Abstract
The use of electronic cigarettes (e-cigarettes), or vaping, has risen significantly over the past decade as an alternative to traditional smoking. Despite growing evidence of vaping’s adverse health effects, limited data exist on medical students’ knowledge, attitudes, and behaviors regarding vaping, as well as the extent of education they receive on this topic. This study aimed to assess medical students’ perceptions of vaping-related harms and their evaluation of vaping education in medical school. A cross-sectional online survey was conducted among currently enrolled students at St. George’s University’s School of Medicine (n = 5794) over a five-week period from February to March 2024. The survey focused on students’ experiences, behaviors, attitudes, and perceptions toward e-cigarettes and vaping and their assessment of vaping-related education. Of 5794 invited students, 1400 (24%) responded, with 1193 (94%) completing the survey. While 82% had never used conventional tobacco cigarettes, 29% reported having vaped at least once. Nearly all respondents (97%) recognized vaping as a health risk; however, 75% reported receiving no formal education on vaping in their curriculum, and 68% rated their education on the topic as poor or very poor. Despite awareness of vaping’s risks, a notable proportion of medical students have engaged in the practice. The findings highlight a gap in medical education, underscoring the need for improved curriculum coverage to equip future physicians with the knowledge necessary to address vaping-related health concerns.
1. Introduction
E-cigarettes, battery-powered devices that heat liquid into an aerosol containing substances like nicotine, diacetyl, benzene, and heavy metals, have become increasingly popular, especially among young adults. The World Health Organization has noted that the rise in their use is largely attributed to the availability of over 16,000 unique flavors and compelling marketing strategies targeting younger demographics [1]. More than 85% of e-cigarette users aged 12–17 report that appealing flavors are a primary attraction of these products [2]. Additionally, targeted advertisements have reached approximately 18.3 million adolescents, fueled curiosity, and contributed to increased initiation rates of e-cigarette use [3].
Despite their popularity, the long-term health effects of e-cigarettes remain largely uncertain. The acute health risks, however, have been well-documented, particularly in the context of the 2019 e-cigarette or vaping product use-associated lung injury (EVALI) epidemic, which resulted in 2807 hospitalizations and 68 deaths in the US [4]. Non-hospitalized individuals also experienced significant symptoms, including respiratory distress, gastrointestinal issues, and systemic symptoms like fever and weight loss [4]. Research has shown that vitamin E acetate, a common additive in THC-containing e-cigarettes which may contribute to lung injury, was present in bronchoalveolar-lavage fluid of EVALI patients, identifying it as a likely causative agent for the 2019 outbreak [5].
While e-cigarettes emit fewer toxicants than traditional tobacco products, their aerosol contains harmful substances such as volatile organic compounds and cancer-causing agents [6]. Beyond impaired respiratory health, e-cigarette use has been associated with cardiovascular and oral health concerns, including hypertension, impaired angiogenesis, periodontal disease, and nicotine stomatitis [7]. A major concern is the high nicotine content in e-cigarettes, often delivered through acidified nicotine salts that increase addiction potential and pose risks to young users’ brain development [7].
Although some consider e-cigarettes a harm-reduction tool, they are not FDA-approved for smoking cessation. Misconceptions about their use persist, even among future healthcare providers. A cross-sectional study conducted at a university hospital in Saudi Arabia found that 13.5% of medical students mistakenly believed e-cigarettes were FDA-approved for smoking cessation [8]. Furthermore, a meta-analysis of e-cigarette use and adult cigarette smoking cessation found inconsistent evidence supporting e-cigarettes as an effective cessation aid [9]. This uncertainty is further compounded by deficiencies in medical education. A study at the University of Minnesota found that 84.7% of medical students had not received formal instruction on e-cigarettes, and 95% felt they lacked sufficient knowledge on the topic [10].
Medical students’ behaviors and perceptions of e-cigarettes warrant further investigation, as they will significantly shape future public health outcomes. Surveys have shown that medical students exhibit higher rates of e-cigarette use compared to the general population. At Nova Southeastern University’s Dr. Kiran C. Patel College of Osteopathic Medicine, 37.5% of students reported having used an e-cigarette at least once, a rate significantly higher than the 14.9% reported among adults aged 18 and older [11,12]. Similarly, a cross-sectional study at Umm Al-Qura University found that 31.8% of medical students were regular e-cigarette users, despite having inadequate knowledge of the associated health risks [13].
Given the increasing prevalence of e-cigarette use and its associated health risks, this study aims to evaluate the knowledge, attitudes, and behaviors of medical students at St. George’s University (SGU) toward e-cigarettes. With over 5000 enrolled students, SGU’s School of Medicine, located in Grenada, contributes a significant number of healthcare professionals to the global workforce. Understanding their perspectives will help identify educational gaps and enhance medical curricula to better address vaping-related health issues.
2. Materials and Methods
2.1. Participants and Setting
In accordance with the Declaration of Helsinki [14], ethical approval for this study was obtained from the Institutional Review Board (Application #323035) and St. George’s University’s Survey Committee (Application #04-Fall-2023). Invitations with a link to an online survey were emailed to all currently enrolled medical students in St. George’s University’s 4-year MD program, including those in clinical rotations (n = 5794). The survey was accessible from 13 February to 15 March 2024. During this period, three reminder emails were sent to students who had not yet completed the survey.
2.2. Survey Measures
The survey questions for this study were developed based on several similar studies involving medical students [8,10,11]. The survey was divided into the following categories: Demographics, Vaping Experience, Education on the Health Effects of Vaping, and Vaping Attitudes and Practices as a Medical Student and Future Physician. All respondents were assured that participation in the study was entirely voluntary and that no personal identifying information would be collected, ensuring that their responses could not be traced back to them. The survey was designed to take approximately 10 min to complete.
2.3. Analyses
Survey data were captured and extracted from the online survey software program Qualtrics https://www.qualtrics.com (accessed on 1 February 2024). The primary outcomes measured included students’ smoking and vaping status, personal experiences with e-cigarettes, vaping behaviors among those who reported vaping, attitudes and perceptions toward vaping, accessibility of e-cigarettes, and students’ evaluations of their education on e-cigarettes.
3. Results
3.1. Participants
Out of the 5794 emailed invitations, 1400 (24%) responded, with 1193 (94%) consenting to take and complete the survey. The majority of the respondents were aged 21–30 years (78%), with 59% being female (Table 1).
Table 1.
Demographics of medical school survey respondents, smoking status, and vaping status.
3.2. Smoking and Vaping Status
Among the respondents, 82% never smoked tobacco, while 71% never used e-cigarettes. Additionally, 18% had vaped in the past but not in the last 30 days, and 11% had vaped in the last 30 days (Table 1). Among the 329 respondents who reported that they vaped, 26% believe that they will probably use an e-cigarette in the next six months, with 12% stating that they definitely will.
3.3. Vaping Experience
Among the 329 respondents who vaped, most first started between 18 and 25 years of age (62%). The frequency of vaping varied, with 38% reporting vaping daily and 16% a few times per week. The top four reasons for vaping were recreational/social activity (59%), curiosity (39%), pleasurable feelings (32%), and stress relief (30%) (Table 2).
Table 2.
Vaping experience and reasons for vaping.
3.4. Behavioral Insights
Since attending medical school, 44% reported an increase in their vaping, while 15% reported a decrease (Table 2). Of the 127 respondents who currently vape, 52% expressed a desire to quit, while 33% were considering it. Of the 112 respondents who stated that they were planning to quit, 54% intended to quit “cold turkey”, while 32% planned to quit gradually (Table 2).
3.5. Attitudes and Perceptions
A significant majority (97%) believed that vaping poses some level of health risk, with 54% viewing it as harmful as smoking and 21% viewing it as more harmful. Regarding addictiveness, 55% believed e-cigarettes are as addictive as conventional cigarettes, and 39% considered them more addictive. Notably, 61% would not recommend vaping as a safer alternative to smoking (Table 3). Further, 64% think vaping impacts the health of others around the vaper, and of the 196 respondents who reported that they vaped, 39 (20%) would stop (Table 3).
Table 3.
Survey respondents’ attitudes toward and perceptions of the health effects of vaping.
3.6. Educational Aspects
A considerable number of respondents (75%) had not encountered any information about vaping in their MD curriculum, and 68% rated their education on vaping’s health effects as poor or very poor. The preferred formats for effective education included lectures (36%) and small group discussions (29%). Despite these preferences, 76% reported unchanged views on vaping since enrollment, while 23% developed more negative views (Table 4).
Table 4.
Survey respondents’ evaluation of their MD curriculum education on the health effects of vaping.
3.7. Role of Medical Practitioners
Over half of the respondents (51%) believed that physicians play a key role in evaluating the health impact of vaping. In patient interactions, 71% felt that it was essential to capture a patient’s vaping status, and 62% would advise patients to quit vaping (Table 5).
Table 5.
Attitudes and practices of respondents toward vaping.
4. Discussion
The findings from this survey indicate that a substantial proportion of SGU medical students have experimented with e-cigarettes, despite their advanced health education compared to the general population. While 97% of respondents acknowledged the health risks of vaping, and 71% believed it was important to inquire about a patient’s vaping status during consultations, a notable proportion of participants reported current e-cigarette usage or openness to future vaping. Furthermore, only 62% stated they would actively encourage patients to quit vaping, underscoring potential gaps in the education of future healthcare providers.
Although the majority of respondents reported never smoking tobacco (82%) or using e-cigarettes (71%), 11% reported vaping within the past 30 days, and 26% were likely to start vaping in the next six months. This prevalence mirrors national trends showing increased e-cigarette usage among young adults, often due to misconceptions about reduced harm compared to combustible cigarettes [15]. Furthermore, the daily vaping behavior observed in 38% of respondents aligns with concerns regarding the addictive potential of e-cigarettes, particularly products containing nicotine salts that enhance absorption and addiction potential [3,4,7].
While 97% of respondents acknowledged the health risks of vaping, perceptions about its severity varied. A significant portion viewed vaping as equally harmful (54%) or even more harmful (21%) than smoking traditional cigarettes. This reflects an increased awareness of the risks associated with vaping, including pulmonary complications like e-cigarette, or vaping, product use-associated lung injury (EVALI). The 2019 EVALI outbreak, primarily associated with THC-containing products adulterated with vitamin E acetate, underscores the severity of vaping-related health risks [5]. Additionally, evidence continues to accumulate linking vaping to adverse cardiovascular and respiratory outcomes, contradicting the perception of e-cigarettes as a “safer alternative” [7].
The motivations for vaping among respondents—recreational use (59%), curiosity (39%), stress relief (30%), and pleasurable feelings (32%)—reflect broader psychosocial and behavioral drivers. Notably, 44% of participants reported increased vaping since entering medical school, suggesting that the stress of medical education may amplify reliance on vaping as a coping mechanism. Such patterns parallel national findings that highlight stress and social influences as key determinants of e-cigarette use [16]. Additionally, the co-use of nicotine and THC products, commonly associated with EVALI cases, warrants attention as dual usage compounds health risks [5].
These findings underscore the critical role of medical education in addressing vaping. Despite widespread awareness of health risks, 75% of respondents reported receiving little to no formal education on vaping and its effects, and 51% felt unprepared to counsel patients effectively. This knowledge gap aligns with broader calls to integrate vaping-related content into medical curricula, equipping future practitioners to recognize, manage, and counsel patients about vaping-related health issues [8,10]. Notably, 62% of respondents indicated they would advise their patients to quit vaping, reinforcing the need for evidence-based strategies to support cessation efforts.
While the health risks associated with e-cigarettes are well-documented, emerging research suggests potential benefits in specific contexts. For instance, e-cigarettes have shown promise as a tool for smoking cessation among adult smokers, particularly when combined with behavioral interventions [17]. Some studies even recommend e-cigarettes as a harm reduction strategy for patients with chronic obstructive pulmonary disease (COPD), particularly those unable to quit smoking by other means [18]. However, these benefits must be weighed against the risks of youth uptake and potential long-term health consequences. Further, a study which analyzed survey data from the Behavioral Risk Factor Surveillance System of more than 240,000 individuals aged 18 to 29 years found that flavored e-cigarette bans led to an 80% decrease in daily vaping among young adults but also resulted in a 22% increase in daily cigarette smoking, potentially offsetting public health gains [19]. The implication of these findings is that, while flavored e-cigarette bans reduce vaping among young adults, they may unintentionally lead to increased cigarette smoking, potentially offsetting the public health benefits of these policies [20]. Thus, policies aimed at reducing tobacco-related diseases by promoting the switch to e-cigarettes must be carefully evaluated and monitored to ensure they achieve genuine harm reduction.
The results of this study highlight the need for targeted interventions to address vaping behaviors among medical students. First, integrating comprehensive vaping education into medical curricula is essential to bridge knowledge gaps and equip students with the tools to counsel patients effectively. Second, stress management programs tailored to medical students may reduce reliance on vaping as a coping mechanism. Lastly, public health campaigns targeting young adults should emphasize the risks of vaping, including the potential for addiction and lung injury, while challenging misconceptions about safety relative to smoking [5,7,16].
As a cross-sectional survey, a key limitation of this study is the inability to determine the true incidence of e-cigarette use and the potential for response bias, as those who chose to participate may differentially differ from those who did not. Additionally, self-reported assessments of the adequacy of medical school curricula are subject to recall bias. There is also the possibility that self-reported tobacco and e-cigarette use may not fully reflect actual usage patterns. However, previous studies have indicated that self-reported tobacco use is a reliable measure of actual consumption [21]. Lastly, while St. George’s University has a diverse student body representing multiple countries, the majority of its medical students are US citizens or intend to practice in the US. As a result, the findings may not be fully generalizable to medical students in other regions. Future research should explore longitudinal trends in vaping behaviors among medical students and assess the effectiveness of educational interventions in altering perceptions and practices.
5. Conclusions
Medical students’ knowledge, attitudes, and behaviors regarding e-cigarette use play a crucial role in shaping their approach to patient care. Although most recognize the health risks and addictive nature of e-cigarettes, a significant proportion continue to engage in vaping. These findings underscore the urgent need for enhanced educational initiatives within medical curricula to better prepare future physicians for addressing vaping-related health concerns. Strengthening medical education in this area may not only reduce e-cigarette use among medical students but also improve the guidance they provide to patients, ultimately contributing to better public health outcomes.
Author Contributions
H.H., J.F., S.Z. and M.S.F. all contributed to the writing of this paper. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of St. George’s University (Application #323035, 6 November 2023).
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement
The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author(s).
Conflicts of Interest
The authors declare no conflicts of interest.
Abbreviations
The following abbreviations are used in this manuscript:
| EVALI | E-cigarette or vaping product use-associated lung injury |
| SGU | St. George’s University |
| THC | Tetrahydrocannabinol |
References
- WHO. Hooking the Next Generation: How the Tobacco Industry Captures Young Customers; World Health Organization: Geneva, Switzerland, 2024. [Google Scholar]
- U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General; U.S. Department of Health and Human Services: Washington, DC, USA, 2016. [Google Scholar]
- Wang, Y.; Duan, Z.; Weaver, S.R.; Self-Brown, S.R.; Ashley, D.L.; Emery, S.L.; Huang, J. Association of e-Cigarette Advertising, Parental Influence, and Peer Influence with US Adolescent e-Cigarette Use. JAMA Netw. Open 2022, 5, e2233938. [Google Scholar] [CrossRef] [PubMed]
- Rebuli, M.E.; Rose, J.J.; Noel, A.; Croft, D.P.; Benowitz, N.L.; Cohen, A.H.; Goniewicz, M.L.; Larsen, B.T.; Leigh, N.; McGraw, M.D.; et al. The E-cigarette or Vaping Product Use-Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions: An Official American Thoracic Society Workshop Report. Ann. Am. Thorac. Soc. 2023, 20, 1–17. [Google Scholar] [CrossRef] [PubMed]
- Blount, B.C.; Karwowski, M.P.; Shields, P.G.; Morel-Espinosa, M.; Valentin-Blasini, L.; Gardner, M.; Braselton, M.; Brosius, C.R.; Caron, K.T.; Chambers, D.; et al. Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI. N. Engl. J. Med. 2020, 382, 697–705. [Google Scholar] [CrossRef] [PubMed]
- Esteban-Lopez, M.; Perry, M.D.; Garbinski, L.D.; Manevski, M.; Andre, M.; Ceyhan, Y.; Caobi, A.; Paul, P.; Lau, L.S.; Ramelow, J.; et al. Health effects and known pathology associated with the use of E-cigarettes. Toxicol. Rep. 2022, 9, 1357–1368. [Google Scholar] [CrossRef] [PubMed]
- Rose, J.J.; Krishnan-Sarin, S.; Exil, V.J.; Hamburg, N.M.; Fetterman, J.L.; Ichinose, F.; Perez-Pinzon, M.A.; Rezk-Hanna, M.; Williamson, E.; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Cardiopulmonary Impact of Electronic Cigarettes and Vaping Products: A Scientific Statement from the American Heart Association. Circulation 2023, 148, 703–728. [Google Scholar] [CrossRef] [PubMed]
- Alzahrani, S.H.; Alghamdi, R.A.; Almutairi, A.M.; Alghamdi, A.A.; Aljuhani, A.A.; ALbalawi, A.H. Knowledge and Attitudes Among Medical Students Toward the Clinical Usage of e-Cigarettes: A Cross-Sectional Study in a University Hospital in Saudi Arabia. Risk Manag. Health Policy 2021, 14, 1969–1984. [Google Scholar] [CrossRef] [PubMed]
- Wang, R.J.; Bhadriraju, S.; Glantz, S.A. E-Cigarette Use and Adult Cigarette Smoking Cessation: A Meta-Analysis. Am. J. Public Health 2021, 111, 230–246. [Google Scholar] [CrossRef] [PubMed]
- Hinderaker, K.; Power, D.V.; Allen, S.; Parker, E.; Okuyemi, K. What do medical students know about e-cigarettes? A cross-sectional survey from one U.S. medical school. BMC Med. Educ. 2018, 18, 32. [Google Scholar] [CrossRef]
- Ruppel, T.; Alexander, B.; Mayrovitz, H.N. Assessing Vaping Views, Usage, and Vaping-Related Education Among Medical Students: A Pilot Study. Cureus 2021, 13, e13614. [Google Scholar] [CrossRef] [PubMed]
- Villarroel, M.A.; Cha, A.E.; Vahratian, A. Electronic Cigarette Use Among U.S. Adults, 2018; NCHS Data Brief; DHHS Publication: Washington, DC, USA, 2020; pp. 1–8. [Google Scholar]
- Alshanberi, A.M.; Baljoon, T.; Bokhari, A.; Alarif, S.; Madani, A.; Hafiz, H.; Altayyar, A.; Abo-Ali, E.A. The prevalence of E-cigarette uses among medical students at Umm Al-Qura University; a cross-sectional study 2020. J. Fam. Med. Prim. Care 2021, 10, 3429–3435. [Google Scholar] [CrossRef]
- Association, W.M. World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. JAMA 2013, 310, 2191–2194. [Google Scholar] [CrossRef]
- Bandi, P.; Cahn, Z.; Goding Sauer, A.; Douglas, C.E.; Drope, J.; Jemal, A.; Fedewa, S.A. Trends in E-Cigarette Use by Age Group and Combustible Cigarette Smoking Histories, U.S. Adults, 2014–2018. Am. J. Prev. Med. 2021, 60, 151–158. [Google Scholar] [CrossRef] [PubMed]
- Erhabor, J.; Boakye, E.; Osuji, N.; Obisesan, O.; Osei, A.D.; Mirbolouk, H.; Stokes, A.C.; Dzaye, O.; El-Shahawy, O.; Rodriguez, C.J.; et al. Psychosocial stressors and current e-cigarette use in the youth risk behavior survey. BMC Public Health 2023, 23, 1080. [Google Scholar] [CrossRef] [PubMed]
- Levett, J.Y.; Filion, K.B.; Reynier, P.; Prell, C.; Eisenberg, M.J. Efficacy and Safety of E-Cigarette Use for Smoking Cessation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Am. J. Med. 2023, 136, 804–813.e4. [Google Scholar] [CrossRef] [PubMed]
- Stevens, E.R.; Lei, L.; Cleland, C.M.; Vojjala, M.; El-Shahawy, O.; Berger, K.I.; Kirchner, T.R.; Sherman, S.E. Electronic cigarettes as a harm reduction strategy among patients with COPD: Protocol for an open-label two arm randomized controlled pilot trial. Addict. Sci. Clin. Pract. 2022, 17, 2. [Google Scholar] [CrossRef] [PubMed]
- Friedman, A.S.; Pesko, M.F.; Whitacre, T.R. Flavored E-Cigarette Sales Restrictions and Young Adult Tobacco Use. JAMA Health Forum 2024, 5, e244594. [Google Scholar] [CrossRef] [PubMed]
- Anderer, S. Flavored E-Cigarette Bans Might Increase Young Adults’ Cigarette Smoking. JAMA 2025, 333, 657. [Google Scholar] [CrossRef] [PubMed]
- Post, A.; Gilljam, H.; Rosendahl, I.; Meurling, L.; Bremberg, S.; Galanti, M.R. Validity of self reports in a cohort of Swedish adolescent smokers and smokeless tobacco (snus) users. Tob. Control 2005, 14, 114–117. [Google Scholar] [CrossRef] [PubMed]
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