Background

Electronic cigarettes (e-cigarettes) have gained global popularity in the past decade, especially among adolescents. However, little is known about them and no current evidence-based guidelines exist surrounding their use. A 2020 Cochrane review found moderate evidence that e-cigarettes are superior to nicotine replacement for smoking cessation, but limited evidence exists comparing them to pharmacotherapies.¹ One study showed that misperceptions about e-cigarette use are especially common among pregnant patients.² Because nicotine has known toxic effects on developing fetuses and the amount of nicotine consumed when using e-cigarettes is similar to that when smoking cigarettes, the American College of Obstetricians and Gynecologists advises against e-cigarette use during pregnancy and recommends extensive counseling about risks and benefits before any sort of nicotine replacement is used by pregnant patients.

Physicians report lacking knowledge of health impacts of e-cigarettes and discomfort providing counseling on their use, yet patients look to them for guidance.^{3, 4} Age-related trends suggest e-cigarette use is more prevalent among medical students than attending physicians. In one study, 14.7% of medical students had used e-cigarettes, 39% considered them safer than combustible cigarettes and 28% considered them useful smoking cessation tools.⁵ Personal experience with e-cigarettes may influence physicians’ beliefs about safety and patient recommendations.

The purpose of this pilot study was to identify associations between demographics, role (medical student, trainee, and attending), and personal use of e-cigarettes with beliefs about their safety, utility for smoking cessation, and recommendation for use by pregnant patients.

Methods

Literature review revealed no pre-existing validated survey instrument. We created a questionnaire querying demographics, e-cigarette, use, and beliefs about e-cigarettes using a four-point Likert scale with no neutral option (Strongly Disagree, Disagree, Agree, Strongly Agree). All 1,672 medical students, trainees, and attendings at one academic medical center were invited to participate in the anonymous online survey (Qualtrics, Provo, UT). Invitations were e-mailed via institutional listservs to students in January 2020 with two reminders two weeks apart. Invitations were emailed to trainees and attendings once in February 2020 without reminders out of respect for COVID-19 pandemic-related demands. The George Washington University’s Institutional Review Board determined this study exempt (#NCR191674).

Likert responses were converted to numerical scale (1=Strongly Disagree, 2=Disagree, 3=Agree, 4=Strongly Agree) for analysis. We examined associations between age, gender, role, prior e-cigarette use, and use in the past month with responses to each of the following statements:

• “E-cigarettes are safe”
• “E-cigarettes are safer than traditional cigarettes”
• “E-cigarettes are useful for smoking cessation”
• “If she could not quit smoking, I would recommend my pregnant patient use e-cigarettes.”

We used analysis of variance to examine associations of item scores with categorical variables and Pearson r for associations with age (SAS, version 9.4, Cary, NC). We considered p<0.05 statistically significant.

Results

We received 343 responses (20.5% response rate): 65% were medical students, 13% trainees and 21% attendings, 59% were female, 40% were male and 1% were other gender. Eighty-two respondents had used e-cigarettes (23.9%). Eighteen respondents used e-cigarettes in the past month (5.2%). Rates of “ever” use were higher among medical students (27.7%) and trainees (37.0%) than attendings (4.1%). Those who previously used e-cigarettes, or used in the past month, had significantly higher mean scores on safety perception (p=0.011, p<0.001) and deemed e-cigarettes safer than traditional cigarettes (p<0.001, p<0.001). Age, gender, and role were not significantly associated with perception of safety. Age and role were not significantly associated with perception that e-cigarettes are safer than traditional cigarettes, but male gender was associated with stronger perception of their safety relative to traditional cigarettes (p=0.002).

Being a medical student (p<0.001), younger age (p=0.002), previous e-cigarette use (p<0.001), or use in the past month (p<0.001) were all associated with higher mean scores on perception that e-cigarettes are useful smoking cessation aids. Prior use was associated with higher scores on recommending them to pregnant patients (p=0.003). Students “would recommend e-cigarettes” to pregnant patients to quit smoking more frequently than trainees and attendings (p=0.047). This recommendation nadired among physicians 36-50 years of age, with higher scores given by physicians outside the 36-50 years of age range. (p=0.022).

Discussion

Overall, we found that physicians and medical students who had ever used or currently use e-cigarettes have stronger beliefs regarding their safety and “would recommend e-cigarettes” as a smoking cessation tool, including to pregnant patients. Among all-comers, students and respondents under age 25 years more strongly agreed that e-cigarettes are useful smoking cessation aids and would recommend them to pregnant patients for such use. Our pilot study is the first to investigate this association that may impact recommendations to patients. Nearly one-quarter of respondents had ever used e-cigarettes, with rates seven times higher among medical students and nine times higher among trainees than among attendings. These preliminary findings suggest the coming generation of physicians, who are more likely to have used e-cigarettes, may regard them as safer.

Prior studies have demonstrated substantial knowledge deficits about e-cigarettes among physicians and medical students.⁴ Taken together, increasing e-cigarette use by patients, lack of knowledge and misperceptions of their safety by patients and physicians, and the potential association between physicians’ personal use and recommendations given to patients as illustrated by our data, support the need to incorporate e-cigarette education into undergraduate and graduate medical curricula.

This single-institution study has limitations. Because we used a non-validated questionnaire, our results are hypothesis-generating. The low response rate from a convenience sample may cause selection bias, although it is unlikely that e-cigarette users would participate differentially, as anonymity should have mitigated social desirability bias. Given our preliminary findings, next steps should include designing and rigorously validating a survey tool. Subsequent multi-institutional research using such a tool should explore this possible association between personal use of e-cigarettes and smoking cessation recommendations given to patients, including whether current or former users may recommend e-cigarettes over proven pharmacotherapies.