‘What about vaping?’ Exploring the facilitators and barriers experienced by health professionals in offering vaping cessation support − a scoping review

Lack of knowledge and information about e-cigarettes were the most common barriers identified in the Knowledge domain. Reported knowledge deficits included general knowledge about e-cigarettes (types, terminology and chemical content), and the prevalence, harm and health effects of e-cigarette use and associated laws and regulations. Other barriers included a lack of knowledge about effective ways to support vaping cessation (initiating screening and cessation counselling, approaches to address vaping, where and how to refer clients for cessation support) and the differences between addressing vaping and other substance use. One study highlighted a dearth of available scientific information about e-cigarettes, including long-term harms and effective treatment.⁴³ Some HPs obtained their knowledge from channels that do not always contain evidence-based information (e.g. popular media, advertising or Internet searches).^28,43

Similarly, lack of experience and practice in helping clients quit e-cigarettes or using motivational interviewing techniques were the common barriers in the Skills domain.^26,35,44 HPs self-identified training needs within a broad spectrum of clinical skills necessary to support vaping cessation, including assessing e-cigarette use, counselling and motivating clients to quit, recommending treatments and referring clients for quitting support. The following vaping-related communication issues were also highlighted: challenges in communicating the long-term effects of e-cigarette use and difficulties in staying up-to-date with the evolving terminology used to describe e-cigarettes.

Knowledge and skills gaps were related to barriers in the Environmental context and resources domain and included lack of training, scientific information and clear evidence about e-cigarette cessation.^{24,25,28,36,38,40} HPs also felt there were no policies, recommendations or clinical guidelines on vaping cessation interventions (for example, calculating the dosage of nicotine replacement therapy) to rely on, meaning they obtained knowledge from the news media or their peers and they needed to make decisions based on their clinical judgement or instincts. This contributed to their hesitancy in addressing e-cigarette use. Additionally, competing priorities under time constraints were barriers to e-cigarette cessation counselling in three studies, with two other studies highlighting that e-cigarette cessation counselling limits HPs’ capacity to ask other health-related questions in a consultation. Furthermore, some multifaceted barriers existed at the organisational level. For example, some stop-smoking services were unable to support vaping cessation for ex-smokers, who then became regular vapers, due to limited funding and capacity. Systemic difficulties included that screening questions about tobacco use did not ask about e-cigarettes and that incorporating e-cigarette screening tools into electronic health records (EHRs) was challenging. One paper from Australia highlighted that the rapidly changing regulatory environment contributed to clients’ reluctance to disclose their vaping and left HPs feeling unprepared to address vaping.⁴⁴

In contrast to the majority of other HPs who reported a lack of time to screen or counsel for e-cigarette cessation,^26,28,40 more than half the dental hygienists surveyed in one study reported that they had the time and the choice to ask adolescent clients about e-cigarette use.³¹

Most HPs were interested in learning more about e-cigarettes, and short courses were found to improve knowledge and skills about e-cigarette devices and approaches to cessation. Although most studies highlighted deficits in knowledge of e-cigarettes, three studies reported that HPs did have some knowledge about e-cigarettes, including their function, chemical content, likelihood of containing nicotine and common health concerns, such as their addictive nature, and oral and neurological health consequences. Three studies reported that HPs had medium to high levels of knowledge about e-cigarettes and their health effects (measured through self-assessment or correct/incorrect answers to multiple-choice knowledge questions).^30,31,41 However, one study found that despite self-rating their knowledge as ‘somewhat knowledgeable’, pulmonologists only answered 33% of knowledge questions regarding e-cigarettes accurately.⁴¹

HPs often reported that more resources were needed, including training, virtual shared resources, educational material for themselves and their clients, scripts, vaping lingo dictionaries, screening tools, more scientific information from credible sources, and a standardised curriculum in general practice and residency training and in ongoing education to address e-cigarette use. An online interactive program in the US employing presentations, case discussions and role-plays was found to improve physicians’ screening and treatment practices. Attending training also helped nurses develop motivational interviewing expertise using the Screening, Brief Intervention and Referral to Treatment skillset, with a resultant self-reported improvement in skills. Most importantly, the inclusion of specific e-cigarette screening questions in the EHR system was identified as the most effective way to increase screening rates when compared to education and training.³⁹ This EHR built-in screening intervention was also found to be brief. Regardless of clients’ vaping status, it did not lengthen the duration of clients’ visits or cost extra time for clinicians.

Finally, in the Environmental context and resources domain some HPs reported that they would still help clients quit vaping while working with a finite budget and capacity.³⁴ Some HPs also expressed interest in updating e-cigarette policies.³⁷

Discussing vaping with clients was not universally accepted as core practice for HPs. An action-intention gap was highlighted in a study with physiotherapists, where 73% believed that they had a role in addressing vaping but only 3% reported that they routinely addressed it.³²

Most HPs reported a responsibility to screen for e-cigarette use, counsel or intervene with those who use e-cigarettes.^{24,30,32,35,38} This sense of responsibility contributed to actions like banning indoor vaping in their practices, despite the absence of specific anti-vaping policies.³⁷ Others reported that assigning responsibilities to specific members of the (general practice) team could help HPs understand how they could contribute to e-cigarette cessation.³⁶

Most HPs did not feel confident or comfortable addressing e-cigarette use, including answering questions, explaining known harms, detecting clinical signs of e-cigarette use or using cessation support techniques (offering cessation support, asking about vape use, providing education and counselling about e-cigarette cessation). Some studies also explored the causes and effects of HPs’ lack of confidence. Paediatricians had varying levels of confidence, and those who reported less confidence attributed this to a lack of robust research about the health impacts and safety of e-cigarettes.²⁸ A lack of formal training and continuing education on e-cigarettes contributed to low levels of confidence across HPs working with adolescents.²⁴ Low screening rates and infrequent conversations about e-cigarette use may reflect HPs’ lack of confidence in addressing the topic. Additionally, some nurses struggling to adapt to telehealth because of COVID-19 reported that this change in care delivery impeded their ability to meaningfully connect with clients, resulting in forgetting how to ask or feeling uncomfortable about asking about e-cigarette use.

Two studies reported that over half of primary care physicians, nurse practitioners and dental hygienists felt confident in discussing e-cigarettes or asking about e-cigarette use. Respondents from two studies (physicians, social workers and nurses who worked closely with adolescents) reported feeling somewhat confident in discussing e-cigarettes with their patients or clients. Pulmonologists were also relatively comfortable in counselling their patients to quit e-cigarette use. Those who felt confident stated that training (and resources in the consultation room) on screening, brief intervention and referral to treatment improved their confidence. Additionally, some HPs reported that their abilities to offer effective e-cigarette cessation counselling would improve with more research, clinical guidelines, and client and family resources.

Some HPs believed that their advice would not lead to behaviour change among clients. One study revealed a concern that even if providers were trained about screening for e-cigarettes, only 11% of them were optimistic that their advice would help their clients stop using e-cigarettes.²⁵ Additionally, some HPs believed that providing e-cigarette cessation advice to clients who were not contemplating quitting would be perceived negatively by their clients and could cause patients to ‘shut down’, although this goes against recommended practice.^28,44 They emphasised that clients needed to be willing to make changes for advice to be effective.²⁸

Beliefs about the effectiveness of cessation counselling were also considered facilitators. Two studies reported that most HPs believed that providing counselling was effective for e-cigarette cessation^38,42 and that screening for use was important.^24,42 One study reported that the training provided was perceived to be useful and there was optimism that it would result in increased support for cessation. Some dental hygienists considered that asking about e-cigarette use and documenting it in the medical records at every appointment would create an opportunity for education about the oral harms of e-cigarettes.³¹

Two papers found that some providers had little intention of asking their clients about vaping.

In most studies, HPs expressed a willingness to provide vaping cessation support in general^{25,26,31,35,38,46} and more specifically by asking about and assessing e-cigarette use, modifying treatment plans, increasing client communication,²⁶ conducting motivational interviewing,³⁵ discussing risks of vaping,³⁸ adding new skills into client care²⁶ or by using the 5As used in combustible tobacco cessation support (Ask, Advise, Assess, Assist and Arrange follow-up).^31,47 Some of these intentions to provide vaping cessation support were increased by training received.²⁶

Barriers related to goals were described in one paper reporting on a project undertaken by a General Practitioner (GP) clinic aiming to increase implementation of e-cigarette cessation support in the clinic.³⁶ One of the perceived challenges was that the project goals tended to focus more on the system and process rather than client care or recent vaping trends and, therefore, might not engage other key stakeholders.³⁶

Facilitators in the Goals domain identified in the paper describing the GP clinic project included creating a strong project vision to enable multiple stakeholders’ engagement that was informed by the local prevalence of e-cigarette use, clients’ narratives or HPs’ personal experiences.³⁶

HPs reported that certain client characteristics could prompt screening for e-cigarette use,²⁵ including the odour of tobacco or sighting the client’s vaping device.²⁵ Others reported that incorporating screening questions into the EHR would prompt them to ask about and document e-cigarette use consistently.^36,39

HPs highlighted two barriers: (1) influences from their colleagues and (2) gaps in engaging their peers in wider contexts. Two studies discussed how colleagues’ behaviours or beliefs affected how vaping was addressed. In one, only half the dental hygienists surveyed reported receiving support from their supervisors or dentists to screen for e-cigarette use.³¹ The lack of social pressure and influence from friends, colleagues and supervisors contributed to HPs’ infrequent screening for e-cigarette use, especially when competing priorities arose during the appointment.³¹ Staff reported challenges in a UK stop-smoking service where e-cigarettes were provided for smoking cessation when the ultimate goal was quitting both smoking and vaping.³³ Challenges included conflicting advice provided by different advisors and some undesirable social influences from the e-cigarette technical support staff who were also e-cigarette users, impacting service delivery.³³ In a study with family medicine practices, HPs identified missed opportunities to influence other HPs to incorporate e-cigarette cessation into their practice as most had minimal experience working with HPs outside their immediate circle.³⁶

Two studies described social factors that could potentially enable HPs to incorporate e-cigarette cessation into their practices: leadership through influence and normative beliefs.^31,36 HPs in GPs practices acknowledged that incorporating e-cigarette cessation into practice required making changes to the system and, thus, the influence of leadership was essential to affect this change.³⁶ Some dental hygienists stated that most of their peers asked about e-cigarette use and many considered that being like their colleagues was extremely important,³¹ reinforcing the importance of positive social influence in taking this first step in identifying people who needed cessation support.