Patient counseling in regard to e-cigarettes and erectile dysfunction


In this interview, Omar El Shahawy, MD, MPH, PhD, discusses patient counseling in regard to e-cigarette use or vaping by using data from a recent study on evaluating the association of e-cigarette use and erectile dysfunction.

The association of e-cigarettes, or vaping, with erectile dysfunction is another reason for urologists to advise their patients on quitting all types of tobacco use. But how can urologists get the message through to their patients when smoking is highly addictive, and oftentimes, patients misrepresent their true smoking status?

Omar El Shahawy, MD, MPH, PhD

Omar El Shahawy, MD, MPH, PhD

In this interview, Omar El Shahawy, MD, MPH, PhD, discusses patient counseling in regard to e-cigarette use or vaping by using data from a recent study on evaluating the association of e-cigarette use and erectile dysfunction.1 He stresses the importance of maintaining a non-judgmental outlook as a clinician and working with patients to set goals for ultimately reaching the goal of complete tobacco and nicotine cessation. Dr. El Shahawy is an assistant professor in the department of population health, and affiliated faculty in the division of global health at the New York University School of Global Public Health in New York City, New York.

Please discuss the background for the study.

My research focus is evaluating the risk and benefits of alternative tobacco products on health, in the context of smoking cessation and smoking harm reduction. While there is abundant evidence that smoking cigarettes impacts health overall, particularly with erectile dysfunction for adult men, there are [also] several [other] causes for erectile dysfunction, like cardiovascular disease, hypertension, [or] psychological distress. Tobacco use is a major cause for that as well, and there is evidence for adose response relationship. The more you smoke, then the more prone you are to experience or report having erectile dysfunction. Now with e-cigarette use being on the rise among adult smokers [who are] using it [to try] to reduce the harms of smoking or trying to quit, my co-authors and I tried to better understand whether there is a connection between e-cigarette use and erectile dysfunction. Particularly, this is important now because the e-cigarettes that are available in the market are quite efficient in delivering nicotine. Actually, some of the e-cigarettes available in the market deliver way higher nicotine than what's in combustible cigarettes at this point. So, we thought that it's imperative to try to understand what the impact of using e-cigarettes could be on a population level. And for that, we decided to do this study.

What were some of the notable findings of this study? Were any of them surprising to you or your co-authors?

We decided to use a national dataset representing the whole United States, which is a very big strength for the study in comparison to using data from a clinical setting because it's subject to some biases. The notable finding [was] that using e-cigarettes on a daily basis posed a risk for erectile dysfunction. [Using e-cigarettes, but particualry on daily basis] was associated with more than doubling the risk of reporting erectile dysfunction. We did a lot of different types of analyses, looking at what we call sensitivity analysis in survey studies to [determine] whether there [were differences] by excluding people who've had cardiovascular disease, for example, from the sample, limiting only for patients under 65 and so forth. All different types of analysis [revealed] findings [that] were very robust, and the association was maintained throughout.

But something that was surprising is that the association with erectile dysfunction was not statically signfianct among current cigarette smokers in this study , but is was significant among former smoking. And there are several ways to look at that to really undertand the data with the known limitation of using a crossectional survey rather than a cohort design. Although this is [a] collective sample from the whole United States, you have people, for example, from states like New York or California where taxes are high and [the] frequency of smoking is low. In other settings, [maybe] that frequency per user is still high. We've looked at that, but we didn't find a particular association and there is limitations for how much we can probe to all this because of the sample sizeand the power you have with more combinations in the sample. Overall, a potential reason could be the advancements in our tobacco control efforts so far. People maybe smoking less than they used to per day, compared to 10 or 20 years ago. But there's also other possible explanations, like what we call the “healthy smoker syndrome.” People are more likely to quit smoking when they feel the detreimantal impact of smoking on their health in general. [daily vapiung then] could be also associated with erectile dysfunction [or] it could be the other causes that former smokers have experienced because of their smoking history or otherwise. So, that's why maybe we found that this association still exists among former smokers rather than current smokers.

Is there further research on this topic planned? If so, what will its focus be?

A foundational component of my program of research and what we try to apply to grant funding is to try to contextualize the full risks and benefits of using e-cigarettes, whether it's for smoking harm reductions among populations where it's very hard to get them to quit, or to understand what the extent the harm would be. What kind of frequency of using e-cigarettes is relatively safe? Are there differences between types of e-cigarettes that you use and the way it can impact health? Is it just the nicotine or it could be other constituents of the E-liquid or the vape that people use that could cause bad effects on health? So, there are several plans to address some of these questions, but immediately, what we're already working on with other colluegues and [what] we're going to be submitting soon, [are] 2 papers. [One is] looking at [the] association of dual use of cigarette and e-cigarettes, which was people who maintain using cigarettes while vapingwith erectile dysfunction. [The other is looking at] the different patterns of tobacco use, like people who use one product versus multiple products, which is another proxy of frequent use of tobacco. We found significant associations in both of these studies, and we're probably going to be published in the next few months.

What is the take-home message for the practicing urologist?

We should always screen for tobacco use, of course, and with that, I would say proper screening is something that needs to happen. It's not just by asking patients, "Do you smoke?" Even when you ask patients [this], some patients may perceive themselves [differently and answer] "No, I don't smoke. I just have a cigarette ocassioally and do not precieve themselves as smokers, or I just smoked last week, or something like that." So, it's good to standardize the way that we screen for that, and to also probe [about] other products. It's good to be very specific, and to ask, "Have you used any tobacco in the last 30 days?" If they say "no," probe with asking about e-cigarettes as well because a lot of people do not perceive e-cigarettes as a type of tobacco. From a regulatory perspective it is, but from the public's or the user's perspective, [they think,] "No, I'm not using tobacco; it's just e-cigarettes." It is always good to probe because e-cigarettes may be a less harmful option, for example, but it's not with no harm in the absolute sense. What we know is that e-cigarettes could be less harmful to the degree [that] it could substitute smoking for somebody who smokes. So, if you get one of your patients, for example, to switch to e-cigarettes because it's maybe less harmful than smoking cigarettes, it is really less harmful [to] the degree [that] this substitution happened. [It] doesn't mean that people could switch to e-cigarettes and just use [them] frequently because then this would present its own set of harms and detrimental effects [on] health with this frequent use. It should be basically used to get over the craving of smoking , which is how harm reduction works and then eventually it is best to stop every-tobacco at some point. So, I would say that the advice would be to probe [on] different types of tobacco and to try to advise anybody to completely quit all nicotine products eventually. Whether it is e-cigarettes or other products, the goal should be complete tobacco cessation.

Given that you cannot always rely on patient self-identification for e-cigarette use status, how can clinicians facilitate more transparency with their patients when managing conditions like erectile dysfunction?

I think the interaction between the patient and a physician [should not be] judgmental and be [more] from a supportive manner. [That] is really a key in getting patients to take that advice from physician [to] heart and [set goals]. So, when you apply the five A's, which [are] the framework for counseling for smoking cessation, for example, you first ask the patient very specifically whether they currently smoke any tobacco or smoked any tobacco in the past 30 days [and] probe to e-cigarettes as well. You should then move toward follow up activities, which is [when] you [advise] patients to quit [and] link this advice that you're going to give to the patient to their current health situation for example, or something that it important to them. So, if you have a patient that, for example, has erectile dysfunction, it is good to mention, "Well, this could be connected to your smoking, or this could be connected to your e-cigarette use." Explaining to [patients] how this could impact their health directly is something important for the patient to be able to have that 'ah-ha' moment. The most important thing is to do it in a non-judgmental manner, and to always bridge to be more of a goal setting with the patient. Smoking is very much a chronic disease, and there is a lot of relapse, so [it's important that we are] encouraging patients. For example, [we can ask] a simple question like, "How much do you want to quit smoking right now, on a scale from one to 10?" When a patient says, "3," which is quite low, [we] shouldn't be judgmental. Any number could be reflected upon in a positive way. [We can] say, "Okay, It's good that it's not a 2. So, how could [we] help you to make it a 5 or a 6? What would help you to try to quit next month or in the near future?" This sort of non-judgmental counseling with the patient, or advice, would usually motivate the patients eventually to try to quit and discuss their challenges openly with their doctors and encourage them if they relapse. On average, for a smoker to quit completely takes an average of 9 to 10 times of trying to quit. So, continuous support for the patient and goal setting is important.

Arranging follow up is the last point in the 5 A's. The goal setting for the patient is important. [We can] say, "When I see you in your follow-up visit the next 3 months, let's try to half [your use]. If you don't want to quit now, let's try to minimize the use or cut it by half." This supportive counseling [will have a] better impact in the long run [to get] patients to actually quit all tobacco and nicotine, rather than just giving very directive advice, and just [leaving] it at that. For the context of erectile dysfunction, in particular, there's something that we also highlighted [in this study]. Maybe it wasn't one of the big findings because it's something that's known, but it was very interesting to me to show impact of the protective factors against erectile dysfunction. We adjusted for other issues, like cardiovascular disease, hypertension, diabetes, [and] all that, in our analysis, but we also adjusted for physcial excersice frequency for example. And it was very interesting to me to see that physical exercise frequency on a weekly basis with all factors considered was incrementally and significantly protective against erectile dysfunction with increasing in frequency of physcial excersice. So, it's good to remind people to always be physically active. This is a protective factor, in general, against a lot of morbidity and disease.

Is there anything else you feel our audience should know about this specific topic?

I would say that [vaping] e-cigarettes is not risk free, but at the same time, we know that there is some angle of smoking harm reduction for it. So, if you have a patient that comes to you, and they've consistently tried to quit smoking cigarettes and they couldn't, and they asked about whether they [should] try e-cigarettes or not, that is a signal that they may be motivated or interested to try. Instead of say[ing], "Oh no, you should not try this. This is something that's you shouldn't do. Only use smoking cessation aids." If they've tried it before and failed, you could perhaps be more open to encourage them to try and see whatever may work. At the same time, give them clear advice to not use e-cigarettes excessively, and [emphasize that they're] using it only as a vehicle to try to quit eventually. [We can say], "If you do switch, then you shouldn't get stalled in this phase. You should try to eventually quit all nicotine and tobacco." This is more of a point that is very controversial, but so far, the evidence suggests that complete nicotine [or tobacco] cessation is the way to go of course. But if there is a phase where people could switch to a less harmful product as a way to eventually quit, that could be good advice that physicians could give at this point with the evidence that we know.


1. El-Shahawy O, Shah T, Obisesan OH, et al. Association of e-cigarettes with erectile dysfunction: The population assessment of tobacco and health study. Epub November 30, 2021. American Journal of Preventative Medicine. Doi: 10.1016/j.amepre.2021.08.004

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