Knowledge, Beliefs, Behaviors, and Social Norms Related to Use of Alternative Tobacco Products among Undergraduate and Graduate Nursing Students in an Urban U.S. University Setting

Nurses and other healthcare providers play key roles in screening and smoking cessation for their patients. However, studies have shown that providers who themselves smoke are less likely to assess and counsel their patients about smoking cessation (Braun et al. 2004; Sarna, Brown, Lillington, Wewers, & Brecht, 2000; Ulbricht et al., 2008). A report analyzing data from the U.S. National Tobacco Use Supplement comparing smoking rates in healthcare professionals from 2003 to 2010- 2011 demonstrated continued declines among physicians to 1% and registered nurses to 7% (Sarna, Bialous, Nandy, Antonio, & Yang, 2014). These rates are significantly lower than the general population rate of 18.1%. Healthcare providers as a group have among the lowest rates of smoking in the United States. An international review of tobacco smoking among nurses revealed an overall pattern of smoking reduction since the 1970s, with higher rates in some developing countries. However, there were considerable inconsistencies in developed countries, with some reporting rates significantly higher than those in the United States. Asian countries generally had lower rates for female nurses, who are culturally less inclined to smoke (Smith & Leggat, 2007).Though rates of cigarette smoking in the United States have declined dramatically over the past several decades, the Centers for Disease Control and Prevention (CDC) recently warned that the rise in use of alternative tobacco products (ATPs) may undercut the success of efforts to decrease cigarette consumption (CDC, 2012a). For example, recent studies of U.S. college and university students have showen that 40% to 54% have used ATPs during their lifetimes (Cobb, Ward, Maziak, Shihadeh, & Eissenberg, 2010; Primack et al., 2008; Rahman, Chang, Hadgu, Salinas-Miranda, & Corvin, 2014). Little is known about use of these products by healthcare providers. Reports of ATP use among international medical students have found rates of up to 20% (Nawaz, et al. 2007; Senkubuge, Ayo-Yusuf, Louwagie, & Okuyemi, 2012). A recent study conducted with medical students in an urban U.S. medical center found that about 4% reported current cigarette use, 4.8% currently used ATPs, and 51.7% reported lifetime use of ATPs. Students in the study consistently estimated cigarettes to be more harmful that ATPs despite the absence of research evidence comparing the two (Zhou et al., 2015). No studies of nurses' use of ATPs have been published to date.The most common ATPs used today are hookahs, electronic cigarettes (e-cigarettes), cigars, and cigarillos. Hookah, also known as waterpipe and narghile, is an alternative nicotine delivery system to cigarettes in which shisha (tobacco or nontobacco combustible materials) is smoked. The shisha is heated in a bowl of charcoal that is ignited to create smoke. Smoke from the bowl is drawn through a tube that passes through a water jar that cools and humidifies the smoke (American Lung Association, 2007). In contrast, e-cigarettes, which resemble tobacco cigarettes, do not contain any tobacco but do deliver nicotine that has been vaporized electronically to simulate tobacco smoke (Caponnetto, Campagna, Papale, Rosso, & Polosa, 2012). Smokeless tobacco, also called chewing and spit tobacco, is a less commonly used ATP. Bidis and kreteks are small rolled cigarettes containing tobacco, cloves, and sometimes flavors. While the prevalence of bidi and kretek use in the United States is low compared to other ATPs, they contain more nicotine, tar, and carbon monoxide than conventional cigarettes and are therefore more injurious to the health of smokers (Watson, Polzin, Calafat, & Ashley, 2003).The health effects of all ATPs are understudied. A systematic review of 24 studies conducted by Akl and colleagues (2010) concluded that hookah smoking was associated with increased risks for lung cancer, respiratory disease, and low birth weight. These studies, however, had some methodological limitations, and more rigorous studies are needed. …