Usage, knowledge and attitudes towards electronic cigarettes use among nursing students in Croatia: a cross-sectional study

The study protocol was approved by the Ethics Committee of the Catholic University of Croatia (Class: 602-04/23 − 11/045, Reg. No.: 498-15-06-23-004) and subsequently by Ethics committees of all other universities that participated in the study. Written informed consent was obtained from all study participants. The study was conducted in accordance with the institutional Codes of Ethics. All methods were performed in accordance with the relevant guidelines and regulations.

A cross-sectional study was conducted using an online questionnaire. The study began on March 5, 2024, with the first invitation sent to students. The first reminder was sent on March 12, 2024, and the second reminder on March 19, 2024.

The participants were undergraduate (bachelor’s) and graduate (master’s) nursing students, regardless of their study status (full-time and part-time). An invitation to participate in the study was sent to 11 higher education institutions in Croatia. Ten institutions agreed to participate in the study: (1) Department of Nursing, Catholic University of Croatia in Zagreb; (2) Faculty of Dental Medicine and Health; Josip Juraj Strossmayer University of Osijek; (3) Faculty of Health Studies, University of Rijeka; (4) Department of Health Studies, University of Zadar; (5) Nursing and Clinical Nursing Studies, University of Dubrovnik; (6) Department of Nursing, University of Juraj Dobrila in Pula; (7) University Department of Health Studies, University of Split; (8) University of Applied Health Sciences in Zagreb; (9) Nursing Studies, Polytechnic of Bjelovar; (10) Department of Nursing, University North in Varaždin.

First, the link to the survey and accompanying files were sent to the nursing program coordinators in each institution. Then, the coordinators invited students via e-mail to participate in the study. Students accessed the questionnaire (Appendix 1) via online link to the Lime Survey platform. Before completing the questionnaire, students were asked to read the information sheet about the study (Appendix 2) and to provide in the online platform their informed consent to participate, after which they were able to access the questionnaire. The students were not offered any compensation or any other incentive to participate in the survey.

The questionnaire was adapted from the study conducted by Alsanea et al. [21]. The questionnaire was translated from English to Croatian. First, two individuals independently translated the questionnaire from English to Croatian. Then, a unified version of the Croatian translation was created. After that, two individuals independently performed a back-translation into English, and the back-translation was compared with the original English version. The pre-final version of the Croatian translation was tested on eight students of the School of Medicine at the Catholic University of Croatia. After the pilot testing, minimal linguistic revisions were made to the questionnaire. The responses from the medical students in the pilot testing were not included in the study.

The first part of the questionnaire consisted of sociodemographic questions—such as their higher education institution, study status (full-time or part-time), year of study, education on smoking cessation topics at the university, gender, age, smoking status, e-cigarette use, and the purpose of their use. The second part of the questionnaire included 11 questions on students’ knowledge and attitudes. Five knowledge-related questions were either multiple-choice questions with three possible answers or questions on a Likert scale. For multiple-choice questions, one answer was considered correct. For Likert scale-based questions, two answers were considered correct (“strongly agree” and “agree” were considered the same; “disagree” and “strongly disagree” were also considered the same), with the participant receiving one point if either of these options was selected. The total knowledge score for each student could range from 0 to 5. The remaining six questions in the second part pertained to perceptions and attitudes assessed using Likert scales or multiple-choice questions. To examine participants’ attitudes toward the role of nurses in counseling patients and assisting with smoking cessation, three questions from the modified Croatian translation of the “19-item Helping Smokers Quit” questionnaire from the Master of Nursing thesis of Lovro Ačkar [22, 23] were added to the questionnaire.

The results of this study indicate that smoking and e-cigarette use among nursing students in Croatia was alarmingly high in 2024. Nearly half of the participants (43%) reported being current smokers, and over half of the participants in our study reported using e-cigarettes, with 76% using them recreationally and 24% using them as a smoking cessation aid. These findings highlight that cigarette smoking and e-cigarette use among nursing students in Croatia represent a significant public health concern.

In general population, adult smoking prevalence in Croatia is 36% [24]. We do not have current data on the prevalence of smoking among healthcare professionals, particularly nurses, at the national level in Croatia. However, the findings from this survey, indicating that nurses smoke at higher rates than the general population, are especially concerning. Healthcare professionals are expected to have greater awareness of the health consequences of smoking and to serve as role models by promoting healthier behaviors.

A very similar percentage of smokers was reported in a 2022 study by Čivljak et al. conducted among registered nurses employed at Sestre Milosrdnice University Hospital Center in Zagreb, where 44% of surveyed nurses reported to be current smokers [23]. Furthermore, a study of Kuzmić, conducted in 2023 among nurses in Croatia examined the knowledge, attitudes, and experiences of 139 nurses regarding smoking. Among the participants, 46% were current smokers, and 16% used e-cigarettes. The proportion of smokers in that study was similar to the results in our sample [25].

Another online study conducted in 2022 among 318 nurses in Croatia showed that the majority (63%) smoked cigarettes, nearly 20% used e-cigarettes, and 25% did not use any tobacco products [26]. Differences in the prevalence of e-cigarette use described in our study and those two studies could be explained by differences in the way questions about e-cigarette use were asked. For example, in Ritoša’s study, which was conducted among nurses in Croatia, the question was phrased as “I consume tobacco in the form of (cigarettes/e-cigarettes/chewing tobacco or do not consume)” [26]. In Kuzmić’s study, the question was phrased as “In what form do you consume tobacco products?” [25].

In our study, the question was phrased as “Have you ever used e-cigarettes? Yes/No.” Therefore, in our study, the question did not pertain to current e-cigarette use but to the experience of e-cigarette use, which may have been in the past. To summarize, the high prevalence of smoking among nurses and nursing students in Croatia is a cause for concern. Therefore, particular attention should be given to interventions to aid nurses to quit smoking.

A systematic review by Duaso et al. published in 2017, which included 14 studies from the USA, Canada, and Europe, showed that the prevalence of smoking ranged from 4.0 to 47%. Fewer nurses in North America smoked compared to European countries [27].

Furthermore, Nilan et al., in 2019, published a systematic review on the prevalence of tobacco use among healthcare workers. The review included data from 229 studies conducted across 63 countries, covering prevalence data on 457,415 health care workers collected between 2000 and 2014. Of these studies, 65 studies contained data on nurses. According to this study, the pooled prevalence of smoking among women nurses was 18%, and among men nurses it was 28% [14].

The findings of our study indicate that knowledge of nursing students about e-cigarettes is insufficient. Only 0.2% of participants correctly answered all the knowledge-assessing questions. Smokers and former smokers were more likely than non-smokers to correctly identify that e-cigarettes are not well-known smoking cessation products. Additionally, more students who smoked correctly recognized the harmful effects of e-cigarettes compared to non-smokers. However, non-smokers were more likely than smokers and former smokers to correctly answer that e-cigarettes do not only produce vaporized nicotine. Regarding the statement that long-term use of e-cigarettes increases the dose of inhaled carcinogens and cytotoxic substances, there were no statistically significant differences in knowledge between groups based on their smoking status. Over half of the students (66%) indicated they cannot confidently advise smokers about e-cigarettes. Furthermore, the majority of students had a negative attitude toward e-cigarettes as a smoking cessation method. When comparing students’ attitudes based on their smoking status, no statistically significant differences were found in the responses.

Multiple studies have explored nursing and medical students’ knowledge and attitudes toward e-cigarettes, revealing varying levels of understanding. A 2021 study in the Philippines found that smokers among nursing students had more knowledge than non-smokers, though overall knowledge was insufficient [28]. Those findings were similar to our study.

In Saudi Arabia, medical and dental students exhibited slightly better knowledge about e-cigarettes than their peers, and non-smokers generally had greater knowledge than smokers [21]. Those findings are in contrast with our study in Croatia, where non-smokers did not demonstrate significantly greater knowledge about e-cigarettes. In fact, more smokers answered two questions correctly than non-smokers. In contrast, a study conducted at the University of Jordan showed a high level of knowledge about e-cigarettes [29].

When it comes to the attitudes and perceptions of nursing students toward e-cigarettes, slightly more than half of the students would not support the use of electronic cigarettes as a smoking cessation method. Over two-thirds of students indicated that e-cigarettes can encourage smoking among non-smokers and lead to nicotine addiction in smokers of conventional tobacco cigarettes. A meta-analysis and systematic review conducted by Soneji et al. provides consistent and strong evidence linking the use of electronic cigarettes with a high likelihood of initiating and continuing usage of tobacco cigarettes among adolescents and young adults [30].

Over 80% of the students indicated that e-cigarettes are used more as a modern alternative to conventional tobacco cigarettes than as a smoking cessation method, while more than half of the students disagreed with the statement that if they lack sufficient knowledge about electronic cigarettes, they should not ask the patient whether they have or haven’t used them. Additionally, 63% of students who participated in the study from Saudi Arabia believe that electronic cigarettes are a modern alternative to tobacco cigarettes [21]. More than half of the students (66%) were not confident in their ability to advise smokers about e-cigarettes.

More than two-thirds (70%) of the students indicated that physicians should be the most knowledgeable healthcare professionals to educate and advise users of electronic cigarettes and lead smoking cessation programs, while less than one-third (25%) of the students indicated that this role should belong to nurses. Research evidence suggest that interventions conducted by nurses are of high quality and proven effectiveness, and the support they provide increases the chances of smoking cessation among those who have developed nicotine addiction [11, 31].

In this study, a comparison of students’ attitudes based on smoking status revealed that there was no statistically significant difference in the attitudes of students toward the use of e-cigarettes, in our sample. On the other hand, a study conducted in the Philippines found different results. Comparing students’ attitudes toward e-cigarettes, non-smoking students had more negative attitudes toward e-cigarettes and their use. Former smokers also had more negative attitudes toward electronic cigarettes and their use, while students who were current smokers had more positive attitudes and supported the use of e-cigarettes [28].

Furthermore, this study showed a comparison of nursing students’ attitudes based on smoking status regarding their views on nurses with statistically significant differences among the groups for all three questions among the observed student groups. Non-smokers were the most likely to agree that nurses should set a good example for patients by not smoking, followed by slightly more than half of the students who were former smokers. As expected, smokers had a more negative attitude, with only a third indicating that their non-smoking behavior serves as a good example for patients.

A study conducted by Čivljak et al. on nurses in Zagreb, Croatia, found similar results when comparing the smoking status of the nurses. Nurses who were smokers had more negative attitudes and did not believe that their non-smoking behavior set an example for patients [23].

In our study, non-smoking students were the most likely to agree with the statement that nurses should be actively involved in aiding patients to quit smoking. Students who were smokers or former smokers were slightly less likely to agree with this statement. Given that nurses are healthcare professionals who spend the most time with patients, their active role in patient health education and implementing smoking cessation interventions can greatly contribute to a patient’s attempt to quit smoking [32].

Most non-smokers and former smokers in this study agreed that nurses needed additional education and training in smoking cessation, while a lesser number of smokers felt that nurses required additional education. According to a 2022 study conducted in Zagreb, Croatia, only 1.6% of nurses reported receiving education on smoking cessation interventions in the past two years, and 18% reported having received such education during their professional careers [23].

A study conducted in the Czech Republic demonstrated that nurses were significantly more willing and involved in implementing smoking cessation interventions and in helping and advising patients after attending smoking cessation education courses or seminars [22].

More than half of the nursing students in Croatia who participated in this study (60.2%) reported that they did not receive education on smoking cessation during their university studies. Comparing the knowledge and attitudes of students based on whether they had learned about smoking cessation during their education, it can be concluded that a quarter (24%) of students who had received such education felt they could not confidently advise smokers about electronic cigarettes, while the same was true for 42% of those who had not received this education. Additionally, only a small number of students who had been educated on smoking cessation failed to recognize or incorrectly believed that electronic cigarettes have no harmful effects compared to traditional tobacco cigarettes, whereas this belief was more common among students who had not been educated on smoking cessation. More students (13%) who had not been educated agreed with the statement that they should not ask a patient about their use of electronic cigarettes if they did not have enough knowledge about them themselves, compared to only 5.2% of educated participants. A study conducted in Greece showed that nursing education on smoking cessation topics and interventions is closely linked to students’ readiness and more positive attitudes toward getting involved in the process of implementing smoking cessation interventions and patient education [32].

Moreover, a study conducted in China emphasized the importance of integrating mandatory courses on smoking cessation into nursing education, as this increases clinical knowledge and skills needed for helping patients quit smoking [17].

Results of the logistic regression analyses highlight several factors that could influence participants’ confidence to provide effective smoking cessation counseling. Smoking status was a significant positive predictor, as smokers demonstrated higher confidence in counseling compared to non-smokers. However, this finding also raises concerns about potential biases in counseling. Namely, it is possible that smokers could unconsciously project their own experiences onto patients, potentially affecting the quality of advice provided.

Age was identified as a significant negative predictor, with younger participants reporting higher confidence levels in conducting counseling sessions. This could reflect a generational shift in educational approaches or attitudes toward smoking cessation, where younger individuals are more exposed to contemporary evidence-based practices. Alternatively, this finding might suggest that younger participants perceive counseling as less intimidating, possibly due to differences in self-perception or exposure to training during their education. Future studies should explore the mechanisms underlying this age-related confidence gap and its implications for counseling effectiveness.

In contrast, gender and knowledge acquired during university were not found to be significant predictors in the logistic regression model. The lack of statistical significance for university-acquired knowledge may indicate that the formal education on smoking cessation is either insufficient or not effectively retained by students. This emphasizes the need to reevaluate and potentially enhance smoking cessation training within medical curricula, incorporating practical, hands-on experiences to build confidence and competence among healthcare professionals.

These findings underscore the importance of targeted interventions that address specific predictors of counseling confidence. For example, structured mentorship programs or continuing education tailored to older healthcare professionals may help bridge the confidence gap observed with age. Furthermore, interventions to improve the content and delivery of smoking cessation training during formal education could enhance counseling efficacy across all demographics.

Overall, our results contribute to a deeper understanding of the factors influencing smoking cessation counseling and offer actionable insights for improving training and practice. Further research is needed to validate these findings across different settings and to explore additional variables, such as cultural attitudes or workplace support, that may impact counseling outcomes.

The strength of the study is the large sample size, which included more than a thousand students from ten higher education institutions in Croatia. In our study, 89% of participants were women, which aligns with the demographics of nursing students and nurses in Croatia. Thus, the results contribute to a better understanding of the level of knowledge among nursing students regarding new and alternative smoking methods. Additionally, the results provide insight into students’ attitudes and perceptions toward the use of e-cigarettes. Furthermore, the results allowed us to understand the smoking habits of students, their use of e-cigarettes, and whether they are aware of topics related to the harmful effects of smoking and topics of smoking cessation interventions. The results may encourage the development of mandatory courses in nursing programs to educate nursing students about smoking cessation and new alternative nicotine consumption methods and their dangers, as smoking remains a global public health problem.

The study had several limitations; it examined the knowledge and attitudes of nursing students only about e-cigarettes, even though other types of alternative nicotine delivery devices are available on the market, which differ from e-cigarettes in technology and nicotine delivery methods. Furthermore, nursing students may feel embarrassed about smoking or vaping, which could make them less likely to report their use honestly. The data was self-reported and not biochemically verified.

Additionally, some questions in the questionnaire could have been worded more clearly. The questionnaire was adopted from a previous study [21] and during pilot-testing, no major issues with the understanding of questions were flagged. However, it is possible that the first item assessing knowledge (“E-cigarettes are well-known smoking cessation products (i.e. they help in reducing and quitting smoking”) was confusing to some participants. Namely, it is possible that for some participants it was unclear whether the question is focusing on whether e-cigarettes are well-known, or whether e-cigarettes are effective for smoking cessation. Likewise, the last item assessing knowledge (“Long-term use of e-cigarettes increases the (inhaled) dose of carcinogens”) uses the word “increases”, but it does not mention what this is in comparison to. I.e. it could have been unclear to the participants whether this refers to an increase compared to everyday exposure of non-smokers or an increase compared to smoking.

Future research could include questions that would examine the use of different types of nicotine delivery devices, such as heated tobacco devices or products like tobacco pouches. It is also necessary to examine students’ knowledge and attitudes towards such devices and aids, as these products are becoming more popular, and more users are beginning to use these devices or nicotine delivery products. Research on interventions that could be introduced at higher education institutions to help nursing students quit smoking during their studies would also be very useful.