Knowledge and Perceptions of Texas Community Pharmacists Regarding Electronic Nicotine Delivery Systems

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The increase of ENDS use leads to concerns about their impact on public health. In the United States, ENDS are readily available for purchase and pose risks. Community pharmacists can play a crucial role in educating adult and adolescent patients about ENDS. Objectives: This study aimed to understand Texas community pharmacists' perceptions of ENDS with three objectives: 1) to identify consensus on perceptions and comfort among community pharmacists in Texas and 2) assess basic knowledge of the ENDS use landscape in the United States. Methods: A cross-sectional survey targeting community pharmacists in Texas was conducted in 2019. Sixty-eight responses were collected, and 43 were included in the analysis. The survey covered pharmacist demographics and ENDS questions related to knowledge and perceptions or ENDS and a ranking question of tobacco cessation strategies. Results: Most respondents 40 or more years of practice. Respondents expressed low confidence in ENDS as an effective smoking cessation tool. Nicotine replacement therapy was considered the most effective method, while e-cigarettes were deemed the least effective. Knowledge about ENDS was limited, with significant gaps in understanding. Conclusion: Community pharmacists in Texas require additional education and knowledge enhancement regarding ENDS. This study highlights the urgent need for more comprehensive ENDS education in pharmacy curricula and continuing education to equip pharmacists with the knowledge to counsel patients on ENDS effectively. Clinical Pharmacology ENDS electronic nicotine delivery systems tobacco cessation smoking cessation nicotine cessation nicotine pharmacy community pharmacy pharmacy practice pharmacy education Highlights The Centers for Disease Control and Prevention (CDC) reported 2,668 cases of e-cigarette or vaping use-associated lung injury (EVALI) between August 2019 and January 2020, predominantly affecting the 18-24 age group. Despite these risks, the FDA has not approved ENDS as a nicotine or tobacco cessation therapy Community pharmacists often interact with the public and can play a crucial role in educating patients about the risks and facts of ENDS use. However, there is a notable gap in pharmacists' knowledge and confidence in counseling patients about ENDS, with many pharmacists needing further education and clear clinical guidelines In the study, community pharmacists in Texas overwhelmingly ranked nicotine replacement therapy (NRT) as the most effective smoking cessation method, while e-cigarettes were considered the least effective. This reflects a general skepticism among pharmacists regarding the efficacy of ENDS for smoking cessation The survey revealed that most Texas pharmacists did not view ENDS favorably as a therapeutic option for smoking cessation. This sentiment was consistent across various perception questions, highlighting the need for improved education and research to address pharmacists' concerns and knowledge gaps Introduction Electronic nicotine delivery systems (ENDS), also known as vapes or e-cigarettes, are devices that deliver vaporized nicotine via inhalation. These devices are sold in the United States without a prescription and are readily available for purchase at pharmacies, convenience stores, and grocery stores among other places. Xiao and colleagues have found that common reasons for ENDS use include flavoring, perception that they are safe, tobacco cessation, limitations to public smoking, affordability, and social acceptability but these reasons vary based on socioeconomic status and other user demographics. 1 The most recent large-scale data available to date suggests the prevalence of ENDS use in the United States is decreasing overall, but is still increasing in young adults aged 18–24 years old. 2,3 According to the Centers for Disease Control and Prevention (CDC), ENDS can cause neurological harm during this crucial time of brain development in young adults. 4 According to surveillance data published by CDC investigators, there have been 2,668 cases of e-cigarette or vaping use-associated lung injury (EVALI) reported in the United States between August 2019 and January 2020 with most cases occurring in the 18–24 age group. 5 Community pharmacists frequently interact with the public and may be a critical touchpoint to educating patients regarding the facts about ENDS for them to make an informed decision about their use. The United States Food and Drug Administration (FDA) has not approved ENDS as a nicotine or tobacco cessation therapy. 6 FDA-approved tobacco or nicotine cessation products are either prescription or available without a prescription over the counter. In the United States, prescription tobacco cessation products include oral tablets such as varenicline or bupropion. There are also two nicotine replacement therapy (NRT) products that are available by prescription only, the nicotine inhaler and nicotine nasal spray. Over the counter NRT consists of the nicotine patch, lozenge, or gum. In Texas, community pharmacists do not have a state-wide standing order to prescribe tobacco cessation products without a provider’s prescription. Other states such as Idaho, Colorado, and New Mexico have statutes or regulations that allow pharmacists to prescribe tobacco cessation aids without a collaborative practice agreement. 7 However, pharmacists may verbally recommend and provide counseling on over-the-counter NRT such as the nicotine patch, lozenge, or gum. There has been significant investigation into the attitudes and perspectives of ENDS for American physicians, dentists, and nurses, but there is little information from community pharmacists. 8 In 2016, Marques Gomes and colleagues collected comprehensive survey data from 92 community pharmacists in London that focused on their attitudes of ENDS and concluded that pharmacists had safety concerns, sought additional education, and recommended clear clinical practice guidelines regarding ENDS. 9 ENDS are considered a legitimate therapy to tobacco cessation in the United Kingdom and this was reflected in the survey questions and makes extrapolation to the United States landscape difficult. 10,11 Erku and colleagues issued a cross-sectional survey to 64 pharmacists and 76 pharmacy assistants in Queensland, Australia. The perceptions of pharmacy staff were evaluated regarding safety of ENDS compared to combustible cigarettes and NRT and most respondents believed patients would be interested in ENDS as a smoking cessation aid. 13 The ENDS use landscape in Australia is also different than in the United States as the vape liquid is prescription only in Australia. 14 In 2019, Hagan and colleagues published survey results of ENDS knowledge and perceptions of 255 pharmacists’ ENDS counseling comfort, knowledge, and perceptions of harm in California. 15 While no conclusions were drawn from the study, the authors found that pharmacists’ ENDS knowledge of regulator status was accurate, the pharmacists did not see ENDS as a therapeutic option for smoking cessation, and ENDS cessation counseling was not reported by pharmacists in any setting. 7 While the study is valuable, it lacks community pharmacist specific data and leaves many knowledge, attitude, and comfort questions unanswered . To date, the current data regarding American pharmacists’ perceptions, knowledge, and comfort related to ENDS comes from one limited study that is not focused on community pharmacists. Other, more comprehensive survey studies are available outside the United States, but perceptions may differ due to the differing landscape. The aim of this study was to determine Texas pharmacists’ perceptions regarding ENDS. There were two objectives by which the study planned to accomplish this aim: 1) to identify consensus on perceptions and comfort among community pharmacists in Texas and 2) assess basic knowledge of the ENDS use landscape in the United States. Methods This was a regional cross-sectional study that took place in Texas in the summer of 2019. The Texas Pharmacy Association membership list has 347 pharmacists who indicated themselves as community pharmacists. These pharmacists were engaged via an email announcement for a $ 100 gift card drawing for those that disclosed their email address. To maintain confidentiality, the respondents’ email addresses were separated from the results, used only for the purposes of the randomized drawing, then deleted. Respondents had 30 days from the day the recruitment email was sent to complete the survey. Respondents were required to complete the survey and have an email address listed in the database for inclusion. The 27-question survey consisted of 6 demographic questions, 1 tobacco cessation strategy ranking question, 5 ENDS knowledge questions, and 15 ENDS perceptions questions. The respondents were asked to rank the following in order of effectiveness for smoking cessation: motivational interviewing, support group therapy, nicotine replacement therapy, e-cigarettes, and family encouragement. Research from Marques Gomes served as an inspiration and basis for the knowledge and attitudes components of the survey. 9 The Likert answers were reduced to binomial coding (0 and 1) and were analyzed using a non-parametric one-sample binomial test with Lilliefors correction for the sample. 16 Questions with multiple categorical variable answers (ie: the ranking question and most common nicotine purchase age) were analyzed using a non-parametric one-sample chi-square test. The five knowledge questions were analyzed using descriptive statistics. The survey was delivered by email and created using Qualtrics®. An analysis was completed with Microsoft® Excel for Mac Version 16.60 and IBM® SPSS® Statistics Version 25. Excel was used to find descriptive statistics while SPSS was used for ANOVA, chi-square, and binomial tests. Excel was also used to randomize the participants’ email addresses for the gift card drawing. This study was exempted from review by the university’s Institutional Review Board. Results Of the 347 pharmacists engaged via email, 68 responses were recorded (19.6% response rate). Of the 68 responses, 44 completed every question. One respondent answered “n/a” for the age demographic free-text question which the authors excluded for analysis purposes. The final number of respondents who completed the survey and were included in the analysis was 43 (n = 43). Demographics of the respondents are available in Table 1. Of note, the mean age of respondents was 46 years old, and that 82% of respondents indicated they have been a pharmacist for 5 or more years. Table 1 compares this study’s demographic data to the most recent Pharmacy Workforce Center’s National Pharmacist Workforce Study (NPWS) 2019 findings. 17 Several of the perception questions had a statistically significant consensus answer and are available in Table 2. When assessing the respondents ranked selection of most effective to least effective smoking cessation therapy by the one-sample chi-square test, the middle choice was excluded from assessment, and the remaining selections were statistically significant. Respondents were more likely to have clear choices for their perceived most effective, more effective, less effective, and least effective therapies. The most, second most, second least, and least effective therapies of the five ranked options were as follows (the answer count, and the p value): nicotine replacement therapy (17, p = 0.002), family encouragement (14, p = 0.038), support group (13, p = 0.019), and e-cigarettes (35, p < 0.001), respectively. The complete performance of the five knowledge questions is available in Table 3. Four of the five knowledge questions had correct response rates of < 70%. Most (93%) of respondents knew healthcare provider counseling has evidence for efficacy for tobacco cessation. The question about the purchase age for tobacco in Texas was dropdown multiple choice with one-year integer answer choices ranging from 16 to 23 years old; however, all respondents answered either 18 (35%) or 21 years old (65%). The True or False question “Nicotine replacement therapy dosing is different in adults than in adolescents” had a 39.5% correct response rate. Discussion The sample of Texas pharmacists was small; however, it did have similar characteristics to the large sample of pharmacists from the NPWS. 17 Of note, for the gender demographic question, the authors combined the “nonbinary” and “other” gender categories into one “other” group. The authors also acknowledge that the frame of “gender identity today” using the options “male/man, female/woman, indigenous or other culture gender minority identity (eg. two-spirit), and something else (eg. gender fluid, non-binary)” would have been more appropriate for the time in retrospect. 18 Also, the year of licensure was subtracted from the year of the survey (2019) to create the “years of practice” comparison to the survey. 17 While the difference between the survey date and date of licensure doesn’t necessarily mean the pharmacists have been practicing during those years, it gives added information to compare to a large sample of pharmacists on the basis of experience. The common demographics that can be compared are age, gender/sex, and years in practice. The age demographic was very similar in all categories except for an under-representation of pharmacists in their fifties (9.3% compared to 20.9% in NPWS). There was only a slight under-representation of female pharmacists in the study compared to the NPWS at 51.2% and 61.9%, respectively. The study had fewer new practitioners (0–9 years of practice) and more late-career pharmacists (≥ 40 years of practice) than the NPWS. Overall, the comparable demographics were similar with the exceptions described above. Among respondents, NRT was the preferred selection for the most effective tobacco cessation method, and e-cigarettes were overwhelmingly selected as the least effective tobacco cessation method. Most perception questions had either a pro- or anti-ENDS stance in terms of their use as a legitimate tobacco cessation therapy. For example, questions like “E-cigarettes are effective as a therapy for smoking cessation,” “E-cigarettes are safer to use than smokeless tobacco […],” “Vapor produced from e-cigarettes is NOT harmful,” “E-cigarettes are primarily used by patients as a smoking cessation aid,” and “E-cigarettes are primarily used by patients as a cheaper alternative to cigarettes.” The respondents consistently had a consensus on almost all questions that indicated they did not perceive ENDS to be a good therapeutic option for tobacco cessation. The knowledge questions may hint at exposure of an area for improvement for continuing education. Despite low scores on 4 of the 5 knowledge questions, a high percentage of pharmacists felt confident in initiating conversations with parents about adolescent ENDS use. There may have been some misunderstanding surrounding the nicotine replacement therapy adolescent dosing question as these therapies are not FDA approved for use in patients under 18 years old. Additionally, the term “adolescent” was not defined in the survey for the pharmacists. That said, off-label use and studies support using adult dosing. 19 There were some limitations to this study. The perception and knowledge questions were not obviously distinct from one another as some of the perception questions had objective correct answers. The sample was small, and the low response rate may have resulted in selection bias; however, the 2019 NPWS had a response rate of 5.8% compared to the 19.6% response rate of this study. 17 The respondents tended to be experienced as over 30% have been practicing for at least 30 years and over 50% of respondents were age 40 or over. Because the ongoing conversations about ENDS in a healthcare context are contemporary, the age and years in practice may have influenced the sample’s answer tendencies and may make results less externally valid. In fact, the sample was homogenous except for locale classification and gender. Based on the prevalence of young adults using ENDS, one might suspect that younger representation in the sample may have demonstrated more pro-ENDS sentiment; however, a survey of 420 pharmacy students in 2020 showed that pharmacy students overall felt negatively about ENDS and more so than other healthcare professional students. 20 It is unclear how additional age diversity would have impacted the results, but this an opportunity for future research on this topic. Doctor of Pharmacy (PharmD) curricula and continuing pharmacy education may be areas to improve pharmacists’ knowledge regarding ENDS. PharmD curricula is currently lacking in ENDS education which may be contributing to the lack of knowledge of practitioners. 21 A 2018 study of first through fourth professional year pharmacy students showed a decreased confidence in ability to counsel patients regarding e-cigarettes compared to combustible cigarettes. 22 Conclusions Community pharmacists in Texas have a need for increased education regarding ENDS safety, efficacy, and patient counseling. While no significant predictors of perceptions regarding ENDS were determined, the overall pharmacists’ ENDS perceptions were not positive as an option for tobacco cessation therapy. More research with larger, more diverse samples is needed to further investigate such perceptions and their predictors. Declarations CRediT Statement: Joshua Wollen: Supervision, Data Curation, Writing – Original Draft, Formal Analysis, Data Curation Priyanka Kochuparambil: Writing - Original Draft, Writing – Review & Editing, Conceptualization, Investigation Harleen Singh: Writing - Original Draft, Writing – Review & Editing, Conceptualization, Investigation Olivia Mottley: Writing – Review & Editing, Visualization Natalie Rosario: Writing - Review & Editing, Visualization Acknowledgement The authors would like to acknowledge and thank the participants for taking place in the study, the peer reviewers for this article, and Dr. Gianpiero Calabrese of Kingston University London for access to his team’s survey and his collegiality. Disclosure statement: The authors do not have any conflict of interest of financial disclosures to declare. References Xiao C, Heley K, Kennedy R, Lagasse L, Moran M. Sociodemographic differences in reasons for ENDS use among US youth within Wave 2 of the PATH study. Tob Induc Dis . 2019;17(January). doi:10.18332/tid/99879 Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco Product Use Among Adults - United States, 2019. MMWR Morb Mortal Wkly Rep . 2020;69(46):1736-1742. doi:10.15585/mmwr.mm6946a4 Cornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco Product Use Among Adults - United States, 2020. MMWR Morb Mortal Wkly Rep . 2022;71(11):397-405. doi:10.15585/mmwr.mm7111a1 CDC. Quick Facts on the Risks of E-cigarettes for Young People. Centers for Disease Control and Prevention. Published April 7, 2022. Accessed May 19, 2022. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html Krishnasamy VP, Hallowell BD, Ko JY, et al. Update: Characteristics of a Nationwide Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury — United States, August 2019–January 2020. MMWR Morb Mortal Wkly Rep . 2020;69(3):90-94. doi:10.15585/mmwr.mm6903e2 Center for Tobacco Products. E-Cigarettes, Vapes, and other Electronic Nicotine Delivery Systems (ENDS). FDA Website . Published online July 21, 2023. Accessed December 19, 2023. https://www.fda.gov/tobacco-products/products-ingredients-components/e-cigarettes-vapes-and-other-electronic-nicotine-delivery-systems-ends Pharmacist Prescribing: Tobacco Cessation Aids. NASPA. Accessed May 20, 2022. https://naspa.us/resource/tobacco-cessation/ Pepper JK, McRee AL, Gilkey MB. Healthcare providers’ beliefs and attitudes about electronic cigarettes and preventive counseling for adolescent patients. J Adolesc Health Off Publ Soc Adolesc Med . 2014;54(6):678-683. doi:10.1016/j.jadohealth.2013.10.001 Marques Gomes ACN, Nabhani-Gebara S, Kayyali R, Buonocore F, Calabrese G. Survey of community pharmacists’ perception of electronic cigarettes in London. BMJ Open . 2016;6(11):e013214. doi:10.1136/bmjopen-2016-013214 Rehan HS, Maini J, Hungin APS. Vaping Versus Smoking: A Quest for Efficacy and Safety of E-Cigarette .; 2018:92-101. Accessed June 2, 2022. http://www.eurekaselect.com/160136/article Medicines and Healthcare products Regulatory Agency. Guidance for licensing electronic cigarettes and other inhaled nicotine-containing products as medicines. GOV.UK. Published October 29, 2021. Accessed June 1, 2022. https://www.gov.uk/guidance/licensing-procedure-for-electronic-cigarettes-as-medicines Hammond D, Rynard VL, Reid JL. Changes in Prevalence of Vaping Among Youths in the United States, Canada, and England from 2017 to 2019. JAMA Pediatr . 2020;174(8):797. doi:10.1001/jamapediatrics.2020.0901 Erku DA, Gartner CE, Do JT, Morphett K, Steadman KJ. Electronic nicotine delivery systems (e-cigarettes) as a smoking cessation aid: A survey among pharmacy staff in Queensland, Australia. Addict Behav . 2019;91:227-233. doi:10.1016/j.addbeh.2018.09.013 Erku D, Gartner CE, Morphett K, Snoswell CL, Steadman KJ. Nicotine vaping products as a harm reduction tool among smokers: Review of evidence and implications for pharmacy practice. Res Soc Adm Pharm RSAP . 2020;16(9):1272-1278. doi:10.1016/j.sapharm.2020.02.002 Hagan J, Kedzior S, Pimentel L, Tran D, Vallabh P, Apollonio DE. A Cross-sectional Survey of California Pharmacists’ Knowledge and Perceptions about Electronic Nicotine Delivery Systems (ENDS). Calif J Health-Syst Pharm CJHP . 2019;31:56-68. Williams RBG. The Aims of Statistics. In: Introduction to Statistics for Geographers and Earth Scientists . Macmillan Education UK; 1984:1-3. doi:10.1007/978-1-349-06815-9_1 Pharmacy Workforce Center. 2019 National Pharmacist Workforce Study: Final Report .; 2020:1-94. Accessed December 13, 2022. https://www.aacp.org/sites/default/files/2020-03/2019_NPWS_Final_Report.pdf Morgan RE, Dragon C, Daus G, et al. Updates on Terminology of Sexual Orientation and Gender Identity Measures . Federal Committee on Statistical Methodology; 2020. Accessed October 19, 2023. https://www.fcsm.gov/assets/files/docs/FCSM_SOGI_Terminology_FY20_Report_FINAL.pdf Karpinski JP, Timpe EM, Lubsch L. Smoking cessation treatment for adolescents. J Pediatr Pharmacol Ther JPPT Off J PPAG . 2010;15(4):249-263. Sahr M, Kelsh S, Ottney A, Young M, Larson R, Sohn M. Pharmacy Students’ Perceptions of Electronic Nicotine Delivery Systems as Compared to Those of Other Health Care Students. Am J Pharm Educ . 2020;84(7):ajpe7690. doi:10.5688/ajpe7690 Marti KM, Marti KE, Salvo MC. A call for student pharmacist education on vaping and vaping device use. Curr Pharm Teach Learn . 2021;13(3):203-205. doi:10.1016/j.cptl.2020.10.014 Nduaguba SO, Ford KH, Bamgbade BA, Ubanyionwu O. Comparison of pharmacy students’ self-efficacy to address cessation counseling needs for traditional and electronic cigarette use. Curr Pharm Teach Learn . 2018;10(7):955-963. doi:10.1016/j.cptl.2018.04.016 Tables Table 1. Respondent Demographics Study Count (%) n=43 NPWS 2019 Count (%) n=5,534 Age (years) n=5,467 ≤30 8 (18.6) 843 (15.4) 31-40 13 (30.2) 1,408 (25.8) 41-50 8 (18.6) 907 (16.6) 51-60 4 (9.3) 1,146 (20.9) 61-70 8 (18.6) 888 (16.3) >70 2 (4.7) 275 (5.0) Gender n=5,534 Female 22 (51.2) 3,427 (61.9) Male 20 (46.5) 2,098 (37.9) Other 1 (2.3) 9 (0.2) Years in practice n=5,534 0-9 8 (18.2) 1,869 (33.8) 10-19 8 (18.2) 790 (14.3) 20-29 9 (20.5) 940 (17.0) 30-39 6 (13.6) 1,020 (18.4) ≥40 13 (29.5) 733 (13.2) Percentage of adolescent patients N/A 75% 1 (2.3) Parental status N/A No 13 (30.2) Yes 30 (69.8) Locale classification N/A Urban 14 (32.6) Suburban 19 (44.2) Rural 10 (23.3) NPWS=National Pharmacist Workforce Survey N/A= not available Table 2. Perception Consensus Analysis by Question Agree, n (%) P value Classic nicotine replacement therapy (ie. Nicotine patch, lozenge, gum, etc.) is effective as a therapy for smoking cessation. 36 (84) <0.001* E-cigarettes are effective as a therapy for smoking cessation. 10 (23) 0.001* E-cigarettes are safer to use than smokeless tobacco (ie. Chew, snuff, dip, etc.). 13 (30) 0.014* Vapor produced from e-cigarettes is NOT harmful. 3 (7) <0.001* E-cigarettes should be more strictly regulated. 40 (93) <0.001* E-cigarettes make nicotine more accessible to adolescents. 38 (88) <0.001* The flavoring chemicals in e-cigarettes may be toxic. 40 (93) <0.001* Discussing e-cigarettes with patients may encourage them to use e-cigarettes. 25 (58) 0.360 It is important to discuss e-cigarettes with adolescent patients. 40 (93) <0.001* E-cigarettes are primarily used by patients as a smoking cessation aid. 12 (28) 0.005* E-cigarettes are primarily used by patients as a cheaper alternative to cigarettes. 16 (37) 0.126 E-cigarettes are primarily used by patients for social/recreational use. 38 (88) <0.001* I am comfortable with initiating conversations about e-cigarette usage to parents with adolescent children given my current knowledge about e-cigarettes. 33 (77) 0.001* I am comfortable dosing nicotine replacement therapy for e-cigarette cessation. 21 (49) 1.000 * p < 0.05 was considered to be statistically significant Table 3. Knowledge Question Performance by Frequency Answer Correct, n (%) What is the current age for buying tobacco products in Texas? 21 28 (65.1) Healthcare provider counseling is effective as a therapy for smoking cessation. True 40 (93.0) All e-cigarettes contain nicotine. False 23 (53.5) For which age range is electronic nicotine delivery device (ie. e-cigarettes) use most prevalent? 18 – 25 years old 24 (55.8) Nicotine replacement therapy dosing is different in adults than in adolescents. True or False? False a 17 (39.5) a Nicotine replacement therapy is not FDA approved for those < 18 years old; however, off-label use and studies suggest using adult dosing. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4505377","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":308851065,"identity":"b8964f74-09ec-47a6-9890-81114db5df8d","order_by":0,"name":"Joshua Wollen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBACxgYg8aCAgYEfKiDDwMADpNjwaGkDEgkGDAySIL0HwOoJaAHLgbQYHCBWC/P8HsMHCQY2ecbHDx97/HGPHQ+DRO4Bhg9lh/E4jMfYIMEgrdjsTFq6wYFnyUAteQmMM87h08K7TSLB4HDiths8ZhIHDjADteQYMPO2EdTyP3HzDP5vQC31EC1/CWs5kLhBgocNqOUwRAsjXi35n4F+SU6ccSbNTOLMgeM8bDxvDA72nEvHqcWw+Vjigw8Vdon97YefSVQcqJbjZ88xfPCjzBq3lgZ0EVCMHMCpHgjk8UmOglEwCkbBKAADAEuQUkmb9G9KAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-3944-4875","institution":"University of Houston","correspondingAuthor":true,"prefix":"","firstName":"Joshua","middleName":"","lastName":"Wollen","suffix":""},{"id":308851066,"identity":"ec8a759b-9645-4474-ad92-340173447f8d","order_by":1,"name":"Priyanka Kochuparambil","email":"","orcid":"","institution":"Baylor University Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Priyanka","middleName":"","lastName":"Kochuparambil","suffix":""},{"id":308851067,"identity":"42a35586-585b-4460-b63a-83172a204964","order_by":2,"name":"Harleen Singh","email":"","orcid":"","institution":"BronxCare Health System","correspondingAuthor":false,"prefix":"","firstName":"Harleen","middleName":"","lastName":"Singh","suffix":""},{"id":308851068,"identity":"f4719a63-e8a0-4a90-8265-eae740820734","order_by":3,"name":"Olivia Mottley","email":"","orcid":"","institution":"Life University","correspondingAuthor":false,"prefix":"","firstName":"Olivia","middleName":"","lastName":"Mottley","suffix":""},{"id":308851069,"identity":"f0aa4545-cf44-4ef5-bb50-a04f0ae855c8","order_by":4,"name":"Natalie Rosario","email":"","orcid":"","institution":"University of Houston","correspondingAuthor":false,"prefix":"","firstName":"Natalie","middleName":"","lastName":"Rosario","suffix":""}],"badges":[],"createdAt":"2024-05-30 23:55:55","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4505377/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4505377/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57615731,"identity":"26511861-7070-4939-a85d-892cf1ac6d64","added_by":"auto","created_at":"2024-06-03 11:28:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":390260,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4505377/v1/ecc2648d-0825-4084-84c3-c9d0d44594c5.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eKnowledge and Perceptions of Texas Community Pharmacists Regarding Electronic Nicotine Delivery Systems\u003c/p\u003e","fulltext":[{"header":"Highlights","content":"\u003cul\u003e\n \u003cli\u003eThe Centers for Disease Control and Prevention (CDC) reported 2,668 cases of e-cigarette or vaping use-associated lung injury (EVALI) between August 2019 and January 2020, predominantly affecting the 18-24 age group. Despite these risks, the FDA has not approved ENDS as a nicotine or tobacco cessation therapy\u003c/li\u003e\n \u003cli\u003eCommunity pharmacists often interact with the public and can play a crucial role in educating patients about the risks and facts of ENDS use. However, there is a notable gap in pharmacists\u0026apos; knowledge and confidence in counseling patients about ENDS, with many pharmacists needing further education and clear clinical guidelines\u003c/li\u003e\n \u003cli\u003eIn the study, community pharmacists in Texas overwhelmingly ranked nicotine replacement therapy (NRT) as the most effective smoking cessation method, while e-cigarettes were considered the least effective. This reflects a general skepticism among pharmacists regarding the efficacy of ENDS for smoking cessation\u003c/li\u003e\n \u003cli\u003eThe survey revealed that most Texas pharmacists did not view ENDS favorably as a therapeutic option for smoking cessation. This sentiment was consistent across various perception questions, highlighting the need for improved education and research to address pharmacists\u0026apos; concerns and knowledge gaps\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eElectronic nicotine delivery systems (ENDS), also known as vapes or e-cigarettes, are devices that deliver vaporized nicotine via inhalation. These devices are sold in the United States without a prescription and are readily available for purchase at pharmacies, convenience stores, and grocery stores among other places. Xiao and colleagues have found that common reasons for ENDS use include flavoring, perception that they are safe, tobacco cessation, limitations to public smoking, affordability, and social acceptability but these reasons vary based on socioeconomic status and other user demographics.\u003csup\u003e1\u003c/sup\u003e The most recent large-scale data available to date suggests the prevalence of ENDS use in the United States is decreasing overall, but is still increasing in young adults aged 18\u0026ndash;24 years old.\u003csup\u003e2,3\u003c/sup\u003e According to the Centers for Disease Control and Prevention (CDC), ENDS can cause neurological harm during this crucial time of brain development in young adults.\u003csup\u003e4\u003c/sup\u003e According to surveillance data published by CDC investigators, there have been 2,668 cases of e-cigarette or vaping use-associated lung injury (EVALI) reported in the United States between August 2019 and January 2020 with most cases occurring in the 18\u0026ndash;24 age group.\u003csup\u003e5\u003c/sup\u003e Community pharmacists frequently interact with the public and may be a critical touchpoint to educating patients regarding the facts about ENDS for them to make an informed decision about their use.\u003c/p\u003e \u003cp\u003eThe United States Food and Drug Administration (FDA) has not approved ENDS as a nicotine or tobacco cessation therapy.\u003csup\u003e6\u003c/sup\u003e FDA-approved tobacco or nicotine cessation products are either prescription or available without a prescription over the counter. In the United States, prescription tobacco cessation products include oral tablets such as varenicline or bupropion. There are also two nicotine replacement therapy (NRT) products that are available by prescription only, the nicotine inhaler and nicotine nasal spray. Over the counter NRT consists of the nicotine patch, lozenge, or gum. In Texas, community pharmacists do not have a state-wide standing order to prescribe tobacco cessation products without a provider\u0026rsquo;s prescription. Other states such as Idaho, Colorado, and New Mexico have statutes or regulations that allow pharmacists to prescribe tobacco cessation aids without a collaborative practice agreement.\u003csup\u003e7\u003c/sup\u003e However, pharmacists may verbally recommend and provide counseling on over-the-counter NRT such as the nicotine patch, lozenge, or gum.\u003c/p\u003e \u003cp\u003eThere has been significant investigation into the attitudes and perspectives of ENDS for American physicians, dentists, and nurses, but there is little information from community pharmacists.\u003csup\u003e8\u003c/sup\u003e In 2016, Marques Gomes and colleagues collected comprehensive survey data from 92 community pharmacists in London that focused on their attitudes of ENDS and concluded that pharmacists had safety concerns, sought additional education, and recommended clear clinical practice guidelines regarding ENDS.\u003csup\u003e9\u003c/sup\u003e ENDS are considered a legitimate therapy to tobacco cessation in the United Kingdom and this was reflected in the survey questions and makes extrapolation to the United States landscape difficult.\u003csup\u003e10,11\u003c/sup\u003e Erku and colleagues issued a cross-sectional survey to 64 pharmacists and 76 pharmacy assistants in Queensland, Australia. The perceptions of pharmacy staff were evaluated regarding safety of ENDS compared to combustible cigarettes and NRT and most respondents believed patients would be interested in ENDS as a smoking cessation aid.\u003csup\u003e13\u003c/sup\u003e The ENDS use landscape in Australia is also different than in the United States as the vape liquid is prescription only in Australia.\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn 2019, Hagan and colleagues published survey results of ENDS knowledge and perceptions of 255 pharmacists\u0026rsquo; ENDS counseling comfort, knowledge, and perceptions of harm in California.\u003csup\u003e15\u003c/sup\u003e While no conclusions were drawn from the study, the authors found that pharmacists\u0026rsquo; ENDS knowledge of regulator status was accurate, the pharmacists did not see ENDS as a therapeutic option for smoking cessation, and ENDS cessation counseling was not reported by pharmacists in any setting.\u003csup\u003e7\u003c/sup\u003e While the study is valuable, it lacks community pharmacist specific data and leaves many knowledge, attitude, and comfort questions unanswered .\u003c/p\u003e \u003cp\u003eTo date, the current data regarding American pharmacists\u0026rsquo; perceptions, knowledge, and comfort related to ENDS comes from one limited study that is not focused on community pharmacists. Other, more comprehensive survey studies are available outside the United States, but perceptions may differ due to the differing landscape. The aim of this study was to determine Texas pharmacists\u0026rsquo; perceptions regarding ENDS. There were two objectives by which the study planned to accomplish this aim: 1) to identify consensus on perceptions and comfort among community pharmacists in Texas and 2) assess basic knowledge of the ENDS use landscape in the United States.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This was a regional cross-sectional study that took place in Texas in the summer of 2019. The Texas Pharmacy Association membership list has 347 pharmacists who indicated themselves as community pharmacists. These pharmacists were engaged via an email announcement for a \u003cspan\u003e$\u003c/span\u003e100 gift card drawing for those that disclosed their email address. To maintain confidentiality, the respondents\u0026rsquo; email addresses were separated from the results, used only for the purposes of the randomized drawing, then deleted. Respondents had 30 days from the day the recruitment email was sent to complete the survey. Respondents were required to complete the survey and have an email address listed in the database for inclusion.\u003c/p\u003e \u003cp\u003eThe 27-question survey consisted of 6 demographic questions, 1 tobacco cessation strategy ranking question, 5 ENDS knowledge questions, and 15 ENDS perceptions questions. The respondents were asked to rank the following in order of effectiveness for smoking cessation: motivational interviewing, support group therapy, nicotine replacement therapy, e-cigarettes, and family encouragement. Research from Marques Gomes served as an inspiration and basis for the knowledge and attitudes components of the survey.\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe Likert answers were reduced to binomial coding (0 and 1) and were analyzed using a non-parametric one-sample binomial test with Lilliefors correction for the sample.\u003csup\u003e16\u003c/sup\u003e Questions with multiple categorical variable answers (ie: the ranking question and most common nicotine purchase age) were analyzed using a non-parametric one-sample chi-square test. The five knowledge questions were analyzed using descriptive statistics.\u003c/p\u003e \u003cp\u003eThe survey was delivered by email and created using Qualtrics\u0026reg;. An analysis was completed with Microsoft\u0026reg; Excel for Mac Version 16.60 and IBM\u0026reg; SPSS\u0026reg; Statistics Version 25. Excel was used to find descriptive statistics while SPSS was used for ANOVA, chi-square, and binomial tests. Excel was also used to randomize the participants\u0026rsquo; email addresses for the gift card drawing. This study was exempted from review by the university\u0026rsquo;s Institutional Review Board.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 347 pharmacists engaged via email, 68 responses were recorded (19.6% response rate). Of the 68 responses, 44 completed every question. One respondent answered \u0026ldquo;n/a\u0026rdquo; for the age demographic free-text question which the authors excluded for analysis purposes. The final number of respondents who completed the survey and were included in the analysis was 43 (n\u0026thinsp;=\u0026thinsp;43). Demographics of the respondents are available in Table\u0026nbsp;1. Of note, the mean age of respondents was 46 years old, and that 82% of respondents indicated they have been a pharmacist for 5 or more years. Table\u0026nbsp;1 compares this study\u0026rsquo;s demographic data to the most recent Pharmacy Workforce Center\u0026rsquo;s National Pharmacist Workforce Study (NPWS) 2019 findings.\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSeveral of the perception questions had a statistically significant consensus answer and are available in Table\u0026nbsp;2. When assessing the respondents ranked selection of most effective to least effective smoking cessation therapy by the one-sample chi-square test, the middle choice was excluded from assessment, and the remaining selections were statistically significant. Respondents were more likely to have clear choices for their perceived most effective, more effective, less effective, and least effective therapies. The most, second most, second least, and least effective therapies of the five ranked options were as follows (the answer count, and the p value): nicotine replacement therapy (17, p\u0026thinsp;=\u0026thinsp;0.002), family encouragement (14, p\u0026thinsp;=\u0026thinsp;0.038), support group (13, p\u0026thinsp;=\u0026thinsp;0.019), and e-cigarettes (35, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), respectively.\u003c/p\u003e \u003cp\u003eThe complete performance of the five knowledge questions is available in Table\u0026nbsp;3. Four of the five knowledge questions had correct response rates of \u0026lt;\u0026thinsp;70%. Most (93%) of respondents knew healthcare provider counseling has evidence for efficacy for tobacco cessation. The question about the purchase age for tobacco in Texas was dropdown multiple choice with one-year integer answer choices ranging from 16 to 23 years old; however, all respondents answered either 18 (35%) or 21 years old (65%). The True or False question \u0026ldquo;Nicotine replacement therapy dosing is different in adults than in adolescents\u0026rdquo; had a 39.5% correct response rate.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe sample of Texas pharmacists was small; however, it did have similar characteristics to the large sample of pharmacists from the NPWS.\u003csup\u003e17\u003c/sup\u003e Of note, for the gender demographic question, the authors combined the \u0026ldquo;nonbinary\u0026rdquo; and \u0026ldquo;other\u0026rdquo; gender categories into one \u0026ldquo;other\u0026rdquo; group. The authors also acknowledge that the frame of \u0026ldquo;gender identity today\u0026rdquo; using the options \u0026ldquo;male/man, female/woman, indigenous or other culture gender minority identity (eg. two-spirit), and something else (eg. gender fluid, non-binary)\u0026rdquo; would have been more appropriate for the time in retrospect.\u003csup\u003e18\u003c/sup\u003e Also, the year of licensure was subtracted from the year of the survey (2019) to create the \u0026ldquo;years of practice\u0026rdquo; comparison to the survey.\u003csup\u003e17\u003c/sup\u003e While the difference between the survey date and date of licensure doesn\u0026rsquo;t necessarily mean the pharmacists have been practicing during those years, it gives added information to compare to a large sample of pharmacists on the basis of experience. The common demographics that can be compared are age, gender/sex, and years in practice. The age demographic was very similar in all categories except for an under-representation of pharmacists in their fifties (9.3% compared to 20.9% in NPWS). There was only a slight under-representation of female pharmacists in the study compared to the NPWS at 51.2% and 61.9%, respectively. The study had fewer new practitioners (0\u0026ndash;9 years of practice) and more late-career pharmacists (\u0026ge;\u0026thinsp;40 years of practice) than the NPWS. Overall, the comparable demographics were similar with the exceptions described above.\u003c/p\u003e \u003cp\u003eAmong respondents, NRT was the preferred selection for the most effective tobacco cessation method, and e-cigarettes were overwhelmingly selected as the least effective tobacco cessation method. Most perception questions had either a pro- or anti-ENDS stance in terms of their use as a legitimate tobacco cessation therapy. For example, questions like \u0026ldquo;E-cigarettes are effective as a therapy for smoking cessation,\u0026rdquo; \u0026ldquo;E-cigarettes are safer to use than smokeless tobacco [\u0026hellip;],\u0026rdquo; \u0026ldquo;Vapor produced from e-cigarettes is NOT harmful,\u0026rdquo; \u0026ldquo;E-cigarettes are primarily used by patients as a smoking cessation aid,\u0026rdquo; and \u0026ldquo;E-cigarettes are primarily used by patients as a cheaper alternative to cigarettes.\u0026rdquo; The respondents consistently had a consensus on almost all questions that indicated they did not perceive ENDS to be a good therapeutic option for tobacco cessation. The knowledge questions may hint at exposure of an area for improvement for continuing education. Despite low scores on 4 of the 5 knowledge questions, a high percentage of pharmacists felt confident in initiating conversations with parents about adolescent ENDS use. There may have been some misunderstanding surrounding the nicotine replacement therapy adolescent dosing question as these therapies are not FDA approved for use in patients under 18 years old. Additionally, the term \u0026ldquo;adolescent\u0026rdquo; was not defined in the survey for the pharmacists. That said, off-label use and studies support using adult dosing.\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere were some limitations to this study. The perception and knowledge questions were not obviously distinct from one another as some of the perception questions had objective correct answers. The sample was small, and the low response rate may have resulted in selection bias; however, the 2019 NPWS had a response rate of 5.8% compared to the 19.6% response rate of this study.\u003csup\u003e17\u003c/sup\u003e The respondents tended to be experienced as over 30% have been practicing for at least 30 years and over 50% of respondents were age 40 or over. Because the ongoing conversations about ENDS in a healthcare context are contemporary, the age and years in practice may have influenced the sample\u0026rsquo;s answer tendencies and may make results less externally valid. In fact, the sample was homogenous except for locale classification and gender. Based on the prevalence of young adults using ENDS, one might suspect that younger representation in the sample may have demonstrated more pro-ENDS sentiment; however, a survey of 420 pharmacy students in 2020 showed that pharmacy students overall felt negatively about ENDS and more so than other healthcare professional students.\u003csup\u003e20\u003c/sup\u003e It is unclear how additional age diversity would have impacted the results, but this an opportunity for future research on this topic.\u003c/p\u003e \u003cp\u003eDoctor of Pharmacy (PharmD) curricula and continuing pharmacy education may be areas to improve pharmacists\u0026rsquo; knowledge regarding ENDS. PharmD curricula is currently lacking in ENDS education which may be contributing to the lack of knowledge of practitioners.\u003csup\u003e21\u003c/sup\u003e A 2018 study of first through fourth professional year pharmacy students showed a decreased confidence in ability to counsel patients regarding e-cigarettes compared to combustible cigarettes.\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eCommunity pharmacists in Texas have a need for increased education regarding ENDS safety, efficacy, and patient counseling. While no significant predictors of perceptions regarding ENDS were determined, the overall pharmacists\u0026rsquo; ENDS perceptions were not positive as an option for tobacco cessation therapy. More research with larger, more diverse samples is needed to further investigate such perceptions and their predictors.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCRediT Statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJoshua Wollen:\u003c/strong\u003e Supervision, Data Curation, Writing \u0026ndash; Original Draft, Formal Analysis, Data Curation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePriyanka Kochuparambil:\u0026nbsp;\u003c/strong\u003eWriting - Original Draft, Writing \u0026ndash; Review \u0026amp; Editing, Conceptualization, Investigation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHarleen Singh:\u003c/strong\u003e\u0026nbsp; Writing - Original Draft, Writing \u0026ndash; Review \u0026amp; Editing, Conceptualization, Investigation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOlivia Mottley:\u003c/strong\u003e Writing \u0026ndash; Review \u0026amp; Editing, Visualization\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNatalie Rosario:\u0026nbsp;\u003c/strong\u003eWriting - Review \u0026amp; Editing, Visualization\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge and thank the participants for taking place in the study, the peer reviewers for this article, and Dr. Gianpiero Calabrese of Kingston University London for access to his team\u0026rsquo;s survey and his collegiality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors do not have any conflict of interest of financial disclosures to declare.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eXiao C, Heley K, Kennedy R, Lagasse L, Moran M. Sociodemographic differences in reasons for ENDS use among US youth within Wave 2 of the PATH study. \u003cem\u003eTob Induc Dis\u003c/em\u003e. 2019;17(January). doi:10.18332/tid/99879\u003c/li\u003e\n\u003cli\u003eCornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco Product Use Among Adults - United States, 2019. \u003cem\u003eMMWR Morb Mortal Wkly Rep\u003c/em\u003e. 2020;69(46):1736-1742. doi:10.15585/mmwr.mm6946a4\u003c/li\u003e\n\u003cli\u003eCornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco Product Use Among Adults - United States, 2020. \u003cem\u003eMMWR Morb Mortal Wkly Rep\u003c/em\u003e. 2022;71(11):397-405. doi:10.15585/mmwr.mm7111a1\u003c/li\u003e\n\u003cli\u003eCDC. Quick Facts on the Risks of E-cigarettes for Young People. Centers for Disease Control and Prevention. Published April 7, 2022. Accessed May 19, 2022. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html\u003c/li\u003e\n\u003cli\u003eKrishnasamy VP, Hallowell BD, Ko JY, et al. Update: Characteristics of a Nationwide Outbreak of E-cigarette, or Vaping, Product Use\u0026ndash;Associated Lung Injury \u0026mdash; United States, August 2019\u0026ndash;January 2020. \u003cem\u003eMMWR Morb Mortal Wkly Rep\u003c/em\u003e. 2020;69(3):90-94. doi:10.15585/mmwr.mm6903e2\u003c/li\u003e\n\u003cli\u003eCenter for Tobacco Products. E-Cigarettes, Vapes, and other Electronic Nicotine Delivery Systems (ENDS). \u003cem\u003eFDA Website\u003c/em\u003e. Published online July 21, 2023. Accessed December 19, 2023. https://www.fda.gov/tobacco-products/products-ingredients-components/e-cigarettes-vapes-and-other-electronic-nicotine-delivery-systems-ends\u003c/li\u003e\n\u003cli\u003ePharmacist Prescribing: Tobacco Cessation Aids. NASPA. Accessed May 20, 2022. https://naspa.us/resource/tobacco-cessation/\u003c/li\u003e\n\u003cli\u003ePepper JK, McRee AL, Gilkey MB. Healthcare providers\u0026rsquo; beliefs and attitudes about electronic cigarettes and preventive counseling for adolescent patients. \u003cem\u003eJ Adolesc Health Off Publ Soc Adolesc Med\u003c/em\u003e. 2014;54(6):678-683. doi:10.1016/j.jadohealth.2013.10.001\u003c/li\u003e\n\u003cli\u003eMarques Gomes ACN, Nabhani-Gebara S, Kayyali R, Buonocore F, Calabrese G. Survey of community pharmacists\u0026rsquo; perception of electronic cigarettes in London. \u003cem\u003eBMJ Open\u003c/em\u003e. 2016;6(11):e013214. doi:10.1136/bmjopen-2016-013214\u003c/li\u003e\n\u003cli\u003eRehan HS, Maini J, Hungin APS. \u003cem\u003eVaping Versus Smoking: A Quest for Efficacy and Safety of E-Cigarette\u003c/em\u003e.; 2018:92-101. Accessed June 2, 2022. http://www.eurekaselect.com/160136/article\u003c/li\u003e\n\u003cli\u003eMedicines and Healthcare products Regulatory Agency. Guidance for licensing electronic cigarettes and other inhaled nicotine-containing products as medicines. GOV.UK. Published October 29, 2021. Accessed June 1, 2022. https://www.gov.uk/guidance/licensing-procedure-for-electronic-cigarettes-as-medicines\u003c/li\u003e\n\u003cli\u003eHammond D, Rynard VL, Reid JL. Changes in Prevalence of Vaping Among Youths in the United States, Canada, and England from 2017 to 2019. \u003cem\u003eJAMA Pediatr\u003c/em\u003e. 2020;174(8):797. doi:10.1001/jamapediatrics.2020.0901\u003c/li\u003e\n\u003cli\u003eErku DA, Gartner CE, Do JT, Morphett K, Steadman KJ. Electronic nicotine delivery systems (e-cigarettes) as a smoking cessation aid: A survey among pharmacy staff in Queensland, Australia. \u003cem\u003eAddict Behav\u003c/em\u003e. 2019;91:227-233. doi:10.1016/j.addbeh.2018.09.013\u003c/li\u003e\n\u003cli\u003eErku D, Gartner CE, Morphett K, Snoswell CL, Steadman KJ. Nicotine vaping products as a harm reduction tool among smokers: Review of evidence and implications for pharmacy practice. \u003cem\u003eRes Soc Adm Pharm RSAP\u003c/em\u003e. 2020;16(9):1272-1278. doi:10.1016/j.sapharm.2020.02.002\u003c/li\u003e\n\u003cli\u003eHagan J, Kedzior S, Pimentel L, Tran D, Vallabh P, Apollonio DE. A Cross-sectional Survey of California Pharmacists\u0026rsquo; Knowledge and Perceptions about Electronic Nicotine Delivery Systems (ENDS). \u003cem\u003eCalif J Health-Syst Pharm CJHP\u003c/em\u003e. 2019;31:56-68.\u003c/li\u003e\n\u003cli\u003eWilliams RBG. The Aims of Statistics. In: \u003cem\u003eIntroduction to Statistics for Geographers and Earth Scientists\u003c/em\u003e. Macmillan Education UK; 1984:1-3. doi:10.1007/978-1-349-06815-9_1\u003c/li\u003e\n\u003cli\u003ePharmacy Workforce Center. \u003cem\u003e2019 National Pharmacist Workforce Study: Final Report\u003c/em\u003e.; 2020:1-94. Accessed December 13, 2022. https://www.aacp.org/sites/default/files/2020-03/2019_NPWS_Final_Report.pdf\u003c/li\u003e\n\u003cli\u003eMorgan RE, Dragon C, Daus G, et al. \u003cem\u003eUpdates on Terminology of Sexual Orientation and Gender Identity Measures\u003c/em\u003e. Federal Committee on Statistical Methodology; 2020. Accessed October 19, 2023. https://www.fcsm.gov/assets/files/docs/FCSM_SOGI_Terminology_FY20_Report_FINAL.pdf\u003c/li\u003e\n\u003cli\u003eKarpinski JP, Timpe EM, Lubsch L. Smoking cessation treatment for adolescents. \u003cem\u003eJ Pediatr Pharmacol Ther JPPT Off J PPAG\u003c/em\u003e. 2010;15(4):249-263.\u003c/li\u003e\n\u003cli\u003eSahr M, Kelsh S, Ottney A, Young M, Larson R, Sohn M. Pharmacy Students\u0026rsquo; Perceptions of Electronic Nicotine Delivery Systems as Compared to Those of Other Health Care Students. \u003cem\u003eAm J Pharm Educ\u003c/em\u003e. 2020;84(7):ajpe7690. doi:10.5688/ajpe7690\u003c/li\u003e\n\u003cli\u003eMarti KM, Marti KE, Salvo MC. A call for student pharmacist education on vaping and vaping device use. \u003cem\u003eCurr Pharm Teach Learn\u003c/em\u003e. 2021;13(3):203-205. doi:10.1016/j.cptl.2020.10.014\u003c/li\u003e\n\u003cli\u003eNduaguba SO, Ford KH, Bamgbade BA, Ubanyionwu O. Comparison of pharmacy students\u0026rsquo; self-efficacy to address cessation counseling needs for traditional and electronic cigarette use. \u003cem\u003eCurr Pharm Teach Learn\u003c/em\u003e. 2018;10(7):955-963. doi:10.1016/j.cptl.2018.04.016\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Respondent Demographics\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.12643678160919%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.39080459770115%\" valign=\"top\"\u003e\n \u003cp\u003eStudy\u003c/p\u003e\n \u003cp\u003eCount (%)\u003c/p\u003e\n \u003cp\u003en=43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003eNPWS 2019\u003c/p\u003e\n \u003cp\u003eCount (%)\u003c/p\u003e\n \u003cp\u003en=5,534\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003en=5,467\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026le;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e8 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e843 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e31-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e13 (30.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e1,408 (25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e41-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e8 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e907 (16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e51-60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e4 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e1,146 (20.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e61-70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e8 (18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e888 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e275 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003en=5,534\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e22 (51.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e3,427 (61.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e20 (46.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e2,098 (37.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e9 (0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003eYears in practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003en=5,534\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e0-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e8 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e1,869 (33.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e10-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e8 (18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e790 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e20-29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e9 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e940 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e30-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e6 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e1,020 (18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e13 (29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e733 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003ePercentage of adolescent patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e34 (79.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e25-50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e6 (14.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e51-75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003eParental status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e13 (30.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e30 (69.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003eLocale classification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e14 (32.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003eSuburban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e19 (44.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.97701149425287%\" valign=\"top\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.54022988505747%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e10 (23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eNPWS=National Pharmacist Workforce Survey\u003c/p\u003e\n \u003cp\u003eN/A= not available\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2. Perception Consensus Analysis by Question\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003eAgree, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eClassic nicotine replacement therapy (ie. Nicotine patch, lozenge, gum, etc.) is effective as a therapy for smoking cessation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e36 (84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eE-cigarettes are effective as a therapy for smoking cessation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e10 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eE-cigarettes are safer to use than smokeless tobacco (ie. Chew, snuff, dip, etc.).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e13 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e0.014*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eVapor produced from e-cigarettes is \u003cstrong\u003eNOT\u003c/strong\u003e harmful.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e3 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eE-cigarettes should be more strictly regulated.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e40 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eE-cigarettes make nicotine more accessible to adolescents.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e38 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eThe flavoring chemicals in e-cigarettes may be toxic.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e40 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eDiscussing e-cigarettes with patients may encourage them to use e-cigarettes.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e25 (58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e0.360\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eIt is important to discuss e-cigarettes with adolescent patients.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e40 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eE-cigarettes are primarily used by patients as a smoking cessation aid.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e12 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e0.005*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eE-cigarettes are primarily used by patients as a cheaper alternative to cigarettes.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e16 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e0.126\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eE-cigarettes are primarily used by patients for social/recreational use.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e38 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eI am comfortable with initiating conversations about e-cigarette usage to parents with adolescent children given my current knowledge about e-cigarettes.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e33 (77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"75%\" valign=\"top\"\u003e\n \u003cp\u003eI am comfortable dosing nicotine replacement therapy for e-cigarette cessation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.942307692307692%\" valign=\"top\"\u003e\n \u003cp\u003e21 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.057692307692308%\" valign=\"top\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e* \u0026nbsp; \u0026nbsp; p \u0026lt; 0.05 was considered to be statistically significant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 3. Knowledge Question Performance by Frequency\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.60032102728732%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.940609951845907%\" valign=\"top\"\u003e\n \u003cp\u003eAnswer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.459069020866774%\" valign=\"top\"\u003e\n \u003cp\u003eCorrect, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.60032102728732%\" valign=\"top\"\u003e\n \u003cp\u003eWhat is the current age for buying tobacco products in Texas?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.940609951845907%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.459069020866774%\" valign=\"top\"\u003e\n \u003cp\u003e28 (65.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.60032102728732%\" valign=\"top\"\u003e\n \u003cp\u003eHealthcare provider counseling is effective as a therapy for smoking cessation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.940609951845907%\" valign=\"top\"\u003e\n \u003cp\u003eTrue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.459069020866774%\" valign=\"top\"\u003e\n \u003cp\u003e40 (93.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.60032102728732%\" valign=\"top\"\u003e\n \u003cp\u003eAll e-cigarettes contain nicotine.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.940609951845907%\" valign=\"top\"\u003e\n \u003cp\u003eFalse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.459069020866774%\" valign=\"top\"\u003e\n \u003cp\u003e23 (53.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.60032102728732%\" valign=\"top\"\u003e\n \u003cp\u003eFor which age range is electronic nicotine delivery device (ie. e-cigarettes) use most prevalent?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.940609951845907%\" valign=\"top\"\u003e\n \u003cp\u003e18 \u0026ndash; 25 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.459069020866774%\" valign=\"top\"\u003e\n \u003cp\u003e24 (55.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.60032102728732%\" valign=\"top\"\u003e\n \u003cp\u003eNicotine replacement therapy dosing is different in adults than in adolescents. True or False?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.940609951845907%\" valign=\"top\"\u003e\n \u003cp\u003eFalse\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.459069020866774%\" valign=\"top\"\u003e\n \u003cp\u003e17 (39.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eNicotine replacement therapy is not FDA approved for those \u0026lt; 18 years old; however, off-label use and studies suggest using adult dosing.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Houston","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"ENDS, electronic nicotine delivery systems, tobacco cessation, smoking cessation, nicotine cessation, nicotine, pharmacy, community pharmacy, pharmacy practice, pharmacy education","lastPublishedDoi":"10.21203/rs.3.rs-4505377/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4505377/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eElectronic nicotine delivery systems (ENDS) have gained popularity in the United States among adults and adolescents for social use and as a smoking cessation tool. The increase of ENDS use leads to concerns about their impact on public health. In the United States, ENDS are readily available for purchase and pose risks. Community pharmacists can play a crucial role in educating adult and adolescent patients about ENDS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to understand Texas community pharmacists' perceptions of ENDS with three objectives: 1) to identify consensus on perceptions and comfort among community pharmacists in Texas and 2) assess basic knowledge of the ENDS use landscape in the United States.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional survey targeting community pharmacists in Texas was conducted in 2019. Sixty-eight responses were collected, and 43 were included in the analysis. The survey covered pharmacist demographics and ENDS questions related to knowledge and perceptions or ENDS and a ranking question of tobacco cessation strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost respondents 40 or more years of practice. Respondents expressed low confidence in ENDS as an effective smoking cessation tool. Nicotine replacement therapy was considered the most effective method, while e-cigarettes were deemed the least effective. Knowledge about ENDS was limited, with significant gaps in understanding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCommunity pharmacists in Texas require additional education and knowledge enhancement regarding ENDS. This study highlights the urgent need for more comprehensive ENDS education in pharmacy curricula and continuing education to equip pharmacists with the knowledge to counsel patients on ENDS effectively.\u003c/p\u003e","manuscriptTitle":"Knowledge and Perceptions of Texas Community Pharmacists Regarding Electronic Nicotine Delivery Systems","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-03 11:20:44","doi":"10.21203/rs.3.rs-4505377/v1","editorialEvents":[{"type":"communityComments","content":1}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9952c1ca-e634-4d85-997f-4ecfa4234ca4","owner":[],"postedDate":"June 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":32631452,"name":"Clinical Pharmacology"}],"tags":[],"updatedAt":"2024-06-03T11:20:44+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-03 11:20:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4505377","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4505377","identity":"rs-4505377","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}