|Year : 2022 | Volume
| Issue : 6 | Page : 765-772
Prevalence of electronic cigarette usage among medical students in Saudi Arabia – A systematic review
S Patil1, HN Fageeh2, S Mushtaq3, M Ajmal4, SN Chalikkandy4, H Ashi5, ZH Ahmad6, SS Khan1, S Khanagar7, S Varadarajan8, SC Sarode9, GS Sarode9
1 Department of Maxillofacial Surgery and Diagnostic Sciences, Division of Oral Pathology College of Dentistry, Jazan University, Jazan, Saudi Arabia
2 Department of Preventive Dental Science, College of Dentistry, Jazan University, Jazan, Saudi Arabia
3 College of Applied Medical Sciences, Dental Health Department, King Saud University, Riyadh, Saudi Arabia
4 Department of Diagnostic Sciences and Oral Biology, College of Dentistry, King Khalid University, Abha, Saudi Arabia
5 Department of Dental Public Health, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
6 Dental College Hospital, King Saud University Medical City, Riyadh, Saudi Arabia
7 Department of Preventive Dental Science, College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; College of Public Health, Texila American University, Guyana, South America
8 Department of Oral Pathology and Microbiology, Sri Venkateswara Dental College and Hospital, Chennai, Tamil Nadu, India
9 Department of Oral Pathology & Microbiology, Dr. D.Y. Patil Dental College & Hospital, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||11-Dec-2021|
|Date of Acceptance||09-Mar-2022|
|Date of Web Publication||16-Jun-2022|
Dr. S Patil
Department of Maxillofacial Surgery and Diagnostic Sciences, Division of Oral Pathology College of Dentistry, Jazan University, Jazan - 45142
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The systematic review aimed to report the prevalence of electronic cigarette (e-cigarette) usage among medical students in Saudi Arabia. Electronic databases were searched for scientific research articles published from January 2010 until December 2020. The data search was performed in electronic search engines such as PubMed, Google Scholar, Scopus, Web of Science, Medline, Embase, Cochrane, and Saudi Digital Library. A total of five research articles that qualified the eligibility criteria were analyzed for qualitative data. The sample size in the included studies ranged from 229 to 1007 participants. The prevalence of e-cigarette usage ranged from 10.6% to 27.7% among medical students in Saudi Arabia. Studies have also reported that the prevalence of e-cigarette usage is higher among the male population in comparison with the female population. The prevalence of e-cigarette usage among medical students in Saudi Arabia is high. Similar to tobacco smoking, e-cigarette usage is a major public health issue and concern among the younger population because they have potential benefits in some and are harmful to some and also it is still unclear whether they are effective for quitting smoking. Regulatory bodies must focus and initiate strict laws and policies to minimize the sales of these products to the younger population. Health promotion strategies need to be developed to reduce the usage of e-cigarettes.
Keywords: Electronic cigarettes, medical students, prevalence, smoking cessation
|How to cite this article:|
Patil S, Fageeh H N, Mushtaq S, Ajmal M, Chalikkandy S N, Ashi H, Ahmad Z H, Khan S S, Khanagar S, Varadarajan S, Sarode S C, Sarode G S. Prevalence of electronic cigarette usage among medical students in Saudi Arabia – A systematic review. Niger J Clin Pract 2022;25:765-72
|How to cite this URL:|
Patil S, Fageeh H N, Mushtaq S, Ajmal M, Chalikkandy S N, Ashi H, Ahmad Z H, Khan S S, Khanagar S, Varadarajan S, Sarode S C, Sarode G S. Prevalence of electronic cigarette usage among medical students in Saudi Arabia – A systematic review. Niger J Clin Pract [serial online] 2022 [cited 2022 Dec 3];25:765-72. Available from: https://www.njcponline.com/text.asp?2022/25/6/765/347626
| Introduction|| |
Electronic cigarette (e-cigarette) is a device designed for delivering nicotine when used as a substitute for tobacco products, especially cigarettes. In the year 2003, a Chinese pharmacist, Hon Lik, designed this new device with the concept of delivering nicotine and a product that can be used as a device for tobacco cessation. The basic design of the e-cigarette mainly consists of a nicotine-holding compartment, a heating component, and a mouthpiece, all of which are run on a battery. This device when heated synthesizes an aerosol that is inhaled through the mouthpiece, and this delivers the nicotine for which it has been designed.
The marketing strategies adopted by the manufacturing companies to promote these products are exceptional and therefore have captured the global market. These manufacturing companies are advertising these products, which mainly target children and young adults using social media networking systems., The information on these online media has been heavily criticized as they advertise these potentially dangerous products because most of the information is misleading and inaccurate. These marketing strategies have drastically increased the sale of e-cigarettes in the global market, which has in turn significantly increased its usage among the younger populations. A study conducted in Poland reported that the usage of e-cigarettes was over 24% from 2011 to 2014. The prevalence of usage of e-cigarettes is relatively higher among the younger adults as reported from several studies.,,, There have been a good number of studies that have been conducted among the Saudi Arabian population regarding the usage of e-cigarettes, and these studies have reported that the prevalence of usage of e-cigarettes among the younger adults ranges from 25 to 33.5%.,
Considering the high usage and popularity of e-cigarettes among the younger youths, they are now a rising public health concern. The role of e-cigarettes as a smoking cessation tool and their public health effect are debatable. The Center for Disease Control and Prevention clearly states that e-cigarettes have the potential to benefit some people and also harm others. The concern is mainly because of the reports on the harmful substances that are released through the aerosols produced from e-cigarettes. These compounds which are found within the aerosols mainly include propylene glycol, glycerin, and toxic metals such as lead, nickel, and cadmium. Added to this, they also contain carcinogenic carbonyl compounds, which include formaldehyde.,, These harmful compounds may tend to damage the deoxyribonucleic acid and thereby reduce its ability to repair by itself during replication and may cause diseases related to the respiratory system., Studies have also reported on the consequences of long-term exposure to nicotine, which usually causes attention deficits and mood disorders. A study has also reported that nicotine exposure at any age group has been shown to reduce insulin sensitivity and can contribute to diabetes mellitus. Prolonged usage of nicotine carries a risk of developing cardiovascular diseases and can also affect the immune system. Among the females, exposure to nicotine during pregnancy could impact the development of the fetal brain and may lead to pre-term delivery and also a low birth weight in the newborn. Although a few reports have also shown that e-cigarettes could have beneficial health effects, there is limited scientific evidence of the same health.,,,
Studies have also reported that e-cigarette usage increases the risk of initiation of conventional cigarette smoking among youngsters. A study conducted by Barrington-Trimis JL et al. reported that more than 40% of the e-cigarette users in their study had initiated the use of conventional cigarettes during the 16-month follow-up, with an odds ratio of more than 6 compared to never e-cigarette users. Another study, conducted by Leventhal AM et al., also reported that e-cigarette users are more likely to initiate conventional cigarette smoking when compared with non-users, with an odds ratio of 1.75 compared to never users at the end of the 12-month follow-up. Another study, conducted by Wills T.A. et al., also reported that e-cigarette users exhibited an odds ratio of 2.87 in initiating conventional cigarette smoking when compared with never users at 12 months of follow-up. Similar results were also reported by a study conducted by Primack BA et al.,,,
Considering these reports and also the fact that e-cigarette is more of a product of initiation of tobacco than a product of preventing tobacco usage, several countries have restricted the use of e-cigarettes, including Canada and Australia. The Saudi Arabian government had raised a ban on the import of e-cigarettes in the year 2014, following the recommendations of the Saudi Food and Drug Authority. Later, this ban had been revoked in the year 2019, allowing travelers to carry one e-cigarette and a limited amount of flavorants. This also allows the business owners to import and sell the e-cigarette and its products. These policies have been raising many concerns about the current prevalence of usage of e-cigarettes among the younger population as they might consider them as safe and as an aid to quit tobacco. Hence, this systematic review aimed to report on the prevalence of e-cigarette usage among medical students in Saudi Arabia.
| Material and Methods|| |
This systematic review was conducted following the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles related to the topic were searched manually and in electronic databases by two independent researchers. Scientific research was restricted for the articles that were published over the past 10 years, which was from January 2010 until December 2020, in the electronic databases. The data search was mainly performed in the most renowned electronic search engines such as PubMed, Google Scholar, Web of Science, Scopus, Medline, Embase, Cochrane, and Saudi Digital Library. Several combinations of keywords such as E-cigarettes, electronic cigarettes, medical students, smoking, smoking cessation, prevalence, Saudi Arabia, and vaping were used for searching the scientific articles in the search engines, and manual search was also performed simultaneously.
Original research articles were chosen based on their title and the abstract during the preliminary search. The preliminary search conceded 186 articles that were related to our research topic. Out of this, 128 articles had to be eliminated because of the duplication of the data. After this elimination, 58 articles were left for evaluation in the next stage. In the next stage, the following eligibility criteria were applied. The title and abstracts of the selected articles were evaluated to determine the relevance of the article.
In this systematic review, cross-sectional observational studies that had reported on the prevalence of e-cigarette usage among medical students in Saudi Arabia were included.
Unpublished papers uploaded online, articles where the full text was not available, case reports, review articles, research articles that reported only knowledge and attitude toward e-cigarette usage, and articles that were not in the English language were excluded.
Six scientific research articles that met our eligibility criteria were analyzed for complete details. During this process, the journal details were covered and distributed among the three-panel members for critically analyzing the included studies. The panel members were instructed to assess the quality of the report by referring to the criteria for Strengthening the Reporting of Observational Studies in Epidemiology (STROBE), which is designed to assess 22 key items that should be present in the title, abstract, introduction, methodology, results, and discussion of a cross-sectional survey, case control, and cohort observational studies., Following this, the panel members had a difference in opinion for the inclusion of one article; hence, they had to be excluded from the systematic review after an agreement between the panel members. Finally, the five articles which met the eligibility criteria were considered in this systematic review for quality synthesis [Figure 1].
Quality assessment of the cross-sectional studies included in this systematic review
A detailed analysis of the methodological quality of the included cross-sectional studies was performed after referring to the criteria for STROBE [Supplementary Table 1]. The articles that included 0–7 items were considered to be of low quality, 8–14 items were of intermediate quality, and 15–22 items were of high quality. All the five articles included in this systematic review were categorized as high quality based on the STROBE 22 analysis.
| Results|| |
Out of the 186 articles that were retrieved during the preliminary search, only five articles that had met the eligibility criteria were assessed for qualitative data in this systematic review. The included studies were conducted recently in different parts of Saudi Arabia between 2019 and 2020. The sample size in these included studies ranged from 229 to 1007 samples. The prevalence of e-cigarette usage ranged from 10.6% to 27.7% among medical students in Saudi Arabia. [Figure 2].
|Figure 2: Summary of the prevalence of e-cigarette usage among medical students in Saudi Arabia|
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Data extraction and qualitative synthesis
[Table 1] shows the details of the characteristics of cross-sectional studies that were included in this systematic review. The included studies were reported from different regions of Saudi Arabia. There was no mention of sample size estimation in four of the included studies;,,, only one study had mentioned sample size estimation. These studies were conducted in five major cities of Saudi Arabia, which included Buraydah, Jeddah, Medina, Jazan, and Riyadh.
|Table 1: Details of the characteristics of cross-sectional studies that were included in this systematic review|
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The sample size of the study population in the included studies ranged from 229 to 1007 participants. All the studies have mentioned the eligibility criteria for enrolling the study participants in their respective studies.
The data regarding the prevalence of e-cigarette usage among medical students was assessed through a questionnaire survey.
A study was conducted by Abdullah Almutham et al. among medical students in Buraydah, Saudi Arabia. A total of 229 students responded to the survey questionnaire, where the authors reported a prevalence of 10.6% of e-cigarette usage among the participants.
Another study was conducted by Qanash S et al. among students of health science colleges in Jeddah. A total of 1007 students responded to the survey questionnaire. The authors reported a prevalence of 27.7% of e-cigarette usage among the participants.
Another study was conducted by Alzalabani et al. among medical students in Medina. A total of 527 students responded to the online survey questionnaire. The authors reported a prevalence of 15.9% of e-cigarette usage among the participants. The results also revealed that the prevalence was high among male participants when compared to female participants, which were statistically significant (p < 0.05).
Another study was conducted by Abdulwahab A. Aqeeli et al. among Jazan University students. A total of 775 students responded to the online survey questionnaire. The authors reported a prevalence of 21.0% of e-cigarette usage among the study participants.
Another study was conducted by Eiad Habib et al. among medical students in Riyadh. A total of 401 students responded to the survey questionnaire. The authors reported a prevalence of 12.2% of e-cigarette usage among the participants. The results also revealed that the prevalence was 3 times higher among male participants when compared to female participants.
| Discussion|| |
Over the past few years, there has been a drastic increase in the usage of e-cigarettes globally. This is mainly because of the strong and aggressive marketing strategies adopted by the manufacturing companies. These companies target people of all age groups, including the younger age groups and also the female population. E-cigarette companies advertise their products as safety devices that help in meeting an individual's need for nicotine, thereby helping a replacement for conventional smoking. The availability of the products in different forms and flavors makes them more attractive and appealing for the buyers., The promotion of e-cigarettes as a healthier alternative to conventional cigarettes is mainly increasing their popularity among the younger population.,,,,,,
This systematic review is intended to critically review the articles reporting on the prevalence of e-cigarette usage among medical students in Saudi Arabia. The included studies in this systematic review revealed that there is a higher prevalence of e-cigarette usage among medical students in Saudi Arabia, which ranged from 10.6% to 27.7%.,,,, These findings were similar to the studies where the prevalence was assessed among the young adults, where the authors reported that the prevalence was 25% in the UK and 20.8% in a study conducted in USA. A study conducted among young high school students in USA reported a 27.5% prevalence of e-cigarette usage. A study conducted among medical students at the University of Minnesota reported a 14.7% prevalence of e-cigarette usage.
The higher prevalence of e-cigarette usage among medical students in Saudi Arabia can be attributed to the fact that there are an increase and ease in the availability of e-cigarettes nowadays and also with the belief among the users that they are less harmful.
Most of the included studies that have reported on the prevalence of usage of e-cigarettes have been conducted in the past 2 years. This could be attributed to the fact that there was a ban on the import and sales of e-cigarettes in Saudi Arabia since 2014. The ban was eventually lifted in 2019, and henceforth, the usage and reporting on the prevalence of usage of e-cigarettes were after the 2019 policy. In the present study, the usage of e-cigarettes has been widely reported among the male participants in comparison with the female participants, which can be attributed to social desirability bias in reporting about the smoking behavior among the female participants. This can also be attributed to cultural unacceptability and fear of societal rejection.,
The findings of this systematic review show a higher interest in e-cigarettes since the legalization of e-cigarette marketing in Saudi Arabia. The aggressive marketing strategies adopted by the manufacturing companies, especially through online media and social media, have highly influenced the consumers. Similar to conventional cigarettes, health warning messages need to be incorporated into the products. There is sufficient evidence from the reported studies, that incorporation of warning messages in the e-cigarette products can increase the harm perception among the buyers and this can eventually help in reducing the sale and publicity of e-cigarettes.,,,, Surprisingly, the majority of these products have warning messages, but they are usually inconsistent in the location and content of the health warning messages.,, Hence, the policymakers should consider implementing and regulating the compulsion of standardization of health warning messages on the e-cigarette products, which can help in reducing the purchasing of e-cigarettes.
Even though there is insufficient evidence for the health care professions to promote these products as safe and tobacco cessation aids, health professional students in these included studies still believed that e-cigarettes could help tobacco users in quitting the habit. In another study, conducted by Qanash S et al., a majority of the e-cigarette users considered them as a tool for tobacco cessation. Several other studies have also shown that the e-cigarette users considered them in an attempt to quit conventional smoking. Considering these facts and to prevent the public health disaster, which could be similar to the widely prevalent conventional cigarette smoking, raises urgent concern for the regulatory policies concerning sales and marketing of the products.
The higher prevalence of e-cigarette usage among health professional students must not be under-estimated. This has to be dealt with high priority by the regulatory bodies. Despite several potential side effects of these products, there is a lack of sufficient knowledge among medical students and the general population about the potential consequences of using e-cigarettes.
| Conclusion|| |
The present systematic review reports on the higher prevalence of e-cigarette usage among medical students in Saudi Arabia. Similar to tobacco smoking, e-cigarette usage is a major public health issue and concern among the younger population in Saudi Arabia. E-cigarettes themselves being an addictive substance must be considered with great caution. Efforts must be made to educate and create awareness among the health care professionals and the general public at large, regarding the risks associated with e-cigarette usage. Regulatory bodies must focus and initiate strict laws and policies to minimize the sales of these products to the younger population. To minimize the popularity of e-cigarettes, the aggressive advertising of these products has to be reduced. Health promotion strategies need to be developed to reduce the usage of e-cigarettes, especially among the younger population.
All authors have read and agreed to the published version of the manuscript.
Data availability statement
No new data were created or analyzed in this study. Data sharing does not apply to this article.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]