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Int. J. Environ. Res. Public Health 2016, 13(5), 514; doi:10.3390/ijerph13050514

Article
Knowledge and Perceptions about Nicotine, Nicotine Replacement Therapies and Electronic Cigarettes among Healthcare Professionals in Greece
Anastasia Moysidou 1,, Konstantinos E. Farsalinos 2,*,, Vassilis Voudris 2, Kyriakoula Merakou 1, Kallirrhoe Kourea 1 and Anastasia Barbouni 1
1
National School of Public Health, Alexandras Av. 196, Athens 11521, Greece
2
Onassis Cardiac Surgery Center, Sygrou 356, Kallithea 17674, Greece
*
Correspondence: Tel.: +30-697-745-4837; Fax: +30-210-949-3373
These authors contributed equally to this work.
Academic Editor: Paul B. Tchounwou
Received: 25 February 2016 / Accepted: 12 May 2016 / Published: 20 May 2016

Abstract

: Introduction. The purpose of this study was to evaluate the knowledge and perceptions of Greek healthcare professionals about nicotine, nicotine replacement therapies and electronic cigarettes. Methods. An online survey was performed, in which physicians and nurses working in private and public healthcare sectors in Athens-Greece were asked to participate through email invitations. A knowledge score was calculated by scoring the correct answers to specific questions with 1 point. Results. A total of 262 healthcare professionals were included to the analysis. Most had daily contact with smokers in their working environment. About half of them considered that nicotine has an extremely or very important contribution to smoking-related disease. More than 30% considered nicotine replacement therapies equally or more addictive than smoking, 76.7% overestimated their smoking cessation efficacy and only 21.0% would recommend them as long-term smoking substitutes. For electronic cigarettes, 45.0% considered them equally or more addictive than smoking and 24.4% equally or more harmful than tobacco cigarettes. Additionally, 35.5% thought they involve combustion while the majority responded that nicotine in electronic cigarettes is synthetically produced. Only 14.5% knew about the pending European regulation, but 33.2% have recommended them to smokers in the past. Still, more than 40% would not recommend electronic cigarettes to smokers unwilling or unable to quit smoking with currently approved medications. Cardiologists and respiratory physicians, who are responsible for smoking cessation therapy in Greece, were even more reluctant to recommend electronic cigarettes to this subpopulation of smokers compared to all other participants. The knowledge score of the whole study sample was 7.7 (SD: 2.4) out of a maximum score of 16. Higher score was associated with specific physician specialties. Conclusions. Greek healthcare professionals appear to overestimate the adverse effects of nicotine, and many would not recommend any nicotine-containing product as a long-term smoking substitute. Additionally, they have poor knowledge about the function and characteristics of electronic cigarettes.
Keywords:
smoking/harm reduction; nicotine; electronic cigarettes; healthcare; physicians; nurses

1. Introduction

Smoking is an important reversible cause of morbidity and mortality in the modern world, with the World Health Organization (WHO) expecting one billion smoking-related deaths in the 21st century. Smoking is a serious public health threat, even among developed European countries [1,2] where intensive tobacco control measures have been implemented in recent years. The currently available smoking cessation medications have limited success. Nicotine substitutes have smoking cessation rates below 7% at 1 year [3,4], although combination therapy with multiple nicotine replacement products may be more effective [5]. Oral medications have less than 20% success rate in well-organized clinical studies [6], and are usually less effective in everyday clinical practice [7]. As a result, smoking prevalence remains high, with the latest data estimating that, in 2014, 26% of the population >15 years in the European Union (EU) smokes [2], compared to 28% in 2012 [8].
The situation in Greece concerning smoking is particularly worrisome, with 38% of the population smoking in 2014 [2] compared to 40% in 2012 [8]. This is happening despite the intense efforts of the local tobacco control community and regulators, which has resulted in the implementation of public places smoke-free laws, warnings on tobacco cigarette packaging and media campaigns educating the population about the adverse effects of smoking. Additionally, a network of specialized smoking cessation clinics (in both public and private healthcare sectors) has been developed, which is mainly managed by respiratory physicians and, to a somewhat lesser extent, by cardiologists.
Tobacco harm-reduction, a strategy of providing less harmful alternative products to smokers to substitute the use of combustible tobacco, have been developed in an effort to accelerate the reduction in smoking prevalence and reduce smoking-related disease and death [9]. This is based on the fact that nicotine, although contributing to dependence, is of low health-harm potential when obtained through a non-combustible product. According to the International Agency for Research on Cancer (IARC), nicotine is not classified as a carcinogen [10]. Several laboratory studies have identified a tumor-promoting effect of nicotine [11,12] as well as an effect on atherosclerosis [13,14]. However, clinical studies have failed to reproduce these findings. The Lung Health Study followed up a cohort of 3320 users of nicotine replacement therapy (nicotine gum) for 7.5 years and found that smoking, but not nicotine replacement therapy, was a predictor of lung cancer [15]. The same study group found that, after 5 years of follow-up, use of nicotine gum was not associated with higher rates of hospitalizations for cardiovascular conditions and cardiovascular deaths [16]. A recent metanalysis of the cardiovascular effects of smoking cessation pharmacotherapies evaluated 21 randomized controlled trials of nicotine replacement therapies and found an elevated risk of all cardiovascular events which was driven predominantly by less serious events, mainly tachycardia [17]. More extensive epidemiological data on the association between nicotine intake and cancer or cardiovascular disease are available from studying snus use. Snus users obtain equal or higher amounts of nicotine on a daily basis compared to smokers [18,19]. However, snus use, especially Scandinavian snus which is a low-nitrosamine smokeless tobacco product, carries a very low risk of developing cancer compared to smoking. Luo et al. found that the risk of oral and lung cancer among snus users was similar to never smokers, while only pancreatic cancer risk was elevated in current snus users and those using more than 10 grams per day [20]. A systematic review of the relation between snus use and cancer concluded that, if all smoking population was instead using snus, only 1.1% of the smoking-attributed cancers would occur [21], showing that the risk for cancer is higher than non-use but minimal compared to smoking. Similar evidence exists for the association between snus use and cardiovascular disease. A retrospective case control study in Sweden found that the risk for acute myocardial infarction was similar between snus users and never smokers [22]. An analysis of eight prospective studies also found no association between snus use and acute myocardial infarction [23]. Similarly, an analysis of eight prospective cohort studies on stroke risk (ischemic and hemorrhagic), with more than 130,000 non-smoking men participating, found no association between snus use and risk of stroke [24]. These studies have shown that nicotine is highly unlikely to contribute significantly to smoking-related cancer and cardiovascular disease.
Electronic cigarettes are the latest addition in tobacco harm reduction [25]. These battery devices produce an aerosol by heating a liquid which may contain nicotine and other food-approved ingredients, including flavors; the aerosol is subsequently inhaled by the user. Despite the lack of long-term epidemiological studies, currently-available evidence from chemistry, toxicology and few short-term clinical studies suggests that electronic cigarettes are by far less harmful than smoking [26,27]. This is mostly related to the lack of combustion and the low temperatures of evaporation, resulting in far lower toxic emissions compared to tobacco cigarette smoke [28,29,30]. The efficacy of electronic cigarettes on smoking cessation has been questioned. Two randomized controlled trials have shown a small effect of electronic cigarettes on smoking cessation [31,32]. However, both used outdated and ineffective products. Moreover, the design of randomized controlled trials, which dictates the use of a single product by all participants, may be inappropriate to evaluate the overall efficacy of electronic cigarettes on smoking cessation considering that switching from smoking to electronic cigarette use is related to a behavioral change and that there is a huge variability of electronic cigarette products which are selected by users based on self-preference. A recent study using more advanced products showed substantially higher cessation rate [33], while a population study in the UK showed that they are substantially more effective compared to nicotine replacement therapies [34].
The role of healthcare professionals in properly advising and guiding the smoking population has long been established. A meta-analysis of 31 studies which included over 26,000 smokers found that even brief advice increased the chances of smoking cessation [35]. Another meta-analysis concluded that counseling of smokers by nurses increases the chances of quitting by 29% [36]. A prerequisite for effective counseling to smokers is proper education and knowledge of healthcare professionals about the effects of smoking on health and about all the available methods and products that could contribute to smoking reduction or cessation. Healthcare professionals are the most important source of information about the relative risks of different products for smokers, due to the respect and corresponding confidence enjoyed by society. Current evidence shows that the knowledge and concepts of healthcare professionals about smoking and nicotine are not always appropriate and science-based. A study of physicians from UK and Sweden showed that a large proportion (40%) of respondents incorrectly believed that nicotine was the most important or second most important cause of smoking-related disease [37]. This can have negative effects on the management of smokers. For example, it could discourage smokers from using pharmaceutical nicotine preparations or other nicotine-containing products which are less harmful than smoking. Studies in Norway and in other countries showed that the population overestimates the harmful effects of smokeless tobacco (snus) [38,39,40] and nicotine replacement therapies [41] compared to smoking, and this seems to be related to misconceptions about the relative risks of different products by healthcare professionals [42].
Considering the exponential growth in awareness and use of electronic cigarettes over the past few years [43,44], it is expected that, over time, more smokers will seek advice from healthcare professionals about these alternative to smoking products. Therefore, the purpose of this study was to evaluate the concepts and beliefs of a convenient sample of Greek healthcare professionals about nicotine, nicotine replacement therapies and electronic cigarettes through an online questionnaire.

2. Methods

A questionnaire was developed by the researchers and was uploaded to an online survey tool (www.surveymonkey.com). Initially, participants had to read a brief presentation of the research purpose and agree to an informed consent. Then they were transferred to the questions of the survey. The questionnaire had five main sections, asking for information about: (1) demographics of the participants, including age, gender, profession, working time and working sector (public or private); (2) smoking status of the participants; (3) perceptions and knowledge about the contribution of nicotine to smoking-related disease; (4) knowledge about the efficacy and dependence potential of nicotine replacement therapies, and; (5) knowledge about electronic cigarettes. Concerning nicotine, the main purpose was to evaluate the perceived relative risk of nicotine exposure compared to exposure to other smoking-related toxins, and its contribution to smoking-related disease. For nicotine replacement therapies, questions were mainly focused on the willingness to propose the long-term use as smoking substitutes (as suggested by recent guidelines [45,46,47]), their dependence potential compared to smoking and the knowledge about their efficacy in smoking cessation. Since electronic cigarettes are novel products, our purpose was to evaluate the knowledge about their functional and design characteristics, nicotine source in e-liquids and pending EU regulation, and evaluate whether healthcare professionals would recommend them as a substitute for smoking in those unable or unwilling to quit with other methods. Finally, participants were asked to report what they would consider appropriate regulation for electronic cigarettes. The questionnaire of the survey is presented in Supplementary materials. To improve the questionnaire design and ensure the comprehension of the survey items, five healthcare professionals (two cardiologists, one respiratory physician, one general practitioner and one nurse) were recruited and the assessment of the questionnaire was performed using the method of cognitive interviewing [48]. This process occurred before the questionnaire was released online. The study was approved by the ethics committee of the National School of Public Health in Athens, Greece (Ethics Committee Approval Code: 1701/16-12-2014). The questionnaire was anonymous and participants were informed through the consent form that they could exit the questionnaire at any time. The IP addresses were recorded with the only purpose to remove double entries.
A personal invitation to participate, together with the link to the questionnaire, was sent by email to a convenient sample of physicians and nurses working at the seven largest (in terms of bed capacity) hospitals and eight primary care centers located in Athens, Greece. Additionally, private practice physicians and nurses were selected through online search tools. The purpose of the hospitals and primary care centers selection was to cover all major districts of Athens, while private practice physicians and nurses were selected from the same areas. In an effort to balance the selection process, a similar number of public and private sector professionals were invited from each Athens district. The selection was based on availability of email addresses, and no other communication tool (telephone, personal contact) was used for survey participation. A total of 865 healthcare professionals were contacted. For physicians, general practitioners, cardiologists, dentists, internists, pediatricians and respiratory physicians were asked to participate. The main reasons for recruiting cardiologists and respiratory physicians were that they treat the most common smoking-related diseases (cardiovascular and respiratory diseases) and that they are directing smoking cessation centers in Greece. Other specializations were also selected based on their interaction with smokers and smoking-related disease. The only exclusion criteria were not responding to the question about occupation (Supplementary materials, question 3) and responding to less than 80% of the questions.

Statistical Analysis

Results were reported for the whole sample, with categorical variables presented as number (%) and continuous variables as mean (SD). Subsequently, comparisons were made between smokers (current and former) and never-smokers, between physicians and nurses and between a subgroup of physicians working in tobacco cessation in Greece (cardiologists and respiratory physicians) and all other participating healthcare professionals. The reason for dividing the sample into these subgroups is related to the expectation that smokers would have better knowledge about the study subject due to personal experience and use, physicians would be better educated about health issues related to smoking and cardiologists and respiratory physicians would also be better educated since they are responsible for treating the major causes of smoking-related morbidity and mortality and they manage the smoking cessation clinics in Greece. Comparisons between groups were performed with independent-samples t-test, one way ANOVA and χ2 test. A “knowledge score” was calculated for each participant, by scoring 1 point for every correct answer of the participants in some of the questions (see Supplementary materials). Univariate and multivariate linear regression analysis was performed to explore the association between the knowledge score and various characteristics of the study participants. All variables with p < 0.05 in univariate analysis were included in the multivariate model. A p value of <0.05 was considered statistically significant and all analyses were performed with commercially available software (SPSS v22.0, Chicago, IL, USA).

3. Results

3.1. Descriptive Analysis of the Study Sample

The results of the descriptive analysis of the whole study sample are shown in Table 1. From the 865 healthcare professionals invited, 316 entered the survey questionnaire. After excluding double entries (through the IP addresses), rejections to the informed consent, participants not responding to the question about profession and participants responding to less than 80% of the questions, a total of 262 subjects (77 were nurses and 185 were physicians) were included in the analysis (response rate of 30.3%). Healthcare professionals from all hospitals and primary care centers participated in the study. There was no statistical difference in gender, profession and working sector between the participants and those who were excluded or did not enter the survey. Most physicians were cardiologists, followed by respiratory physicians. More than half of the participants were working in the public healthcare sector, while the average working time was 12 years. The vast majority said they had daily contact with smoking patients in their working environment, while a high proportion considered they had very of fairly high level of knowledge about smoking. More than 50% were current or former smokers. Among former smokers, most had stopped smoking without the use of any aid, while seven participants reported smoking cessation with the use of electronic cigarettes.
Participants were asked to score the risk for several tobacco and alternative products, using a scale from 1 (minimum risk) to 10 (maximum risk). The following products were listed: tobacco cigarettes, snus, electronic cigarettes, nicotine replacement therapies and oral smoking cessation medications. Significant differences were found in risk scores among different products (p < 0.001). As expected, participants gave the highest risk score to tobacco cigarettes. The risk score for snus was very close to that of tobacco cigarettes while the risk score for electronic cigarettes was lower than both tobacco cigarettes and snus. Nicotine replacement therapies and oral smoking cessation medications had the lowest scores, with no statistically significant difference between them.
Participants were also asked to score the risk from several tobacco cigarette components, again using a scale from 1 (minimum risk) to 10 (maximum risk). The following components were listed: nicotine, inhaled smoke, carbon monoxide, tar and tobacco. Statistically significant differences were observed in risk scores among the different components (p < 0.001). The highest score was recorded for tar while slightly lower scores were given for smoke and carbon monoxide, without statistically significant difference between them. The risk score for nicotine was 8.0 (2.1) and was ranked 4th in terms of risk among the five components of smoking listed. Tobacco was considered by the participants as the component with the lowest risk.
More than half of the participants reported that nicotine has an extremely or very important contribution to the development of smoking-related diseases, mainly lung cancer and atherosclerosis, while approximately 45% considered extremely or very important the contribution of nicotine to the development of cancer to other than the lung organs. Almost four out of five participants considered nicotine replacement therapies less harmful than smoking; 6.5% said they did not know and 17.0% considered them equally or more harmful than smoking. About one out of three participants considered nicotine replacement therapies more addictive than smoking. Participants overestimated the efficacy of nicotine replacement therapies on smoking cessation, with just 23% correctly responding that their success rate is less than 10% at one year. The vast majority believed that nicotine in nicotine replacement therapies is synthetically-produced rather than extracted from the tobacco plant. Only one out of five participants would recommend the long-term (over 6 months) use of nicotine replacement therapies as an aid to reduce or quit smoking.
Concerning electronic cigarettes, one out of three participants reported that they have recommended the use of the electronic cigarettes to smokers in the past. The majority believed that electronic cigarettes are less harmful than smoking; only 1.5% of the participants considered them more harmful than smoking. Almost half, however, considered electronic cigarettes equally or more addictive than smoking. As with nicotine replacement therapies, most participants thought that the nicotine present in electronic cigarettes is synthetically-produced. One out of three believed that electronic cigarettes involve combustion, while the majority believed that the ingredients are approved for inhalational use. More than half reported they would recommend electronic cigarette use to smokers who have failed to stop smoking by other means, while about 55% would also recommend it to smokers who refuse to use pharmaceutical methods for smoking cessation. Ιt was noteworthy that less than 15% of the respondents knew the EU legislation on electronic cigarettes. The majority believed that electronic cigarettes sales to minors should be banned, while about 40% recommended to ban nicotine, ban advertising, be licensed as pharmaceutical products and include a warning on the label that they are equally harmful to smoking.

3.2. Comparison between Smoking and Never Smoking Participants

The results of the comparison between smoking (current and former) and never smoking participants are presented in Table 2. There was no difference between groups in the number of physicians and nurses, working time and the frequency of contact with smokers at work. Small differences were observed in the responses between the two groups. Specifically, never smokers gave higher risk score to snus and nicotine compared to smokers, although both groups gave a fairly high risk score. Similar perceptions about the contribution of nicotine to smoking-related disease, the dependence potential of nicotine replacement therapies and electronic cigarettes and the origin of nicotine in replacement therapies and electronic cigarettes were observed in both groups. More never smokers compared to smokers supported the ban of nicotine use in electronic cigarettes, while more smokers supported the ban of flavors.

3.3. Comparison Between Physicians and Nurses

The results of the comparison between physicians and nurses are presented in Table 3. Physicians were older and had more working time than nurses. More nurses were current smokers compared to physicians. Physicians reported a better level of information about smoking. Both groups, however, reported mostly very or fairly high level of knowledge about smoking.
Significant differences were observed between the two groups in their responses. Physicians gave higher risk scores to conventional cigarettes and lower to nicotine replacement therapies and oral smoking cessation medications compared to nurses. They also gave a lower risk score to nicotine and a higher score to inhaled smoke. Nicotine was ranked fourth by physicians in terms of the risk among all components of smoking listed, while nurses ranked nicotine third, with a slightly higher risk score compared to inhaled smoke. More nurses considered extremely or very important the contribution of nicotine to the development of smoking-related diseases compared with physicians. More physicians than nurses considered that nicotine replacement therapies were associated with lower health risk compared to smoking. Both groups overestimated the smoking cessation rates of nicotine replacement therapies and thought that nicotine in these products is synthetically produced rather than extracted from the tobacco plant. A greater proportion of physicians compared to nurses would recommend the long-term use of nicotine replacement therapies, although the rates were very low in both groups. About one out of three participants in both groups had recommended electronic cigarette use to smokers in the past; however, more nurses compared to physicians would recommend electronic cigarettes as smoking substitutes for smokers who are not willing to use other smoking cessation aids. More nurses than physicians believed erroneously that electronic cigarettes contain chemical additives approved for inhalation and that established quality certificates exist. More physicians than nurses suggested bans on electronic cigarettes use in public places as well as bans in advertising. Finally, more physicians than nurses said they knew the EU legislation on electronic cigarettes, although the rate of knowledge in both groups was extremely low.

3.4. Responses by Cardiologists and Respiratory Physicians

The responses of cardiologists and respiratory physicians compared to all other healthcare professionals are presented in Table 4. Participants of the former subgroup were older and had more working time. They also had more frequent contact with smokers in their working environment and reported better level of information about smoking, while fewer were current smokers.
Significant differences were observed between the two groups in their responses. Cardiologists and respiratory physicians gave higher risk scores to conventional cigarettes and to electronic cigarettes, and marginally lower risk score (p = 0.049) to oral smoking cessation medications compared to all other healthcare professionals. They also gave a slightly higher risk score to inhaled smoke. Nicotine was ranked fourth among all smoking components listed by both groups. More than half of the participants of both groups considered the contribution of nicotine to smoking-related disease in general and to atherosclerosis as extremely or very important. The vast majority in both groups considered that nicotine replacement therapies were associated with lower health risk compared to smoking. Additionally, both groups overestimated the smoking cessation rates of nicotine replacement therapies and thought that nicotine in these products is synthetically produced rather than extracted from the tobacco plant. Fewer cardiologists and respiratory physicians compared to all other participants had recommended electronic cigarette use to smokers in the past and a lower proportion would recommend electronic cigarettes as smoking substitutes for smokers who are unable or unwilling to quit smoking with approved smoking cessation aids. A higher proportion of cardiologists and respiratory physicians compared to all other participants considered that electronic cigarettes were not effective in substituting smoking and proposed a ban on sales to youngsters, on use in public places and on advertising. More physicians than nurses suggested bans on electronic cigarettes use in public places as well as bans in advertising. Finally, more cardiologists and respiratory physicians said they knew the EU legislation on electronic cigarettes, although the rate of knowledge in both groups was very low.

3.5. Knowledge Score

To assess the knowledge about nicotine, nicotine replacement therapies and electronic cigarettes, a ”knowledge score“ was calculated for each participant. The correct answers to specific questions were scored with 1 point, while no point was given or deducted for wrong answers. Questions 12–20, 22–24, 27, 28 and 30 were used to generate the knowledge score (see Supplementary materials).
The total knowledge score for all participants was 7.7 ± 2.4 points out of a maximum of 16 points. Males had higher knowledge score than women (8.3 ± 2.3 vs. 7.2 ± 2.3, p < 0.001). Furthermore, physicians had higher knowledge score than nurses (8.1 ± 2.4 vs. 6.8 ± 2.0 respectively, p < 0.001). Significant differences were found among participants depending on the profession and their specialty (one-way ANOVA p < 0.001). General practitioners (9.1 ± 1.9), respiratory physicians (8.6 ± 2.4) and pediatricians (8.5 ± 2.5) had higher knowledge scores, while nurses had the lowest score. No association was found between the knowledge score and the frequency of contact with smokers at work or the self-perceived level of knowledge about smoking. Also, there were no differences between smokers (current and former) and never smokers. A statistically significant but weak correlation between the knowledge score and working time was found (Pearson's r = 0.153, p = 0.013). In multivariate analysis (linear regression) high knowledge score was associated with male gender (β = 0.755, 95% CI = 0.153–6.041, p = 0.014) and general practitioners (β = 1.780, 95% CI = 0.533–3.008, p = 0.004), pediatricians (β = 1.415, 95% CI = 0.231–2.599, p = 0.019) and respiratory physicians (β = 1.379, 95% CI = 0.437–2.321, p = 0.004).

4. Discussion

This study evaluated the knowledge and perceptions of healthcare professionals about nicotine, nicotine replacement therapies and electronic cigarettes. Participants had very frequent contact with smokers at work and felt they had high level of knowledge about smoking. However, an overestimation of the risks of nicotine was observed, with a significant proportion of participants considering that it has an extremely or very important contribution to the development of smoking-related diseases, including lung cancer and cancer in other organs, despite the fact that nicotine is not classified as a carcinogen. Additionally, a substantial proportion considered nicotine replacement therapies equally addictive to smoking. The negative perception about nicotine was evident from the fact that the majority would not recommend the long-term use of nicotine replacement therapies to smokers although guidelines from health organizations note that the risk from long-term use of nicotine is minimal and incomparable to continuous smoking [45,46,47]. The knowledge about electronic cigarettes was rather poor, with many thinking that they involve combustion and that their operating temperature is higher compared to the combustion temperature of a tobacco cigarette. Few participants were aware of the pending EU legislation on electronic cigarettes. A significant proportion suggested that appropriate regulation should include banning nicotine and flavors in electronic cigarettes, although studies have shown that they contribute significantly to the smoking cessation effort [49,50,51,52]. Many proposed that electronic cigarettes should be licensed as medications, despite the fact that they are not used as a therapeutic product by consumers [53]. Finally, more than 40% would not recommend electronic cigarettes to smokers unable or unwilling to quit smoking by using approved medications, despite the fact that recently the American Heart Association suggested that the effort to quit smoking with the use of electronic cigarettes should be supported in this population of smokers [54].
It was noteworthy that more than half of participants reported being current or former smokers. Smoking among healthcare professionals has been a long-standing issue. In fact, one of the first epidemiological studies highlighting the correlation between smoking and cancer was conducted in British physicians [55]. In past decades, there were even cigarette advertisements from physicians [56]. In the U.S., 40% of physicians smoked in 1959, with the rate falling to 21% in the 70s and 18% in the 80s [57,58,59]. A meta-analysis of 81 studies examined the prevalence of smoking among healthcare professionals of various countries [60]. The lowest smoking rates were observed in the U.S., UK and Australia while Greece had the highest rate with a smoking prevalence of 49%. Recently, a study of Greek nurses found that 32% of the participants were current and 14% were former smokers [61], while another study found high prevalence of smoking and lack of formal training on cessation counseling among healthcare professions students [62]. Herein, the smoking prevalence was similar to the above-mentioned studies. This is an important problem since healthcare professionals are role models for their patients and society, and the fact that they smoke compromises their potential to persuade their smoking patients to quit.
The differences in responses between smokers (current and former) and non-smokers were examined, assuming that personal experience with the smoking habit would differentiate their perceptions about nicotine and nicotine-containing products. Indeed we found that smokers gave a lower risk score to snus, while fewer supported the ban on the use of nicotine in electronic cigarettes compared with non-smokers. However, both groups overestimated the risk of nicotine and its contribution to smoking-related disease. Additionally, the two groups showed a similar deficit in their knowledge about electronic cigarettes.
Large differences in the responses between physicians and nurses were observed. The nurses felt less informed about smoking. As a result, they considered nicotine replacement therapies and oral medications more hazardous and the contribution of nicotine to smoking-related disease more important compared to physicians. Nurses had a lower knowledge score compared to physicians. Although some physician specialties (general practitioners, pediatricians and lung physicians) were associated with higher knowledge score than nurses, the score of knowledge was relatively low in the whole sample. Given that smoking prevalence is extremely high in Greece and counseling by nurses has been shown to increase the chance of quitting smoking [36], the present study clearly demonstrates the need for the more thorough education of nurses, but also of physicians, about smoking in order to counsel smokers more effectively.
Significant knowledge gaps were observed in the study sample of cardiologists and respiratory physicians. These physicians treat the most prevalent smoking-related disease conditions and are also responsible for the smoking cessation clinics in Greece. Thus, they are probably considered by smokers as the most reliable source of information about smoking and smoking cessation. There is no doubt that it is preferable for smokers to quit without the use of any aid or with approved smoking cessation medications. However, the survey questions assessed the approach to a specific subpopulation of smokers: those who are unable or unwilling to quit with currently approved methods. These smokers will most likely maintain their smoking habit for a long time; thus, it is important that they receive reliable and unbiased information not only about electronic cigarettes but also about the long term use of nicotine replacement therapies, because these products could have an important role in significantly reducing their health risk.
Misconceptions about the relative risk of alternative nicotine-containing products compared to smoking have also been observed in the general public. Kiviniemi and Kozlowski recently reported that only 9% of a nationally representative sample of U.S. adults perceived smokeless tobacco products to be less harmful than smoking [63]. One of the reasons for such perceptions is related to the “not safe” (in absolute terms) argument, which has been one of the central themes of tobacco control efforts and of various scientific organizations but has been criticized as poor-quality health information [64]. Herein a significant proportion considered electronic cigarettes equally or even more harmful than smoking. This is expected, since there are scientific societies which have proposed to ban alternative to smoking products such as electronic cigarettes [65], despite emerging evidence showing clinical benefit for smokers who switch to such products [66,67]. The basis for such proposals has been the precautionary principle (based on the lack of long-term studies) which, however, seems to be applied erroneously [68]. Additionally, there is a strong ideological opposition against the use of products containing nicotine [69]. Thus, there are confusing reports about the benefits and risks of products such as electronic cigarettes [68,70], which are likely influencing the perceptions of healthcare professionals. Moreover, participants were not aware of the pending EU legislation which, once implemented in May 2016, will create some quality standards through a proposed testing regime, will define limits on nicotine content and require consistent nicotine delivery, and will enforce the registration of all products available in the market. Thus, many healthcare professionals may think that electronic cigarettes will remain completely unregulated, creating uncertainty about their safety, quality and efficacy. Finally, there is a well-established lack of education especially at the undergraduate level in medical and nursing schools about smoking and smoking cessation [71,72]. Potential improvements in healthcare professionals’ understanding about, and approach to, smoking alternatives are expected through better personal education (undergraduate and postgraduate) and through a reconsideration of the scientific community positioning towards tobacco harm reduction.
One of the limitations of the study is the applicability of the findings to all healthcare professionals in Greece and abroad. Obviously, the study recruited a convenient sample of healthcare professionals, so the findings should be interpreted with caution. However, the observations are not very different from similar surveys (mainly on physicians) evaluating perceptions for electronic cigarettes or other tobacco harm reduction products. Evidence from a study in Norway showed that healthcare professionals overestimate the adverse effects of another tobacco harm reduction product, snus [42]. Another study among Swedish and British general practitioners found that participants had limited knowledge about nicotine in tobacco products and pharmaceutical nicotine [37]. Finally, two recent studies found that only 30%–35% of surveyed physicians from the United States have recommended electronic cigarettes to smokers [73,74]. Our findings are consistent with all these studies but present the views of a more generalized sample of healthcare professionals, including nurses and several physician specialties. However, future research recruiting a random sample of healthcare professionals would be valuable to further explore this issue. Another limitation of the study is the 30.3% response rate, which appears to be low. However, this is considered acceptable [75,76] and comparable to other physician email surveys. Dykema et al. had a response rate of 7.4% despite using a financial incentive for participation [77]. Pepper et al. evaluated the perceptions of physicians who treat adolescents about electronic cigarettes and had a response rate of 28% [78], while Kandra et al. performed a similar study among North Carolina physicians and had a response rate of 31% [74]. General practitioners represented only 6.5% of the study sample. Although for most countries smokers are more likely to visit general practitioners for health-related issues, including smoking, the situation in Greece is different. Patients can visit specialist physicians in primary care on their own initiative (without the need to be referred by a general practitioner), and all medical specialties included in this study are available in primary care centers in Greece. Additionally, it is very common for specialists to have private offices and work as primary healthcare providers. Thus, the low proportion of general practitioners is not surprising. Finally, while a knowledge score was calculated, it does not cover all aspects of scientific information about nicotine and electronic cigarettes, it was a secondary objective of the study and was calculated to provide a rough generalized estimate of knowledge based on the specific questions of the survey. It is not proposed as a validated score to determine such knowledge in future studies.

5. Conclusions

Greek healthcare professionals have a significant knowledge deficit about nicotine, nicotine replacement therapies and electronic cigarettes. This is expected to have negative implications in providing appropriate and reliable counseling to smokers. A substantial proportion of the participants were reluctant to recommend nicotine-containing pharmaceutical products or electronic cigarettes as long-term smoking substitutes to smokers unwilling or unable to quit with currently approved methods. The continuous elevation in awareness and use of electronic cigarettes by smokers is expected to increase their demand for appropriate information and advice about these products. To fulfill their role as reliable providers of factual information and advice to smokers, healthcare professionals need to be properly educated and to closely follow the scientific evidence on nicotine and electronic cigarettes, which is expanding at a very rapid rate in recent years.

Supplementary Materials

The following are available online at www.mdpi.com/1660-4601/13/5/514/s1, Survey Questionnaire.

Author Contributions

Anastasia Moysidou and Konstantinos Farsalinos were responsible for the study conception and design. Anastasia Moysidou, Konstantinos Farsalinos, Kallirrhoe Kourea and Anastasia Barbouni prepared the survey questionnaire. Konstantinos Farsalinos, Vassilis Voudris, Kyriakoula Merakou and Anastasia Barbouni were responsible for data collection and analysis. Anastasia Moysidou, Konstantinos Farsalinos, Kyriakoula Merakou, Kallirrhoe Kourea and Anastasia Barbouni were responsible for interpretation of the study findings. All authors read and approved the manuscript.

Conflicts of Interest

Two (unpublished) studies by Konstantinos Farsalinos and Vassilis Voudris were performed using unrestricted funds provided to the institution by e-cigarette companies in 2013 and 1 study was funded by Tennessee Smoke-Free Association, a non-profit advocacy group and trade organization with a focus on tobacco harm reduction, in 2015.

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Table 1. Characteristics and responses of all survey participants.
Table 1. Characteristics and responses of all survey participants.
Participant Characteristics and Responses (n = 262)Mean (SD) or n (%)
Gender
 Males138 (52.7%)
 Females124 (47.3%)
Age (Years)39 (9)
Profession
 Nurse77 (29.4%)
 Physician185 (70.6%)
 General practitioner17 (6.5%)
 Cardiologist53 (20.2%)
 Dentist32 (12.2%)
 Internist32 (12.2%)
 Pediatrician17 (6.5%)
 Respiratory physician34 (13.0%)
Working Sector
 Public sector162 (61.8%)
 Private sector100 (38.2%)
Working time12 (8)
Contact with smokers in the working environment
 Daily222 (84.7%)
 At least 3 days per week15 (5.7%)
 1–2 days per weekly6 (2.3%)
 <1 day per week18 (6.9%)
Smokers80 (30.5%)
 Consider quitting *48 (60.0%)
Former smokers59 (22.5%)
Smoking cessation method for former smokers
 No aid47 (17.9%)
 Nicotine replacement therapy1 (0.4%)
 Oral medications3 (1.1%)
 Electronic cigarette7 (2.7%)
 Other1 (0.4%)
Self-perceived level of knowledge about smoking
 Very high99 (37.8%)
 Fairly high116 (44.3%)
 Moderate43 (16.4%)
 Low4 (1.5%)
Risk score for products
 Tobacco cigarettes9.3 (1.1)
 Snus8.3 (1.7)
 Electronic cigarettes5.9 (2.4)
 Nicotine replacement therapy4.0 (2.3)
 Oral medications4.2 (2.2)
Risk score for smoking components
 Nicotine8.0 (2.1)
 Inhaled smoke8.8 (1.4)
 Carbon monoxide9.1 (1.4)
 Tar9.5 (0.9)
 Tobacco6.7 (2.4)
Contribution of nicotine to smoking-related disease
 Extremely important63 (24.0%)
 Very important106 (40.5%)
 Important55 (21.0%)
 Less important26 (9.9%)
 Minimal12 (4.6%)
Contribution of nicotine to lung cancer
 Extremely important63 (24.8%)
 Very important86 (32.8%)
 Important49 (18.7%)
 Less important37 (14.1%)
 Minimal25 (9.5%)
Contribution of nicotine to cancer in other organs
 Extremely important28 (10.7%)
 Very important88 (33.6%)
 Important71 (27.1%)
 Less important53 (20.2%)
 Minimal22 (8.4%)
Contribution of nicotine to atherosclerosis
 Extremely important68 (26.0%)
 Very important105 (40.1%)
 Important50 (19.1%)
 Less important28 (10.7%)
 Minimal11 (4.2%)
Risk of nicotine replacement therapies compared to smoking
 Higher3 (1.1%)
 Equal42 (16.0%)
 Lower200 (76.3%)
 Do not know17 (6.5%)
Dependence potential of nicotine replacement therapies compared to smoking
 Higher3 (1.1%)
 Equal84 (32.1%)
 Lower146 (55.7%)
 Do not know29 (11.1%)
Success rate of nicotine replacement therapies in smoking cessation at 1 year
 >50%12 (4.6%)
 30%–50%63 (24.0%)
 10%–30%126 (48.1%)
 <10%61 (23.3%)
Origin of nicotine in nicotine replacement therapies
 Tobacco-extracted42 (16.0%)
 Synthetically-produced220 (84.0%)
Safe to use nicotine replacement therapies for >6 months as substitutes to smoking?
 Yes65 (24.8%)
 No197 (75.2%)
Recommend the long-term (>6 months) use of nicotine replacement therapies for those who cannot reduce or quit smoking with short-term use?
 Yes55 (21.0%)
 No207 (79.0%)
Have you ever recommended e-cigarettes to smokers?
 Yes87 (33.2%)
 No175 (66.8%)
Risk of e-cigarettes compared to smoking
 Higher4 (1.5%)
 Equal60 (22.9%)
 Lower174 (66.4%)
 Do not know24 (9.2%)
Dependence potential of e-cigarettes compared to smoking
 Higher6 (2.3%)
 Equal112 (42.7%)
 Lower120 (45.8%)
 Do not know24 (9.2%)
Origin of nicotine in e-cigarettes
 Tobacco-extracted34 (13.0%)
 Synthetically-produced228 (87.0%)
Would you recommend e-cigarettes to smokers who refuse to take medications to quit?
 Yes147 (56.1%)
 No115 (43.9%)
Would you recommend e-cigarettes to smokers who failed to quit with other methods?
 Yes156 (59.5%)
 No106 (40.5%)
Which of the following are correct concerning e-cigarettes?
 They contain tobacco19 (7.3%)
 There is combustion93 (35.5%)
 E-liquid ingredients are approved for inhalation172 (65.6%)
 Working temperature is lower than in tobacco cigarettes97 (37.0%)
 They have official quality certificates66 (25.2%)
 There are e-cigarettes without nicotine152 (58.0%)
Do you consider e-cigarettes effective in substituting smoking?
 Yes134 (51.1%)
 No128 (48.9%)
What do you think regulation on e-cigarettes should include?
 Available only through prescription114 (43.5%)
 Ban on nicotine115 (43.9%)
 No flavors52 (19.8%)
 Ban on the sales to youngsters193 (73.7%)
 Ban on the use in public places74 (28.2%)
 They should be licensed as medications113 (43.1%)
 They should be sold only in pharmacies100 (38.2%)
 Product variability should be reduced64 (24.4%)
 Advertising should be banned104 (39.7%)
 There should be a warning that they are equally harmful to Smoking110 (42.0%)
Do you know the European Union regulatory framework on e-cigarettes?
 Yes38 (14.5%)
 No223 (85.1%)
* Percentage represents proportion of smokers.
Table 2. Comparison of survey responses between smokers (current and former) and never-smokers.
Table 2. Comparison of survey responses between smokers (current and former) and never-smokers.
Participant Characteristics and Responses (n = 262)Smokers (Current and Former)Never Smokersp
139 (53.1%)123 (46.9%)
Gender
 Males69 (49.6%)55 (44.7%)0.426
 Females70 (50.4%)68 (55.3%)
Age (Years)39 (9.0%)39 (8.0%)0.462
Profession
 Nurse46 (33.1%)31 (25.2%)0.162
 Physician93 (66.9%)92 (74.8%)
 General practitioner10 (7.2%)7 (5.7%)
 Cardiologist24 (17.3%)29 (23.6%)
 Dentist18 (12.9%)14 (11.4%)
 Internist14 (10.1%)18 (14.6%)
 Pediatrician9 (6.5%)8 (6.5%)
 Respiratory physician18 (12.9%)16 (13.0%)
Working sector
 Public sector88 (63.3%)74 (60.2%)
 Private sector51 (36.7%)49 (39.8%)
Working time13 (8)12 (8)0.710
Contact with smokers in the working environment
 Daily117 (84.2%)105 (86.1%)0.919
 At least 3 days per week8 (5.8%)7 (5.7%)
 1–2 days per weekly3 (2.2%)3 (2.5%)
 <1 day per week11 (7.9%)7 (5.7%)
Smoking cessation method for former smokers
 No aid47 (17.9%)
 Nicotine replacement therapy1 (0.4%)
 Oral medications3 (1.1%)
 Electronic cigarette7 (2.7%)
 Other1 (0.4%)
Self-perceived level of knowledge about smoking
 Very high57 (41.0%)42 (34.1%)0.080
 Fairly high63 (45.3%)53 (43.1%)
 Moderate19 (13.7%)21 (19.5%)
 Low0 (0.0%)4 (3.3%)
Risk score for products
 Tobacco cigarettes9.3 (1.2)9.4 (1.0)0.252
 Snus7.8 (1.9)8.9 (1.2)<0.001
 Electronic cigarettes5.9 (2.4)5.9 (2.5)0.923
 Nicotine replacement therapy4.3 (2.2)4.5 (2.3)0.529
 Oral medications4.3 (2.3)4 (2.1)0.201
Risk score for smoking components
 Nicotine7.7 (2.4)8.3 (1.8)0.012
 Inhaled smoke8.8 (1.4)8.9 (1.4)0.577
 Carbon monoxide9.0 (1.5)9.2 (1.2)0.101
 Tar9.6 (0.8)9.5 (1.0)0.386
 Tobacco6.7 (2.5)6.7 (2.4)0.773
Contribution of nicotine to smoking-related disease
 Extremely important29 (20.9%)34 (27.6%)0.679
 Very important57 (41.0%)49 (39.8%)
 Important31 (22.3%)24 (19.5%)
 Less important16 (11.5%)10 (8.1%)
 Minimal6 (4.3%)6 (4.9%)
Contribution of nicotine to lung cancer
 Extremely important32 (23.0%)33 (26.8%)0.894
 Very important48 (34.5%)38 (30.9%)
 Important26 (18.7%)23 (18.7%)
 Less important21 (15.1%)16 (13.0%)
 Minimal12 (8.6%)13 (10.6%)
Contribution of nicotine to cancer in other organs
 Extremely important15 (10.8%)13 (10.6%)0.880
 Very important46 (33.1%)42 (34.1%)
 Important37 (26.6%)34 (27.6%)
 Less important31 (22.3%)22 (17.9%)
 Minimal10 (7.2%)12 (9.8%)
Contribution of nicotine to atherosclerosis
 Extremely important39 (28.1%)29 (23.6%)0.299
 Very important60 (43.2%)45 (36.6%)
 Important20 (14.4%)30 (24.4%)
 Less important15 (10.8%)13 (10.6%)
 Minimal5 (3.6%)6 (4.9%)
Risk of nicotine replacement therapies compared to smoking
 Higher1 (0.7%)2 (1.6%)0.302
 Equal27 (19.4%)15 (12.2%)
 Lower104 (74.8%)96 (78.0%)
 Do not know7 (5.0%)10 (8.1%)
Dependence potential of nicotine replacement therapies compared to smoking
 Higher1 (0.7%)2 (1.6%)0.702
 Equal48 (34.5%)36 (29.3%)
 Lower74 (53.2%)72 (58.5%)
 Do not know
Success rate of nicotine replacement therapies in smoking cessation at 1 year
 >50%5 (3.6%)7 (5.7%)0.145
 30%–50%28 (20.1%)35 (28.5%)
 10%–30%67 (48.2%)59 (48.0%)
 <10%39 (28.1%)22 (17.9%)
Origin of nicotine in nicotine replacement therapies
 Tobacco-extracted22 (15.8%)20 (16.3%)0.924
 Synthetically-produced117 (84.2%)103 (83.7%)
Safe to use nicotine replacement therapies for >6 months as substitutes to smoking?
 Yes35 (25.2%)30 (24.4%)0.883
 No104 (74.8%)93 (75.6%)
Recommend the long-term (>6 months) use of nicotine replacement therapies for those who cannot reduce or quit smoking with short-term use?
 Yes26 (18.7%)29 (23.6%)0.334
 No113 (81.3%)94(76.4%)
Have you ever recommended e-cigarettes to smokers?
 Yes46 (33.1%)41 (33.3%)0.967
 No93 (66.9%)82 (66.7%)
Risk of e-cigarettes compared to smoking
 Higher1 (0.7%)3(1.1%)0.451
 Equal36 (25.9%)24 (19.5%)
 Lower90 (64.7%)84 (68.3%)
 Do not know12 (8.6%)12 (9.8%)
Dependence potential of e-cigarettes compared to smoking
 Higher4 (2.9%)2 (1.6%)0.649
 Equal63 (45.3%)49 (39.8%)
 Lower61 (43.9%)59 (48.0%)
 Do not know11 (7.9%)13 (10.6%)
Origin of nicotine in e-cigarettes
 Tobacco-extracted20 (14.4%)14 (11.4%)0.470
 Synthetically-produced119 (85.6%)109 (88.6%)
Would you recommend e-cigarettes to smokers who refuse to take medications to quit?
 Yes81 (58.3%)66 (53.7%)0.453
 No58 (41.7%)57 (46.3%)
Would you recommend e-cigarettes to smokers who failed to quit with other methods?
 Yes82 (59.0%)74 (60.2%)0.847
 No57 (41.0%)49 (39.8%)
Which of the following are correct concerning e-cigarettes?
 They contain tobacco11 (7.9%)8 (6.5%)0.661
 There is combustion51 (36.7%)42 (34.1%)0.668
 E-liquid ingredients are approved for inhalation92 (66.2%)80 (65.0%)0.845
 Working temperature is lower than in tobacco cigarettes49 (35.3%)48 (39.0%)0.528
 They have official quality certificates36 (25.9%)30 (24.4%)0.779
 There are e-cigarettes without nicotine86 (61.9%)66 (53.7%)0.179
Do you consider e-cigarettes effective in substituting smoking?
 Yes69 (49.6%)65 (52.8%)0.604
 No70 (50.4%)58 (47.2%)
What do you think regulation on e-cigarettes should include?
 Available only through prescription56 (40.3%)61 (49.6%)0.131
 Ban on nicotine48 (34.5%)67 (54.5%)0.001
 No flavors35 (25.2%)17 (13.8%)0.021
 Ban on the sales to youngsters104 (74.8%)89 (72.4%)0.652
 Ban on the use in public places33 (23.7%)41 (33.3%)0.085
 They should be licensed as medications56 (40.3%)57 (46.3%)0.323
 They should be sold only in pharmacies46 (33.1%)54 (43.9%)0.072
 Product variability should be reduced36 (25.9%)28 (22.8%)0.556
 Advertising should be banned53 (38.1%)51 (41.5%)0.582
 There should be a warning that they are equally harmful to smoking62 (44.6%)48 (39.0%)0.361
Do you know the European Union regulatory framework on e-cigarettes?
 Yes17 (12.2%)21 (12.2%)0.255
 No122 (87.8%)101 (82.8%)
Table 3. Comparison of survey responses between physicians and nurses.
Table 3. Comparison of survey responses between physicians and nurses.
Participant Characteristics and Responses (n = 262)PhysiciansNursesp
185 (70.6%)77 (29.4%)
Gender
 Males109 (58.9%)15 (19.5%)<0.001
 Females76 (41.1%)62 (81.5%)
Age41 (8)33 (6)<0.001
Working sector
 Public sector98 (53.0%)64 (83.1%)<0.001
 Private sector87 (47.0%)13 (16.9%)
Working time14 (9)9 (5)<0.001
Contact with smokers in the working environment
 Daily159 (85.9%)63 (82.9%)0.676
 At least 3 days per week11 (5.9%)4 (5.3%)
 1–2 days per weekly3 (1.6%)3 (3.9%)
 <1 day per week12 (6.5%)6 (7.9%)
Smokers44 (23.8%)36 (46.8%)<0.001
 Consider quitting *25 (56.8%)23 (63.9%)0.521
Former smokers49 (34.8%)10 (24.4%)0.212
Smoking cessation method for former smokers
 No aid39 (79.6%)8 (80.0%)0.792
 Nicotine replacement therapy1 (2.0%)0 (0.0%)
 Oral medications3 (6.1%)0 (0.0%)
 Electronic cigarette5 (10.2%)2 (20.0%)
 Other1 (2.0%)0 (0.0%)
Self-perceived level of knowledge about smoking
 Very high80 (43.2%)19 (24.7%)0.006
 Fairly high79 (42.7%)37 (48.1%)
 Moderate25 (13.5%)18 (23.4%)
 Low1 (0.5%)3 (3.9%)
Risk score for products
 Tobacco cigarettes9.5 (0.9)9.0 (1.7)0.008
 Snus8.3 (1.7)8.3 (1.6)0.952
 Electronic cigarettes6.0 (2.4)5.7 (2.5)0.240
 Nicotine replacement therapy4.2 (2.2)5.0 (2.2)0.005
 Oral medications3.8 (2.1)5.1 (2.3)<0.001
Risk score for smoking components
 Nicotine7.8 (2.3)8.5 (1.6)0.005
 Inhaled smoke9.0 (1.3)8.4 (1.5)0.007
 Carbon monoxide9.1 (1.4)9.1 (1.3)0.794
 Tar9.6 (0.9)9.5 (0.9)0.496
 Tobacco6.6 (2.4)6.9 (2.4)0.401
Contribution of nicotine to smoking-related disease
 Extremely important42 (22.7%)21 (27.3%)0.011
 Very important65 (35.1%)41 (53.2%)
 Important45 (24.3%)10 (13.0%)
 Less important23 (12.4%)3 (3.9%)
 Minimal10 (5.4%)2 (2.6%)
Contribution of nicotine to lung cancer
 Extremely important43 (23.2%)22 (28.6%)<0.001
 Very important47 (25.4%)39 (50.6%)
 Important38 (20.5%)11 (14.3%)
 Less important34 (18.4%)3 (3.9%)
 Minimal23 (12.4%)2 (2.6%)
Contribution of nicotine to cancer in other organs
 Extremely important21 (11.4%)7 (9.1%)0.007
 Very important51 (27.6%)37 (48.1%)
 Important50 (27.0%)21 (27.3%)
 Less important43 (23.2%)10 (13.0%)
 Minimal20 (10.8%)2 (2.6%)
Contribution of nicotine to atherosclerosis
 Extremely important45 (24.3%)23 (29.9%)<0.001
 Very important62 (33.5%)43 (55.8%)
 Important42 (22.7%)8 (10.4%)
 Less important26 (14.1%)2 (2.6%)
 Minimal10 (5.4%)1 (1.3%)
Risk of nicotine replacement therapies compared to smoking
 Higher2 (1.1%)1 (1.3%)0.044
 Equal23 (12.4%)19 (24.7%)
 Lower150 (81.1%)50 (64.9%)
 Do not know10 (5.4%)7 (9.1%)
Dependence potential of nicotine replacement therapies compared to smoking
 Higher3 (1.6%)0 (0.0%)0.006
 Equal53 (28.6%)31 (40.3%)
 Lower114 (61.6%)32 (41.6%)
 Do not know15 (8.1%)14 (18.2%)
Success rate of nicotine replacement therapies in smoking cessation at 1 year
 >50%8 (4.3%)4 (5.2%)0.991
 30%–50%45 (24.3%)18 (23.4%)
 10%–30%89 (48.1%)37 (48.1%)
 <10%43 (23.2%)18 (23.4%)
Origin of nicotine in nicotine replacement therapies
 Tobacco-extracted32 (17.3%)10 (13.0%)0.386
 Synthetically-produced153 (82.7%)67 (87.0%)
Safe to use nicotine replacement therapies for >6 months as substitutes to smoking?
 Yes53 (28.6%)12 (15.6%)0.026
 No132 (71.4%)65 (84.4%)
Recommend the long-term (>6 months) use of nicotine replacement therapies for those who cannot reduce or quit smoking with short-term use?
 Yes45 (24.3%)10 (13.0%)0.040
 No140 (75.7%)67 (87.0%)
Have you ever recommended e-cigarettes to smokers?
 Yes58 (31.4%)29 (37.7%)0.323
 No127 (68.6%)48 (62.3%)
Risk of e-cigarettes compared to smoking
 Higher4 (2.2%)0 (0.0%)0.542
 Equal43 (23.2%)17 (22.1%)
 Lower120 (64.9%)54 (70.1%)
 Do not know18 (9.7%)6 (7.8%)
Dependence potential of e-cigarettes compared to smoking
 Higher5 (2.7%)1 (1.3%)0.212
 Equal75 (40.5%)37 (48.1%)
 Lower91 (49.2%)29 (37.7%)
 Do not know14 (7.6%)10 (13.0%)
Origin of nicotine in e-cigarettes
 Tobacco-extracted25 (13.5%)9 (11.7%)0.689
 Synthetically-produced160 (86.5%)68 (88.3%)
Would you recommend e-cigarettes to smokers who refuse to take medications to quit?
 Yes95 (51.4%)52 (67.5%)0.016
 No90 (48.6%)25 (32.5%)
Would you recommend e-cigarettes to smokers who failed to quit with other methods?
 Yes104 (56.2%)52 (67.5%)0.089
 No81 (43.8%)25 (32.5%)
Which of the following are correct concerning e-cigarettes?
 They contain tobacco11 (5.9%)8 (10.4%)0.206
 There is combustion68 (36.8%)25 (32.5%)0.509
 E-liquid ingredients are approved for inhalation114 (61.6%)58 (75.3%)0.033
 Working temperature is lower than in tobacco cigarettes72 (38.9%)25 (32.5%)0.325
 They have official quality certificates40 (21.6%)26 (39.4%)0.039
 There are e-cigarettes without nicotine109 (58.9%)43 (55.8%)0.646
Do you consider e-cigarettes effective in substituting smoking?
 Yes91 (49.2%)43 (55.8%)0.326
 No94 (50.8%)34 (44.2%)
What do you think regulation on e-cigarettes should include?
 Available only through prescription81 (43.8%)36 (46.8%)0.660
 Ban on nicotine76 (41.1%)39 (50.6%)0.155
 No flavors38 (20.5%)14 (18.2%)0.663
 Ban on the sales to youngsters141 (76.2%)52 (67.5%)0.146
 Ban on the use in public places61 (33.0%)13 (16.9%)0.008
 They should be licensed as medications84 (45.4%)29 (37.7%)0.249
 They should be sold only in pharmacies75 (40.5%)25 (32.5%)0.220
 Product variability should be reduced46 (24.9%)18 (23.4%)0.798
 Advertising should be banned81 (43.8%)23 (29.9%)0.036
 There should be a warning that they are equally harmful to smoking73 (39.5%)37 (48.1%)0.199
Do you know the European Union regulatory framework on e-cigarettes?
 Yes34 (18.5%)4 (5.2%)0.006
 No150 (81.5%)73 (94.8%)
* Percentages represent proportion of smokers.
Table 4. Survey responses of cardiologists and respiratory physicians compared to all other participants.
Table 4. Survey responses of cardiologists and respiratory physicians compared to all other participants.
Participant Characteristics and Responses (n = 262)Cardiologists and Respiratory PhysiciansAll Othersp
87 (33.2%)175 (66.8%)
Gender
 Males58 (66.7%)66 (37.7%)<0.001
 Females29 (33.3%)109 (62.3%)
Age43 (9)37 (8)<0.001
Working sector
 Public sector49 (56.3%)113 (64.6%)0.195
 Private sector38 (43.7%)62 (35.4%)
Working time15 (9)11 (7)0.001
Contact with smokers in the working environment
 Daily82 (94.3%)140 (80.5%)0.013
 At least 3 days per week4 (4.6%)11 (6.3%)
 1–2 days per weekly0 (0.0%)6 (3.4%)
 <1 day per week1 (1.1%)17 (9.8%)
Smokers18 (20.7%)62 (35.4%)0.015
 Consider quitting *12 (66.7%)36 (58.1%)0.512
Former smokers24 (34.8%)35 (31.0%)0.594
Smoking cessation method for former smokers
 No aid19 (79.2%)28 (80.0%)0.017
 Nicotine replacement therapy1 (4.2%)0 (0.0%)
 Oral medications3 (12.5%)0 (0.0%)
 Electronic cigarette0 (0.0%)7 (20.0%)
 Other1 (4.2%)0 (0.0%)
Self-perceived level of knowledge about smoking
 Very high46 (52.9%)53 (30.3%)0.003
 Fairly high30 (34.5%)86 (49.1%)
 Moderate11 (12.6%)32 (18.3%)
 Low0 (0.0%)4 (2.3%)
Risk score for products
 Tobacco cigarettes9.6 (0.7)9.2 (1.2)<0.001
 Snus8.3 (1.6)8.3 (1.7)0.921
 Electronic cigarettes6.7 (2.4)5.6 (2.4)<0.001
 Nicotine replacement therapy4.1 (2.5)4.5 (2.1)0.292
 Oral medications3.8 (2.4)4.3 (2.1)0.049
Risk score for smoking components
 Nicotine7.8 (2.3)8.1 (2.1)0.327
 Inhaled smoke9.2 (1.2)8.6 (1.5)0.002
 Carbon monoxide9.1 (1.4)9.1 (1.3)0.725
 Tar9.6 (0.9)9.5 (0.9)0.225
 Tobacco6.5 (2.5)6.8 (2.4)0.292
Contribution of nicotine to smoking-related disease
 Extremely important18 (20.7%)45 (25.7%)0.305
 Very important32 (36.8%)74 (42.3%)
 Important25 (28.7%)30 (17.1%)
 Less important8 (9.2%)18 (10.3%)
 Minimal4 (4.6%)8 (4.6%)
Contribution of nicotine to lung cancer
 Extremely important20 (23.0%)45 (25.7%)0.130
 Very important23 (26.4%)63 (36.0%)
 Important15 (17.2%)34 (19.4%)
 Less important17 (19.5%)20 (11.4%)
 Minimal12 (13.8%)13 (7.4%)
Contribution of nicotine to cancer in other organs
 Extremely important11 (12.6%)17 (9.7%)0.186
 Very important29 (33.3%)59 (33.7%)
 Important17 (19.5%)54 (30.9%)
 Less important19 (21.8%)34 (19.4%)
 Minimal11 (6.3%)11 (12.6%)
Contribution of nicotine to atherosclerosis
 Extremely important25 (28.7%)43 (24.6%)0.040
 Very important25 (28.7%)80 (45.7%)
 Important18 (20.7%)32 (18.3%)
 Less important15 (17.2%)13 (7.4%)
 Minimal4 (4.6%)7 (4.0%)
Risk of nicotine replacement therapies compared to smoking
 Higher2 (2.3%)1 (0.6%)0.135
 Equal9 (10.3%)33 (18.9%)
 Lower72 (82.8%)128 (73.1%)
 Do not know4 (4.6%)13 (7.4%)
Dependence potential of nicotine replacement therapies compared to smoking
 Higher2 (2.3%)1 (0.6%)0.137
 Equal27 (31.0%)57 (32.6%)
 Lower53 (60.9%)93 (53.1%)
 Do not know5 (5.7%)24 (13.7%)
Success rate of nicotine replacement therapies in smoking cessation at 1 year
 >50%5 (5.7%)7 (4.0%)0.660
 30%–50%24 (27.6%)39 (22.3%)
 10%–30%38 (43.7%)88 (50.3%)
 <10%20 (23.0%)41 (23.4%)
Origin of nicotine in nicotine replacement therapies
 Tobacco-extracted16 (18.4%)26 (14.9%)0.463
 Synthetically-produced71 (81.6%)149 (85.1%)
Safe to use nicotine replacement therapies for >6 months as substitutes to smoking?
 Yes26 (29.9%)39 (22.3%)0.180
 No61 (70.1%)136 (77.7%)
Recommend the long-term (>6 months) use of nicotine replacement therapies for those who cannot reduce or quit smoking with short-term use?
 Yes23 (26.4%)32 (18.3%)0.127
 No64 (73.6%)143 (81.7%)
Have you ever recommended e-cigarettes to smokers?
 Yes21 (24.1%)66 (37.7%)0.028
 No66 (75.9%)109 (62.3%)
Risk of e-cigarettes compared to smoking
 Higher4 (4.6%)0 (0.0%)0.006
 Equal26 (29.9%)34 (19.4%)
 Lower50 (57.5%)124 (70.9%)
 Do not know7 (8.0%)17 (9.7%)
Dependence potential of e-cigarettes compared to smoking
 Higher3 (3.4%)3 (1.7%)0.160
 Equal44 (50.6%)68 (38.9%)
 Lower35 (40.2%)85 (48.6%)
 Do not know5 (5.7%)19 (10.9%)
Origin of nicotine in e-cigarettes
 Tobacco-extracted12 (13.8%)22 (12.6%)0.782
 Synthetically-produced75 (86.2%)153 (87.4%)
Would you recommend e-cigarettes to smokers who refuse to take medications to quit?
 Yes34 (39.1%)113 (64.6%)<0.001
 No53 (60.9%)62 (35.4%)
Would you recommend e-cigarettes to smokers who failed to quit with other methods?
 Yes41 (47.1%)115 (65.7%)0.004
 No46 (52.9%)60 (34.3%)
Which of the following are correct concerning e-cigarettes?
 They contain tobacco5 (5.7%)14 (8.0%)0.508
 There is combustion32 (36.8%)61 (34.9%)0.759
 E-liquid ingredients are approved for inhalation53 (60.9%)119 (68.0%)0.256
 Working temperature is lower than in tobacco cigarettes34 (39.1%)63 (36.0%)0.627
 They have official quality certificates16 (18.4%)50 (28.6%)0.074
 There are e-cigarettes without nicotine55 (63.2%)97 (55.4%)0.229
Do you consider e-cigarettes effective in substituting smoking?
 Yes35 (40.2%)99 (56.6%)0.013
 No52 (59.8%)76 (43.4%)
What do you think regulation on e-cigarettes should include?
 Available only through prescription35 (40.2%)82 (46.9%)0.310
 Ban on nicotine30 (34.5%)85 (48.6%)0.030
 No flavors20 (23.0%)32 (18.3%)0.369
 Ban on the sales to youngsters72 (82.8%)121 (69.1%)0.018
 Ban on the use in public places38 (43.7%)36 (20.6%)<0.001
 They should be licensed as medications43 (49.4%)70 (40.0%)0.147
 They should be sold only in pharmacies34 (39.1%)66 (37.7%)0.830
 Product variability should be reduced24 (27.6%)40 (22.9%)0.401
 Advertising should be banned45 (51.7%)59 (33.7%)0.005
 There should be a warning that they are equally harmful to smoking40 (46.0%)70 (40.0%)0.356
Do you know the European Union regulatory framework on e-cigarettes?
 Yes23 (26.4%)15 (8.6%)<0.001
 No64 (73.6%)159 (91.4%)
* Percentages represent proportion of smokers.
Int. J. Environ. Res. Public Health EISSN 1660-4601 Published by MDPI AG, Basel, Switzerland RSS E-Mail Table of Contents Alert
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