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Abstract
Objectives E-cigarettes have gained popularity, especially among young adults. This study aims to determine the prevalence of e-cigarette smoking, assess knowledge and attitudes and identify associated factors among Palestinian university students.
Design A cross-sectional study.
Setting and participants The study was conducted among Palestinian university students in early 2023.
A self-administered questionnaire was used to survey 1792 students from six Palestine universities in the West Bank. The questionnaire covered various aspects, including sociodemographic information, daily habits, exposure to smoking, attitudes and knowledge about e-cigarettes. Data were analysed using descriptive statistics, χ2 tests and multivariate regression analysis.
Results The study revealed a high prevalence of tobacco use (41.2%), with e-cigarette use prevalent among 19.7% of participants. Knowledge about e-cigarettes was suboptimal, with misconceptions regarding their safety and health effects. Negative attitudes towards e-cigarettes were common, and students with negative attitudes were more likely to use e-cigarettes (aOR=2.6, 95% CI: 1.9 to 3.6). Gender (aOR=2.1, 95% CI: 1.4 to 3.0), waterpipe smoking (aOR=4.5, 95% CI: 3.2 to 6.3), physical inactivity (aOR=1.4, 95% CI: 1.1 to 1.9), high coffee consumption (aOR=1.6, 95% CI: 1.1 to 2.3), spending time with friends (aOR=2.4, 95% CI: 1.5 to 3.7), having a mother who is a smoker (aOR=1.5, 95% CI: 1.1 to 2.2) and having a friend who uses e-cigarettes (aOR=1.5, 95% CI: 1.1 to 2.1) were significantly associated with e-cigarettes use.
Conclusions E-cigarette use is a growing concern among Palestinian university students. Combating this trend should include educational initiatives, social interventions and policy measures to promote informed decision-making and discourage e-cigarette use. Comprehensive tobacco control programs considering various tobacco and nicotine products and involving multiple stakeholders are warranted.
- health education
- preventive medicine
- primary prevention
- public health
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
The prevalence of e-cigarette usage is on the rise, particularly among adolescents, fueled by misconceptions surrounding its use.
The high response rate (95.1%) and large sample size (1792 students) from six universities enhance the power and generalisability of the results.
The cross-sectional design limits the ability to establish causal relationships between variables, capturing only a snapshot in time.
The use of self-reported data may introduce information bias since participants’ responses may be influenced by social desirability.
Introduction
Tobacco use is widely recognised as a significant and preventable contributor to the global disease burden despite extensive efforts to combat the tobacco epidemic. Current smoking and passive smoking have been shown to increase the risk of all-cause, cardiovascular diseases (CVD)-related and cancer-related mortality.1
Electronic cigarettes (e-cigarettes), commonly known as vapes, are nicotine delivery devices that have been promoted as a healthier alternative to traditional cigarettes since they were first introduced. Initially, they were produced and advertised as a smoking cessation aid despite inevitable negative consequences on users’ health. The emissions of e-cigarettes commonly consist of nicotine and various toxic substances, posing risks to both users and individuals who are indirectly exposed to the aerosols. The addictive nature of nicotine in e-cigarettes poses a severe risk to brain development in youth,2 and the heavy metals and toxicants in their vapour may contribute to cancer development.3
The effectiveness and safety of e-cigarettes as a smoking cessation aid are still being debated. Nonetheless, their use has significantly increased recently, particularly among adolescents and young adults.4 5 A systematic review and meta-analysis study reported that the lifetime and current prevalence of e-cigarette vaping was 23% and 11%, respectively; the lifetime and current prevalence of e-cigarette vaping among women was 16% and 8%, while among males, it was 22% and 12%, respectively.6 While the prevalence of young people’s conventional cigarette use has decreased in many countries, e-cigarette use has risen. A recent international systematic review found that the global pooled prevalence of young people’s lifetime usage of e-cigarettes was 15.3%, the current use was 7.7% and the dual use was 4.0%.7 Many studies have shown that the prevalence of e-cigarette smoking among university students is high, reaching up to 40%.8 9
Tobacco smoking is particularly prevalent among young adults and university students in Palestine. Findings from the 2015 Youth Survey show that 23.5% of Palestinians aged 15–29 use cigarettes, with male respondents using tobacco at a higher rate (40.9%) than female respondents (5.4%).7 Of university students, approximately 30% were identified as current tobacco users, 22.0%–25.0% as current waterpipe smokers and 18.0% as current cigarette smokers, with male students significantly more likely than female students to use cigarettes.10–12
The evidence shows that knowledge, attitudes and social norms about risky behaviours highly predict individuals' behavioural intentions.13 However, university students' knowledge and attitudes about e-cigarettes are suboptimal. A Chinese study found that only 21.6% of university students believed e-cigarettes had carcinogens and were less addictive than conventional cigarettes.14 In Saudi Arabia, only 22.5% and 48.4% of students believed e-cigarettes had the same risk and toxins as regular cigarettes.15
There has been no previous research on the prevalence of e-cigarette smoking among Palestinian university students. Therefore, one of the primary objectives of this study is to determine the prevalence of e-cigarette smoking among university students in Palestine and assess their knowledge and attitudes towards this behaviour. This will aid policymakers in developing initiatives to increase public awareness of e-cigarette use and its associated risks.
Methodology
Study design and population
This cross-sectional study occurred within Palestinian universities between January and May 2023, encompassing the entire student population across six major universities in the West Bank. These universities include The Arab American University, An-Najah National University and Palestine Technical University in the northern West Bank; Birzeit University in the central West Bank; and Hebron University and Bethlehem University in the southern West Bank.
The estimated target population consisted of 70 000 university students. We used OpenEpi’s online sample size calculator to identify the required sample size.16 With a population size of 70 000 students, a desired margin of error of 3%, and an anticipated proportion of 50%, the initial sample size was set at 1600 students. Subsequently, we increased the sample size by 20% to account for potentially incomplete questionnaires, leading to a final sample size of 1900 students. Initially, a random sampling method was planned, but due to constraints in accessing student enrolment records, a convenience sampling approach was adopted, with students drawn from each university’s campuses. A proportional sample from each university was selected, ensuring that the selection process reflected the student population of each chosen university, with visits scheduled at different times, days, locations and faculties. We included all full-time undergraduate students enrolled at the specified universities.
Patient and public involvement
Patients or the public were not involved in this study’s design, conduct or reporting.
Measurement tool and variables
The collection of data was conducted through a self-administered questionnaire. Students have been interviewed in person on campus and invited to participate voluntarily in the study. For those who agreed to participate, the questionnaire was disseminated through a QR code directing them to the corresponding Google Form.
The research team developed the questionnaire (online supplemental material 1), selecting the items carefully after thoroughly reviewing the relevant literature.17–22 It consisted of three sections. The first section focused on collecting data regarding sociodemographic variables, including gender, age, place of residence, faculty, daily habits (like smoking, exercise, diet, coffee consumption and social interactions) and exposure to cigarette smoking (including the number of smokers nearby and the smoking habits of parents and friends). In line with the Centers for Disease Control and Prevention (CDC) definition, a smoker was identified as an individual who had smoked more than 100 cigarettes and was currently smoking at the time of the study.23 A current regular e-cigarette smoker was defined as someone who had used an e-cigarette for at least 30 days, including the past 7 days.24
Supplemental material
The second section consisted of 13 statements assessing students' attitudes regarding e-cigarettes. Statements expressing positive attitudes aligned with societal approval and community norms. These included statements advocating for government regulation of e-cigarette use, encouraging organisations and individuals to refrain from selling e-cigarettes to minors and prohibiting e-cigarette use in workplaces and public spaces. Participants expressed their level of agreement with these statements using a 4-point Likert scale, excluding a neutral option in statements assessing attitude to avoid potential bias.25 For positive attitude items, ‘strongly agree’ received a score of 4, while ‘strongly disagree’ received a score of 1. However, the scoring was reversed for the items meant to measure negative attitudes. The total score ranged from 13 to 52, with a cut-off point at 39 (75%), where a score of ≥39 indicated a positive attitude, while a score of<39 indicated a negative attitude.18
The last part of the questionnaire included 13 carefully chosen items from different studies to evaluate participants' knowledge of e-cigarette smoking.17 20–22 These statements addressed the effects of e-cigarettes on overall health and the respiratory system, the suitability of e-cigarette use for pregnant women and children and the potential for e-cigarette addiction. Each statement included three response options: ‘yes’, ‘no’ and ‘do not know’. Participants were awarded 2 points for a correct ‘yes’ response, 0 points for a correct ‘no’ response and 1 point for selecting ‘do not know’. In instances where ‘no’ was the correct answer, the scoring was reversed. This resulted in a scoring range from 0 to 26. The cut-off point was set at 20 (75%); a score of ≥20 denoted a high level of knowledge, while a score of<20 indicated a lower level of knowledge.
The questionnaire was first created in English and later translated into Arabic. Afterward, a proficient English speaker conducted a back-translation to verify linguistic accuracy. To validate the questionnaire, three experts in the field evaluated it, followed by a pilot test involving 20 university students. The questionnaire was adjusted based on feedback received during the pilot study. The reliability of the Attitude and Knowledge items was confirmed through Cronbach’s alpha coefficients, which yielded satisfactory values of 0.78 and 0.75, respectively.
Analysis plan
The data collected through Google Forms were processed into an Excel spreadsheet and analysed using IBM SPSS V.23 (IBM Corp, Armonk, New York, USA). Descriptive analyses included mean and SD for continuous variables and frequencies and percentages for categorical variables. Independent t-tests and χ2 tests were used to assess univariate associations. Multivariate regression analysis was conducted to account for potential confounding variables. The model outcomes were presented as adjusted ORs (aOR) and their 95% CIs to assess the precision of the estimations. There were no missing data on the variables of interest, and the significance level was set at 0.05.
The study adhered to ethical guidelines and received approval from An-Najah National University’s Institutional Review Board before initiation (Reference #: Med.Jan.2023/1). Participants were informed about their voluntary participation, the study’s purpose and confidentiality. They were assured that their involvement would not affect their academic standing or university life. Data were anonymised and stored securely, with access restricted to the research team. Confidentiality measures were implemented throughout the research, including data collection, analysis, and reporting. Personal identifiers were removed, and participants were assigned unique codes.
Results
The study involved 1884 university students, with 1792 willingly participating, resulting in a response rate of 95.1%. The participants were primarily female (66.4%), with over half (53.3%) from rural areas, and their average age was 20.1±1.6 years. The study revealed that 41.2% (95% CI: 39.4% to 43.8%) of students were smokers, with 16.0% (95% CI: 14.4% to 17.8%) smoking traditional cigarettes, 20.1% (95% CI: 18.2% to 22.0%) smoking waterpipes and 19.7% (95% CI: 17.8% to 21.6%) smoking e-cigarettes. Most (63.3%) were physically inactive, and only 27.6% adhered to a healthy diet. The majority (54.2%) had smoking fathers, 14.4% had smoking mothers and 68.1% had smoking friends (table 1).
Demographic characteristics, daily habits and exposure to smoking among the study participants (n=1792)
Table 2 illustrates the various levels of knowledge among participants regarding e-cigarettes. Notably, many respondents expressed a lack of knowledge about several aspects of e-cigarettes. More than one-third (35.6%) were unaware that e-cigarettes do not contain any dangerous compounds other than nicotine, and 20.0% incorrectly believed that e-cigarettes were Food and Drug Administration (FDA) approved. Furthermore, a significant majority of respondents had misconceptions about the link between e-cigarettes and health hazards. For example, 23.8% do not know or think that e-cigarettes are suitable for pregnant women, and 23.8% do not know or think that e-cigarettes have no risk to the heart. Over 60% of students were categorised as having lower knowledge of e-cigarettes. Female students, those enrolled in medical science colleges, and those with positive attitudes towards e-cigarettes had significantly higher knowledge about e-cigarettes. On the other hand, students who smoked cigarettes, those residing in environments with a more significant number of smokers and students with close friends who smoked were associated with significantly lower knowledge levels regarding e-cigarettes (online supplemental table 1).
Supplemental material
Study participants' level of knowledge about e-cigarettes (n=1792)
Table 3 examines the attitudes regarding e-cigarettes. A significant percentage of the respondents agreed that e-cigarettes are safer than conventional smoking (19.2%) and that using e-cigarettes is perceived as a sign of sophistication and civilisation (17.4%). Furthermore, a significant percentage agreed that individuals using e-cigarettes should not be labelled as smokers (34.4%) and believed that e-cigarettes are more cost-effective than traditional cigarettes (37.9%). Moreover, 24.8% opposed the idea of banning e-cigarettes in workplaces and public spaces, and a high percentage (92.2%) thought that the availability of various e-cigarette flavours contributes to the widespread adoption of this practice. Only 40.2% of university students were categorised as having positive attitudes regarding e-cigarettes, with significantly higher levels of positive attitudes observed among female students, those enrolled in colleges of medical sciences and students with higher levels of knowledge on e-cigarettes. Conversely, students who smoked traditional cigarettes or waterpipes were physically inactive, had smoking parents, had close friends who were smokers or lived in environments with more smokers tended to exhibit more negative attitudes towards e-cigarettes (online supplemental table 2).
Supplemental material
Attitude regarding e-cigarettes among university students (n=1792)
Table 4 reveals that e-cigarette smoking prevalence is significantly influenced by various factors, including gender, type of faculty, urban residency, daily habits, physical inactivity and time spent with friends. Living with smokers and parental smoking are also linked to e-cigarette use. Additionally, having friends who smoke or use e-cigarettes and having lower knowledge levels with a negative attitude towards e-cigarettes are additional factors. It is essential to highlight that a statistically significant positive correlation has been observed between knowledge and attitude scores (correlation coefficient (r): 0.37, p value<0.001).
Univariate and multivariate analysis of the relationship between sociodemographic status, daily habits, exposure to smoking, e-cigarette knowledge and attitude and e-cigarette smoking
On multivariate analysis, the results showed that males (aOR=2.1, 95% CI: 1.4 to 3.0, p<0.001), waterpipe smoking students (aOR=4.5, 95% CI: 3.2 to 6.3, p<0.001), physically inactive students (aOR=1.4, 95% CI: 1.1 to 1.9, p=0.025) and students who drank seven or more cups of coffee per week (aOR=1.6, 95% CI: 1.1 to 2.3, p=0.28) were more likely to use e-cigarettes. Additionally, the prevalence of e-cigarette use was significantly higher among students residing with six or more smokers (aOR=2.1, 95% CI: 1.2 to 4.0, p=0.021), spending over 5 hours per day with friends (aOR=2.4, 95% CI: 1.5 to 3.7, p<0.001), or having a mother (aOR=1.5, 95% CI: 1.1 to 2.2, p=0.038) or close friend (aOR=1.5, 95% CI: 1.1 to 2.1, p=0.036) who smokes. Attitudes towards e-cigarette smoking exhibited a significant influence, with students holding negative attitudes having 2.6 times higher odds of e-cigarette use (aOR=2.6, 95% CI: 1.9 to 3.6, p<0.001) (table 4).
Discussion
E-cigarette smoking has been on the rise, especially among young adults.26 27 Previous research has shown varying prevalence rates of e-cigarette use among university students and adults.26 28 The study’s findings are crucial for stakeholders like public health experts, healthcare professionals, social workers and families in addressing rising e-cigarette smoking patterns. The study reveals that students often have suboptimal health habits, including physical inactivity (63.3%), unhealthy diet (73.4%) and high coffee consumption (54.2%). These habits are linked to various illnesses like obesity, diabetes, cardiovascular disease and mental health issues. Recognising the interconnectedness of these hazardous behaviours is crucial since engaging in one may increase the risk of engaging in others, such as smoking.29
The study found a smoking prevalence rate of 41.2% among students in the West Bank, consistent with the Palestinian Central Bureau of Statistics (40.1%).30 This reflects the persistent issue of young individuals using tobacco despite public health efforts. The study also revealed a variety of tobacco and nicotine products consumed by students, with 16.0% using traditional cigarettes, 20.1% using waterpipes and 19.7% using e-cigarettes.
The prevalence of e-cigarette usage among students is notable, as it approaches 20%. This aligns with a prevailing global pattern of e-cigarette utilisation, particularly among the younger population.27 31 Despite being seen as a less harmful alternative to traditional cigarettes, e-cigarettes still carry risks like addiction and adverse health effects.2 3 Moreover, the majority of the university students reported living with other smokers, exposing them to the potential dangers of secondhand smoking. Recent evidence suggests that students surrounded by smoky environments are more likely to accept smoking or become smokers, including e-cigarettes.32
The study revealed that university students lack sufficient knowledge about e-cigarettes, many of them believing they are harmless and not linked to health issues like lung cancer or decreased fertility and that they are FDA-approved. These results align with previous literature from Saudi Arabia,33 China34 and Qatar.35 This implies that significant efforts are required to enhance awareness and offer smoking cessation services to university students.
The study reveals that university student’s e-cigarette use is significantly influenced by gender, with males being 2.1 times more likely to use them than females, a finding consistent with previous research suggesting gender disparities in tobacco and nicotine product use.26 36 Waterpipe smoking was found to be significantly related to e-cigarette use, with those using waterpipes being 4.5 times more likely to use e-cigarettes. This underscores the potential link between tobacco and nicotine consumption among young adults, emphasising the need for comprehensive tobacco control programmes.37
Physical activity and coffee consumption are significant predictors of tobacco use, with physically inactive students being 1.4 times more likely to use e-cigarettes and students consuming one cup of coffee or more per day being 1.6 times more likely to use e-cigarettes. The findings align with a study on Spanish university graduates, where physical inactivity and higher coffee consumption were identified as critical predictors of tobacco use.38
Social factors significantly influence e-cigarette use. Spending over 5 hours with friends increases the likelihood of e-cigarette use by 2.4 times. Additionally, individuals with more smokers in their living environment are more likely to use e-cigarettes, highlighting the importance of social context in determining tobacco and nicotine product use.39 40 Family and peer behaviours significantly influence e-cigarette use, with higher chances of usage if one’s mother or friend is a smoker.41 42 Notably, having a friend who uses e-cigarettes showed the strongest association, emphasising the considerable impact of peer behaviour and attitudes on young adults' e-cigarette use.43
The study revealed that a significant number of university students have a negative attitude towards e-cigarettes, highlighting their diverse opinions and perceptions. These concerns include safety, social norms, government regulation and potential as smoking cessation aids. Students with negative attitudes were 2.6 times more likely to use e-cigarettes, emphasising the importance of understanding these attitudes as behavioural predictors.43 Students with negative attitudes towards e-cigarette use may view them as a safer alternative to traditional smoking and associate their use with sophistication and cultural advancement, consistent with findings documented in other countries.33–35
The study emphasises the need for policymakers to develop targeted initiatives to address negative attitudes and behaviours related to e-cigarettes, which can help reduce usage and aid current smokers in quitting. It also found a positive correlation between knowledge and attitude scores, suggesting that knowledge-based initiatives can influence and correct attitudes towards e-cigarettes.
The study’s primary strengths lie in its large sample size and that it was conducted across a diverse selection of six large universities, emphasising its statistical power and the potential for generalisability of its findings. However, the study is subject to several limitations that should be considered. First, the cross-sectional design of a study is efficient for data collection. However, it limits the ability to establish causal relationships between variables due to its limited ability to track changes over time. Second, despite efforts to enhance the reliability of the measurement tool, the reliance on self-reported data introduces potential information bias, as participants' responses may be influenced by social desirability. Third, while the study had a large sample size of Palestinian university students, caution should be taken when extrapolating the findings to other populations since cultural and environmental differences may influence the generalisability of the results. Finally, the knowledge section of the study may have covered only some aspects of e-cigarette awareness. This was done to keep the questionnaire concise and promote increased student participation.
Conclusion
This study highlights the worrying rise in e-cigarette use among young people, particularly university students. Negative attitudes towards e-cigarettes underline the need for specific initiatives to clarify misperceptions and encourage educated student decision-making. The study reflects the importance of knowledge in shaping attitudes and behaviours regarding e-cigarettes, as many students were unaware of their health risks. Social factors, including peer interactions and living surroundings, also affect university students' e-cigarette use. Gendered differences, waterpipe smoking, physical activity, and coffee consumption affect e-cigarette use.
Strategies to address smoking among university students should be multifaceted, considering factors such as peer influence, marketing and advertising tactics by the tobacco and vaping industries, and the role of educational institutions in promoting healthy behaviours.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Institutional Review Board of An-Najah National University (Reference #: Med.Jan.2023/1), Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors would like to express their sincere appreciation and gratitude for all those who participated in the study. We thank the university administrations for granting permission and cooperating with data gathering at their campuses. The authors would like to thank An-Najah National University (www.najah.edu) for the technical support provided to publish this article.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors ZN and BM contributed to the study conception. ZN led the study design and supervised data collection and analysis. ZN also acted as guarantor for this study. RA, BD, MH, FA-J and IA were responsible for data collection. ZN and BM did the final analysis and interpretation and wrote the first draft of the manuscript. All authors contributed to successive drafts of the manuscript. All authors approved the final draft.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.