Defense Date


Document Type


Degree Name

Doctor of Philosophy


Social and Behavioral Health

First Advisor

Jennifer Elston Lafata

Second Advisor

Levent Dumenci

Third Advisor

Richard Brown

Fourth Advisor

Andrew Barnes

Fifth Advisor

Randy Koch


Introduction: E-cigarettes have been marketed as smoking cessation aids and harm reduction strategies. Prior regional surveys found that physicians are recommending them to patients despite the lack of evidence supporting these industry claims. Yet, little is known about physicians’ beliefs regarding e-cigarettes and whether these beliefs are associated with them recommending e-cigarette use in clinical practice. Methods: This three-manuscript dissertation used a mixed-methods approach including both qualitative and quantitative research methods. The aims were to: (1) Uncover the factors associated with primary care physicians’ (PCPs) decisions to recommend e-cigarettes to their patients for tobacco use cessation; (2) Estimate the prevalence of PCPs who recommend e-cigarettes to their patients as a tobacco use cessation aid; (3) Estimate the influence of factors identified in Aim 1 on PCPs’ decisions to recommend e-cigarettes to their patients for tobacco use cessation; (4) Evaluate the conceptual model which demonstrates the factors contributing to PCPs’ decisions to recommend e-cigarettes to their patients for tobacco use cessation. Results: Study 1 found that PCPs expressed a lack of information about e-cigarette safety and efficacy along with skepticism about the role of e-cigarettes in tobacco control in general and in smoking cessation in particular. However, once a patient initiates a discussion with them, PCPs seem to be endorsing patients’ interests in using e-cigarettes, as well as recommending e-cigarettes to particular types of patients who smoke for both smoking cessation and as a harm reduction strategy. Study 2 found that over three-quarters (82.7%, n=220) of PCPs reported previously discussing e-cigarettes with their patients. Overall, 57.8% (n=155) reported previously recommending e-cigarettes to an adult patient who smoked. Among those recommending e-cigarettes, the majority reported recommending them for smoking cessation and harm reduction (71.6%, n=111), 18.8% for smoking cessation only, and 9.6% for harm reduction only. The likelihood of recommending e-cigarettes to patients was associated with considering their patients’ interest in using e-cigarettes, PCP’s belief that e-cigarettes can help in quitting smoking, and PCP’s belief that e-cigarettes limit secondhand smoke exposure for others. Study 3 found that PCPs intend to recommend e-cigarettes for smokers with prior unsuccessful quit attempts (mean=3.63, ±2.1), followed by heavy smokers wanting to quit (3.57, ±2.2), and heavy smokers refusing to quit (mean=3.50, ±2.2). The mean for PCPs’ recommendation intentions was 3.04 (±2.0) for light smokers wanting to quit, and 3.01 (±1.9) for light smokers refusing to quit. Nevertheless, these recommendation intentions were driven by PCPs’ beliefs and perceptions of e-cigarette benefit and harm; however, these intentions varied by patients’ tobacco use profile. Discussion: Findings across the three studies highlight the significance of PCPs’ beliefs in driving their recommendations of e-cigarettes versus evidence based knowledge, as well as, the importance of patients’ factors and interest in using e-cigarettes for PCPs’ recommendations for e-cigarette use.


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