OPEN ACCESS J PREV MED HYG 2021; 62: E770-E775

Research article

Knowledge and attitude related to use of electronic

cigarettes among undergraduate nursing students
in an urban university setting in Philippines
MADONNA PALMES1, SHEILLA M. TRAJERA2, ANAND K. SAJNANI3
1
College of Nursing, West Visayas State University, Iloilo City, Philippines; 2 College of Nursing, University of St. La Salle, Bacolod
City, Philippines; 3 Department of Pediatric Dentistry KIMS Qatar Medical Centre, Wakra, Qatar

Keywords

E-cigarettes • Nursing students • Health knowledge • Attitude of health personnel • Health care surveys

Summary

Background. Electronic cigarette (e-cigarette) use has risen Results. Majority of the participants were female, were never
dramatically since its introduction in 2004. Nurses play a criti- smokers and were aware or conscious of the existence of the
cal role in screening, disease prevention and smoking cessation e-cigarettes but had poor knowledge on e-cigarettes. Further-
for their patient. Their knowledge and attitude related to e-cig- more, in terms of attitude the students as an entire group had
arettes will play a major part in development of tobacco control a positive attitude opposing e-cigarette use. Never and former
activities. smokers had positive attitude opposing e-cigarette use while
Aim. Thus, this study was conducted to determine the knowledge current smokers had negative attitude supporting e-cigarette
and attitude toward e-cigarettes among undergraduate nursing use. There was no significant relationship between knowledge
students in the Philippines. and attitude of nursing students towards e-cigarettes.
Methods. The participants of the study were 122 level four nurs- Conclusion. Nursing students did not have adequate knowledge
ing students of West Visayas State University, Iloilo city, Philip- regarding e-cigarettes but maintained a positive attitude oppos-
pines. A standardized self-administered questionnaire was used ing e-cigarette use. Poor knowledge did not influence the atti-
to collect the data and statistical analyses were performed. tude of participants towards e-cigarettes.

Introduction effects is equivocal. The Royal College of Physicians

suggests that e-cigarettes represent a “viable harm-
Electronic cigarette (e-cigarette) is a battery-powered reduction option” with respect to tobacco smoking
device that resembles tobacco cigarette and delivers and that “the hazard to health arising from long-term
nicotine that is vaporized electronically to simulate vapour inhalation from e-cigarettes available today
tobacco smoke [1]. E-cigarettes have been made is unlikely to exceed 5% of the harm from smoking
available commercially as a “healthier” substitute to tobacco” [12]. In contrast, the European Respiratory
tobacco and its use has become progressively common, Society (ERS) stated that there is no evidence that
predominantly among the youth [2-4]. Past 30-day e-cigarettes would be safer than tobacco in the long
e-cigarette use prevalence increased from 1.5% in 2011 term [13]. However, ERS did acknowledge that
to 20.8% in 2018 in United States (US) high school e-cigarette aerosol contained potentially less toxic
students [5]. A similar rise in e-cigarette use have been chemicals and in fewer concentration when compared
reported amongst adolescents in Poland, Korea, Canada, to conventional cigarette.
and Hong Kong [6-9]. Nurses play a critical role in screening, disease
Despite the fact that e-cigarettes are a worldwide prevention and smoking cessation for their patients.
phenomenon, there is a paucity of data regarding They have the potential to influence patient behaviour
the knowledge and attitude of e-cigarette users as well as promote healthy lifestyle. Nursing students’
particularly among the youth in the Philippines. Since knowledge and attitude towards e-cigarettes are of
its introduction in 2004, e-cigarettes have been marketed utmost importance because it has been demonstrated
as an alternative to nicotine delivery as well as been that healthcare providers who themselves smoke are less
advertised as a suitable means for smoking cessation likely to assess and counsel their patients about smoking
worldwide [10]. These claims made by e-cigarette cessation [14]. Healthcare providers as a group have
advertisers, have sparked an international debate as amongst the lowest rates of smoking with smoking rates
clinical and laboratory studies to determine the long and having declined among physicians and registered nurses
short-term potential harmful health effects on e-cigarette in the last two decades [15]. An international review
users remain insufficient and inconclusive [11]. of tobacco smoking among nurses revealed an overall
The data on use of e-cigarette and its potential harmful pattern of smoking reduction since the 1970’s with

E770 https://doi.org/10.15167/2421-4248/jpmh2021.62.3.1709
 ATTITUDE AND KNOWLEDGE ON E-CIGARETTES

higher rates in some developing countries. However, Tab. I. Socialized Tuition Fee Assistance Program bracketing accord-
ing to annual income.
Asian countries generally had lower rates for tobacco
smoking for female nurses who culturally are less Bracket Income (in Philippine Peso)
inclined to smoke [16]. Bracket 1 25,000 and below
Nevertheless, as the use of e-cigarettes increases Bracket 2 25,001-50,000
dramatically, nurses will have to adapt their counselling Bracket 3 50,001-75,000
skills to address these changes. Moreover, understanding Bracket 4 75,001-100,000
the nursing students’ knowledge and attitude towards Bracket 5 101,000-200,000
e-cigarettes would be valuable for development of Bracket 6 200,001-300,000
tobacco control activities. Furthermore, there is a Bracket 7 301,000-400,000
dearth of data on the knowledge and attitudes of Bracket 8 400,001-500,000
nursing student towards e-cigarettes in Asian countries, Bracket 9 Over 500,000
particularly Philippines [4]. Thus, the objective of this
study was to determine the knowledge and attitude of
nursing students towards e-cigarettes and to assess the on characteristics of e- cigarettes, its chemical content,
relationship between these two variables. health effects of e-cigarettes, regulation status and
policies on e-cigarettes. A correct answer to individual
question was assigned a score of “one” while a wrong
Methods answer fetched a score of “zero”. A cumulative score
range of 0-4.99 indicated that the participant had
The investigation was conducted among level 4 nursing insufficient knowledge about e-cigarettes whilst a
students of the Western Visayas State University cumulative score range of 5-10 demonstrated that
(WYSU), Iloilo city, Philippines using a descriptive the participant had sufficient knowledge about
correlation design. The total number of students in the e-cigarettes. Section four recorded the attitude of
level 4 nursing for the academic year 2017-2018 was participants towards e-cigarettes and consisted of 13
175 as ascertained by the Registrar’s office of WVSU. items. These set of questions measured the attitude
The sample size of the study was determined using and beliefs towards e-cigarettes as well as perceived
the Slovin’s formula (1960): n = N/ (1 + Ne2); where advantages and disadvantages of e-cigarettes with the
n = number of samples, N = total population admitted use of a Likert scale. It was categorized as attitudes
in level 4 in the University and e = error tolerance [17]. supporting e-cigarette use and attitudes opposing e-
The margin of error was set at 0.05 which provided a cigarette use. Response options on the 5-point Likert
confidence interval of 95% and the minimum sample size scale included “Strongly Agree”,” Agree”, “Neutral”,
was calculated to be 102. The simple random sampling “Disagree” and “Strongly Disagree”. Corresponding
technique was employed to determine the participants of points were given depending on the question: 5 points
the study. Participants not available on the day of data merited to responses having positive attitudes opposing
collection were replaced with other participants from the the use of e- cigarettes while those with negative
total population. attitudes supporting e-cigarette use garnered only 1
A standardized self-administered 25-point questionnaire point. Participants who obtained a score of 40 points
was used to gather data and consisted of four sections. or higher were classified as having positive attitudes
The standardized research instrument was adapted from opposing e-cigarette use while those who obtained a
University of Philippines Manila Public Health [18] and score of 39 or less were classified as having negative
several valid and reliable measures were accommodated attitudes supporting e-cigarette use.
from international tobacco research studies including Data were coded and entered in a computer to
National Youth Tobacco Survey [19] and Global facilitate retrieval, processing and statistical analyses.
Health Professional Surveyv[20]. Section one of the The questionnaire was tested in a pilot study which
questionnaire recorded personal data and information preceded the main study to test the feasibility of this
regarding the participant’s name, sex, smoking status, approach. The pilot study included 25 nursing students
socioeconomic status based on STFAP (Socialized of level 3 at the Western Visayas State University,
Tuition Fee Assistance Program) Bracketing. STFAP who were selected using the simple random sampling
program is a program where brackets are assigned technique. This study determined the appropriateness
to students based on their annual family income of the data collection method and assisted to identify
(Tab. I) [18]. Section two recorded the awareness status if the questionnaire format was comprehensible. The
of participants on e-cigarettes and consisted of only two data from the pilot study were not included in the
items. Item 1 recorded the participants’ awareness of main study. The standardized instrument underwent
e-cigarettes whilst item 2 determined how the participant reliability testing with Cronbach’s alpha score of 0.71
had learned about e-cigarettes. If the response of the for knowledge and 0.89 for attitude.
participants was yes, then they were categorized as Permission to conduct the study was secured from the
“aware” or otherwise “unaware”. University President of WVSU and from the Dean of
Part three determined the knowledge of participants the College of Nursing. The chi-square test was used
and consisted of 10 items that measured the knowledge to determine the significance of difference between

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 M. PALMES ET AL.

the scores obtained by the participants across different Pearson’s correlation coefficient demonstrated that
variables. Pearson’s Correlation Coefficient was there was no significant association between knowledge
used to measure the degree of association between and association towards e-cigarettes among the nursing
knowledge and attitude of the nursing students towards students (Computed r-value of -0.107 at 0.241).
e-cigarettes. The p-value for all inferential treatments
was set at 0.05. Tab. II. Distribution of participants according to sex, socioeconomic
status, smoking status, awareness status and source of awareness.
Category Frequency (%)
Results Sex
Male 13 (10.7)
Majority of the participants in this investigation
Female 109 (89.3)
(89.34%) were female and more than half of the
Socioeconomic status
participants (66.30%) belonged to Bracket 9 on the (STFAP bracket)
socioeconomic status scale. A large number of subjects Bracket 5 10 (8.2)
were never smokers (80.33%), while 11.48% were Bracket 6 7 (5.74)
former smokers and 8.20 % were current smokers. Bracket 7 16 (13.11)
Most of the participants (93.40%) were aware of the Bracket 8 6 (4.92)
existence of e-cigarettes and the most common source
Bracket 9 80 (65.57)
of this knowledge were “friends” (n = 95, 77.87%)
Smoking status
(Tab. II).
Non smoker 98 (80.33)
The nursing students had poor knowledge (Mean
Former smoker 14 (11.48)
score 3.50 ± 1.64) on e-cigarettes particularly on
Current smoker 10 (8.2)
the characteristics of e- cigarettes, chemical content,
Awareness status
health effects, regulation status and policies (Tab. III).
Aware 114 (93.4)
Participants belonging to bracket 5 had a significantly
Unaware 8 (6.6)
higher mean score (4.20 ± 2.35) for knowledge when
Source of awareness
compared to other brackets on the socioeconomic
Friends 95 (77.87)
status scale (p = 0.03). Also, current smokers had
Internet 88 (72.13)
a statistically significant (p = 0.04) higher mean
Saw one 81 (66.39)
score (4.30 ± 1.64) for knowledge when compared
TV/radio 49 (40.16)
to never smokers (3.42 ± 1.66) and former smokers
(3.50 ± 1.40). However, when classified according Stores 48 (39.34)
to sex, socioeconomic status, smoking status and Family 31 (25.41)
awareness status, the participants still demonstrated Printed materials 28 (22.95)
poor knowledge on e-cigarettes. Overall 122 (100)
Overall, the level 4 nursing students exhibited
an opposing attitude towards e-cigarette use Tab. III. Knowledge of nursing students on e-cigarettes categorized
(Tab. IV). However, when classified according according to sex, socioeconomic status, smoking status and aware-
to sex, socioeconomic status, smoking status and ness status.
awareness status, the participants had a varying Category Mean (± S.D.) Chi square test
attitude toward e-cigarette use. Male participants Sex
demonstrated an attitude supporting e-cigarette use Male 3.46 (1.45) χ2 (1) = 7.43, p = 0.15
(mean score 39.85 ± 4.90) while female participants Female 3.50 (1.66)
had a mean score of 40.07 which favoured attitude Socioeconomic
opposing e-cigarette use. However, this difference status
was statistically insignificant (p = 0.19). In terms Bracket 5 4.20 (2.35)
of socioeconomic status, participants belonging to Bracket 6 2.88 (1.46) χ2 (4) = 10.07, p = 0.03
Bracket 5, 6 and 8 had an attitude opposing e-cigarette Bracket 7 3.00 (1.75)
while participants belonging to Bracket 7 and Bracket Bracket 8 3.33 (1.97)
9 had an attitude supporting e-cigarette use (p = Bracket 9 3.60 (1.49)
0.67) (Tab. IV4). Majority of the participants were Smoking status
never smokers and maintained an attitude opposing Never 3.42 (1.66)
χ2 (2) = 4.6, p = 0.04
e-cigarette use. Former smokers favoured an attitude Former 3.50 (1.40)
opposing e-cigarette use while, participants who Current 4.30 (1.64)
were current smokers had an attitude supporting Awareness
e-cigarette use (p = 0.03). Furthermore, participants status
who were aware about the existence of e-cigarettes Aware 3.49 (1.65) χ2 (1) = 7.2, p = 0.14
exhibited an attitude supporting the use of e-cigarettes Unaware 3.63 (1.51)
when compared to students who had not heard about Overall 3.50 (1.64)
e-cigarettes previously (p = 0.04). 0.00-4.99: poor knowledge; 5.00-10.00: sufficient knowledge.

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Tab. IV. Attitude of nursing students on e-cigarettes categorized ac- It is possible that school environments with prevalent
cording to sex, socioeconomic status, smoking status and awareness
status.
e-cigarette use normalized not only e-cigarette use but
also “smoking-like” behaviours in general and thus led
Category Mean (± S.D.) Chi square test students to be more susceptible to cigarette smoking.
Sex This effect of e-cigarette use, if confirmed, would
Male 39.85 (4.90) χ2 (1) = 6.97, p = 0.19 represent a pathway by which e-cigarettes negatively
Female 40.07 (4.35) affect population health.
Socioeconomic The use of e-cigarettes has a conflicting influence
status
on assisting traditional smokers to quit cigarettes. A
Bracket 5 40.60 (5.21)
Cochrane review updated in 2016 concluded that nicotine
Bracket 6 40.63 (3.93) χ2 (4) = 11.77, p = 0.67 e-cigarettes helped smokers quit smoking in the long term
Bracket 7 39.94 (3.57) compared with placebo e-cigarettes but the evidence for
Bracket 8 42.67 (1.21) this conclusion was rated low [4, 22]. However, a meta-
Bracket 9 39.81 (4.67) analysis of 38 studies found that the odds of quitting
Smoking status traditional cigarettes were 28% lower in those who used
Never 40.09 (4.41) e-cigarettes than in those who did not [4, 23]. Hence, it is
χ2 (2) = 5.9, p = 0.03
Former 41.20 (3.36) critical to determine the knowledge and attitude related
Current 36.93 (5.69) to use of e-cigarettes particularly among students.
Awareness Although, majority of participants in this investigation
status were females, both males and females demonstrated
Aware 39.91 (4.47) χ2 (1) = 5.3, p = 0.04 similar level of knowledge on e-cigarettes. This result
Unaware 42.33 (2.24) is supported by the study of Lozano and colleagues
Overall 40.09 (4.41) (2015) who showed that levels of knowledge in students
40.00-65.00: attitude opposing e-cigarette; 00.00-39.99: attitude sup-
porting e-cigarette.
between sexes are similar [18]. However, community-
based surveys have revealed that knowledge rate was
higher among males (73.5%) than females (26.5%).
Discussion Also, in the present survey, the male participants
possessed an attitude supporting e-cigarette use when
Worldwide, e-cigarettes have surged in popularity with compared to females. This may be attributed to the fact
an increase in product awareness, rise in internet search the knowledge about cigarettes and similar products,
queries, and growth in sales [18]. Media marketing including e-cigarettes is considered a taboo for females
strategies through print, television, radio, and the and hence female participants may deliberately
internet such as endorsing with popular celebrities and deny knowledge of e-cigarettes and maintain an
brandishing various flavours to e-cigarettes have further attitude opposing the use of these products to avoid
amplified the popularity of e-cigarettes. A real-time retribution [24, 25].
surveillance method based on internet search query Education and income levels have shown to have
data from Google showed that searches for e-cigarettes inconsistent association with the awareness of
increased in all nations from July 2008 to February 2010; e-cigarettes [26]. Currently, there is no data on the
and were several hundred times greater than the search knowledge of e-cigarettes amongst Filipinos based
for smoking alternatives in the United Kingdom [2]. on their income bracket. In the present investigation,
However, the major contributor to the boosted sales of all nursing students demonstrated poor knowledge
these products is the frequent use of unsubstantiated about e-cigarettes based on their annual family income
marketing claims. These claims include: e-cigarettes bracket. This finding asserts the fact that e-cigarettes are
are healthier and cleaner than conventional cigarettes; comparatively a novel nicotine delivery product and no
e-cigarettes are smoking cessation aids; and the aerosols knowledge is imparted to the nursing students about e-
emitted are safe for people who are exposed, among cigarettes in their nursing curriculum. However, students
others. Although cited by some tobacco harm reduction belonging to the higher income groups i.e. bracket 7
advocates as a viable replacement for smoking, the and bracket 9 possessed an attitude supporting the use
limited scientific knowledge on the potential adverse of e-cigarettes though this finding was not statistically
health effects of the product has sparked disagreement significant. A plausible explanation for this outcome
and concern among healthcare authorities. Decades of is that the participants from the higher socioeconomic
efforts in tobacco control have reduced daily cigarette strata of the society may display a pretentious behaviour
smoking prevalence across many countries worldwide. and spuriously support the use of e-cigarettes as it is a
Any renormalization of tobacco through new products relatively contemporary commodity.
such as e-cigarettes would threaten to halt or reverse the An online survey of e-cigarette users found that 35%
progress made [9]. of the respondents heard about e- cigarettes from a
School level e-cigarette use has been associated with personal contact, 41% from the internet, 10% via
cigarette smoking susceptibility in never cigarette other media sources while 8% saw it being used [27].
smokers. This is consistent with the e-cigarette industry’s Likewise, nearly all healthcare providers (92%) were
vision of using vaping to renormalize smoking [21]. aware of e-cigarettes in an investigation conducted in

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 M. PALMES ET AL.

Minnesota [28]. The most frequently cited sources of may thus be affected by reporting bias. The findings of
information about e-cigarettes for healthcare providers the study pose an urgent need to be addressed in terms of
have been patient, news, stories, advertisements and the inadequacy of knowledge among nursing students in
internet rather than professional sources [18]. In relation to chemical content, possible health effects and
the present study, almost all students reported that regulation of e-cigarettes.
they had heard about e-cigarettes, indicating a high
level of awareness. These results are in line with
the results of other studies carried out in the United Conclusions
Kingdom and United States, which have also shown
high awareness among smokers and non-smokers in Nursing students did not have adequate knowledge
the adult population [29-31]. Irrespective of the source regarding e-cigarettes but maintained an attitude opposing
of information; it cannot be denied that personal e-cigarette use. Poor knowledge did not influence the
contacts and media have a vital role in the awareness attitude of participants towards e-cigarettes.
of e-cigarettes.
The knowledge about the content and regulations of
e-cigarettes has been low amongst the population. Acknowledgements
In spite of being aware of e-cigarettes, healthcare
providers knew “a little” or “nothing at all” about Funding sources: this research did not receive any
e- cigarettes [28]. Majority of young adults did specific grant from funding agencies in the public,
not know that some e-cigarettes contain nicotine commercial, or not-for-profit sectors.
and were incorrect about toxic chemical content
of e-cigarette [28]. Compared to knowledge about
e-cigarettes constituents, even fewer young adults were Conflict of interest statement
knowledgeable about the regulation [32]. The results of
this study revealed that even though nursing students The authors declare no conflict of interest.
had poor knowledge and were not familiar with the
characteristics of e- cigarettes, chemical content, health
effects, regulation status and policies but they still Authors’ contributions
possessed an attitude opposing to e-cigarette use. This
suggests that the participants were aware of healthy Study conception and design: PM, TSM.
demeanour and possessed an attitude promoting well Data acquisition: PM, TSM.
being. Analysis and interpretation of results: PM, TSM, SAK.
Knowledge about e-cigarettes may not necessarily be Draft manuscript preparation: PM, TSM, SAK.
related to smoking status [24]. However, in the present All authors reviewed the results and approved the final
study, current smokers had more information about version of the manuscript.
e-cigarettes than former smokers and non-smokers
probably due to their present exposure to smoking. Also, References
current smokers possessed an attitude supporting the use
of e-cigarettes. Likewise, participants who were aware [1] Caponnetto P, Campagna D, Papale G, Russo C, Polosa R. The
about the existence of e-cigarettes also displayed an emerging phenomenon of electronic cigarettes. Expert Rev
attitude supporting the use of this product. With the current Respir Med 2012;6:63-74. https://doi.org/10.1586/ers.11.92
survey design, it is difficult to ascertain the rationale [2] Ayers JW, Ribisl KM, Brownstein JS. Tracking the rise in
popularity of electronic nicotine delivery systems (electronic
behind this result but one conceivable explanation is cigarettes) using search query surveillance. Am J Prev Med
that the projection of e-cigarettes as smoking cessation 2011;40:448-53. https://doi.org/10.1016/ j.amepre.2010.12.007
tools as a marketing strategy, influences the decision of [3] Pippard BJ, Shipley MD. Healthcare staff attitudes towards the
current smokers to exhibit an attitude supporting the use use of if electronic cigarettes (‘e-cigarettes’) compared with a
of e-cigarettes. local trust policy. Perspect Public Health 2017;137:216-9. htt-
The current investigation provides new insights to the ps://doi.org/10.1177/1757913916659311
limited data available on the knowledge and attitude [4] Canzan F, Finocchio E, Moretti F, Vincenzi S, Tchepnou-
Kouaya A, Marognolli O, Poli A, Verlato G. Knowledge and use
of nursing students towards e-cigarettes. In spite of the
of e-cigarettes among nursing students: results from a cross-
interesting findings, this study is not without drawbacks. sectional survey in north-eastern Italy. BMC Public Health
Although the sample size for the study was sufficient 2019;19:976. https://doi.org/10.1186/s12889-019-7250-y
to conduct a statistical analysis, it is not large enough [5] Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A,
to be representative of all nursing college students. The King BA. Notes from the field: use of electronic cigarettes and
sample was drawn from the senior class and had higher any tobacco product among middle and high school students
proportions of female students. Thus, the study may not – United States, 2011-2018. MMWR Morb Mortal Wkly Rep
2018;67:1276-7. Https://doi.org/10.15585/mmwr.mm6745a5
represent the knowledge and attitude of the entire student
[6] Goniewicz ML, Gawron M, Nadolska J, Balwicki L, Sobczak
body particularly of male and younger college students. A. Rise in electronic cigarette use among adolescents in Poland.
Therefore, the ability to generalize the results is limited. J Adolesc Health 2014;55:713-5. https://doi.org/10.1016/j.jado-
The study was based on questionnaire survey data and health.2014.07.015

E774
 ATTITUDE AND KNOWLEDGE ON E-CIGARETTES

[7] Lee S, Grana RA, Glantz SA. Electronic cigarette use among bacco. 2012. Retrieved from: http://www.cdc.gov/mediareleas-
Korean adolescents: a cross-sectional study of market pen- es/2012/p0802_tobacco_consumption.html
etration, dual use, and relationship to quit attempts and for- [20] CDC Foundation. World Health Organization and World Lung
mer smoking. J Adolesc Health 2014;54:684-90. https://doi. Foundation. The GATS Atlas: Global Adult Tobacco Survey
org/10.1016/j.jadohealth.2013.11.003 2015. Retrieved from: http://www.who.int/tobacco/publica-
[8] Azagba S, Baskerville NB, Foley K. Susceptibility to cigarette tions/surveillance.gatlas/en
smoking among middle and high school e-cigarette users in [21] Fairchild AL, Bayer R, Colgrove J. The renormalization of
Canada. Prev Med 2017;103:14-9. https://doi.org/10.1016/j. smoking? E-cigarettes and tobacco “endgame”. N Engl J Med
ypmed.2017.07.017 2014;370:2354. https://doi.org/10.1056/NEJMp1313940
[9] Chen J, Ho SY, Leung LT, Wang MP, Lam TH. School-level [22] Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead
electronic cigarette use prevalence and student-level tobacco LF, Hajek P. Electronic cigarettes for smoking cessation.
use intention and behaviours. Sci Rep 2019;9:1690. https://doi. Cochrane Database Syst Rev 2016;9:CD010216. https://doi.
org/10.1038/s41598-018-38266-z org/10.1002/14651858.CD010216.pub3
[10] Bertholon JF, Becquemin MH, Annesi-Maesano I, Dautzen- [23] Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation
berg B. Electronic cigarettes: a short review. Respiration in real-world and clinical settings: a systematic review and
2013;86:433-38. https://doi.org/10.1159/000353253 meta-analysis. Lancet Respir Med 2016;4:116-128. https://doi.
[11] Farsalinos KE, Romagna G, Allifranchini E, Ripamonti E, Boc- org/10.1016/S2213-2600(15)00521-4
chietto E, Todeschi S, Tsiapras D, Kyrzopoulos S, Voudris V. [24] Abo-Elkheir OI, Sobh E. Knowledge about electronic cigarettes
Comparison of the cytotoxic potential of cigarette smoke and and its perception: a community survey, Egypt. Respir Res
electronic cigarette vapour extract on cultured myocardial cells. 2016;17:58. https://doi.org/10.1186/s12931-016-0365-0
Int J Environ Res Public Health 2013;10:5146-62. https://doi.
[25] Shaikh A, Ansari HT, Ahmad Z, Shaikh MY, Khalid I, Jahangir
org/10.3390/ijerph10105146
M, Majeed A, Shakeel N, Ahmed A, Memon RS, Tariq E, Irfan
[12] Royal College of Physicians. Nicotine without smoke: tobacco R, Madni D. Knowledge and attitude of teenagers towards elec-
harm reduction. London: RCP 2016. Available at: https//www. tronic cigarettes in Karachi, Pakistan. Cureus 2017;9:e1468.
rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-to- https://doi.org/10.7759/cureus.1468
bacco-harm-reduction-0 (accessed January 5, 2020).
[26] King BA, Alam S, Promoff G, Arrazola R, Dube SR. Aware-
[13] Bals R, Boyd J, Esposito S, Foronjy R, Hiemstra PS, Jiménez- ness and ever-use of electronic cigarettes among U.S. adults,
Ruiz CA, Katsaounou P, Lindberg A, Metz C, Schober W, Spira 2010-2011. Nicotine Tob Res 2013;15:1623-7. https://doi.
A, Blasi F. Electronic cigarettes: a task force report from the org/10.1093/ntr/ntt013
European Respiratory Society. Eur Respir J 2019;53:1801151. [27] Dawkins L, Turner J, Roberts A, Soar K. ‘Vaping’ profiles and
https://doi.org/10.1183/13993003.01151-2018 preferences: an online survey of electronic cigarette users. Ad-
[14] Braun BL, Fowles JB, Solberg LI, Kind EA, Lando H, Pine diction 2013;108:1115-25. https://doi.org/10.1111/add.12150
D. Smoking-related attitudes and clinical practices of medical [28] Pepper JK, Reiter PL, McRee AL, Cameron LD, Gilkey MB,
personnel in Minnesota. Am J Prevent Med 2004;27:316-22. Brewer NT. Adolescent males’ awareness of and willingness
https://doi.org/10.1016/j.amepre.2004.07.010 to try electronic cigarettes. J Adolesc Health 2013;52:144-150.
[15] Sarna L, Bialous SA, Nandy K, Antonio AL, Yang Q. Changes https://doi.org/10.1016/j.jadohealth.2012.09.014
in smoking prevalences among healthcare workers from 2003 [29] Dockrell M, Morrison R, Bauld L, McNeill A. E-cigarettes:
to 2010-2011. JAMA 2014;311:197-9. https://doi.org/10.1001/ prevalence and attitudes in Great Britain. Nicotine Tob Res
jama.2013.284871 2013;15:1737-44. https://doi.org/10.1093/ntr/ntt057
[16] Smith DR, Leggat PA. An international review of tobacco smok- [30] Zhu SH, Gamst A, Lee M, Cummins S, Yin L, Zoref L. The
ing research in the nursing profession, 1976-2006. J Res Nursing use and perception of electronic cigarettes and snus among U.S.
2007;12:165-81. https://doi.org/10.1177/1744987106074875 population. PLoS One 2013;8:e79332. https://doi.org/10.1371/
[17] Blair E, Blair J. Applied survey sampling. USA: Inc journal.prone.0079332
Sage Publications 2015. https://doi.org/https://dx.doi. [31] Brown J, West R, Beard E, Michie S, Shahab L, McNeill A.
org/10.4135/9781483394022 Prevalence and characteristics of e-cigarettes users in Great
[18] Lozano P, Sabino A, David V, Villarta Jr. R, Salvedia K. Aware- Britain: findings from a general population survey of smokers.
ness, knowledge, attitudes and practices (AKAP) toward elec- Addict Behav 2014;39:1120-25. https://doi.org/10.1016/j.ad-
tronic cigarettes among 3rd and 4th year undergraduate students dbeh.2014.03.009
of the University of the Philippines. November 2015. https:// [32] Sanders-Jackson AN, Tan AS, Bigman CA, Henriksen L.
doi.org/10.13140/RG.2.1.4242.8881 Knowledge about e-cigarette constituents and regulation: re-
[19] Centres for Disease Control and Prevention. Drop in cigarette sults from a national survey of U.S. young adults. Nicotine Tob
consumption offset by increases in other forms of smoked to- Res 2015;17:1247-54. https://doi.org/10.1093/ntr/ntu276

Received on August 4, 2020. Accepted on June 23, 2021.

Correspondence: Anand K. Sajnani, KIMS Qatar Medical Centre, Abdulrahman Bin Jassim Al Thani Street, 82125 Wakra, Qatar - Tel.:
+974-30181952 - E-mail: aksajnani@gmail.com

How to cite this article: Palmes M, Trajera SM, Sajnani AK. Knowledge and attitude related to use of electronic cigarettes among under-
graduate nursing students in an urban university setting in Philippines. J Prev Med Hyg 2021;62:E770-E775. https://doi.org/10.15167/2421-
4248/jpmh2021.62.3.1709

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