|Year : 2020 | Volume
| Issue : 4 | Page : 318-322
Awareness regarding E-cigarettes among public health dentists in dental colleges of Bengaluru: A population study
Aarya N Bharadwaj, B Vijayalakshmi, Rekha Raju, Radha Gubbihal, Pallavi Swami Kousalya
Department of Public Health Dentistry, V S Dental College and Hospital, Bengaluru, Karnataka, India
|Date of Submission||06-Mar-2020|
|Date of Decision||07-Apr-2020|
|Date of Acceptance||07-Oct-2020|
|Date of Web Publication||16-Dec-2020|
Aarya N Bharadwaj
Department of Public Health Dentistry, V S Dental College and Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Available in the market as replacements to conventional cigarettes, the evidence regarding the efficacy of electronic cigarettes (E-cigarettes) in smoking cessation is unclear, while potentially harmful health effects have been reported. Public health dentists in dental colleges are likely to encounter E-cigarette users as they are involved in tobacco cessation counseling. Aim: The aim was to assess the knowledge and awareness about E-cigarettes among dental public health faculty and postgraduate students in dental colleges of Bengaluru. Materials and Methods: Dental public health faculty members and postgraduate students in all dental colleges of Bengaluru participated in this population-based, cross-sectional, questionnaire study. Questionnaires were handed out after written consent was obtained. Questions included the participants' details and ten knowledge questions with sub-questions on E-cigarettes. Data analysis was done by computing descriptive statistics and Chi-square test to determine its associated factors using SPSS v. 22. Level of significance was kept at 5%. Results: A total of 129 public health dentists were a part of the study, with 60.5% being postgraduate students and the rest comprising faculty members. One hundred and seven participants had previously heard of E-cigarettes. The mean knowledge score of the whole study population was 5.813 (standard deviation –1.83) out of a maximum score of 14 and was considered fair. This was statistically significantly associated with participants' smoking status (P = 0.05). Conclusions: This study concluded that most participants were aware of E-Cigarettes. Their knowledge level ranged from poor to fair and was significantly associated with their smoking status.
Keywords: Awareness, cross-sectional study, electronic nicotine deliver systems, nicotine, public health dentistry, vaping
|How to cite this article:|
Bharadwaj AN, Vijayalakshmi B, Raju R, Gubbihal R, Kousalya PS. Awareness regarding E-cigarettes among public health dentists in dental colleges of Bengaluru: A population study. J Indian Assoc Public Health Dent 2020;18:318-22
|How to cite this URL:|
Bharadwaj AN, Vijayalakshmi B, Raju R, Gubbihal R, Kousalya PS. Awareness regarding E-cigarettes among public health dentists in dental colleges of Bengaluru: A population study. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2021 Apr 13];18:318-22. Available from: https://www.jiaphd.org/text.asp?2020/18/4/318/303639
| Introduction|| |
Electronic cigarettes (Electronic Nicotine Delivery Systems/E-cigarettes) are battery-powered vaporizers that, without tobacco, simulate the feeling of smoking, and, thus avoid the adverse health effects of conventional cigarette smoking. While limited evidence is available on the potential health effects of these products, these devices have gained popularity in the last two decades, as “safer” alternative to conventional cigarette smoking.
The benefits, risks, and the cumulative impact of these products are occurring in the current context of widespread and continuous availability of conventional cigarettes and other tobacco products. It is expected that, over time, more smokers will seek advice from health-care professionals about these devices as alternatives to smoking products considering the exponential growth in awareness and use of E-cigarettes over the past few years., Dental health professionals who play a pivotal role in the tobacco cessation process may themselves not be fully aware of E-cigarettes and the potential harms associated with them.
Dental colleges and hospitals now provide mandatory structured tobacco cessation services and have thereby recognized the value of this health maintenance intervention. Public health dentists, both faculty members and postgraduate students, at all dental institutions can actively involve in tobacco cessation counseling and can incorporate information on nicotine addiction, tobacco use, and these alternate devices into patient counseling to promote safe and effective smoking cessation strategies.,
Little is known about their awareness regarding these emerging trends. Understanding public health dentists' knowledge about emerging tobacco trends is an important step toward improving best practice guidelines to prompt effective tobacco control practices. Thus, the purpose of the current study was to assess the awareness regarding E-cigarettes among dental public health faculty and postgraduate students in dental colleges of Bengaluru.
| Materials and Methods|| |
Between June and August 2018, a cross-sectional, population-based, questionnaire study on all the faculty and postgraduate students in the department of public health dentistry in dental colleges in Bengaluru city was conducted following the STROBE guidelines. This study was approved by the institutional review board, and permission to conduct the survey was obtained from the respective college authorities (ref no. VSDCH/414/2018–19). As this was a population-based study, no sample was drawn. The investigator visited all the dental colleges and invited the faculty members and postgraduate students in 16 colleges to participate in the study. Information about the study and informed consent was handed out to the study participants and those who gave consent to be a part of this study were given the study questionnaire. All postgraduates and faculty members who were available during the study period were included in the survey.
A self-administered questionnaire in English was handed out to the participants and their demographic information, such as age, gender, designation, clinical/teaching experience, and smoking status, was sought. The second section of the questionnaire had ten questions on E-Cigarettes with sub-questions that were adapted from a study done by Anatasia Moysidou et al. and modified according to the objectives of this study. Content validity, which was performed using Aiken, was 0.96 and interpreted as excellent. A total of 14 questions were considered knowledge questions and were scored 1 for the right answer and 0 for the wrong answer. The investigator was present during the completion of the questionnaire and answered any doubts and cleared any queries regarding the questions.
Descriptive statistics such as frequencies and proportions were calculated. Associations between discrete variables were assessed using the Chi-square test. Data analysis was conducted using SPSS software version 22 (SPSS Inc., Chicago, IL, USA). Statistical significance was determined atP≤ 0.05.
| Results|| |
The study included all faculty members and postgraduate students of public health dentistry in dental colleges of Bengaluru that totaled up to 154 participants. Ten participants were a part of the pilot study and were not included in the final analysis, 15 participants were excluded as they were not available during the study period, and a total of 129 participants returned the duly filled questionnaire, with a response rate of 89%, who were included in the final analysis. The mean age of the study participants was 31.15 ± 7.34 years [Table 1]. Majority of the study participants belonged to the age group of 25–34 years and over half of the study participants were female. Postgraduate students formed 60.5%, while dental public faculty formed 39.5% of the study participants. About 44% of the study participants had no prior clinical and/or teaching experience and 91.5% of the study participants were nonsmokers [Table 1].
|Table 1: Distribution of demographic information of the study participants|
Click here to view
In this study, 83.7% of the participants had previously heard about E-cigarettes, while 28.8% answered that nicotine in these devices was extracted from tobacco [Table 2]. Half of the participants rightly answered that there was no regulatory body for E-cigarettes in India, and close to half (47.2%) were unaware of any ban on these devices in Karnataka [Table 2].
Half of the study participants identified correct statements regarding E-cigarettes [Figure 1]. In comparison with traditional cigarettes, most participants answered that the harmful health effects of E-cigarettes were lesser, except regarding dependence potential, which participants felt as being similar with both the products [Figure 2]. As alternative methods in tobacco cessation, a higher percentage of participants felt that these devices were not suitable [Figure 3].
|Figure 1: Awareness regarding different properties of electronic cigarettes|
Click here to view
The overall mean knowledge score of the study participants was 5.813 ± 1.83 out of a maximum score of 14, with 34.9% having poor knowledge, 64.3% having fair knowledge, and 0.8% having good knowledge [Table 2]. A statistically significant association between E-Cigarette awareness and smoking status was observed (P = 0.05) [Table 3].
|Table 3: Association between participant characteristics and E-cigarette knowledge|
Click here to view
| Discussion|| |
E-cigarettes are considered safe when compared to traditional cigarettes as the combustion of hydrocarbons in tobacco that results in the release of carcinogens does not occur in E-cigarettes., However, the US-Food and Drug Administration-regulated products such as nicotine inhalers are safer than E-cigarettes. Various testimonials by long-term users of E-cigarettes have mentioned the use of these in successful quitting of many years' tobacco use, while other literature suggests the negative impact of E-cigarette usage. Combined with these contradictions, concerns about long-term effects of the constituents of the E-liquid continue to grow.
Public health dentists play an important role in tobacco cessation and abstinence. This specialty can, apart from assisting in early diagnosis, offer indispensable care and necessary behavioral support and can create a general awareness of various oral health-related diseases and measures to manage them. Public health dentists can also identify and motivate individuals and collaborate with an interdisciplinary team to assist those individuals in quitting tobacco habits and other deleterious habits.
In the current study, current and former smokers constituted a small fraction of the study participants. Literature has evidence that smokers have higher knowledge regarding tobacco, as observed in this study. Current and former smokers had fair to good knowledge about E-cigarettes, and this was significantly associated with their smoking status, where participants with the highest knowledge score were smokers.
A high percentage of the participants had previously heard about E-cigarettes, among whom, the highest source of knowledge was from social media and professional sources, as was observed in the literature., Most of those who were not aware of E-cigarettes were postgraduate students, and this lack of awareness could be due to their relatively recent entry into the field of dental public health.
The E-cigarette knowledge among the study participants was borderline fair, similar to that of a study by Franks et al. Similar to the results of a study by Joshi, in this study, more than half were aware of the make, usage, health effects, and current status of these devices. This reflects the increasing popularity of these devices among health-care students. Tobacco ever use is prevalent among young adults and is a developing health controversy; public health dentistry students are likely to have direct or indirect experience with these. With a future in public health, they are in the position to initiate patient conversations on the subject.
One of the common misconceptions about E-cigarettes is that as it is a battery-driven device, everything about it, including the nicotine, is synthetically produced. Only a small fraction of the participants were aware of the natural source of tobacco in E-cigarettes, which is better than the findings in a study conducted by Moysidou, et al. Synthetic tobacco is not a typical source for nicotine in E-liquids because it is extremely costly to produce. Similar results observed regarding the lower working temperature in E-cigarettes, their availability without nicotine, mechanism of vapor formation, and approval status shed light on how the study participants have just heard of these devices while being not exactly aware and clear about the functioning of these devices or how these devices impact health.
E-cigarettes lend itself to modifications than can impact the nicotine concentration of the E-liquid and the amount delivered to the user. However, it not always delivers a lesser amount of nicotine than conventional cigarettes. The nicotine content of E-cigarettes can vary from 0 mg/mL (no nicotine) to over 25 mg/mL. Regarding its health effects, the results of this study are comparable with the findings in studies by Carreras-Presas et al., Moysidou, et al., and Carreras-Presas et al. While various bodies such as the National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; and the Surgeon General's Report have stressed on the fact that E-cigarette inhalation has adverse health effects, the effect is lesser when compared to that of conventional cigarettes. Consistent with the literature,, the present study findings show that its dependence potential is similar to/less than that of conventional cigarettes and that these devices have significant effects if second-hand exposure occurs. The US Surgeon General's report in 2016 on E-cigarettes concluded that E-cigarette aerosol is not harmless.
E-cigarettes are not approved as nicotine replacement therapies. A higher percentage of participants considered these devices ineffective in smoking cessation and would not recommend them to smokers who have been unable to quit through other methods. These findings are higher than those observed in the literature,, wherein E-cigarettes were considered effective smoking cessation tools. The effectiveness of E-cigarettes in helping smokers quit tobacco usage is still much of debate even among the health-care fraternity. A systematic review by Hartmann-Boyce et al. concluded that because there are a limited number of randomized trials reported so far on the smoking cessation efficacy of these devices, the certainty about the effects is low and that more data would be needed to strengthen this.
During this study period, India was considering a ban on E-cigarettes, although no strict regulations had been put forth by any specific regulatory body. Of the participants, close to half were unaware of any regulatory framework existed in India. Twelve states in India had banned E-cigarettes following an advisory from the Government of India-Ministry of Health and Family Welfare issued in 2018. When asked about the status in Karnataka, a small fraction knew that these devices were banned in the state.
In this study, apart from smoking status, no association was found between E-cigarette knowledge and participants' experience or designation or gender. The WHO, under its mPOWER measure, mentions that both smokers and nonsmokers equally very rarely understand the full extent of the health risks of smoking despite the availability of conclusive evidence on the dangers of tobacco. Dental professionals, however, are aware of the negative impact of tobacco on health. Thus, this association could be due to the small number of smokers in this study.
This study is the first to provide a comprehensive evaluation of E-cigarette knowledge and awareness among dental public health faculty and postgraduate students in Bengaluru. However, inherent limitations may exist that limit the generalizability of the results to other cities and countries. The study population included only dental public health professionals at dental colleges in Bengaluru who are expected to stay updated on the emerging trends in oral health. The sales and ban of E-cigarettes in different states in India could impact the knowledge about these due to their effects on its advertising and marketing. The E-cigarette questionnaire used in this study was adopted from a previous study where it was developed by the authors for use among a sample of various health professionals. It may not cover all aspects of perceptions on E-cigarettes and may not apply to other populations. Although the participants' responses were anonymous, they may have elected to provide socially desirable responses. Finally, this industry remains a rapidly evolving marketplace where new information is being updated constantly at the national and international platforms. The effects of these new additions on the awareness of E-cigarettes among dental public health professionals are unknown.
| Conclusions|| |
This study concluded that more than half of the dental public health faculty and postgraduate students in dental colleges were aware of E-cigarettes. Dentists, particularly dental public health personnel, need to keep abreast with the useful and latest information relevant to nicotine addiction, tobacco use, and smoking cessation.
The authors wish to thank the department of public health dentistry of all dental colleges in Bengaluru for their support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bond CM. Do the benefits of electronic cigarettes outweigh the risks? Can J Hosp Pharm 2018;71:44-7.
Grana R, Benowitz N, Glantz S. Background Paper on E-cigarettes. Center for Tobacco Control Research and Education, University of California, San Francisco and WHO Collaborating Center on Tobacco Control; 2013.
Adkison SE, O'Connor RJ, Bansal-Travers M, Hyland A, Borland R, Yong HH, et al
. Electronic nicotine delivery systems: International tobacco control four-country survey. Am J Prev Med 2013;44:207-15.
Yaldrum A, Ramachandra SS, Arora S, Gujjar KR, Dicksit DD, Squier CA. Knowledge, attitude and willingness to counsel patients regarding e-cigarettes among academic health professionals in Malaysia. Tob Prev Cessation 2017;3:6.
Dockrell M, Morrison R, Bauld L, McNeill A. E-cigarettes: Prevalence and attitudes in Great Britain. Nicotine Tob Res 2013;15:1737-44.
Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: Findings from the Cochrane library. BMJ 2000;321:355-8.
Neumann A, Kumar S, Bangar S, Kookal KK, Spallek H, Tokede O, et al
. Tobacco screening and cessation efforts by dental providers: A quality measure evaluation. J Public Health Dent 2019;79:93-101.
Moysidou A, Farsalinos KE, Voudris V, Merakou K, Kourea K, Barbouni A. Knowledge and Perceptions about Nicotine, Nicotine Replacement Therapies and Electronic Cigarettes among Healthcare Professionals in Greece. Int. J. Environ. Res Public Health 2016;13:514-39.
Aiken LR. Content validity and reliability of single items or questionnaires. Educ Psychol Meas 1980;40:955-9.
Knorst MM, Benedetto IG, Hoffmeister MC, Gazzana MB. The electronic cigarette: the new cigarette of the 21st
century? J Bras Pneumol 2014;40:564-72.
Burstyn I. Peering through the mist: Systematic review of what the chemistry of contaminants in electronic cigarettes tells us about health risks. BMC Public Health 2014;14:18.
Drummond MB, Upson D. Electronic cigarettes. Potential harms and benefits. Ann Am Thorac Soc 2014;11:236-42.
Carreras-Presas CM, Naeim M, Vázquez CA, Pérez M LS, Pérez S, Hsiou S, et al
. Spanish Dental student's perceptions about e-cigarettes as tobacco cessation aids. Tob Prev Cessation 2018;4:A144.
Franks AM, Hawes WA, McCain KR, Payakachat N. Electronic cigarette use, knowledge, and perceptions among health professional students. Curr Pharm Teach Learn 2017;9:1003-9.
Joshi S. Knowledge, Perceptions and Behavior Regarding E-cigarettes among Dental Practitioners [thesis]. Baltimore: University of Maryland; 2018.
Goldenson NI, Leventhal AM, Stone MD, McConnell RS, Barrington-Trimis JL. Associations of electronic cigarette nicotine concentration with subsequent cigarette smoking and vaping levels in adolescents. JAMA Pediatr 2017;171:1192-9.
Carreras-Presas CM, Naeim M, Hsiou D, Perez ML, Messadi DV. The need to educate future dental professionals on E-cigarette effects. Eur J Dent Educ 2018;22:e751-8.
In: Eaton DL, Kwan LY, Stratton K, editors. Public Health Consequences of E-Cigarettes. Washington (DC): National Academies Press (US); 2018.
US Department of Health and Human Services. E-cigarette Use among Youth and Young Adults. A Report of the Surgeon General. Atlanta (GA): US Department of Health and Human Services; 2016.
Stephens WE. Comparing the cancer potencies of emissions from vaporised nicotine products including e-cigarettes with those of tobacco smoke. Tob Cont 2018;27:10-7.
Kamalu N, Prathibha B. E-cigarettes: Views of healthcare professionals. Eur Respir J 2015:46;PA4130.
Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2016;9:CD010216.
World Health Organization. Tobacco-Free Initiative: mPOWER brochures and other resources. Available from: https://www.who.int/tobacco/mpower/publications/en_tfi_mpower_brochure_w.pdf?ua=1. [Last accessed on 2019 Mar 25].
Saddichha S, Rekha DP, Patil BK, Murthy P, Benegal V, Isaac MK. Knowledge, attitude and practices of Indian dental surgeons towards tobacco control: advances towards prevention. Asian Pac J Cancer Prev 2010;11:939-42.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]