E-Tobacco Protocol Integrates Intervention Into EHRs
By Hannah Wisterman


For adult and adolescent patients, physicians now have a seamless way to intervene for tobacco cessation in the form of the eTobacco Protocol, a referral tool integrated into electronic health records (EHRs).

The eTobacco Protocol is a project of The University of Texas at Austin’s Tobacco Research and Evaluation Team, partnering with Texas Quitline, a free, HIPAA-compliant app provided by the Texas Department of State Health Services.

The development comes as e-cigarettes are now overwhelmingly the nicotine-delivery system of choice among minors, according to the 2022 National Youth Tobacco Survey. In Texas, 18.7% of high school students use e-cigarettes, according to the Campaign for Tobacco-Free Kids. With support from Texas Medical Association advocacy, Texas recently saw a $4.3 million increase to state-sponsored nicotine cessation and prevention efforts. TMA-supported legislation also now makes it more difficult to market e-cigarettes to youth.

The Tobacco Research and Evaluation Team recommends using the eTobacco Protocol when a patient is ready to quit within 30 days of referral. With the eTobacco Protocol in place, when physicians insert “Quitline” into their EHR’s order box, they will be prompted to file their patient’s phone number and preferred contact hours. Representatives from Texas Quitline will then contact the patient for counseling and, if eligible, nicotine replacement therapy.

The results of Texas Quitline’s call will be reported to the physician’s results folder in their EHR.

“It’s super cool,” said Lindy McGee, MD, a Houston pediatrician who frequently advocates for TMA on issues related to youth tobacco use. “I even get bidirectional feedback. I talk to [Texas Quitline] and they’re able to communicate back to me whether they’re able to reach the patient and what intervention they did.”

Dr. McGee’s pediatric patients, for instance, would not receive nicotine replacement therapy, which Quitline provides only to adults.

“If adolescents are addicted to nicotine, then that’s something to talk to their physician about,” she said. “But as far as counseling, it's going to be helping them set a quit date, helping them identify triggers, and helping them come up with solutions for those triggers.”

Dr. McGee is particularly pleased that physicians have the option to specify to Texas Quitline which phone number to contact. 

“For pediatric patients, I wanted to make sure that I was able to enter their own phone number, and it didn’t just send the phone number that was associated with the medical record because frequently that’s the parent’s phone number,” she said. “When we’re talking about teens and use of substances like this, we always encourage parent involvement if the teenager wants to quit. But sometimes the teenager does not want the parent to know that they’re using. We want to make sure that we can maintain that confidentiality for a teenager who wants to quit.”

Carving out space for adolescent treatment in the eTobacco Protocol is especially important given shocking rates of e-cigarettes in that age group, Dr. McGee says. After seeing tobacco use rates drop after her medical school training in the late 1990s, she was alarmed to see such data.

“What really woke me up to the issue again were the numbers that came out in 2018,” she said. “By that time, I'd been practicing for almost 20 years as a pediatrician, and I had two teenagers at home who were telling me what they were seeing when they went to parties, and at school, the amount of vaping that was going on there.”

Some patients who use e-cigarettes, or vape, do recognize the adverse health effects such products create and seek out tools to quit on their own. But younger patients, who Dr. McGee says are easily swayed by e-cigarette companies’ marketing, may require a different approach.

“By the late 1990s, early 2000s, everyone knew that smoking was bad for you. You would have to be living under a rock to not know that,” she said. “The difference is that, especially, our adolescent and young adult population perceive using e-cigarettes as not a big deal. Multiple studies show that some teenagers think that they’re not vaping nicotine, but when they test their urine for nicotine derivatives, they find them there.”

Because younger patients view e-cigarettes as entirely distinct from traditional cigarettes, physicians should alter their screening to meet them where they are, she says.

“So important right now is to remember to use the term vaping when asking [patients] about tobacco use,” she said, referring to patients of all ages. “If we are used to asking if they smoke, and they vape, they will say no, I do not smoke. If you don’t ask about vaping, you’re not going to find out about it.”

To learn more about TMA’s advocacy regarding e-cigarettes and other topics, visit TMA’s Advocacy page.

Last Updated On

November 13, 2023

Originally Published On

October 24, 2023

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Hannah Wisterman


(512) 370-1393

Hannah Wisterman is an associate editor for Texas Medicine and Texas Medicine Today. She was born and raised in Houston and holds a journalism degree from Texas State University in San Marcos. She's spent most of her career in health journalism, especially in the areas of reproductive and public health. When she's not reporting, editing, or learning, you can find her exploring Austin or spending time with her partner, cat, and houseplants.

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