The multi-dimensional impact of psycho-socio-economics on the use of electronic cigarettes

Introduction

E-cigarettes are battery-powered electronic devices that aerosolize e-liquids to deliver nicotine in the form of vapor. These devices have grown in popularity in recent years because they are advertised as safer and less dangerous than regular cigarettes.^1,2 Initially, they were introduced as a means of smoking cessation; however, there is limited evidence on their effectiveness.³ There has been an upsurge in the prevalence of e-cigarette use in the last few years.⁴ The prevalence of e-cigarette use in different countries such as Australia, the United States, China, France, and Mexico is 12.5%, 13.5%, 24%, 25.5%, and 42%, respectively.⁴ Its use among young adults is increasing in both developed and developing nations.⁵ Czoli et al. reported a relatively high awareness of e-cigarette use among young Canadian adults, with only 16.1% using e-cigarettes.⁶ In contrast, Althobaiti et al. assessed the prevalence of e-cigarette use in Saudi Arabia and reported that 26.3% of participants had used e-cigarettes at least once.⁵ The study also found that e-cigarette smokers had higher use of smokeless tobacco and smoking conventional tobacco.⁵

Goniewicz et al. evaluated the properties of the vapor produced by e-cigarettes and found that it contained fewer toxic substances than regular cigarettes, which is consistent with the idea that it was used as a harm reduction strategy for smokers who refuse to quit cigarettes.⁷ There is growing evidence that short-term exposure to e-cigarettes has detrimental effects on various biological systems, but the mechanisms by which these effects occur are currently unknown.⁸ Although the long-term consequences have not yet been studied in depth, several possible carcinogens, including nitrosamines and reactive carbonyls, have been identified in recent research on e-cigarettes.⁸ Heated flavoring components can produce adducts that harm host cells. Moreover, e-cigarettes have the potential to harm oral health and are an efficient way to deliver high quantities of nicotine.⁹

Psychological distress is a subject of concern that influences e-cigarette use of e-cigarettes.¹⁰ Research conducted in the United States on middle-aged adults revealed that e-cigarettes are used as a stress reduction strategy.¹¹ Many studies have reported a significant association between e-cigarette use and depression, anxiety, stress, and loneliness.^12–17 Vaping has been demonstrated to have several negative effects on individuals’ psychological well-being.¹⁸ Furthermore, nicotine (an element of e-cigarettes) use in youth has been proven to induce substantial brain deterioration, leading to cognitive and psychological issues such as depression, anxiety, aggression, substance addiction, and self-harm.¹⁸ Additionally, Almutham et al. observed a relationship between exploring e-cigarettes and having a close friend or family member who is an e-cigarette smoker.¹⁹ Similarly, a study conducted in California concluded that individuals who had tobacco smoking acquaintances were more likely to use e-cigarettes.²⁰ Saudi Arabia is in an expeditious era of modernization that has resulted in an increase in socialization outside the home environment, which was correlated with an increase in conventional smoking rates.²¹ The purchase of tobacco cigarettes decreased as the prices increased. However, the availability of e-cigarette puffs at a fixed unit price increases the opportunity to purchasing them.²² Alhajj et al. reported that one of the reasons for initiating the use of e-cigarettes is the economic factor due to its lower price compared to other cigarettes.²³

E-cigarettes continue to gain popularity among youth and young adults.^24,25 Recently, many studies have been conducted on various aspects of e-cigarettes, including the prevalence of use, attitudes toward e-cigarettes, awareness assessments, and facts about e-cigarettes, which are just a few of the topics that have been covered by the public.²⁶ However, there is limited evidence on the relationship and influence of psychosocial factors on e-cigarette use. Therefore, this study aimed to investigate the influence and integration of psychosocial elements among young adults on their use of e-cigarettes. The results of this study will enable authorities to direct educational programs to decrease the use of such substances and further explore the factors that trigger e-cigarette use to tailor control and prevention programs.

Methods

Results

In total, 3017 participants responded to the survey. Table 1 shows the demographic distribution of the study participants. The majority of the study sample were male (63%) and had a college degree or higher (65.4%). Fifty-three percent of the study sample were younger than 25 years of age, and thirty-eight percent of the participants had a monthly income of less than 5000 SR. More than half of the participants were professionals (57.6%), while the remainder (42.4%) were college students. Based on professional background, almost 60% were working in health sectors, including medicine, dentistry, pharmacology, nursing, and applied medical sciences, while the remaining were non-health professionals.

Table 2 shows the distribution of participants’ perceptions and practices regarding e-cigs. The majority of the study sample heard about e-cigs from their friends (65.6%) and were not aware of the various ingredients and chemicals in e-cigs (64%). Half of the participants were unaware of the different levels of nicotine in e-cigs (53%). When they were asked about their thoughts on what makes people start smoking e-cigs, 35.7% stated stress as the main reason, 30% thought it was a way to quit smoking regular cigarettes, and 18% felt it was peer pressure that allowed people to start smoking e-cigs. The least cited reasons were acceptability to the family (8.5%) and depression (7.7%). Thirty-nine percent and twelve percent of the study sample thought that the use of e-cigs could be slightly or extremely effective in helping people quit smoking regular cigarettes, respectively. On the other hand, 27.7% and 20.6% thought that e-cigs were slightly or extremely ineffective in helping people quit traditional smoking.

Similar percentages of participants agreed or strongly agreed that e-cigs were less dangerous and could help in smoking cessation (42.4% and 43.2%, respectively). By contrast, 39% and 35% disagreed or strongly disagreed with the statements, respectively. The remaining 18.5% and 21.6% were neutral to these statements, respectively. In contrast, 48% of the study sample disagreed or strongly disagreed that only smokers used e-cigarettes. Another 31% agreed or strongly agreed with this statement.

The majority of participants were nonsmokers (63%), and only 14% were former smokers ( Table 2). Forty-three percent of the participants reported that someone in their family was a smoker. With regard to e-cig use, 22% of the study sample used e-cigs constantly, while another 22% used it to try it only. Only 17% agreed or strongly agreed with the intention to use e-cigs in the future, while 13% were neutral. The remaining 70% disagreed or strongly disagreed with having any intention to use e-cigs.

Figure 1 presents the distribution of psychological factors that led participants to use e-cigs. About a third of the participants used e-cigs because they cost less than traditional cigs. Twenty-three percent of them use e-cigs because of curiosity, while another 21% use it to reduce their use of traditional cigs. Eleven percent use e-cigs for smoking cessation and 10.5% use them because of peer influence.

Figure 1. The distribution of psychological factors that led participants to use e-cigs.

The distribution of social factors that influenced the use of e-cigs in the study sample is shown in Figure 2. Most participants reported that they had friends who had used e-cigarettes (56%). About a third of the participants reported that no one in their social circle used e-cigs. Only 9.5% and 2.3% of the participants stated that their siblings or parents were using e-cigs, respectively.

Figure 2. The distribution of social factors that led participants to use e-cig.

Table 3 presents the influence of psychosocial factors on the use of e-cigs among study participants in a multiple logistic regression model. The model was adjusted for demographic background, smoking history, employment status, and professional background. Females were more likely to use e-cigs than males (OR = 1.39). However, this estimate was not statistically significant (95% CI = 0.87-2.23). The age of the participants was a significant factor in increasing the odds of using e-cigs. Older participants were more likely to use e-cigs in comparison to those who were younger than 25 years old (OR for 25-30 years old = 2.46, 95% CI = 1.11-5.43, OR for >30 years old = 3.02, 95% CI = 1.44-6.34). Working status and professional background did not significantly influence e-cigarette use among the study sample. The strongest indicator in the model was participants’ traditional smoking status. In comparison to nonsmokers, cig smokers and former smokers were significantly 34.33 and 19.39 more likely to use e-cigs. However, the 95% CI was wide (95% CI for smokers = 18.04-65.37, and 95% CI for former smokers = 9.94-37.82). Economic background was not a significant factor in e-cigs use. In comparison to participants without an income, those who had less than SR5000 monthly income were more likely to use e-cigs (OR = 1.28, 95% CI = 0.52-3.16), while those with an income of SR5000-14,999 were less likely to use it (OR = 0.79, 95% CI = 0.34-1.81). Regarding the psychological factors, those who used e-cigs due to their perception that e-cigs are less dangerous (OR = 0.24), can reduce the use of cigarette smoking (OR = 0.26), have used it because of curiosity (OR = 0.04) or peer influence (OR = 0.33), or because it costs less (OR = 0.12) were less likely to use e-cigs. All these estimates were statistically significant except for those who thought e-cigs were less dangerous, which was not statistically significant. Only those who used e-cigs because they thought it helped them to quit traditional smoking were more likely to use e-cigs (OR = 1.23). However, the estimate was not statistically significant (95% CI = 0.52-2.94, p-value = 0.639). With regards to social factors, those having friends, parents, or siblings using e-cig were less likely to use e-cig (OR = 0.22, 0.27, 0.35, respectively), a difference which was statistically significant (95% CI = 0.45-0.22, 0.40-0.17, 0.51-0.30, respectively). On the contrary, those who did not have any one of their social circles using e-cig were 3.3 times more likely to use e-cigs (95% CI = 1.35-8.01, p-value = 0.009).

Discussion

The present survey assessed the current use of e-cigs among college students and young adults in Eastern Saudi Arabia and the multidimensional influence of psychosocial factors on its use among the study participants. Among the demographic factors, only age was associated with increased use of E-cigs. Economic status was not associated with E-cig use, whereas both psychological and social factors were inversely associated with its use. The findings of the current study provide a better understanding of the relationship between different factors known to affect the use of e-cigarettes. As a result, targeted educational programs for the most influential factors could assist in reducing the prevalence of e-cigarette use in the country.

This study found that females were more likely to use e-cigs than males, although the results were not statistically significant. This finding is inconsistent with recent findings from The Global Adult Tobacco Survey (GATS), which monitors adult tobacco use in KSA in 2019, where females presented with a lower percentage of e-cigarette use (0.4%) than males (1.1%).²⁷ However, previously published studies reported that females were more likely than males to have used e-cigarettes, which was attributed to better economic conditions.²⁸ According to a study that evaluated gender differences in the use of e-cigarettes across various domains, women’s smoking behavior was found to be more likely influenced by non-nicotine elements, such as social and environmental signals, than by nicotine itself. Women often smoke fewer cigarettes per day than males, inhale less deeply, and favor brands with lower nicotine and tar levels. Additionally, women are more optimistic about the effects of smoking on controlling their eating habits, weight, and mood.²⁹ Another study stated that the increase in the percentage of female users of e-cigarettes was due to the sweet flavors of e-cigarette liquids.³⁰ Tobacco companies view women nowadays as key consumers and develop products that appeal most to the female gender by eliciting feelings of liberation, success, glamor, and independence.^31–33 Some distributers appeal more to females by creating devices in forms that attract them: slim, glamorous, pink, and fashionable features.³⁴

The age of the participants in this study was found to be a significant factor in increasing the odds of using e-cigs. Compared to individuals under the age of 25, older participants were more likely to use e-cigarettes. Additionally, college students in our study were less likely to use e-cigs when compared to working professionals; however, it did not significantly influence the use of e-cigs among the study sample. A previous study reporting on the prevalence of e-cigarette use in KSA concluded that e-cigarette smoking was significantly higher among youths between 18 and 24 years of age, which is inconsistent with the results of our study.⁵ Multiple previous studies have also stated that e-cigarette use is more prevalent among adolescents and young adults than among adults.^35,36 Reasons that can explain the increase in the frequency of e-cig use among older age groups may be because they are more likely to be employed and enjoy economic independence.³⁷

The strongest indicator of e-cig use in the current study was participants’ traditional smoking status. Compared to nonsmokers, cig smokers and former smokers were significantly more likely to use e-cigs. Our findings are consistent with those from previously published studies that showed that the use of e-cigarettes has increased considerably among current or former smokers.^37,38 This can be related to the misconceptions that e-cigs are less harmful than conventional smoking or that they can be a tool to quit smoking.³⁹ E-cigs were found to have fewer withdrawal symptoms compared to traditional smoking, and for many smokers who are trying to quit can even help with withdrawal symptoms.⁴⁰ It is critical to investigate the factors that can encourage the commencement and maintenance of e-cigarette usage over time, given the exponential growth in the use of these devices.

In the present study, the overall prevalence of smoking was 23%. This study further showed that most e-cig smokers were non-Health care workers (HCWs). Professional background did not significantly influence e-cigarette use among the study sample. The results of this study are comparable to the findings of a study conducted on Italian healthcare students, which reported no difference in smoking habits between those in the healthcare field and those who were not.⁴¹ Individuals with higher educational levels were significantly less likely to use e-cigs than were high school students. Higher education guarantees better awareness of the negative effects of e-cig use.³⁷ However, our result is inconsistent with that of a study conducted in Saudi Arabia on the prevalence of e-cig use, which proved that e-cig use was more prevalent among individuals with higher educational levels.⁵ This difference might be due to sampling and methodological differences or even the timing of the studies. There could be a true shift in the trends of e-cig use in the country due to increasing popularity and the lack of health awareness programs, particularly regarding e-cigs.

With regard to the psychological influence on e-cig use, the most cited reasons that make individuals choose e-cigs over traditional smoking were because they cost less, followed by curiosity. In one study, which listed the reasons why teenagers tried e-cigarettes, curiosity ranked first, followed by pleasant flavors, usage by friends and family, and lastly, low price. Compared to regular cigarettes, e-cigarettes are significantly more affordable.⁴² Given the health risks that accompany the use of e-cigs, there is a need for legislation that adds tax to e-cig manufacturing.

Stress was the most common reason people started smoking (37.5%). A study assessing the social influences, self-esteem, and stress of high school students who vape perceived stress relief as the most cited reason for vaping.⁴³ According to Finkelstein et al., smoking initiation was substantially associated with increased stress levels among adolescents in grades 7 through 12.⁴⁴ This may be because nicotine affects the activity of the stress response pathway by stimulating and desensitizing nicotinic acetylcholine receptors.⁴⁵

One-third of the participants used e-cigarettes as a means of quitting traditional smoking. Additionally, most respondents believed that e-cigarettes are less dangerous and can be a means of smoking cessation. A survey on health professionals’ attitudes toward the use of e-cigarettes found that nearly 90% of respondents were hesitant about whether e-cigarettes were approved by the FDA as a tool for smoking cessation.⁴⁶ To date, the FDA has not certified e-cigarette products as smoking cessation aids.⁴⁷ The findings of this study are similar to those conducted at a Saudi institution, where the majority of medical students were unaware that the FDA has not authorized e-cigarettes as a method of quitting smoking.⁴⁸ Furthermore, a meta-analysis of 26 studies showed that adult smokers who used e-cigarettes for quitting had a lower likelihood of succeeding in their efforts than those who did not.⁴⁹ According to the findings of a study performed to analyze physicians’ knowledge, concerns, and practices surrounding e-cigarettes, more than half of the participants perceived e-cigarettes as part of a “harm-reduction strategy”.⁵⁰ This misconception among the public regarding the use of e-cigs as an aid to quit using traditional cigarettes needs to change. Awareness programs may assist in addressing this misunderstanding. Health professionals also bear the burden of educating their smoker patients about the health hazards of e-cigs and that the use of e-cigs will not help in tobacco cessation.

In this study, we found that having friends, parents, or siblings using e-cigs was less likely to influence their use. This finding is contradictory to that of Almutham et al., who found that exploring e-cigarettes is related to having a close friend or family member who is an e-cigarette smoker.¹⁹ Another study conducted in California showed that individuals who had tobacco smoking acquaintances were more likely to use e-cigarettes.²⁰ According to Khader and Alsadi, the increased prevalence of smoking is associated with a higher number of family and friends who smoke.⁵¹ A study showed that peer influence is a leading social drive and reinforces the use of vapor.⁵² The discrepancy between our study findings and other reports can be attributed to the fact that the current study investigated the effect of multiple background factors, such as psychological, social, and economic factors, in a multidimensional model. These individual factors might be significant when studied as stand-alone factors; however, they are never isolated from the influence of other factors. Our study looked at the interrelationship of all dynamic factors together, which explains the inconsistent results with other reports. It is also possible that seeing peers or parents unable to quit smoking through their use of e-cigs, harm perceptions, or even developing potential health consequences might have hindered the study participants from using e-cigs as a principal theory in the health belief model.⁵³

According to a previous study, the risk of using e-cigarettes is associated with social class and work position. When compared with high occupational level, those who worked in intermediate or low occupation levels were using e-cigs on a non-daily basis, which might be because of the e-cig cost, which is a dependent factor on smoking habit. Furthermore, when compared to full-time employment, those unemployed had a low relative risk of e-cigs on a non-daily basis, as e-cig consumption depends on individual incomes and their ability to smoke daily.⁵⁴ Another study found that among all socioeconomic groups, among those who quit smoking for at least one year, their usage of e-cigs increased from 3% in 2014 to 10% in 2019, and the use of e-cigs was high among those with low socioeconomic status.⁵⁵ In this study, the results show no significant influence between working status, professional, and economic background on the use of e-cigs in the study sample.

This study had a greater number of nonsmokers (63%) than smokers (23%), which may have affected the findings of the study. The reason behind the lower rate of non-smoking could be related to the fact that 60% of the participants were working in health sectors, which in turn is reflected in their self-awareness of the health risks and consequences of smoking, as the majority of participants (70%) disagreed or strongly disagreed with having any intention to use e-cigarettes in the future. After evaluating the participants’ responses to the question of what reasons make them engage in e-cig use, we found curiosity, low cost, and being a less harmful alternative to cigarette smoking. Similar results were found in multiple studies where curiosity, harmlessness, and low cost compared with smoking, stress relief, and peer pressure influenced the use of e-cigs.^{30,43,56–61} These responses may explain why psychosocial factors are integrated and need to be declared.

The current study has several limitations. As the research population was geographically confined to individuals residing in the eastern province of Saudi Arabia, its generalizability is limited. However, results from this sample of the population could provide insight into national practices, which might encourage further investigation. Due to the self-administered nature of the survey, the possibility of self-selection and social desirability bias cannot be completely excluded. The limitations inherent in a snowball sample may introduce bias and reduce the representativeness of the sample. This can be avoided by using multiple sources and methods to recruit participants. For instance, many participants in this study were male, although a random selection of the study sample was planned. This could be due to the refusal of female participants to participate, probably because of discomfort in reporting smoking behavior. They may also be cautious when reporting socially unacceptable behaviors, which may have led to a social desirability bias.

Owing to the popularity of these devices, it is critical to investigate elements such as psychological, social, and economic factors that may promote both the inception and continuation of e-cigarette use. Our study revealed that older participants, cigarette smokers, and former smokers are more likely to use e-cigarettes. When combining these factors with other social and economic factors, they become stronger predictors of e-cigarette use. The multidimensional relationship of psycho-socioeconomic factors revealed that participants’ practices of regular cigarette smoking were a stronger predictor than any of them combined. The habit of smoking regular cigarettes had the greatest influence on the use of e-cigarettes. Authorities should initiate and monitor campaigns that support smoking cessation and shed light on the harmful effects of e-cigarettes to ensure that these devices are not used as a means of regular smoking cessation. Taxes, health tags, and controls on vaping devices are possible strategies to prevent the use of e-cigs.

Patient and public involvement statement

Patients or the public WERE NOT involved in the design, conduct, reporting, or dissemination plans of our research.

Ethics and consent

This study protocol including the method of consent form was approved by the Institutional Review Board of the Deanship of Scientific Research (IRB-2024-02-027) on Jan 7^th, 2024, 2024. Participation was voluntary with no written or verbal consent required. It was clearly stated that participants were informed through the introductory page in the online survey that proceeding means they consent to take part in the study and choosing to proceed with the survey and submit their responses would be considered as informed consent. The consent was not verbal or written. If the participant proceeded with the online survey after reading the front page, then they are considered consented.