e-Cigarettes for tobacco smoking cessation

Although e-cigarettes are generally considered to be less harmful than combustible cigarettes, whether vaping should be explicitly incorporated into tobacco smoking cessation strategies is controversial. In 2021, the US Preventive Services Task Force (USPSTF) found insufficient evidence to determine the balance of benefits and harms of e-cigarettes for smoking cessation in adults. At that time, the USPSTF cited a lack of well-designed, randomized controlled trials (RCTs) that reported smoking abstinence and adverse events. Other concerns included potential effects of e-cigarette promotion on already high rates of e-cigarette initiation in children and adolescents.

Subsequent studies have supported the utility of e-cigarettes for smoking cessation. A Swiss RCT that compared e-cigarettes to usual care cessation strategies (counseling and medications) found that the e-cigarette group was more likely to be abstinent from tobacco at 6 months (number needed to treat [NNT] = 6-8); adverse events were similar between groups. A Cochrane review of 88 studies, including 47 RCTs, found high-certainty evidence that e-cigarettes increased smoking cessation at 6 months to 1 year compared to nicotine replacement therapy (NRT) and other smoking cessation treatments. e-Cigarettes were associated with a similar incidence of adverse events to NRT and more adverse events than counseling (number needed to harm [NNH] = 7). Serious adverse events were not increased in the e-cigarette groups. Another RCT in persons of low socioeconomic status found that vaping nicotine was more effective than NRT for achieving tobacco abstinence at 6 months (NNT = 5).

A working group of the international Society for Research on Nicotine and Tobacco recently published recommendations to US-based clinicians on integrating e-cigarettes into conversations with patients about the risks and benefits of pharmacologic treatments for smoking cessation. Notably, the group recommends that “patients should not be required to first try or fail an FDA-approved medication before using an e-cigarette for cessation because supporting cigarette cessation is the primary goal.” If a patient chooses e-cigarettes, they advise using products authorized for sale by the US Food and Drug Administration and counseling patients to completely substitute e-cigarettes for combustible cigarettes as quickly as possible.

Like combustible cigarettes, e-cigarettes appear to increase the risk of chronic respiratory conditions in adults. An FPIN Clinical Inquiry found several observational studies that associated e-cigarette use with asthma, chronic obstructive pulmonary disease (COPD), and asthma-COPD overlap syndrome. Nonetheless, the working group endorsed long-term e-cigarette use as a harm reduction strategy for maintaining complete abstinence from combustible cigarettes in patients who are unable to transition away from nicotine altogether.

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This post first appeared on the AFP Community Blog.

Discontinuing statins for primary prevention in older adults

The major randomized controlled trials (RCTs) that established the benefits of statins in preventing atherosclerotic cardiovascular disease (ASCVD) generally did not enroll persons older than 75 years. Once a patient who has been taking a statin for primary prevention reaches that age, are there additional benefits to continuing it, or conversely, are there harms associated with discontinuing? In 2020, a systematic review of international guidelines on cardiovascular disease prevention found “little specific guidance for physicians who are considering statin discontinuation in older adults in the context of declining health status and short life expectancy.”

A 2024 systematic review identified 35 observational studies and a single RCT comparing statin discontinuation to continuation. The observational studies showed that statin discontinuation in all age groups was associated with statistically significant increases in all-cause mortality (hazard ratio (HR) = 1.92), cardiovascular mortality (HR = 1.63), and cardiovascular events (HR = 1.31), with similar results in adults 75 years and older. The single RCT was performed in 381 older adults with deteriorating functional status and an estimated life expectancy of 1 month to 1 year. 60-day mortality was similar between the groups (23.8% with discontinuation vs 20.3% with continuation, p=0.36), and quality of life was better in the group no longer taking statins.

An expert panel recently utilized this limited evidence base to create a clinical practice guideline on deprescribing statins in older persons. A synopsis of the guideline is available in an algorithm. The guideline suggests deprescribing statins in older adults at end-of-life and continuing them for primary and secondary prevention in other adults older than 65. Several factors may prompt a conversation about statins: frailty, pill burden, functional limitations, cognitive impairment, complex care needs, and advanced illness (eg, cancer). Select patients with life expectancies greater than 1 year may reasonably decide to discontinue statins based on their personal goals and the value they assign to preventing future cardiovascular events.

The results of a pragmatic, open-label RCT published this month in The Lancet Healthy Longevity support individualized decision-making regarding statin continuation in older adults. 1,180 French adults 75 years and older who had been taking a stain for primary prevention for at least 1 year and had no evidence of dementia or another progressive life-limiting disease were randomly assigned to stop or continue taking statins. After 3 years, there were no statistical differences in all-cause mortality or cardiovascular events between the groups. However, the group that discontinued statins had no advantages in quality or life, cognitive function, functional status, symptom burden, or adverse events.

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This post first appeared on the AFP Community Blog.

Making measles great again, part 2

Six months ago, I wrote about why measles outbreaks matter to everyone. At that time, Lancaster County had recently diagnosed 5 people with measles, the first cases in Pennsylvania this year. As of today, the state Department of Health has recorded 296 cases of measles in 2026. Of those, 61 cases were confirmed in the past 7 days, most of these in Lancaster County. 52 patients became sick enough to be hospitalized; fortunately, no one has died. I am now practicing at the center of an outbreak that is threatening to become a full-blown epidemic, the likes of which we haven't seen since Covid.

It's not all Robert F. Kennedy, Jr.'s fault - but he certainly fanned the flames of anti-vaccine sentiment that brought us to this point.

The costs of a measles outbreak are not limited to patients' direct medical expenses, or even the indirect costs of missed school or work. Public health workers (Lancaster County, inexplicably, has no public health department, so we are relying on assistance from the state) are mobilized to track down contacts of ill persons and contain the spread. Vaccination clinics are organized and deployed throughout affected communities, requiring additional staff and medical resources. From February to August 2025, the New Mexico Department of Health responded to a 9-county measles outbreak that totaled 99 cases - fewer than the number we've already seen in Lancaster County this year. The estimated cost of the public health response was a staggering $5.4 million, or about $53,500 per case. Those dollars weren't just sitting in a government account waiting to be used - they had to be diverted from education, policing, highway maintenance, and other essential services.

In an incisive commentary on the "hidden costs" of a measles outbreak, Dr. Katherine Wells, the public health director of Lubbock, Texas, wrote: "When people hear that Lubbock had 50 measles cases in 2025, they often picture something manageable: a handful of sick children, some telephone calls, a few weeks of extra work. That is not what 50 measles cases look like." Instead, she explained, it looked like this:

1. An outbreak is not an event but a cascade - "a case is the start of a cascade of exposures, responses, and system disruptions that unfold over time. ... What emerges is not a series of isolated incidents but a pattern: each exposure generates conditions for the rest. Each setting does not simply experience the outbreak. It amplifies its complexity."

2. When systems bend, people improvise - "Clinics expanded capacity, added hours, and brought in additional staff where possible. But these resources did not materialize from nowhere. They were pulled from other services, such as routine immunizations, chronic disease management, [and] sexual health care - that now had to function with less."

3. The hidden erosion of emergency capacity - "An ambulance transports a patient with suspected measles. After the transfer, it must be taken offline, decontaminated, and cleared. Then it happens again. And again. Each time, the delay is measured in hours, but the impact is cumulative."

4. Survival is not the end of the story - For the sickest children, "survival ... entails extended hospital stays, ongoing clinical needs, and the quiet displacement of other patients who depend on the same finite resources."

5. The costs we do not count - "The most consequential impact [of an outbreak] lies elsewhere: in the work that did not happen."

As vaccination coverage declines in young children across the U.S., outbreaks of measles and other preventable diseases will inevitably become more common and widespread. I'll give the last word to Dr. Noel Brewer, a public health professor at the University of North Carolina, who chairs a committee that is evaluating whether the U.S. should lose its hard-won measles elimination status dating back to the year 2000:

Measles is a brutal disease that has no medical cure. Parents of children made sickest must wait it out in the hospital, despairingly wondering whether their child will die. That level of risk is indefensible in 2026 — more than 25 years after the United States achieved measles elimination. Kids are suffering and dying from a disease we already know how to prevent, and that failure is entirely ours.

The long arc of recommendations to prevent peanut and egg allergies

Our approach to preventing egg and peanut allergies has changed over the past 2 decades. At the turn of the century, the American Academy of Pediatrics (AAP) made an expert consensus recommendation that high-risk infants avoid eggs until age 2 years and peanuts until age 3 years. Unfortunately, the ensuing decade saw a substantial increase in self-reported peanut allergy prevalence, rising from 0.4% of US children in 1997 to 1.4% in 2008. Subsequent randomized trials found that introducing peanuts by age 6 months reduces the risk of developing a peanut allergy by age 5 years, leading to a reversal of the earlier recommendation.

In Australia, infant feeding guidelines were revised on a similar timetable as in the United States, with a 2016 guideline recommending that all infants be introduced to peanuts and eggs in the first year of life, regardless of allergy risk factors. A cross-sectional study found that the percentage of Australian infants who consumed eggs by age 6 months increased from 25% in 2007-2011 to 58% in 2018-2019, with 89% consuming eggs by age 12 months. A recent study by the same research team found that adjusted egg allergy prevalence decreased from 9.2% in 2007-2011 to 7.6% in 2018-2019. The prevalence of egg allergy in infants with eczema in the first 6 months of life also decreased from 34.6% to 21.9%.

In an accompanying editorial, Drs. Aaron Carroll and Ron Keren frankly assessed the harms of the AAP’s and other consensus guidelines that had incorrectly advised parents and guardians against early introduction of eggs in a misguided attempt to prevent allergies:

For years, pediatric guidelines in multiple countries told parents to do something that may have increased the risk of the very outcome they feared most. The deeper problem was not that strong evidence had been misinterpreted; it was that strong evidence did not yet exist. Committees faced a plausible theory, rising anxiety, and pressure to give families an answer. Unfortunately, they gave one with more confidence than the data could support.

The lesson that clinicians and expert panels should learn from this humbling experience, Carroll and Keren argued, is to avoid making strong recommendations based on weak or no evidence:

The field issued recommendations that outran the evidence, and families lived with the consequences. We owe families an honest accounting of that. And we owe it to the next generation of patients to hold ourselves to a higher standard—one that includes evidence grading so families understand the degree of certainty behind a recommendation, mandatory reassessment at regular intervals, and a commitment to funding the trials that can fill evidentiary gaps before guidance is issued rather than decades after.

In a 2023 American Family Physician article on food allergies, a key practice recommendation with an A evidence rating (consistent, good-quality patient-oriented evidence) stated that “early introduction of peanuts, cow’s milk, wheat, and cooked eggs between four and six months of age decreases the risk of developing food allergies.” According to a 2018 Cochrane review, children with egg allergies can be desensitized with oral immunotherapy (“daily, steadily increasing doses of egg protein over an extended period of time”), but 75% will experience allergy-related adverse effects, 8.4% of them serious enough to require medication.

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This post first appeared on the AFP Community Blog.

Reducing unnecessary phototherapy for jaundice in newborns

Up to 4 in 5 newborns will develop jaundice from the accumulation of unconjugated bilirubin during the first week of life. Most of the time, neonatal hyperbilirubinemia is benign and does not require intervention. To prevent the rare outcomes of acute bilirubin encephalopathy (1 in 10,000 infants) and kernicterus (1 in 100,000 infants), the American Academy of Pediatrics (AAP) recommends universal screening of newborns 35 weeks' gestational age or greater using total serum bilirubin and transcutaneous bilirubin at 24 to 48 hours of life or before hospital discharge if occurring sooner.

Online tools such as the BiliTool allow clinicians to quickly compare measured bilirubin levels with the AAP’s hour- and gestational age-specific thresholds for phototherapy (these are slightly lower in infants with neurotoxicity risk factors). Phototherapy converts unconjugated bilirubin to lumirubin, a structural isomer that is directly excreted via urine or stool. In its 2022 guideline, the AAP increased previous phototherapy thresholds based on updated evidence regarding the risk of neurotoxicity. An FPIN (Family Physicians Inquiries Network) Clinical Inquiry found that rebound elevation of bilirubin levels after phototherapy discontinuation is uncommon (less than 2% of infants with levels less than 14 mg per dL at initial discontinuation). In infants without known hemolytic disease or other significant risk factors, repeating a bilirubin level after phototherapy discontinuation is not recommended.

Reducing unnecessary treatment of jaundiced neonates with safe bilirubin levels, or subthreshold phototherapy, was previously identified by pediatric hospitalists as a Choosing Wisely campaign goal. Subthreshold phototherapy is common and may have increased after the 2022 AAP guideline.

A recent report in Pediatrics described the Learning and Implementing Guidelines for Hyperbilirubinemia Treatment (LIGHT) Collaborative, a national quality improvement collaborative involving 146 hospitals that aimed to reduce subthreshold phototherapy use to 10% of all phototherapy encounters over a 12-month period. Baseline data was collected from February 2022 to January 2023. Hospitals implemented a combination of quality improvement coaching, educational webinars, electronic health record order sets and documentation templates, clinical algorithms, and communication aids from February 2023 to January 2024. Individual sites were encouraged to use Plan-Do-Study-Act (PDSA) cycles to identify and address barriers to reducing subthreshold phototherapy.

The final analysis included more than 33,000 patient encounters. Subthreshold phototherapy decreased from a median of 48.2% of encounters prior to August 2022 (when the updated AAP guideline was published) to 41.1% during the last 6 months of the intervention, well short of the goal of 10%. A secondary outcome, the median deviation from the phototherapy threshold in subthreshold phototherapy encounters, decreased from 1.57 mg/dL (26.85 μmol/L) to 1.13 mg/dL (19.33 μmol/L). (Of note, the guideline offers the option to consider phototherapy for selected patients when the total serum bilirubin level is within 1.9 mg/dL [32.50 μmol/L] below the phototherapy threshold.) There were no significant changes in hospital length of stay, phototherapy duration, or readmissions for rebound elevation of bilirubin levels.

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This post first appeared on the AFP Community Blog.

Advocacy groups killed the Canadian Task Force. Is the USPSTF next?

If the "third rail" of the U.S. health care system is Medicare, the third rail of preventive medicine is screening mammography. History has shown that North American evidence-based medicine panels are imperiled when they suggest that breast cancer screening can be optional for women younger than 50, even if that happens to be the norm for the rest of the world.

In November 2009, advocacy groups came close to fatally wounding the U.S. Preventive Services Task Force (USPSTF) after it downgraded screening mammography in average-risk women aged 40 to 49 from a "B" (do routinely) to a "C" (do selectively with shared decision-making) grade. Armed with advocacy talking points, politicians from both parties subjected the USPSTF to withering attacks, and Republicans darkly predicted that the health reform legislation then under consideration in Congress (which eventually became the Affordable Care Act of 2010) would lead to widespread rationing of all kinds of health care. Then-Secretary of Health and Human Services Kathleen Sebelius publicly disavowed the recommendations and tried to blame the previous administration for having appointed the members who voted for the changes. Public affairs personnel at the Agency for Healthcare Research and Quality (AHRQ), where I worked, were prevented from assisting USPSTF members with media appearances explaining the recommendations.

The USPSTF eventually recovered and even thrived from 2010 to 2025, becoming more influential and for the most part, managing to keep politics at bay. However, it is facing a different sort of existential crisis under the second Trump administration, not being allowed to meet for the past 16 months and having its support team at AHRQ eviscerated to the point where it's not clear how the panel would function even if HHS Secretary RFK Jr. eventually appoints new members to replace the ones he fired.

Meanwhile, the Canadian Task Force on Preventive Health Care, the original model for the USPSTF, was disbanded earlier this year, a victim of a similar breast cancer screening recommendation that the federal health minister never allowed to be finalized. As Dr. Guylene Theriault, the former chair of the Canadian Task Force, recently wrote in BMJ Evidence-Based Medicine:

The evidence-based guidance conflicted with certain lobbyists' arguments and elected officials' beliefs in the unambiguous positive outcomes of screening. Ultimately, these arguments and perceptions prevailed over rigorous scientific evidence, making it more difficult for a woman to access clear, unbiased information on which to base her decisions. Perhaps naively, the Task Force members and I thought that placing the patient at the center of the decision-making process would be something everyone could agree on. We were wrong.

A recent study in the American Journal of Preventive Medicine documented worrisome trends in primary care associated with the sidelining of the USPSTF and the remaking of the Advisory Committee on Immunization Practices:

Clinicians report that patients are increasingly hesitant about vaccines and preventive services. For example: 64% report patients are confused as to what vaccination guidelines they should follow; 46% report parents are expressing new hesitancy about childhood vaccinations; 36% report patients are declining preventive services they previously accepted. Most responding clinicians (58%) report spending more visit time explaining the evidence behind clinical recommendations, and 61% report patients more frequently are seeking information from non-medical sources.

As the Canadian Task Force is being reconstituted as the National Advisory Committee on Preventive Health Services, the USPSTF may also rise again - but will the next iteration have the necessary resources (in dollars and staff) and editorial independence to write trustworthy recommendations that place patients, rather than politics, at the center? The stakes for patients and public health could not be higher.