatments.MeaningPhysicians may recommend e-cigarettes for cessation under certain circumstances, warranting continued physician education regarding e-cigarette efficacy.
This research did not have any sources of financial support. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.NBER working papers are circulated for discussion and comment purposes. They have not been peer-reviewed or been subject to the review by the NBER Board of Directors that accompanies official NBER publications.
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