Prevalence of Electronic Cigarette Smoking Among Students of Shaqra University, Saudi Arabia

Background Electronic cigarettes are devices that use a flavored nicotine solution instead of burning tobacco leaves. Since their emergence, e-cigarettes have gained popularity in Saudi Arabia, particularly among young adults. Recently, many non-smoking youths have begun to use e-cigarettes as an alternative social behavior. Recent studies have confirmed that e-cigarettes have harmful effects on the respiratory system. Approximately 48.5 million Europeans have used an e-cigarette at least once while 7.5 million Europeans currently use e-cigarettes. This study aims to assess the prevalence of e-cigarette use and possible addictiveness among Shaqra University students. Methodology This is a cross-sectional study conducted at Shaqra University in 2021. A total of 290 students (18 years old and older) from Shaqra University were included in our study. The subjects were selected through simple random sampling. A self-administered online questionnaire related to e-cigarettes was used. Results Completed questionnaires were obtained from 290 students (average age of 20.2 ± 1.8 years). A total of 58 (20.1%) of the respondents were e-cigarette users. The obtained results showed that the mean age of e-cigarette smokers was 20.5 years, e-cigarette usage significantly differed between age groups (p < 0.001), and the highest prevalence of e-cigarette smoking was in Shaqra Governorate (i.e., 13.1%). Conclusion It's vital to acknowledge that the capacity for addiction to e-cigarettes is comparable to traditional smoking and other nicotine-containing items. It's essential to consistently observe students and smokers to better understand the effects of vaping patterns on this specific group


Introduction
The e-cigarette is a device consisting of a mouthpiece, an atomizer, a cartridge, and a battery, which emits nicotine in the form of an aerosol.The cartridge contains a liquid solution containing nicotine, flavorings, and other chemicals.When heated by the atomizer, the liquid transforms into an aerosol that users inhale [1,2].Adolescents' use of electronic cigarettes (e-cigarettes) has risen, likely due to the decline in traditional smoking over the past decade [3,4].
Research indicates that non-smokers using e-cigarettes may inadvertently promote the uptake of other tobacco products, which can have adverse health effects and lead to conditions like lung cancer.A study conducted in the United States found that 21.8% (178,850 out of 820,414) had initiated cigarette smoking within two years of using e-cigarettes.The majority of cases of lung diseases worldwide, including in Saudi Arabia, are linked to tobacco use [4][5][6][7][8][9].
In addition, respiratory consequences encompass conditions such as status asthmaticus and pneumothoraces; however, the most frequently documented and severe adverse effect is diffuse parenchymal lung disease [10].
During the summer of 2019, the EVALI (e-cigarette or vaping use-associated lung injury) outbreak caused 2807 instances of unexplained sudden lung injury primarily in young, healthy individuals, leading to 68

Statistical analysis
We performed data collection, organization, and analysis using

N = number
The results show one-fifth of the respondents (58) had used e-cigarettes.The highest prevalence of ecigarette use is in the Shaqra Governorate 13.1% (38), followed by Dawadmi 5.1% (15), which are Governorates that have the largest branches of Shaqra University and have the largest number of students, some of whom are from other cities.Meanwhile, the lowest prevalence (0) was in Al-Muzahimiyah, Dhurma, Sajir, and Thadiq.A total of 51 (17.5%) of the participants reported using traditional cigarettes and the use of shisha was reported by 13.1% (38) of the participants.Table 2 shows the prevalence of e-cigarette and other tobacco product use.

TABLE 2: E-cigarette user distribution
This table shows the number and percentage of e-cigarette user distribution based on sex and Governorates, with the mean age of the participants.

N = number
We used a coefficient test to assess the factors that would contribute to increasing the usage of e-cigarettes.E-cigarette smoking was the dependent variable while we used age, gender, recommendation for e-cigarettes, and smoking habits as the predictors.The obtained results show that the mean age of e-cigarette smokers is 20.5 (p < 0.001), and those who use regular cigarettes tend to also use e-cigarettes as compared to those who use other types of tobacco products (p < 0.001).Most e-cigarette users (34/58; 58%) state that they are attracted to them because "they have no smell" (p < 0.001), and some of them (17/58; 29.3%) say that more than 60% (p < 0.001) of their friends and relatives use e-cigarettes.These data are presented in Tables 2, 3.

TABLE 4: Perception of e-cigarette safety
This table shows the perception of e-cigarette safety and addictiveness among the participants represented by numbers and percentages using the chisquared test with P<0.05 set as significant.

Discussion
E-cigarette use is currently increasing among young adults in Saudi Arabia because of the spread of the misconception that e-cigarettes are safer compared to regular tobacco cigarettes [12].Recent reports have shown that e-cigarettes have similar hazards to tobacco smoking [13].Thus, it is important to understand the features of e-cigarettes in Saudi Arabia.
In this study, we assessed the prevalence of e-cigarette smoking among Shaqra University students in 2021.
The prevalence of e-cigarette use was 20.1% (58) among students from different Shaqra University branches.This percentage is comparable to the previously reported 27.7% (279/1007) in health science colleges in Jeddah [2,4].Another study was performed at Alfaisal University in Riyadh, whose authors reported a 12.2% (49/401) rate of e-cigarette use [14].In the study on health professional students in the United States, approximately 24.2% (206/853) of the participants confirmed that they had tried e-cigarettes [4,15].Similarly, in a study performed in the United Kingdom, the authors reported that 21.5% (884/4117) of the participants had used e-cigarettes [16].A total of 10.6% (27/256) of the participants stated that they had tried e-cigarettes at Qassim University in Saudi Arabia [17], and 17.8% (51) of the participants smoked regular cigarettes.The percentage of regular cigarette users decreased because there is a policy banning smoking at all facilities on a college campus.Therefore, it is predicted that e-cigarettes have gained more popularity than regular cigarettes due to flavors that give them a pleasant taste, lack of smell, and absence of residue.
In this study, 35.6% (103) of the users considered e-cigarettes to be a helpful tool for stopping smoking entirely.In the city of Jeddah, which is in the western region of Saudi Arabia, 42.7% (119/279) of students used e-cigarettes to quit smoking [2].In addition, 11% (28/256) of students in a study at Qassim University recommended e-cigarettes as a better alternative to tobacco [4].Twenty-three point one percent (23.1%; 197/853) of American university students and approximately 50.7% (~800,000) of smokers in Canada also used e-cigarettes for this reason [2,15,17,18].Similarly, authors of a study performed in Poland reported that 58.7% (56/95) of students used e-cigarettes as a smoking cessation method [19].These results suggest that students need more education about e-cigarettes because these devices are not approved by the U.S. Food and Drug Administration as a tool to stop smoking [14].
The obtained data show that 79.5% (230) of students believe that e-cigarettes encourage starting smoking for those who have never smoked at all.Similarly, other studies confirm that there is an association between e-cigarettes and the initiation of smoking [6].This study also shows that e-cigarettes are possibly addictive and may encourage smoking continuation among smokers who may have already quit smoking.When questioning the students on their awareness of the addictiveness of e-cigarettes, 48.9% (418/854) of them are aware that both regular cigarettes and e-cigarettes are equally addictive [2] because e-cigarettes are devices that contain a nicotine solution [20].Nicotine acts on a nicotinic cholinergic receptor in the brain and triggers the release of neurotransmitters (e.g., dopamine, GABA, and glutamate), which are important in the development of nicotine dependence [21].
A cross-sectional, survey-based study has been previously performed in the United States on 658 medical students from the University of Minnesota to evaluate student knowledge about e-cigarettes.A total of 97 participants (14.7%) stated that they had used e-cigarettes in the past, and four participants (0.6%) confirmed that they were current users.Significantly, most of the participants (619; 95%) felt that they did not receive adequate education about e-cigarettes in medical school.A total of 185 participants (28.2%) stated that e-cigarettes were helpful in smoking cessation, and 258 participants (39.3%) believed that ecigarettes had lower cancer risks than traditional cigarettes.This study suggests that there is a lack of knowledge about e-cigarettes among medical students at the University of Minnesota and indicates the need to include the subject of e-cigarettes in the medical school curriculum [4,22].
In this study, we found that 34.9% (101) of the students believed that e-cigarettes are safer than regular cigarettes.According to a study, 10% (1015/10146) of Mexican middle school students have tried ecigarettes and 19% (1928) think they are less harmful than traditional smoking [2,23].In a general population study in the United Kingdom, 67% (572/854) of the respondents had the same opinion, believing that e-cigarettes were less dangerous than traditional cigarettes [2,15].Therefore, additional studies are needed to determine whether e-cigarettes are safer than regular cigarettes or whether both are equally hazardous.

Limitation
We recognize that our study is limited to a particular group with a high level of education within a specific geographic location, thus reducing the applicability of our findings to the broader population of Saudi Arabia.Additionally, our reliance on self-reported data introduces potential biases such as recall and social desirability.Therefore, conducting a larger study encompassing the diverse population of Saudi Arabia is necessary for more comprehensive insights.

Conclusions
E-cigarette usage surpasses traditional smoking (20.1% versus 17.8%) among Shaqra University students, indicating a growing trend.The allure of e-cigarettes lies in their odorless nature and diverse range of flavors.Interestingly, some students turn to e-cigarettes as a means to quit smoking.Nonetheless, it's crucial to recognize that e-cigarettes carry a similar addictive potential to conventional smoking and other nicotine-based products.It's imperative to continually monitor students and smokers to gain deeper insights into the impact of vaping trends on this particular demographic.

Appendices
Questionnaire

TABLE 1 : Demographical distribution
This table shows the mean age and sex distribution by percentage and number of participants in each Governorate.

TABLE 3 : Correlation of e-cigarette usage This
table shows the number and percentage of e-cigarette users in correlation with multiple variables using the coefficient test with P<0.05 set as significant.Are e-cigarettes safer than regular cigarettes?N (%) pvalueYes NoAre e-cigarettes a helpful aid for smoking cessation?
Do you think electronic cigarettes are a helpful aid for smoking cessation?Yes No 12. Do you think electronic cigarettes are encouraging smoking initiation in those who have never smoked?