Prevalence, perception, and attitude regarding electronic cigarettes usage among young adults in Riyadh, Saudi Arabia. A cross-sectional study

Electronic cigarettes (e-cigarettes) are devices that use battery-power to heat liquids for aerosolization. This liquid typically comprises nicotine, flavors, and a base of glycerol or propylene glycol.¹ A study in Saudi Arabia revealed that e-cigarette users were notably more likely to also smoke tobacco.² Lip and oral cavity cancers have the highest prevalence among cancers caused by tobacco smoking as reported in a study in the Gulf Cooperation Council countries.³

Research indicates that high smoking rates among Saudi Arabian adolescents aged 11-19 years are linked to having a smoker in the household and parents with lower educational levels.⁴ Interestingly, another study involving medical students at a university in Riyadh, discovered that e-cigarette use had more prevalence in this particular group.⁵ Currently, data is lacking on the prevalence of and attitudes toward e-cigarette use among young adults in Riyadh, as previous studies have not particularly targeted this demographic. Young adults in Riyadh are the primary targets of antismoking campaigns. Therefore, this study aimed to estimate the prevalence, perceptions, and attitudes of young adults toward e-cigarette use in Riyadh, Saudi Arabia.

Methods

This descriptive cross-sectional study was carried out according to the principles of the Helsinki Agreement, it employed convenience sampling and was carried out in a general community setting in Riyadh, Saudi Arabia, between December 2023 and April 2024.

The institutional review board of Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia (research number: 23-0169), gave its approval for this study.

All young adults aged 18-25 residing in Riyadh were invited to participate in the study. They were asked to complete an online, self-administered, closed-ended questionnaire developed via Google Forms. Participants’ identities were kept confidential through anonymous questionnaire collection.

Participants aged <18 or >25 years were excluded. As this questionnaire was carried out relying on previous questionnaires which were written in English, it was initially designed in English and then translated into local Arabic using forward and backward translation procedures. Consent was required.

The questionnaire collected socioeconomic data and included questions adapted from validated instruments.^6-8 The first section gathered demographic information and explored e-cigarette usage within the social circles of the participants.

The second section featured 6 multiple-choice questions assessing the perceptions of safety, harm, and legal issues associated with e-cigarette use. The third section examined attitudes toward e-cigarette usage.

The sample size was calculated with a 5% acceptable margin of error, 95% confidence level (CI), 50% response distribution, and an estimated population of 2,333,328 based on Data Saudi and the recommended sample size was found to be 385 young adults aged 18-25 years, residing in Riyadh, Saudi Arabia.

Results

The participants were predominantly female, with 10.5% reporting current usage of e-cigarettes as shown in Table 1.

Significant associations were identified between participants’ beliefs regarding e-cigarette safety and their actual usage. In Table 2, the relationship between the perceptions of participants and their use of e-cigarettes offers intriguing insights.

Participants who believed that e-cigarettes were a safer alternative for quitting smoking (n=22, 43.1%; p<0.001), perceived them as safer than traditional cigarettes (n=38, 42.2%; p<0.001), or were unsure of the legal minimum age for their use (n=6, 6.7%; p<0.001) demonstrated greater prevalence of e-cigarette use. Conversely, those who believed that exposing children to e-cigarette smoke was unsafe (n=82, 18.7%; p=0.023) or that using e-cigarettes indoors could harm nonsmokers (n=60, 16.7%; p=0.001) exhibited a low prevalence of use.

Males and non-Saudis exhibited high e-cigarette usage, potentially due to targeted marketing strategies or social perceptions of acceptability as demonstrated in Table 3.

Furthermore, most participants cited attractive flavors as their primary reason for using e-cigarettes (n=168, 35.30%) followed by using them to manage social issues with family and friends (n=162, 34.10%). Notably, a significant percentage of participants (n=151, 31.80%) reported “out of curiosity” as their reason for use. The least frequently cited reason was a smoking reduction (n=56, 11.80%).

Discussion

The findings of this cross-sectional study shed light on the varied perceptions, practices, and attitudes toward e-cigarette use among young adults in Riyadh, Saudi Arabia. The participants were predominantly female, with 10.5% reporting current usage of e-cigarettes. This trend aligns with global concerns regarding the rising popularity of e-cigarettes among young adults.⁹

Compared to other studies carried out in Saudi Arabia, our study reported a low prevalence of current e-cigarette use (10.5%). Abdulelah et al¹⁰ reported that the e-cigarette use prevalence among 5,012 healthcare students in Saudi Arabian universities was 32.36%. Another study reported a 13.5% prevalence of current e-cigarette use among first-year university students in Riyadh.¹¹

A study in Jazan, Saudi Arabia, reported that only approximately 13.9% of participants believed that using e-cigarettes helped smokers quit.¹² However, a study by Alzahrani et al¹³ involving a Western population demonstrated that 32.1% of participants believed that e-cigarettes were beneficial for ceasing conventional smoking.

Males and non-Saudis exhibited high e-cigarette usage, potentially due to targeted marketing strategies or social perceptions of acceptability. Living arrangements were also influential; individuals living alone or with friends displayed high usage rates suggesting that peer influence plays a crucial role, highlighting the importance of social context in shaping e-cigarette-related behaviors.

The relationship between the perceptions of participants and their use of e-cigarettes offers intriguing insights. Participants who believed that e-cigarettes offered a safe method to quit smoking perceived them as safer than traditional cigarettes or were unsure of the legal minimum age for their use and demonstrated a high prevalence of e-cigarette use. This trend aligns with findings reported in previous studies.^10,14 Public health campaigns aimed to correct misperceptions and raising awareness of the potential risks associated with e-cigarette use could have a great benefit.

Conversely, participants who believed that exposing children to e-cigarette smoke was unsafe or that using e-cigarettes indoors posed risks to nonsmokers had a low prevalence of use.

Prominent reasons for e-cigarette use included the appeal of flavors, coping with problems, and curiosity. These findings are consistent with those reported in previous research that underscore the influence of flavor and psychosocial factors on e-cigarette initiation among young adults.¹⁴ Interventions tailored to address specific motivations, such as imposing flavor restrictions and providing mental health support, could be effective.

Moreover, contextualizing these findings within the broad scope of tobacco control policies in Saudi Arabia is crucial. The high prevalence of e-cigarette use underscores the need for a comprehensive regulatory framework addressing marketing, sales, and public awareness. Therefore, culturally sensitive interventions considering societal norms and values are necessary.