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      Exploring the prevalence, knowledge, attitudes and influencing factors of e-cigarette use among university students in Palestine: a cross-sectional study

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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, χ 2 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.

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          Most cited references41

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          Tobacco Product Use Among Adults — United States, 2019

          Cigarette smoking remains the leading cause of preventable disease and death in the United States ( 1 ). The prevalence of current cigarette smoking among U.S. adults has declined over the past several decades, with a prevalence of 13.7% in 2018 ( 2 ). However, a variety of combustible, noncombustible, and electronic tobacco products are available in the United States ( 1 , 3 ). To assess recent national estimates of tobacco product use among U.S. adults aged ≥18 years, CDC analyzed data from the 2019 National Health Interview Survey (NHIS). In 2019, an estimated 50.6 million U.S. adults (20.8%) reported currently using any tobacco product, including cigarettes (14.0%), e-cigarettes (4.5%), cigars (3.6%), smokeless tobacco (2.4%), and pipes* (1.0%). † Most current tobacco product users (80.5%) reported using combustible products (cigarettes, cigars, or pipes), and 18.6% reported using two or more tobacco products. § The prevalence of any current tobacco product use was higher among males; adults aged ≤65 years; non-Hispanic American Indian/Alaska Native (AI/AN) adults; those whose highest level of educational attainment was a General Educational Development (GED) certificate; those with an annual household income 30% or unweighted denominator 30% or unweighted denominator <50. The figure is a bar chart showing the cigarette smoking status (current, former, or never) among current adult e-cigarette users, by age group. The prevalence of any current tobacco product use was higher among males (26.2%) than among females (15.7%) and among those aged 25–44 years (25.3%), 45–64 years (23.0%), or 18–24 years (18.2%) than among those aged ≥65 years (11.4%) (Table). Current tobacco product use was also higher among non-Hispanic AI/AN adults (29.3%), non-Hispanic adults of other †††† races (28.1%), non-Hispanic White adults (23.3%), non-Hispanic Black adults (20.7%), and Hispanic or Latino adults (13.2%) than among non-Hispanic Asian adults (11.0%); and among those living in the Midwest (23.7%) or South (22.9%) than among those in the Northeast (18.5%) or West (16.4%). The prevalence of current tobacco product use was higher among those whose highest educational attainment was a GED (43.7%) than among those with other levels of education; among those who were divorced/separated/widowed (23.5%) or single/never married/not living with a partner (23.0%) than among those married/living with a partner (19.2%); among those who had annual household income of <$35,000 (27.0%) than among those with higher income; and among LGB adults (29.9%) than among those who were heterosexual/straight (20.5%). Prevalence was also higher among adults who were uninsured (30.2%), insured by Medicaid (30.0%), or had some other public insurance (25.6%) than among those with private insurance (18.0%) or Medicare only (11.4%); among those who had a disability (26.9%) compared with those without (20.1%); and among those who had GAD-7 scores indicating mild (30.4%), moderate (34.2%) or severe (45.3%) anxiety than among those indicating no or minimal (18.4%) anxiety. Discussion In 2019, approximately one in five U.S. adults (50.6 million) reported currently using any tobacco product. Cigarettes were the most commonly used tobacco product among adults, and combustible tobacco products (cigarettes, cigars, or pipes) were used by most (80.5%) adult tobacco product users. Most of the death and disease from tobacco use in the United States is primarily caused by cigarettes and other combustible products ( 1 ); therefore, continued efforts to reduce all forms of combustible tobacco smoking among U.S. adults are warranted. Moreover, approximately one in five current tobacco product users (18.6%) reported using two or more tobacco products, and differences in prevalence of tobacco use were also seen across population groups, with higher prevalence among those with a GED, American Indian/Alaska Natives, uninsured adults and adults with Medicaid, and LGB adults. Each of these groups has experienced social, economic, and environmental stressors that might contribute to higher tobacco use prevalence ( 6 ). Comprehensive strategies at the national, state, and local levels, including targeted interventions and tailored community engagement, can reduce tobacco-related disease and death and help to mitigate tobacco-related disparities ( 1 , 4 , 6 ). U.S. adults also reported using various noncigarette tobacco products, with e-cigarettes being the most commonly used noncigarette tobacco product (4.5%). E-cigarette use was highest among adults aged 18–24 years (9.3%), with over half (56.0%) of these young adults reporting that they had never smoked cigarettes. In addition, the tobacco product with the highest percentage of users aged 18–24 years (24.5%) was e-cigarettes. E-cigarettes contain nicotine, which is highly addictive, can prime the brain for addiction to other drugs, and can harm brain development, which continues until about age 25 years ( 3 ). Although e-cigarette use was lower among the older age groups, more than 40% of e-cigarette users in the 25–44, 45–64 and ≥65 years age groups reported being former smokers. Although some evidence suggests that the use of e-cigarettes containing nicotine and more frequent use of e-cigarettes are associated with increased smoking cessation, smokers need to completely stop smoking cigarettes and stop using any other tobacco product to achieve meaningful health benefits ( 6 , 7 ). The U.S. Surgeon General concluded that there is presently inadequate evidence to conclude that e-cigarettes, in general, increase smoking cessation, and further research is needed on the effects that e-cigarettes have on cessation ( 7 ). Therefore, continued efforts to reduce use of all tobacco products, combustible and noncombustible, are needed. The findings in this report are subject to at least four limitations. First, the 59.1% response rate might have resulted in nonresponse bias, although sample weighting is designed to account for this. Second, self-reported responses were not validated by biochemical testing for cotinine (a biomarker indicating nicotine exposure); however, there is high correlation between self-reported smoking and smokeless use and cotinine levels ( 8 , 9 ). Third, because NHIS is limited to the noninstitutionalized U.S. civilian population, these results might not be generalizable to institutionalized populations and persons in the military. Finally, this analysis does not provide comparisons of prevalence estimates with previous surveys because changes in weighting and design methodology for the 2019 NHIS have the potential to affect comparisons of weighted survey estimates over time. §§§§ The implementation of comprehensive, evidence-based, population-level interventions in coordination with regulation of tobacco products, can reduce tobacco-related disease, disparities, and death in the United States ( 1 , 4 ). These evidence-based, population-level strategies include implementation of tobacco price increases, comprehensive smoke-free policies, high-impact antitobacco media campaigns, and barrier-free cessation coverage ( 1 ). As part of a comprehensive approach, targeted interventions are also warranted to reach subpopulations with the highest prevalence of use, which might vary by tobacco product type. Summary What is already known about this topic? Cigarette smoking remains the leading cause of preventable disease and death in the United States; however, a variety of new combustible, noncombustible, and electronic tobacco products are available in the United States. What is added by this report? In 2019, approximately 20.8% of U.S. adults (50.6 million) currently used any tobacco product. Cigarettes were the most commonly used tobacco product among adults, and e-cigarettes were the most commonly used noncigarette tobacco product (4.5%). The highest prevalence of e-cigarette use was among smokers aged 18–24 years (9.3%), with over half (56.0%) of these young adults reporting that they had never smoked cigarettes. What are the implications for public health practice? The implementation of comprehensive, evidence-based, population-level interventions, combined with targeted strategies, in coordination with regulation of tobacco products, can reduce tobacco-related disease and death in the United States. As part of a comprehensive approach, targeted interventions are also warranted to reach subpopulations with the greatest use, which might vary by tobacco product type.
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            The collective dynamics of smoking in a large social network.

            The prevalence of smoking has decreased substantially in the United States over the past 30 years. We examined the extent of the person-to-person spread of smoking behavior and the extent to which groups of widely connected people quit together. We studied a densely interconnected social network of 12,067 people assessed repeatedly from 1971 to 2003 as part of the Framingham Heart Study. We used network analytic methods and longitudinal statistical models. Discernible clusters of smokers and nonsmokers were present in the network, and the clusters extended to three degrees of separation. Despite the decrease in smoking in the overall population, the size of the clusters of smokers remained the same across time, suggesting that whole groups of people were quitting in concert. Smokers were also progressively found in the periphery of the social network. Smoking cessation by a spouse decreased a person's chances of smoking by 67% (95% confidence interval [CI], 59 to 73). Smoking cessation by a sibling decreased the chances by 25% (95% CI, 14 to 35). Smoking cessation by a friend decreased the chances by 36% (95% CI, 12 to 55 ). Among persons working in small firms, smoking cessation by a coworker decreased the chances by 34% (95% CI, 5 to 56). Friends with more education influenced one another more than those with less education. These effects were not seen among neighbors in the immediate geographic area. Network phenomena appear to be relevant to smoking cessation. Smoking behavior spreads through close and distant social ties, groups of interconnected people stop smoking in concert, and smokers are increasingly marginalized socially. These findings have implications for clinical and public health interventions to reduce and prevent smoking. Copyright 2008 Massachusetts Medical Society.
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              Waterpipe and cigarette tobacco smoking among Palestinian university students: a cross-sectional study

              Background During the last two decades, waterpipe tobacco smoking (WTS), also known as hookah, witnessed a global increase in use, especially among youth. Little information is known about the burden of WTS among Palestinian youth. A cross-sectional study was conducted to estimate the prevalence of WTS and cigarette smoking and explore the associated factors among a sample of Palestinian university students. Methods 1891 students, from five Palestinian universities in the West Bank and Gaza Strip, completed a self-administered, web-based survey in 2014–2015. The questionnaire, which was based on the Global Adults Tobacco Survey (GATS), had questions on WTS and cigarette smoking patterns and socio-demographic and university-related characteristics. Binary logistic regression analyses were computed to investigate associated factors with WTS and cigarette smoking. Results 50.9% of the sample was women. The mean age was 20.1 ± 2.0. Overall, 30.0% of participants were current tobacco smokers and 33.4% reported ever smoking tobacco through a waterpipe. The prevalence of current WTS (24.4%) surpassed the prevalence of current cigarette smoking (18.0%), with a significantly higher prevalence among men compared to women. The gender gap for WTS (36.4% vs. 12.9%) was smaller than that for cigarette smoking (32.8% vs. 3.6%). Binary logistic regression models for the total sample (men and women) revealed that men were more likely to be current waterpipe and cigarette tobacco smokers compared to women (AOR = 4.20, 95% CI = 3.22–5.48, and AOR = 10.91, 95% CI = 7.25–16.42, respectively). Geographic area of residence, faculty of study and self-reported academic achievement were also associated with the likelihood of being current waterpipe and cigarette tobacco smokers. Conclusion A high prevalence of WTS was reported among our study sample, and it surpassed the prevalence of cigarette smoking. Interventions to curb the practice of tobacco smoking among Palestinian youth should be tailored differently to WTS and cigarette smoking, be gender-sensitive and specific and target the regional variation in the smoking behavior. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4524-0) contains supplementary material, which is available to authorized users.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2024
                17 February 2024
                : 14
                : 2
                : e080881
                Affiliations
                [1 ]departmentDepartment of Medicine, Faculty of Medicine and Health Sciences , Ringgold_61284An-Najah National University , Nablus, Palestine
                [2 ]departmentDepartment of Family and Community Medicine, Faculty of Medicine , Ringgold_115527Hebron University , Hebron, Palestine
                [3 ]departmentPrimary Health Care , Ministry of Health , Hebron, Palestine
                [4 ]departmentDepartment of Medicine, Faculty of Medicine , Ringgold_115527Hebron University , Hebron, Palestine
                Author notes
                [Correspondence to ] Dr Zaher Nazzal; znazzal@ 123456najah.edu
                Author information
                http://orcid.org/0000-0002-2655-6109
                http://orcid.org/0000-0002-6997-0449
                Article
                bmjopen-2023-080881
                10.1136/bmjopen-2023-080881
                10875484
                38367977
                0b5cf16f-a27d-4b8f-ae9e-02f4bd775d93
                © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                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/.

                History
                : 13 October 2023
                : 31 January 2024
                Categories
                Smoking and Tobacco
                1506
                1734
                Original research
                Custom metadata
                unlocked

                Medicine
                health education,preventive medicine,primary prevention,public health
                Medicine
                health education, preventive medicine, primary prevention, public health

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