ORIGINAL ARTICLE


https://doi.org/10.5005/jp-journals-11010-1082
Indian Journal of Respiratory Care
Volume 12 | Issue 4 | Year 2023

E-cigarette Perception and Intended Behavior among Medical Students, Egypt


Hala M Elsabagh1, Amira AR Moawad2, Salwa A Atlam3

1Department of Public Health and Community Medicine, Faculty of Medicine, Tanta University, Egypt; Department of Maxillofacial Surgery and Diagnostic Science, Faculty of Dentistry, Majmaah University, Al-Majmaah, Saudi Arabia

2Department of Maxillofacial Surgery and Diagnostic Science, Faculty of Dentistry, Majmaah University, Al-Majmaah, Saudi Arabia

3Department of Public Health and Community Medicine, Faculty of Medicine, Tanta University, Egypt

Corresponding Author: Amira AR Moawad, Department of Maxillofacial Surgery and Diagnostic Science, Faculty of Dentistry, Majmaah University, Al-Majmaah, Saudi Arabia, Phone: +966 0505366417, e-mail: amira.a@mu.edu.sa

Received: 30 October 2023; Accepted: 09 December 2023; Published on: 18 January 2024

ABSTRACT

Objectives: Electronic cigarettes (E-cigarettes) are relatively new devices developed for decreasing tobacco craving and reducing harm when they replace regular cigarettes. They are cheaper than ordinary cigarettes and have an enhanced taste and smell, so many individuals try to use them instead of ordinary cigarettes. Population knowledge and attitudes toward its benefits and harms have become a subject of research interest. The aim of this study is to explore the medical students’ beliefs, attitudes, and intended behavior about E-cigarettes at Tanta University, Egypt.

Methods: A cross-sectional questionnaire-based study among medical students at Tanta University, Egypt, during March 2022 included 814 students.

Results: About 66.8% of participants were male, with mean age 21.88 ± 1.59. About 17.4% were smokers, 74% were nonsmokers, and 8.6% were ex-smokers. About 78.6% of participants had heard about E-cigarettes. Media was the main source of knowledge in 57.9%. Two-thirds of them were interested in learning more about E-cigarette. Only 29.9% of students had moderate to high knowledge about electronic smoking (E-smoking). About 64.8% agreed that E-cigarettes may lead to conventional smoking. About 63.0% of the students agreed that it needs regulation at work and public places. While 57.6% consider it safer than regular cigarette, it is significantly higher in males and younger age <25 years. As a smoking cessation tool, 53.7% recommend it, especially female and younger age group. Older students aged ≥25 years had significantly higher negative attitude toward E-smoking (p = 0.001). Female and older students ≥25 years reported that they were extremely likely to counsel patients or their family members about E-cigarettes.

Conclusion: Student knowledge about E-cigarette is still poor, and media ads are the main source of knowledge. Older students had a significantly higher negative attitude. It is important to increase awareness levels about E-cigarette, especially among school students and adolescents.

How to cite this article: Elsabagh HM, Moawad AA, Atlam SA. E-cigarette Perception and Intended Behavior among Medical Students, Egypt. Indian J Respir Care 2023;12(4):330–338.

Source of support: Nil

Conflict of interest: None

Keywords: Awareness, Education, Interpretation, Pollutants, Respiratory health

INTRODUCTION

The electronic cigarettes (E-cigarettes) or vape pens is an electrically-charged device that produces inhaled atomizer containing nicotine.1 Vape composed of an electronic dispersal substructure, secondary cells and charger, electronic commander, and cartridges that are capable of being replaced containing nicotine and a variety of fabricated substances.2 The heater contains a combination of different fluids, such as vegetable glycerin and propylene glycol, and favors accepting nicotine. It is operated manually or by absorption, acting by converting the nicotine fluid into an evaporated form.3

Electronic cigarettes (E-cigarettes) were developed when 80% of smokers in the United States failed in their trial to stop smoking by themselves. This was one of the most important causes that led to the use of vape pens.4 Other reasons include decreasing tobacco craving and reducing harm when it replaces regular cigarettes. Also, it is cheaper and has an intensified taste and smell compared to the usual cigarettes.5

Nowadays, the utilization of E-cigarettes has grown, especially among adolescents and those in their early years. Its consumption keeps increasing since they are offered for sale as a healthier substitute for tobacco smoking.3 Although E-cigarettes may help ongoing smokers to leave smoking,6 little investigations are made about the probable harm of E-cigarettes in the long-term. Its harm may be increased when used by nonsmokers recreationally because nicotine is compulsive and may give rise to further use of tobacco. Tobacco not only hurts the brain growth of teenagers and young adults, but its aerosol may contain other harmful matters, including cancer-producing agents, vaporous organic compounds, and heavy metals such as lead.7,8

Various studies showed conflicting findings when assessing the E-cigarettes’ effectiveness as a smoking cessation aid. A research synthesis proved that utilizing E-cigarettes as a support to stop smoking was less likely to quit this habit.9 Another research reported a marked elevation in the frequency of E-cigarette use among ex-smoker youngsters.10 Research revealed that E-cigarettes could positively act as a smoking cessation method, as when tobacco smokers were motivated to change their utilization to E-cigarette, they reduced the number of cigarettes consumed/day, and they became less based on cigarettes and more prompt to withdraw from smoking.11

Given that E-cigarettes are recent tools, estimating the individuals’ knowledge and attitude to their harms and advantages is a subject of research attraction. More specifically, medical students are the future health professionals who will provide sufficient awareness and contribute to healthy habits among patients, so they represent a significant target. It is necessary to assess their beliefs, attitudes, and intended behavior about consumption of E-cigarettes. Eventually, it will influence the community’s way of thinking and perceptions and impact the subsequent smoking cessation approaches. The aim of the current study is to explore the underlying beliefs, attitudes, and intended behaviors of medical students at Tanta University, Egypt, about E-cigarettes.

PARTICIPANTS AND METHODS

Study Design

A cross-section study.

Study Population

Medical student, Tanta University, Egypt, during the academic year 2021–2022.

Sample Size

The sample size was calculated using Epi Info version 7.1.5.2. Program of statistics. The acceptable sample of medical students with a total population of 7,000 students and 5% confidence limits at a 99% confidence level was 606 students. To cover any losses due to incomplete questionnaires, 814 students were included in the study.

Sampling

Representative proportion of students withdrawn from the 6 academic years through stratified random sample technique. Each set is bisected into six subsets for practical teaching (36 subsets). Two sets were selected randomly from each class to be incorporated into the investigation sample. Students were selected randomly from each set until the required calculated sample size was reached.

Inclusion Criteria

Tanta University, Medical students in all academic years.

Exclusion Criteria

Students of other faculties and those who refuse to participate.

Data Collection Instruments

A preliminary, independent, valid, and definitive survey form was used to assess knowledge and beliefs about electronic smoking (E-smoking). Data was collected through written questionnaires and personal interviews.

It included questions about personal information—gender, age, university grade, and smoking status, four knowledge questions about E-cigarettes, six questions about beliefs and attitude, two questions about subjective norms, one question about perceived behavioral control, and one question about behavioral intention.

Scores of Beliefs and Attitudes

There were six questions answered as certainly agree, agree, oppose, strongly oppose, and scored as 4, 3, 2, and 1. The overall score ranged from 0 to 24. Those with ≥75% of the overall (outcome ≥18), were designed as positive attitude. Those who gained <75% of the total (score <18) had negative attitude.

Statistical Analysis of Data

Data summarized and analyzed using Statistical Package for the Social Sciences (SPSS) for Microsoft Windows, version 21. Descriptive numbers and percentage are applied to sum up the features of the sample, and quantitative data is presented as mean and standard deviation. Chi-squared test (or Fisher’s exact test, when appropriate) was used to compare variables at a 5% level of significance.

RESULTS

The study included 814 medical students who studied at Tanta University; out of them, 544 (66.8%) were male, and 270 (33.2%) were females, with a mean age of 21.88 ± 1.59. Regarding smoking conditions, 74% of them were nonsmokers, 17.4% were smokers, and 8.6% were ex-smokers. Also, 78.6% of participants had heard about E-cigarettes while 21.4% did not know about it.

Knowledge about Electronic Cigarettes in Different Age-groups

It was found that 57.9% of students heard about E-smoking through media and 12.3% through newspapers and roadside posters. It was higher among students aged ≤20 years (87.5%) compared to 45.8% of students aged ≥25 years. Roadside posters and professional sources (journal articles or newsletters) represent the least important source of knowledge (2.1 and 4. 2%) for the ages ≤20 years and ≥25 years, respectively. All age-groups reported that they know little regarding E-smoking (56.3, 54.2, and 53.6%) for students aged ≤20 years, ≥25 years, and students aged 21–24 years, respectively. Also, all age-groups, especially the elder ones had interested to learn more about E-cigarettes (62.1, 67.4, and 80% among students aged ≤20 years, 21–24, and ≥25 years, respectively) (Table 1).

Table 1: Knowledge about E-cigarette in different age-groups
Question Age-group Total X2/P
≤20 21–24 ≥25
Have you ever heard of a product called an electronic cigarette or E-cigarette, or brands such as Smoke Everywhere, NJOY, Blu, or others? (If you answered no, please pass to next two questions)
Yes 96 (82.8) 496 (77.7) 48 (80.0) 640 (78.6) 0.463
No 20 (17.2) 142 (22.3) 12 (20) 174 (21.4)
Total 116 (100) 638 (100) 60 (100) 814 (100)
How did you first learn about E-cigarette?
Media ads 84 (87.5) 366 (73.8) 22 (45.8) 472 (57.9) 0.000*
Newspaper 4 (4.2) 62 (12.5) 8 (16.7) 74 (9.9)
Roadside poster (billboards or signposts) 2 (2.1) 22 (4.4) 2 (4.2) 26 (3.4)
From patients/clients 4 (4.2) 32 (6.5) 12 (25.0) 48 (5.8)
Professional source (journal articles or newsletters) 2 (2.1) 14 (2.8) 4 (8.3) 20 (2.5)
Total 96 (100) 496 (100) 48 (100) 640 (78.6)
How much do you know about E-cigarette?
Nothing at all 8 (8.3) 40 (8.1) 2 (4.2) 50 (6.1) 0.022*
A little 54 (56.3) 266 (53.6) 26 (54.2) 346 (42.5)
A moderate amount 26 (27.1) 158 (31.9) 10 (20.8) 194 (23.8)
Quite a lot 8 (8.3) 32 (6.5) 10 (20.8) 50 (6.1)
Total 96 (100) 496 (100) 48 (100) 640 (78.6)
Would you be interested in learning more about E-cigarette?
Yes 72 (62.1) 430 (67.4) 48 (80.0) 550 (67.6) 0.054
No 44 (37.9) 208 (33.8) 12 (20.0) 264 (32.4)
Total 116 (100) 638 (100) 60 (100) 814 (100)

*, Significant p-value at < 0.05; χ2, Chi-squared test

Knowledge about Electronic Cigarettes among Gender Groups

Eighty percent of male students, compared to 74.8% of female students, heard about E-smoking. Media was also the main source of knowledge, with a higher percentage among females than males (83.2 and 69.4%, respectively). Only 29.9% of students had moderate to high knowledge about E-smoking, which is significantly higher in males than females (42.1 and 29.7%, respectively) (p = 0.000). Nearly two-thirds of both males and females were interested in learning more about E-cigarettes (Table 2).

Table 2: Knowledge about E-cigarette among different genders
Question Gender Total X2/P
Male Female
Have you ever heard of a product called an electronic cigarette or E-cigarette, or brands such as Smoke Everywhere, NJOY, Blu or others? (If you answered no, please pass to next two questions)
Yes 438 (80.5) 202 (74.8) 640 (78.6) 0.039
No 106 (19.5) 68 (25.2) 174 (21.4)
Total 544 (100) 270 (100) 814 (100)
How did you first learn about E-cigarette?
Media ads 304 (69.4) 168 (83.2) 472 (58.0) 0.000*
Newspaper 62 (14.2) 12 (5.9) 74 (9.0)
Roadside poster (billboards or signposts) 20 (4.6) 6 (3.0) 26 (3.2)
From patients/clients 44 (10.0) 4 (2.0) 48 (5.8)
Professional source (journal articles or newsletters) 8 (1.8) 12 (5.9) 20 (2.4)
Total 438 (100) 202 (100) 640 (78.6)
How much do you know about E-cigarette?
Nothing at all 34 (7.8) 16 (7.9) 50 (6.1) 0.000*
A little 220 (50.2) 126 (62.4) 346 (42.5)
A moderate amount 136 (31.1) 58 (28.7) 194 (23.8)
Quite a lot 48 (11.0) 2 (1.0) 50 (6.1)
Total 438 (100) 202 (100) 640 (78.6)
Would you be interested in learning more about E-cigarette?
Yes 372 (68.4) 178 (65.9) 550 (67.5) 0.265
No 172 (31.6) 92 (34.1) 264 (32.4)
Total 544 (100) 270 (100) 814 (100)

χ2, Chi-squared test; *Significant p-value at < 0.05

Intended Behavior in Different Age-groups

The students in different age-groups had a nearly equal response to subjective norms questions as supervisors and coworkers most likely and most important in making decisions to counsel patients about E-cigarettes. More than a quarter of students (25.7%) found it moderately difficult to counsel the patients about E-cigarettes; it is significantly higher among students aged ≤20 years (44.8%) compared to (22.9 and 20%) of students aged 21–24 years and ≥25 years, respectively (p = 0.000). Higher percentage (25%) of older students ≥25 years reported that they were extremely likely to transfer their experience about E-cigarettes to the patients or their family members (p = 0.005) (Table 3).

Table 3: Intended behavior and perceived behavioral control in different age groups
Question Age-group Total X2/P
≤20 21–24 ≥25
Who is most likely to influence your decision to counsel patients about E-cigarette?
Supervisor/managers 30 (25.9) 168 (26.3) 16 (26.7) 214 (26.2) 0.727
Coworkers 32 (27.6) 220 (34.5) 20 (33.3) 272 (33.4)
Significant others 10 (8.6) 62 (9.7) 8 (13.3) 80 (9.8)
Children 14 (12.1) 54 (8.5) 4 (6.7) 72 (8.8)
Other family members 30 (25.9) 134 (21.0) 12 (20.0) 176 (21.6)
Total 116 (100) 638 (100) 60 (100) 814 (100)
To what extent are the wishes of your (supervisor/manager, coworkers, significant order, etc.) important to you in making decision to counsel patients or their family members about E-cigarettes?
Extremely important 18 (15.5) 112 (17.6) 16 (11.1) 146 (17.9) 0.153
Very important 54 (46.6) 270 (42.3) 26 (43.3) 350 (42.9)
Moderately important 32 (27.6) 198 (31.0) 16 (26.7) 246 (30.2)
Slightly important 4 (3.4) 38 (6.0) 2 (3.3) 44 (5.4)
Not at all important 8 (6.9) 20 (3.1) 0 (0.0) 28 (3.4)
Total 116 (100) 638 (100) 60 (100) 814 (100)
How difficult would it be for you to counsel your patients or their family members about E-cigarettes?
Extremely easy 10 (8.6) 76 (11.9) 4 (6.7) 90 (11.0) 0.000*
Moderately easy 26 (22.4) 238 (37.3) 12 (20.0) 276 (33.9)
Slightly easy 12 (10.3) 126 (19.7) 18 (30.0) 156 (19.1)
Moderately difficult 52 (44.8) 146 (22.9) 12 (20.0) 210 (25.7)
Extremely difficult 16 (13.8) 52 (8.2) 14 (23.3) 82 (10.0)
Total 116 (100) 638 (100) 60 (100) 814 (100)
How likely are you to counsel your patients or their family members about E-cigarettes?
Extremely likely 17 (14.7) 92 (14.4) 15 (25.0) 124 (15.2) 0.005*
Moderately likely 41 (35.3) 250 (39.2) 21 (35.0) 312 (38.3)
Slightly likely 22 (19.0) 114 (17.9) 6 (10.0) 142 (17.4)
Neither likely nor unlikely 14 (12.1) 42 (6.6) 0 (0.0) 56 (6.8)
Slightly unlikely 0 (0.0) 46 (7.2) 4 (6.7) 50 (6.1)
Moderately unlikely 12 (10.3) 60 (9.4) 10 (16.7) 82 (10.0)
Extremely unlikely 10 (8.6) 34 (5.3) 4 (6.7) 48 (5.8)
Total 116 (100) 638 (100) 60 (100) 814 (100)

*, Significant p-value at < 0.05; χ2, Chi-squared test

Intended Behavior According to Gender

The highest percentage of female students (31.1 and 30.4%) reported that supervisors/managers and family members, respectively, influence their decision to counsel patients about E-cigarettes. In case of male students, the answer was coworkers in 38.6% (p = 0.000). It was extremely important for female students (21.5%), the wishes of the supervisor/manager and coworkers in making a decision to counsel patients about E-cigarettes, which is significantly higher than males (p = 0.000). It was moderately difficult among 31.9% of females to counsel their patients about E-cigarettes, compared with 22.8% of males (p = 0.003). Significantly higher percentages were reported among females (46.7%) compared to males (34.2%), indicating that females were moderately likely to transfer their awareness about E-cigarettes to the patients or their family members, (p = 0.000) (Table 4).

Table 4: Intended behavior and perceived behavioral control according to gender
Question Gender Total X2/P
Male Female
Who is most likely to influence your decision to counsel patients about E-cigarette?
Supervisor/managers 130 (23.9) 84 (31.1) 214 (26.2) 0.000*
Coworkers 210 (38.6) 62 (23.0) 272 (33.4)
Significant others 60 (11.0) 20 (7.4) 80 (9.8)
Children 50 (9.2) 22 (8.1) 72 (8.8)
Other family members 94 (17.3) 82 (30.4) 176 (21.6)
Total 544 (100) 270 (100) 814 (100)
To what extent are the wishes of your (supervisor/manager, coworkers, significant order, etc.) important to you in making decision to counsel patients or their family members about E-cigarettes?
Extremely important 88 (16.2) 58 (21.5) 146 (17.9) 0.000*
Very important 216 (39.7) 134 (38.3) 350 (42.9)
Moderately important 186 (34.2) 60 (22.2) 246 (30.2)
Slightly important 38 (7.0) 6 (2.2) 44 (5.4)
Not at all important 16 (2.9) 12 (4.4) 28 (3.4)
Total 544 (100) 270 (100) 814 (100)
How difficult would it be for you to counsel your patients or their family members about E-cigarettes?
Extremely easy 62 (11.4) 28 (10.4) 90 (11.0) 0.003*
Moderately easy 178 (32.7) 98 (36.3) 276 (33.9)
Slightly easy 122 (22.4) 34 (12.6) 156 (19.1)
Moderately difficult 124 (22.8) 86 (31.9) 210 (25.7)
Extremely difficult 58 (10.7) 24 (8.9) 82 (10.0)
Total 544 (100) 270 (100) 814 (100)
How likely are you to counsel your patients or their family members about E-cigarettes?
Extremely likely 81 (14.9) 43 (15.9) 124 (15.2) 0.000*
Moderately likely 186 (34.2) 126 (46.7) 312 (38.3)
Slightly likely 105 (19.3) 37 (13.7) 142 (17.4)
Neither likely nor unlikely 38 (7.0) 18 (6.7) 56 (6.8)
Slightly unlikely 46 (8.5) 4 (1.5) 50 (6.1)
Moderately unlikely 56 (10.3) 26 (9.6) 82 (10.0)
Extremely unlikely 32 (5.9) 16 (5.9) 48 (5.8)
Total 544 (100) 270 (100) 814 (100)

*, Significant p-value at < 0.05; χ2, Chi-squared test

Beliefs and Attitude Scores about Electronic Cigarettes in Different Age-group

A significant association (p = 0.001) was detected between age and negative attitude toward E-smoking as 90% of participants aged ≥25 years old compared to 78 and 65% of participants aged 21–24 years and ≤20 years, respectively, had negative attitude (Fig. 1).

Fig. 1: Beliefs and attitudes score about E-cigarette in different age-groups

More than half of students (57.6%) either strongly agree or agree that E-cigarettes are more conservative than the usual cigarettes, which is more prevalent among younger students <25 years. While in students aged ≥25 years, 53.3% disagree and 6.7% strongly disagree with significant difference. Nearly two-thirds of students (64.8%) either strongly agree or agree that E-cigarettes may lead to conventional smoking. The students aged 21–24 and ≥25 years had significant higher agreement (7.2 + 59.2 and 10.0 + 53.3 strongly agree + agree for each age-group, respectively). About 67.2% of the students agreed that E-cigarette use is a worry among public health, which is significantly higher in students aged 21–24 and ≤20 years (12.1 + 48.3 and 11.3 + 58.3 strongly agree + agree for each age-group, respectively). About 71.9% of the students agreed that it needs to be regulated like other tobacco products, and 63.0% of the students agreed that it needs regulation at work and public places, which is significantly higher in students aged ≤24 (Table 5).

Table 5: Beliefs and attitude according to different age groups
Question Age-group Total X2/P
≤20 21–24 ≥25
E-cigarettes are safer to use than regular cigarette
Strongly agree 6 (5.2) 76 (11.9) 0 (0.0) 82 (10.0) 0.000*
Agree 56 (48.3) 308 (48.3) 24 (40.0) 388 (47.6)
Disagree 38 (32.8) 210 (32.9) 32 (53.3) 280 (34.3)
Strongly disagree 16 (13.8) 44 (6.9) 4 (6.7) 64 (7.8)
Total 116 (100) 638 (100) 60 (100) 814 (100)
E-cigarettes are a helpful aid for smoking cessation
Strongly agree 8 (6.9) 50 (7.8) 4 (6.7) 62 (7.6) 0.474
Agree 54 (46.6) 302 (47.3) 20 (33.3) 376 (46.1)
Disagree 46 (39.7) 248 (38.9) 32 (53.3) 326 (40.0)
Strongly disagree 8 (6.9) 38 (6.0) 4 (6.7) 50 (6.1)
Total 116 (100) 638 (100) 60 (100) 814 (100)
E-cigarette may be a gateway to conventional smoking
Strongly agree 24 (20.7) 46 (7.2) 6 (10.0) 76 (9.3) 0.000*
Agree 42 (36.2) 378 (59.2) 32 (53.3) 452 (55.5)
Disagree 44 (37.9) 186 (29.2) 22 (36.7) 252 (30.9)
Strongly disagree 6 (5.2) 28 (4.4) 0 (0.0) 34 (4.1)
Total 116 (100) 638 (100) 60 (100) 814 (100)
E-cigarette use is a public health concern
Strongly agree 14 (12.1) 72 (11.3) 12 (20.0) 98 (12.0) 0.001*
Agree 56 (48.3) 372 (58.3) 22 (36.7) 450 (55.2)
Disagree 36 (31.0) 168 (26.3) 26 (43.3) 230 (28.2)
Strongly disagree 10 (8.6) 26 (4.1) 0 (0.0) 36 (4.4)
Total 116 (100) 638 (100) 60 (100) 814 (100)
E-cigarette should be regulated like other tobacco product
Strongly agree 26 (22.4) 110 (17.2) 2 (3.3) 138 (16.9) 0.000*
Agree 48 (41.4) 370 (58.0) 30 (50.0) 448 (55.0)
Disagree 34 (29.3) 134 (21.0) 24 (40.0) 192 (23.5)
Strongly disagree 8 (6.9) 24 (3.8) 4 (6.7) 36 (4.4)
Total 116 (100) 638 (100) 60 (100) 814 (100)
E-cigarettes should be regulated in work and public places
Strongly agree 48 (41.1) 138 (21.6) 8 (13.3) 194 (23.8) 0.000*
Agree 28 (24.1) 298 (46.7) 18 (30.0) 344 (42.2)
Disagree 36 (31.0) 146 (22.9) 24 (40.0) 206 (25.3)
Strongly disagree 4 (3.4) 56 (8.8) 10 (16.7) 70 (8.5)
Total 116 (100) 638 (100) 60 (100) 814 (100)

*, Significant p-value at < 0.05; χ2, Chi-squared test

Beliefs and Attitudes about Electronic Cigarettes among Gender Groups

There was no significant association (p = 0.512) between gender and negative attitudes regarding E-smoking among participants. The negative attitude was found among 77.2 and 77% of male and female students, respectively (Fig. 2).

Fig. 2: Beliefs and attitudes score about E-cigarette in different genders

Among male students, more than half either agree (46.3%) or strongly agree (12.9%) that E-cigarettes are safer than regular cigarettes, which is significantly higher than female students. On the other hand, 53.7% of students consider E-cigarettes as a supportive way for smoking cessation, which is significantly higher in female students. Also, a significantly higher percentage of female students expressed considerations about E-cigarette use. They reported that it is a source of society apprehension (7.4% strongly agree and 62.2% agree), needs to be under control like other tobacco products (17.8% strongly agree and 59.3% agree), and requires regulation at work and public places (28.1% strongly agree and 45.2% agree) (Table 6).

Table 6: Beliefs and attitudes according to gender
Question Gender Total X2/P
Male Female
E-cigarettes are safer to use than regular cigarette
Strongly agree 70 (12.9) 12 (4.4) 82 (10.0) 0.003*
Agree 252 (46.3) 136 (50.4) 388 (47.6)
Disagree 180 (33.1) 100 (37.0) 280 (34.3)
Strongly disagree 42 (7.7) 22 (8.1) 64 (7.8)
Total 544 (100) 270 (100) 814 (100)
E-cigarettes are a helpful aid for smoking cessation
Strongly agree 52 (9.6) 10 (3.7) 62 (7.6) 0.000*
Agree 224 (41.2) 152 (56.3) 376 (46.1)
Disagree 232 (42.6) 94 (34.8) 326 (40.0)
Strongly disagree 36 (6.6) 14 (5.2) 50 (6.1)
Total 544 (100) 270 (100) 814 (100)
E-cigarette may be a gateway to conventional smoking
Strongly agree 60 (11.0) 16 (5.9) 76 (9.3) 0.016*
Agree 284 (52.2) 168 (62.2) 452 (55.5)
Disagree 174 (32.0) 78 (28.9) 252 (30.9)
Strongly disagree 26 (4.8) 8 (3.0) 34 (4.1)
Total 544 (100) 270 (100) 814 (100)
E-cigarette use is a public health concern
Strongly agree 78 (14.3) 20 (7.4) 98 (12.0) 0.002*
Agree 282 (51.8) 168 (62.2) 450 (55.2)
Disagree 164 (30.1) 66 (24.4) 230 (28.2)
Strongly disagree 20 (3.7) 16 (5.9) 36 (4.4)
Total 544 (100) 270 (100) 814 (100)
E-cigarette should be regulated like other tobacco products
Strongly agree 90 (16.5) 48 (17.8) 138 (16.9) 0.017*
Agree 288 (52.9) 160 (59.3) 448 (55.0)
Disagree 134 (24.6) 58 (21.5) 192 (23.5)
Strongly disagree 32 (5.9) 4 (1.5) 36 (4.4)
Total 544 (100) 270 (100) 814 (100)
E-cigarettes should be regulated in work and public places
Strongly agree 118 (21.7) 76 (28.1) 194 (23.8) 0.003*
Agree 222 (40.8) 122 (45.2) 344 (42.2)
Disagree 146 (26.8) 60 (22.2) 206 (25.3)
Strongly disagree 58 (10.7) 12 (4.4) 70 (8.5)
Total 544 (100) 270 (100) 814 (100)

*, Significant p-value at < 0.05; χ2, Chi-squared test

DISCUSSION

Electronic smoking (E-smoking) users have increased everywhere with concept that it is safer than conventional smoking. In the current study, 78.6% of participants heard about E-cigarette, it was higher than that detailed in the group of Egyptian society by Abo-Elkheir and Sobh.12 They found that 57.5% of the participants had heard about E-cigarettes. In addition, 80% of male students compared to 74.8% of female students heard about E-smoking, which agree with the study of Kabbash et al.,13 who reported that males had a notably increased awareness compared to females.

Karbouji et al.14 relate the lower knowledge percentage of females about E-cigarettes as due to the reality that women’s smoking as a general role is considered intolerable and blameworthy in Eastward and Muslim populations and is associated with “social stigma.”

In the present study, 57.9% of students heard about E-smoking through media and 12.3% through newspapers and roadside posters. It was higher among students aged ≤20 years (87.5%) compared to 45.8% of students aged ≥25 years. This comes in contrast to the findings of Aghar et al.,15 who investigated the knowledge and attitudes in Lebanon toward E-cigarette use among young population and reported that the majority of the participants (46.3%) heard about E-cigarettes through their family and friends and afterward from social websites (25.2%) and announcements (17.2%). This may be assigned by the power of friends and peer pressure. On the other hand, Alzahrani et al.,16 came in accordance with our results and reported that the main source of knowledge was social media.

More than one-third of students (35.7%) reported that it is moderately to extremely difficult to counsel patients about E-cigarettes, which is higher in younger age-group and female gender. This finding agrees with Alzahrani et al.,16 who reported that students had low level of confidence in counseling patients about E-cigarettes (35.1%).

More than a quarter of students (25.7%) found it moderately difficult to counsel the patients about E-cigarettes. This agrees with Shin et al.,17 who reported that two-thirds of the respondents said that discussing E-cigarettes with patients would encourage the patients to try it. This may be related to the difference in knowledge and practice levels between the study samples.

Regarding beliefs and attitudes toward E-smoking, more than half of students (57.6%) either strongly agree or agree that E-cigarettes are more conservative than traditional cigarettes, which is more prevalent among male and younger students <25 years. This agrees with Alzalabani and Eltaher’s finding,18 who reported that participants of their study mostly agreed that E-cigarettes are less toxic and less habit-forming than cigarettes and also can help people quit smoking. Our findings also come in accordance with Wang et al.,19 who reported in their findings which were carried among Chinese students, that they were convinced that E-cigarettes were less habit-forming than the usual tobacco cigarettes.

Most students reported that utilization of E-cigarette represents a fear among society and needs to be regulated like other tobacco products and may lead to conventional smoking. This disagrees with Katz et al.20 finding in a study about E-cigarettes beliefs, as participants mentioned that E-cigarettes are more socially acceptable than standard cigarettes and assist smoking stoppage. This difference may be related to the type of our sample students who are medical students, while the other study involved nonmedical students.

A significant association (p = 0.001) was detected between age and negative attitude toward E-smoking as 90% of participants aged ≥25 years had negative attitude toward E-cigarettes; also, 53.3 and 6.7% of them disagree and strongly disagree, respectively, that E-cigarettes are safer than traditional cigarette. This was explained by Aghar et al.,15 who reported in their study that there was a significant inverse interconnection between awareness and way of thinking about E-cigarette, suggesting a higher level of knowledge (i.e., knowledge about E-cigarettes is supposed to be increased by increasing age) and it will be linked to a more negative attitude. Those who are well informed about E-cigarettes may possibly perceive it further negatively because they would also be more aware of its probable harms.

There was no significant association (p = 0.512) between gender and negative attitudes regarding E-smoking among participants. On the other hand, 53.7% of students consider E-cigarettes helpful aid for smoking cessation, which is significantly higher in female students. This disagrees with Alzahrani et al.,16 who reported that males were more significantly encouraged the clinical consumption of E-cigarettes as a method for smoking discontinuation than females (33.7 vs 15.4%). This variation may be due to the low prevalence of smoking among females in the Egyptian population, resulting in less females participation than males in the study.

On the other hand, Puteh et al.21 reported among Malaysian university students that everyday E-cigarettes help smokers to quit, in contrast to Chapman and Wu,22 who declared that E-cigarettes use are not correlated with discontinuation of smoking by youngsters since they revealed that E-cigarette’s consumed as an alternative rather than a real method for quitting.

CONCLUSION

Knowledge about E-cigarettes is still poor, and media is the main source of knowledge. Older age and male students had higher knowledge, more interest to learn, and more likely to counsel their patients about E-cigarettes. Older students also had significantly higher negative attitudes. It is important to reinforce education regarding and increase awareness levels about E-cigarette, especially among school and university students.

Ethical Considerations

The authors secured ethical agreement for the research from the Medical College Internal Review Committee. Well-briefed permission was obtained from the students to participate in the research. They informed about the study justification and advantages of their contribution with full confidentiality and privacy.

Study Limitations

This study’s results cannot be generalized, because it was limited to specific population and confined to one geographical area. So, further, broad studies should be done to explore the E-cigarette knowledge, beliefs, attitudes, and intended behavior at community level.

DECLARATIONS

Consent to Publish

Authors agree to publish with copyright agreement.

Authors’ Contributions

Hala M Elsabagh analyzed and interpreted the patient data. Amira AR Moawad and Salwa A Atlam collected data and were major contributors to writing the manuscript. All authors read and approved the final manuscript.

ACKNOWLEDGMENTS

The authors would like to thank the Faculty of Medicine, Tanta University for their offered cooperation during conduction of the study. Also we are thankful for all participants in this study.

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