Medical Trainees’ Knowledge and Attitudes Towards Electronic Cigarettes and Hookah: A Multinational Survey Study

Abstract

BACKGROUND:

The rising prevalence of electronic cigarette (e-cigarette) and hookah use among youth raises questions about medical trainees’ views of these products. We aimed to investigate medical trainees’ knowledge and attitudes toward e-cigarette and hookah use.

METHODS:

We used data from a large cross-sectional survey of medical trainees in Brazil, the United States, and India. We investigated demographic and mental health aspects, history of e-cigarettes and tobacco use, knowledge and attitudes toward e-cigarettes and hookah, and sources of information on e-cigarettes and hookah. Although all medical trainees were eligible for the original study, only senior students and physicians-in-training were included in the present analysis.

RESULTS:

Of 2,036 senior students and physicians-in-training, 27.4% believed e-cigarette use to be less harmful than tobacco smoking. As for hookah use, 14.9% believed it posed a lower risk than cigarettes. More than a third of trainees did not acknowledge the risks of passive e-cigarette use (42.9%) or hookah smoking (35.1%). Also, 32.4% endorsed e-cigarettes to quit smoking, whereas 22.5% felt ill equipped to discuss these tobacco products with patients. Fewer than half recalled attending lectures on these topics, and their most common sources of information were social media (54.5%), Google (40.8%), and friends and relatives (40.3%).

CONCLUSIONS:

Medical trainees often reported incorrect or biased perceptions of e-cigarettes and hookah, resorted to unreliable sources of information, and lacked the confidence to discuss the topic with patients. An expanded curriculum emphasis on e-cigarette and hookah use might be necessary because failing to address these educational gaps could risk years of efforts against smoking normalization.

Introduction

The burden of tobacco smoking on individual health and society is tremendous, making smoking a public health crisis.¹ Cigarette smoking has been associated with several respiratory, cardiovascular, and neoplastic diseases, which results in an estimated global economic cost of ∼1 trillion dollars annually.² Thus, tobacco smoking remains one of the global leading causes of preventable chronic diseases and death, accounting for 7.69 million deaths and the loss of 200 million disability-adjusted life-years in 2019.¹

Since the early 1960s, medical societies and governments worldwide have worked to implement public health measures to reduce the prevalence of active and passive smoking. As a result, over the past 3 decades, smoking prevalence among adolescents and young adults has decreased by 20% globally and by an incredible 50% in Latin America.³ Although this is undoubtedly encouraging, the success might be offset by extensive data, which indicate a sharp rise in the use of alternative tobacco products in this population.⁴ Among these products, we highlight two: (1) hookah, also known as narghile or shisha, a traditional waterpipe used for tobacco consumption deeply rooted in centuries of cultural tradition, especially in Asian and Middle Eastern countries⁵; and (2) electronic nicotine delivery systems (ENDS), among which are the more commonly known electronic cigarettes (e-cigarettes).

E-cigarettes and hookah are frequently considered less harmful alternatives than cigarettes, which has sparked an ongoing debate about whether e-cigarettes should be used for smoking cessation and harm-reduction strategies.^6,7 Although there is little evidence to support the use of e-cigarettes for those who want to quit smoking, a developing body of scientific evidence points to troubling health risks with the use of these devices.^5,8-10

Many adolescents and young adults who use e-cigarettes and hookah have never used cigarettes,¹¹ which might compromise the success of smoke-free policies. Most trainees in health care are also part of the at-risk young adult population, which makes it essential to assess their knowledge and attitudes toward these products,^12,13 including among those involved in respiratory care management. Among medical trainees, there is evidence that, despite having access to reliable scientific information on this topic, the prevalence of e-cigarettes and hookah smoking among medical trainees is high.^13-17 Among allied health-care professionals and other health sciences students, existing evidence is somewhat more limited but usually points to a lack of overall knowledge on the topic, regardless of the actual prevalence of use.^18,19

The knowledge and use of tobacco and alternative tobacco products by health-care professionals and trainees can influence the societal perception of the risks attributed to these devices, which might ultimately impact tobacco-reduction policies. In response to emerging evidence of nicotine delivery devices use among medical students, this study was established to examine the knowledge and attitudes of medical trainees (defined here as medical students, medical residents, and medical fellows) toward e-cigarettes and hookah usage.

QUICK LOOK.

Current Knowledge

Smoking prevalence among adolescents and young adults has decreased by 20% globally. However, many adolescents and young adults who never used cigarettes are now using electronic cigarettes (e-cigarette) and hookahs, which might compromise the success of smoke-free policies in the short and long term. Despite having access to reliable scientific information on this topic, the prevalence of e-cigarette and hookah smoking among medical trainees is high. This is a source of concern because use in this population can influence society’s perception of the risks attributed to these devices.

What This Paper Contributes to Our Knowledge

Senior medical students and physicians-in-training lack sufficient accurate knowledge and hold varying perceptions of the risks associated with e-cigarette and hookah smoking, with many endorsing e-cigarettes use for cigarette cessation.

Methods

Study Population

The present study was part of a more extensive cross-sectional multinational online survey, the Global Vaping Study, which recruited medical trainees in Brazil, the United States, India, Canada, and the United Kingdom, with enrollment conducted between October 2020 and November 2021.¹³ The project received institutional research ethics and human subject review approval in each of the participating countries. The Global Vaping Study aimed to investigate the knowledge, perception, and use of e-cigarettes and hookah among medical students, residents, and fellows (defined collectively as medical trainees). Here, we focused on our findings on the knowledge and attitude of medical trainees toward e-cigarettes and hookah usage in the United States, Brazil, and India.

All medical trainees of participating countries were eligible to participate in the Global Vaping Study. Exclusion criteria encompassed (i) respondents < 18 years old, (ii) respondents who did not sign the consent form, and (iii) those who did not answer a minimum set of 5 essential questions of the study questionnaire (including their medical training level, location of their institution, and questions specific to their current or past use of e-cigarettes or hookah).

For this specific analysis of knowledge and attitudes, only responses from senior students (medical students in the last year of their clinical rotations) and physicians-in-training (graduated physicians who are now residents and fellows) were considered. This decision was made by considering the heterogeneity of medical school curricula among countries and, to a certain extent, even within countries, which could potentially bias comparisons that involved non-senior students by knowledge gaps yet to be addressed in medical school. Furthermore, restricting the analysis to senior students and physicians-in-training would provide a sample of participants already exposed to the core of the medical curriculum and who already had clinical experience. Consequently, it allows for a better understanding of whether medical schools are adequately preparing new physicians to manage e-cigarette and hookah use.

Study Instruments and Procedures

Study Questionnaire.

The study questionnaire (see the supplementary materials at http://www.rcjournal.com) featured 72 multiple-choice questions, and participation was anonymous. The main study protocol and the questionnaire were developed in English and Portuguese, with country-specific versions created to allow for (i) different ethnic and cultural compositions of the populations, (ii) different terms used to refer to electronic cigarettes (eg, pods, e-cigarettes, vape) and hookah (eg, narghile, waterpipe), and (iii) different public health policies with regard to marketing and consumption of e-cigarettes and hookah.

Questionnaire Distribution and Recruitment Strategies.

All questionnaire versions were collected and managed by using REDCap electronic data capture tools hosted at Hospital Israelita Albert Einstein (São Paulo, Brazil).^20,21 Each country had a specific link that would direct the participants to their country-specific questionnaire. Several strategies were used for advertising the study and distributing the link to the questionnaire, which formed the base for a broad snowballing recruitment strategy.¹³

In summary, social media (WhatsApp [Mountain View, California], Facebook [Menlo Park, California], Instagram [Menlo Park, California], and on a smaller scale, Twitter [San Francisco, California], and LinkedIn [Sunnyvale, California]) were strategically used to target the main study population of medical trainees. The study invited eligible individuals to participate and encouraged them to share the study link with their colleagues. Medical professors, preceptors, deans, and program directors helped promote the study to potential participants. In Brazil and the United States, we also created Facebook and Instagram accounts to boost posts that advertised the study. Lastly, in Brazil and India, we had volunteers help advertise the study (listed in the supplementary material [see the supplementary materials at http://www.rcjournal.com]). Due to restrictions by local ethics committees, no financial incentive was offered for the participants in Brazil or India. In the United States, the participants were enrolled in a raffle for 2 gift cards worth $50.00.

Study Sample and Statistical Analysis

The original study had gathered a convenience sample of 7,582 participants distributed throughout the land area of all 3 countries. Of these, 2,036 qualified for the analysis of knowledge and attitudes for being senior students or physicians-in-training (Brazil, 597; United States, 1,125; India, 314). Participants’ characteristics were described for the whole sample and each country with median (interquartile range) for continuous variables and absolute and relative frequencies for categorical variables. Participants were classified according to e-cigarette use status as current users (defined as those who reported ongoing sporadic to frequent use of e-cigarettes), former users (those who reported having used e-cigarettes more than once, sporadically, or frequently but had stopped before the study entry), and non-users (who reported having never used e-cigarettes or who had only tried it once). The same classification was adopted to define hookah use status. Participant responses were stratified by country and compared by using the chi-square test, in which the P value was set at < .05 for statistical significance. All analyses were performed with SPSS version 29.0 (IBM IBM, Armonk, New York).

Results

Characteristics of the Study Population

The characteristics of the study sample are summarized in Table 1. The median age of the respondents was 26 years in Brazil, 29 years in the United States, and 23 years in India. Also, they often belonged to higher family income strata according to their country-specific criteria. Overall, the respondents were equally distributed between the sexes, but responses from Brazil and India showed a slight female predominance; whereas, in the United States, the respondents were mostly male. Of the respondents, 29.3% were active or former users of e-cigarettes, and 25.4% were active or former hookah smokers.

Table 1.

Characteristics of Senior Medical Trainees (senior medical students and physicians-in-training) According to Country (N = 2,036)

Knowledge and Attitudes toward E-Cigarettes

When asked to subjectively compare the health risks of e-cigarette use with those of tobacco cigarette smoking, 59.6% of the respondents believed e-cigarette use poses similar or higher health risks than tobacco smoking (Brazil, 64.1%; United States, 61%; India, 46%), whereas 27.4% believed risks were lower (Brazil, 27%; United States, 28.7%; India, 23.6%), and 13% did not know how the risk compared with smoking. Interestingly, 24.2% of the respondents believed that passive e-cigarette use does not pose serious health risks, but this proportion was statistically higher in the United States compared with Brazil and India. In line with this finding, a higher number of United States medical trainees favored using e-cigarettes in closed spaces because they do not produce any smoke. (Table 2).

Table 2.

Knowledge and Attitude Toward E-Cigarettes and Hookah (senior medical students and physicians-in-training) (N = 2,036)

When questioned about the use of e-cigarettes for smoking cessation, again, a larger proportion of United States medical trainees agreed with the statement “E-cigarettes can be used for smoking cessation,” with a statistical difference compared with respondents in Brazil and India. Moreover, 39.8% of the United States respondents agreed that patients could be encouraged to switch from tobacco cigarettes to e-cigarettes to reduce harm (Table 2). This percentage was again much higher than what was seen among their Brazilian and Indian counterparts.

Knowledge and Attitudes toward Hookah

When enquired about health risks attributed to hookah, 68.1% believed that smoking hookah poses similar or higher health risks than cigarette smoking (Brazil, 79.1%; United States, 66%; India, 54.2%). In comparison, 14.9% believed risks are lower (Brazil, 11.4%; United States, 17.2%; India, 13.6%), and 17% did not know how the risk compared with cigarette smoking. Also, 18.2% of the respondents believed that passive hookah smoking does not pose serious health risks. However, again this proportion was statistically higher in the United States compared with Brazil and India (Table 2).

Sources of Information Related to E-Cigarettes and Hookah

The results of the questions with regard to sources of information for e-cigarette use and hookah smoking are summarized in Table 3. Only 46.8% remembered attending any lecture on e-cigarette use during medical school, but there was a wide variation among countries. The same pattern was noted for hookah use, with only 40.5% of the respondents ever having attended a class on hookah use in medical school. The most common sources reported by the respondents to derive information on e-cigarette use and hookah were social media (54.5%), Google (40.8%), friends and relatives (40.3%), and newspapers and magazines (38.8%). Only 26.8% reported reading scientific articles as a source of information.

Table 3.

Health Literacy of Senior Medical Trainees about E-Cigarettes and Hookah (N = 2,036)

When questioned about their level of confidence to manage smoking and e-cigarette use, only 52.7% of the respondents felt confident to discuss tobacco cigarette smoking with patients. However, this number dropped even further, to 40%, when asked about e-cigarettes and hookah smoking. Brazilian respondents seemed less confident to discuss hookah (P < .01) and especially e-cigarette use (P < .01) with patients when compared with their United States and Indian counterparts (Fig. 1).

Fig. 1.

Perception of quality of training (A) and confidence to discuss tobacco cigarettes (B), hookah (C), and e-cigarette use (D) with patients among respondents from Brazil, the United States, and India.

Discussion

To our knowledge, this was the first large international multi-center study to investigate the knowledge and attitudes of medical trainees toward e-cigarette and hookah use. Our findings are consistent with earlier evidence that there is a significant lack of knowledge and significant variations in attitudes related to e-cigarette and hookah use among medical trainees across the 3 countries. These results provide critical insight into the views on e-cigarette and hookah that medical trainees retain as they step into their clinical practice.

Given the multi-centric nature of our sample, this analysis demonstrates that there is a broad and critical challenge, not restricted to one institution or one country, to improve the content related to tobacco use within medical schools and residencies. An expanded curriculum on substance use, with a particular focus on tobacco products, could help physicians in training to become more adept at addressing these issues with patients.

Knowledge and Perceptions of E-Cigarettes

E-cigarette use has been repeatedly associated with chronic disease development, such as asthma and COPD,^8,9 as well as endothelial damage and inflammation that could potentially result in e-cigarette or vaping use–associated lung injury (EVALI), and increase cardiovascular risk.^22-25 Several carcinogens have also been identified in the steam of e-cigarettes, including formalin, nitrosamines, and toluene.²⁶ Other toxic substances have also been isolated, such as tin, silver, iron, nickel, aluminum, silicate, and chromium, in some cases at even higher concentrations than conventional cigarette smoke.^27,28 As such, evidence is beginning to point to increased cancer risk with e-cigarette use.

Some countries, for example, the United Kingdom, have chosen to endorse e-cigarettes as an alternative for smoking cessation²⁹ based on clinical trials that show the superiority of e-cigarettes compared with nicotine replacement therapy.⁶ Yet, what these studies managed to show was that subjects enrolled in the e-cigarette arm might have simply switched from tobacco cigarettes to vaping, which is not the same as quitting. In fact, real-life study cohorts have demonstrated that traditional validated therapies for smoking cessation seem far superior to a switch to e-cigarettes.³⁰

Despite the evidence of the negative health impacts from e-cigarette use, it seems that the narrative for smoking cessation and harm reduction was already prevalent and seemed to resonate with young medical trainees. This perception is of concern, given that most senior medical trainees in the United States endorsed this narrative. At the same time, major American medical societies, such as the American Thoracic Society and the American Cancer Society, do not support it,^31-34 and the United States Preventive Task Force has stated that there is insufficient evidence to recommend it.³⁵ In the case of the United States, this scenario might also be reflecting mixed messages, including the varying e-cigarette policies in different states or prominent health institutions, such as the Centers for Disease Control and Prevention, which suggests the potential benefit to adult smokers who completely substitute regular cigarette smoking for e-cigarettes as a harm reduction strategy.³⁶

It is also worrisome that so many senior medical trainees in Brazil and India also supported e-cigarette use to quit smoking when considering that e-cigarettes sales and import are banned in both countries. In fact, we were also able to show that new physicians are potentially coming into the health-care market unfamiliar with the regulations that concerned e-cigarettes in Brazil and in India, with most thinking they are regulated in the same way as are tobacco cigarettes.

Finally, it is worth exploring our respondents' perception of passive e-cigarette use. Inhalation of e-cigarette steam particles seems to take place even when standing 4 m away from the active user,³⁶ and secondhand nicotine vape inhalation was associated with an increased risk of bronchitis symptoms and shortness of breath among young adults, increasing the risk of asthma.³⁸ Still, many senior students and physicians-in-training did not acknowledge the potential risks of passive e-cigarette use and many even supported a statement saying that e-cigarettes should be allowed indoors. This cannot be taken lightly because these new physicians could impact society's attitudes and risk perceptions, and they also will be contributing to health-care policies in the coming years.

Knowledge and Perceptions of Hookah

Hookah consumption is deeply rooted in cultural tradition in some Asian and Middle Eastern countries.⁵ In past decades, hookah use also became popular among adolescents and young adults in the Western world as an instrument of socialization.^10,13 Unlike e-cigarettes, the commercialization of hookah is legal in Brazil, the United States, and India.

During a session of hookah use, the individual inhales nicotine, carbon monoxide, tar, formaldehyde, and polyaromatic hydrocarbons in much more important amounts than when smoking conventional cigarettes. These harmful products explain why chronic hookah users develop the same diseases as people who consume cigarettes.¹⁰ Moreover, studies have shown that even sporadic users have lower lung diffusion capacity after only 2 years of recreational use.³⁹

A greater number of senior medical trainees seem aware of the risks of hookah use, possibly because hookah has been available for many more years. Still, it is quite surprising that almost a third of the United States respondents did not acknowledge the risks of passive hookah smoking, and 17% did not know whether it was harmful. It is also worrisome that many young physicians, particularly in Brazil, do not feel confident discussing hookah use with patients.

Health Literacy and the Medical Curriculum

Despite having access to high-quality, scientific-based information, senior students and physicians-in-training reported relying on informal sources of information, including social media, lay literature, friends, and relatives for these tobacco products. This raises a particular concern, given that these information sources are more likely to promote unreliable information. Results indicate a lack of formal lectures in their training, and, thus, a lack of confidence in addressing tobacco use with patients was also reported by many physicians-in-training.

These results are concerning, particularly because the responses in this survey were derived from the 3 countries with the largest numbers of medical schools in the world.⁴⁰ Our findings support the recommendation that medical educators should engage in a critical reevaluation of medical training for substance use, particularly as it relates to alternative tobacco products. Because the study of the health effects of e-cigarettes constitutes a rapidly evolving field, formal lectures during medical training are unlikely to be enough to capacitate students for clinical practice in the long run, which makes continued medical education on this topic a paramount activity.

It would be most desirable that young physicians developed the culture of reading scientific articles, but their preferred sources of information should be considered when choosing the best way to reach them. In that sense, social media could be an interesting tool if used wisely by research and clinical experts, especially when powered by reliable and peer-reviewed sources. Furthermore, educational strategies based on social media use would also carry the benefit of reaching a broader population of other health science students, such as those in nursing and respiratory therapy, who will also play an important role in counseling patients and the general population on the risks attributed to these devices. In fact, it has been shown that practicing respiratory therapists trained in smoking cessation were more efficacious in counseling patients.⁴¹ But, as with physicians, their knowledge will also need to be constantly updated to address issues with regard to alternative tobacco products.

Limitations

First, this convenience sample of medical students, residents, and fellows is subject to selection bias, and, as such, might not be representative of all medical trainees within the 3 countries. Second, results reflect self-reported recall and, thus, might be influenced by recall bias. Third, certain cultural backgrounds might have influenced the opinions of the participants with regard to what could be considered culturally acceptable rather than a risk perception when using these devices. Fourth, given that the study of short- and long-term impacts of e-cigarettes on human health is rapidly evolving, there might not have been enough time for the most recent evidence to reach a broader community. This emphasizes the importance of continued education on alternative tobacco products.

Conclusions

Our findings indicate that senior medical students and physicians-in-training lack sufficient accurate knowledge and hold varying perceptions of the risks associated with e-cigarette use and hookah smoking. This included endorsing e-cigarette use as a strategy for cigarette cessation, even in countries where e-cigarettes are prohibited, such as Brazil and India. Medical trainees seem to be starting clinical practice while unfamiliar with the public health regulations surrounding these devices, with many being unsure about best practices when discussing alternative tobacco products with patients. Fewer than half of the respondents recalled ever attending lectures on these topics, and most of them relied on lay sources with unverified information on the topic as their most common sources of information, including social media, friends, and relatives.

The urgency in addressing this apparent misinformation goes beyond the medical trainee population from this study and is a topic of particular importance to the training of all future allied health professionals involved in patient care. Given the potential health consequences associated with both e-cigarette and hookah use, there is a compelling need for educators to review current curricula to help ensure that future physicians and allied health-care professionals are prepared to address one of the leading causes of disease and death around the globe.