Received: 24-May-2021 Accepted Date: Jun 08, 2021 ; Published: 31-Dec-2021

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Abstract

Background: Electronic cigarette is becoming more popular worldwide recently. However, there is limited evidence on e-cigarette consumption in an environment conducive to smoking as the United Arab Emirates (UAE). The current study aimed to assess the prevalence, risk factors and awareness associated with e-cigarette use among a convenient sample of Inhabitants in the northern emirate of United Arab Emirates. Methods: A cross-sectional descriptive study was conducted in was conducted in the emirate of Ras Al khaimah from November 2019 to January 2020. An anonymous structured self-administrative questionnaire was used to collect data from the selected participants. The objective of the study was adequately explained to participants and their consent was obtained with assured confidentiality. Results: Almost two thirds of the participants (66.3%; 302/455) showed low level of e- cigarettes awareness with a mean score of 6.23(2.1) out of 13. The prevalence of usage was significantly higher among males (75%), Arab nationality (70.5%), occupation not health related (68.9%), higher monthly income (85.8%) and smokers (60.7%). Significant difference in the mean score of awareness toward e-cigarettes among users and non- users (p<0.001, 4.30(1.33) and 9.14(2.69)) respectively. Multivariable logistic regression revealed that current smokers, male group and those showing a low score of awareness associated with e-cigarettes were likely to be users of e-cigarettes. Conclusion: Instituting laws that are more stringent and holding nationwide awareness campaigns regarding safe usage of e-cigarettes targeting those group identified in this study are necessary to control the increasing e-cigarette use in the near future.

Keywords

E-cigarettes; Vaping; Risk factors; United Arab Emirates.

Background

Considerable progress has been made in tobacco control among youth in the last decades.

However, the tobacco product landscape continues to evolve to include a variety of tobacco products. [1] Electronic Cigarettes (ECs) are emerging non-combustible tobacco products that look like conventional cigarettes, cigars, or pipes.

These products use an “e-liquid” that may contain nicotine, as well as varying compositions of flavorings, propylene glycol, vegetable glycerin, and other ingredients. The liquid is heated to create an aerosol that the user inhales. [2]

The use and sale of ECs have been risen dramatically in the recent years, especially among youth and young adults. In 2018, the rapid rise of tobacco products led the U.S. surgeon general to issue an advisory about youth e-cigarette use, calling it an “epidemic.” [3]

In 2019, youth e-cigarette use increased to even higher levels. While the most recent studies show a decrease in youth use in 2020, the rate is still alarmingly high. [4,5]

Marketing and media played a major role in making people believe that smoking vape is less harmful than tobacco cigarettes and they facilitate to smoking cessation. The popularity of ECs shapes, sizes and the variety of Kid-friendly flavors have also contributed to youth uptake. [6]

Unlike tobacco cigarettes, e-cigarettes do not burn tobacco. Instead, they heat a flavored liquid to produce an aerosol that is inhaled into the lungs. The liquid usually contains nicotine which is a highly addictive substance naturally found in tobacco. Nicotine exposure during adolescence can harm the developing brain, which continues to develop until about age 25 years. It can affect learning, memory, attention, and mood and can increase risk for future addiction to other drugs. [1,3] Furthermore, fetal exposure to nicotine during pregnancy can result in multiple adverse consequences, including sudden infant death syndrome, altered corpus callosum, auditory processing deficits, effects on behaviors and obesity, and deficits in attention and cognition. Ingestion of e-cigarette liquids containing nicotine can also cause acute toxicity and possibly death if the contents of refill bottles containing nicotine are consumed. [7,8] In addition to nicotine, e-cigarette aerosol may contain other harmful substances, including volatile organic compounds, ultrafine particles, heavy metals, and cancer-causing chemicals that are inhaled deep into the lungs. [9]

Comprehensive tobacco control and prevention strategies for youth and young adults should address also e-cigarettes vape. Further reductions in tobacco use and initiation among youth and young adults are achievable by implementing proven prevention and educational strategies that advise youth about the dangers of nicotine and discourage tobacco use in any form, including e-cigarettes. Identifying the patterns of ecigarette use among youth and young adults, assessing what they know about the health effects of using these products and outlines interventions that can be adopted to prevent our nation’s young people from the potential of a lifetime of nicotine addiction are critical. The limited scientific knowledge on the potential health hazards of the product has sparked disagreement and concern among health advocates. [10] In light of the paucity of reliable scientific support, however, continued monitoring of the prevalence of e-cigarette and other tobacco product use among youth is important to inform public health policy, planning, and regulatory efforts.

The current study aimed to assess the prevalence, risk factors and awareness associated with e-cigarette use among a convenient sample of inhabitants in Ras Al khaimah, UAE.

Subjects and Methods

khaimah emirate, United Arab Emirates from November 2019 to January 2020. A convenient sample of 384 participants was decided based on the margin of error (5%), confidence level (95%), total population (345000) [11] and response distribution (50%). [12] The study-involved participants in the age range 18-60 years old, and included both genders and different nationalities. An anonymous structured self-administrative questionnaire was used to collect the required data from pedestrians in different places in Ras Al Khaimah (RAK). The northern emirate of UAE has two main areas, the Old Town and Nakheel, on either side of a creek that is home to mangroves. RAK emirate also consists of several villages and new-gated residential development. [13] These areas exhibit diversity in the socio-economic status and provide a relatively representative sample of the community in RAK, UAE. The objective of the study was adequately explained to the participants and their informed written consent was obtained with assured confidentiality. Those who can neither read nor understand English or Arabic were all excluded from our study. The questionnaire included socio demographic characteristics of the studied participants, questions about the pattern of smoking, awareness of the participants about e-cigarettes usage. Dependent variables of e-cigarette use were measured using the question: ‘Do you currently vape? With the response choices: ‘Yes and No’. Independent variables were smoking status of participants (smoker and non-smoker), gender (male, female), nationality (Arab, Non-Arab and Emeriti), educational level (until secondary school , college and postgraduate), age group (18–25, 26–35, 36–45, 46 years and older) and marital status (single, married, widow/divorced). Awareness about ecigarettes was measured using 13 items with response choices: Yes, No and I don’t know”. A value of “1” was assigned to each correct answer the participants gave upon filling the knowledge section of the questionnaire whereas a “0” was given to an incorrect answer or being unaware, (I do not know). All the negative items were recoded before the score. Participant who answered 75% or more of the questions correctly was considered knowledgeable in ECs, otherwise, he/she was considered not knowledgeable. Any score below 9/13 implied a less knowledge. These two newly recoded dichotomized random variables were used as outcomes for knowledge. The questionnaire was adopted from previous studies, translated into Arabic and properly revised by experts. To ensure validity and reliability of questions, a pilot study was carried out that included 10 participants in accordance with the inclusion criteria. Minor corrections were made based on the feedback from the pretest. The institutional ethical approval was obtained before commencement of the study. The data was entered in an IBM compatible computer, using the Statistical Package for Social Science (SPSS), version 22 (Chicago Il, USA). A descriptive analysis using means with standard deviation, frequency counts and percentages was carried out. It is important to note that in the reported Tables some counts do not add up to the total sample size, attributable to the fact that some questions have more than one response. Inferential statistics using Chi-squared analysis was used to test the association between the use of e-cigarettes, socio demographic variables and smoking status. An independent sample t-test was employed to test |the mean difference of knowledge score about e-cigarettes by e-cigarette use. All bivariate analyses with p = 0.25 were included in the multiple regression model. The final model was tested using Hosmer–Lemeshow analysis; the p-value of 0.682 indicated the model is a good fit. All possible two-way interactions between the independent variables in the final model were also analyzed and analysis showed that p<0.05 indicated significant two-way interaction between independent variables in final model.

Results and Observations

The study included 455 participants living in Ras Al Khaimah that represented 95.7% (455/475) responses after exclusion of the incomplete ones. The mean age of all participants was 21.6 (6.67) with 78% of them in age group 18 to 25 years. More than half of the participants (56.3%; 256/455)) were male and 45.5% (207/455) were Arab nationality. Almost all were literate with 85.8% (381/455) of them attained a bachelor’s degree or higher. More than two third (62.3%; 283/455) did not work in a health related occupation. The monthly income is more than 10,000 Emirati Dirhams in 60.3% (274/455) of the studied participants [Table 1].

Table 1: Demographic characters of the studied participants (N=455).

Regarding the smoking habits of the participants in the current study, more than half of the studied sample (59.8%; 272.455) were smokers. Shisha was the most common means of smoking (38.6%) followed by cigarettes (22.6%) and others (17.4%). More than sixty percent (64.3%; 175/272) of them started smoking since five years [Table 2]. E cigarettes use were reported by 56% (255/455) of the studied participants.

They have heard of ECs mostly through media and advertisements (62.4%), followed by friends (38.4%) and family (14.2%). More than half (54.1%) of ECs users have been using it for more than six months. An estimated 33.3% (85/255) and 19.0% (50/255) of EC users reported using it on 20 or more days and daily use respectively in the past 30 days [Table 2]. One in five of EC users (20.4%; 52/255) admitted that they have stopped smoking tobacco cigarette, shisha or medwakh and others after switching to vape. While others continue to use both. The amount of liquid consumed per week was more than 6-15 ml by 52.2% (133/255) of the studied participants, which is equal approximately to two reservoirs. Furthermore, the amount of nicotine used was more than 9 mg per cartridge by 38.8% (97/255) of them. Only 16.2% (41/255) of EC users admitted being satisfied with vaping more than other conventional tobacco smoking. The identified reasons behind the usage of EC by the studied participants were quitting smoking (35.7%), being safer than tobacco smoking (20.4%), peer request (19.6%), cheaper price than tobacco (8.6%) and curiosity about the product (7.8%) [Table 2].

Table 2: The smoking habits of the studied participants (NO=445).

*Percent add to more than 100 due to multiple responses

Participants’ awareness mean score was 6.23 (2.12), which is, is lower than the cutoff of 9 that was designated for a high level of awareness. Specifically, 66.3% (302/455) of our study population showed a lower level of awareness towards ECs with scores falling below this cutoff point. Participants’ gap in EC awareness was made apparent by several questions that were answered incorrectly [Table 3]. More than half of all respondents showed a lack of awareness concerning ECs’ association with lung and bladder cancer (77.5%; 353/455, 96.5%; 439/455), impaired cardiovascular and cerebral functions (78.7%; 358/455, 61.6%; 280/455) and impotence (64.6%; 449/455). About 31.7% (144/455) of the respondents were unaware that ECs contribute to second hand smoking and flavorings differ in their extent of harm (68.8%; 313/455). A great proportion of participants falsely thought that ECs are effective as a smoking cessation method (64.2%; 292/455) and FDA approved and regulated by international agencies (67.9%; 309/455). Students-t test showed a significant difference in the mean score of awareness toward e-cigarettes among users and non- users (p<0.001, 4.30(1.33) & 9.14(2.69)) respectively, which indicates those who have used e-cigarettes tend to have less knowledge about e-cigarettes. Chi-squared statistical test showed a significant higher usage of e-cigarettes among males compared to females (p<0.0001, 75% (192/257) vs. 32.3% (63/195). In addition, bivariate analysis revealed a significant association between nationality groups, smoking status and E-cigarette users. However, no association was observed between age groups, education level, marital status, and E-cigarette users [Table 4].

Table 4: Association between status of EC user and sociodemographic characteristics and smoking status.

Males participants were 2.7 times likely to become E-cigarette users than females (OR=2.7, 95% CI: 0.6–1.68). Moreover, participants with higher education attainment and higher monthly income were more likely to become E-cigarette users (OR=1.69, 95% CI:1.05–2.72), (OR=2.92, 95% CI:1.28–6.65) respectively. Participants who do not work in a health-related occupation were twice as likely to be E-cigarette users (OR=2.408, 95% CI: 1.233-4.705). The odds of current smoking using e-cigarettes was 2.5 times that of non-smoking (OR=3.46, 95% CI: 1.85–6.50). In addition, ECs users were found to be three times less likely to have attained a higher level of knowledge or awareness (OR=.304, 95% CI: 0.107-0.865) [Table 5].

Table 5: Multiple logistic regression of the association of E-cigarettes use with socio demographic and smoking status.

Discussion

This is, to our knowledge, the first study to show the increasing popularity of ECs among a sample of people residue in Ras Al khaimah, UAE. More than half of the studied respondents were ECs users for more than 6 months. Among the current e-cigarette, 59.2% admitted exclusive EC (only using EC) and 33, 3% reported using ECs on 20 or more days in past 30 days. These results are similar to a study conducted in United states in 2019 where 63,6% and 34.2% of youth reported exclusive EC and usage more than 20 days respectively. [14]

The current study results showed a higher use of e-cigarettes among younger age groups (18-25years), which is consistent with the findings by Al-Houqani M., and Fikri M. [15,16] This findings is expected because of the greater interest of the younger age group of participants to new products compared to the older age group, as reported by Helm et al. [17] The prevalence of e-cigarette users was significantly higher among males compared to females (75% vs. 32.3 %), which was similar to the trend of tobacco product usage. [18] However, the actual smoking rates could even be higher still than those indicated by self-reported rates as smoking was not considered socially or culturally acceptable, particularly among women. Consequently, some people who smoke chose not to reveal this. [19]

According to smoking epidemic model by Lopez et al. [20] smoking emerges first among high status groups, who are more open to the latest lifestyle trends, innovations and have the resources to adopt them first. The current study finding also showed higher prevalence of e- cigarette use among participants with higher monthly income. Another plausible reason for our findings can be associated with the diffusion of the use of manufactured e-cigarettes, being both technological and cultural innovations attract the high status group. [21] Health-related occupation displayed a lower prevalence level of ECs as their major, occupation must equip them with the knowledge to make better-informed judgments about health.

The results of the current study are particularly concerning given the high percentage (94.1%) of exposure to nicotine through the use of e-cigarettes , specifically for young people, this is of particular concern because it could promote the development of nicotine dependence, making it easier to the transition to cigarette or other combustible tobacco product use . On the other hand, it may delay cessation among current smokers and serve as an obstacle that maintains smoking habits. [3,19,22,23] This is obvious in the current study results in which 35.7% of the participants who were smokers turned to e-cigarettes in an attempt to quit smoking. Nevertheless, most of the people who took on e-cigarettes ended up as a dual user rather than quitter. [24] Subsequently, 79.6% and 54.0%, of the current study ECs users were not or less able to quit or satisfied with it compared with conventional tobacco respectively. Moreover, a current smoker has a greater propensity to use e-cigarettes compared to a non-smoker. Cornelius et al. [25] reported that 36.9% of e-cigarette smokers also currently smoked cigarettes. Similar finding in the current study showed that 40.3% of the studied respondents who use EC also smoke other tobacco. Thus, the study results support earlier evidence that e-cigarette use increases the frequency and amount of cigarette smoking in the future. [1,26]

E-cigarettes are advertised using the same themes and tactics that have been shown to increase youth initiation of other tobacco products, including cigarettes. The current study results showed that 62.4% of respondents said they had seen e-cigarette in media and advertisements. Wang, et al. reported, about 7 in 10 middle school and high school students (69.3%) that represent more than 18 million youth are EC users because of the widespread of advertisements in News outlets and social media sites. [27]

Various flavors like fruit, candy, mint, and menthol are the primary reason youth reported using e-cigarettes. [28] These flavors look like those found in shisha that is popular in most of the Arab culture and showing the highest frequency of use in the current study (38.6%). ECs have the potential to be used as a portable shisha, which might justify the study’s result that the common reason to start EC smoking was its flavors as mentioned by 18.7%. Furthermore, ECs are relatively new devices, come in many shapes and sizes that make it appeals to youth. Such emerging trends increase the curiosity about the product as mentioned by 7.8% of the current study respondents.

Scientists are still learning about the health effects of e-cigarette, but the available science shows they contain harmful and potentially harmful ingredients. ECs use among youth and young adults was also attributed to its perceived reduced harmful effects compared to tobacco. Forty seven percent (47%) of the studied respondents reported that e-cigarette is safer than conventional tobacco smoking and 20.4% identified the same reason behind their motivation to use ECs. Similar to the findings drawn by a previous study in Egypt, [29] where 31.9% believed it is less harmful than the traditional cigarettes. Indeed, it is difficult for consumers to know what e-cigarette products contain. Some e-cigarettes marketed as containing zero percent nicotine, however, it have been found to contain nicotine. [30]

Scientists are still learning about the health effects of e-cigarette, but the available science shows they contain harmful and potentially harmful ingredients. ECs use among youth and young adults was also attributed to its perceived reduced harmful effects compared to tobacco. Forty seven percent (47%) of the studied respondents reported that e-cigarette is safer than conventional tobacco smoking and 20.4% identified the same reason behind their motivation to use ECs. Similar to the findings drawn by a previous study in Egypt, [29] where 31.9% believed it is less harmful than the traditional cigarettes. Indeed, it is difficult for consumers to know what e-cigarette products contain. Some e-cigarettes marketed as containing zero percent nicotine, however, it have been found to contain nicotine. [31]

Evidence to suggest that ECs may be effective and advisable for quitting smoking or a safe alternative for smoking is lacking. [32] Even after massive advertisements claiming the usefulness of these devices for quitting smoking, several studies assessed the effectiveness of ECs as smoking cessation aids found that ECs were not successful as a vehicle for smoking cessation. [33-35] Other studies presented a conflicting finding. [36-38] In the current study, while 64.2% of the studied participants reported that ECs could help in quitting smoking, a comparative question in our study addressing its use as an effective smoking cessation method obtained a 20.4% positive response [Table 2]. This finding is lower than a study conducted in Lebanon where 48.6% of the participants could use EC as an effective smoking cessation method. [39] There was a 67.9% false knowledge that e-cigarette are FDA approved as smoking cessation aid; a factor substantiated by Callahan P.’s claim that “No e-cigarette has been approved by FDA as a cessation aid”. [10] Indeed, the FDA officially regulated ECs in 2016 to restrict sales to minors, help consumers better understand the risks of using these products, prohibit false and misleading product claims. Building on this groundwork, it has approved a variety of products as cessation aids to help reduce dependence on nicotine such as nicotine gum, nicotine skin patches, and nicotine lozenges. [40]

Therefore, it is clear that, there is a knowledge gap among the studied participants relevant to certain areas like ECs ingredients’ hazards and ECs’ harmful effects on health. The level of awareness is higher among the ECs non-users. Lim, etal. Supported this finding, reporting that knowledge and perception influences the actual behavior of smoking among adults. [41]

Our findings should be viewed in the context of additional limitations. First, the external validity of the study may be affected by the convenient sampling of the participants in the study. In addition, there are possibilities for sampling selection bias. However, participants from different areas in Ras Al khaimah were recruited. Thus, findings might have some limitation in generalization of results. Secondly, the causal relationship cannot be established due to the cross-sectional study design. Thirdly, the results obtained in this questionnaire survey were based on self-reported information, which depends on the honesty and recall ability of the respondents, as well as their understanding of the questionnaire. Finally, excluding all the respondents who had never heard about e-cigarette might affect the study results especially on the distribution of gender, age group and educational status between those who participated and those who did not.

Conclusion

In conclusion, the prevalence of e-cigarette use was found higher among a substantial proportion of participants who were male from Arab ethnicity, working in health unrelated occupation, having higher education attainment and higher monthly income, in addition, being smoker, and having low level of awareness about e-cigarettes use and its possible harms. Therefore, it is important to disseminate relevant information regarding e-cigarettes, especially to the identified population with a tendency to use it. Considering the conducive environment to smoking in UAE, strict measures should be undertaken to regulate its use by instituting more stringent laws and holding nationwide awareness campaigns to control the increasing e-cigarette use in the near future.

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