Saudi Arabia

Most of the studies (n=17) included in this review were conducted in Saudi Arabia^19-35,55. The first study was conducted in 2014 (participants, n=3027). A small number of participants (4.1%) had used e-cigarettes daily; however, less than half of the participants reported that these could be harmful. Less than 20% of the participants reported that the main reason for using e-cigarettes was to quit smoking¹⁹. In five other studies conducted among the general population, between 31.8% to 77.6% of the participants were e-cigarette users^20-24. In addition, the participants were either only e-cigarette or dual users (using e-cigarettes with another smoking product). Generally, the main reason for using e-cigarettes was to quit smoking, as the participants claimed that e-cigarettes could be safer than traditional tobacco smoking. Interestingly, there were also concerns regarding the safety of e-cigarettes among the participants in three studies.

In Saudi Arabia, the use of e-cigarettes among the general population was 2.2% and among the smoking population was 9.6%, which gave it the third smoking method in the country after cigarettes and hookah⁵⁵.

Eleven studies were conducted among university students in Saudi Arabia, where the average age of the participants was <26 years. The findings of these studies indicated that most participants had heard about e-cigarettes, and 5.7–51.4% of them were e-cigarette users. In addition, between 31.0 and 42.7% of the participants reported that they used e-cigarettes to help in quitting smoking. Although the participants in these studies had reported that e-cigarettes were harmful, they also reported that e-cigarettes were ‘less dangerous’ than traditional tobacco smoking. Generally, male students were more likely to use e-cigarettes than females, including medical students^25-35.

Jordan

E-cigarettes use was legalised officially in Jordan in 2019⁵⁶. There were ten published studies related to e-cigarettes^36-45. Three studies were conducted among the general population in Jordan. The participants were found to be familiar with e-cigarettes and thought they could use e-cigarettes as an alternative to traditional smoking^39-41. The prevalence of e-cigarette use ranged between 11.7% and 39.2% in these three studies. In addition, the prevalence of e-cigarette use was more among males than females. Relatively poor knowledge of the content, regulations and types of e-cigarettes was reported among the participants. The general opinions of the participants were that e-cigarettes might have the same or some harmful effects as traditional cigarettes and e-cigarettes could lead to nicotine addiction in the future.

Four studies were conducted among university students^36,43-45. The first study was conducted in 2017, and the use of e-cigarettes was low (2.2%) among students⁴⁵. However, the use of e-cigarettes rose by almost eight- to ten-fold, respectively, in studies published 3 to 4 years later^36,43,44. Generally, the primary motivations to use e-cigarettes were the beliefs that e-cigarettes do not cause dependence, are not as harmful as tobacco smoking, as well as the perception that e-cigarettes could help with quitting smoking. In addition, dual-use was common in these studies. In the two other studies among current and former e-cigarette users, the dual users were 56.7% in the first study and 17.8% in the second study. More than half of the participants believed that e-cigarettes could reduce the cravings for smoking tobacco and help with smoking cessation^38,42. Another reason to use e-cigarettes was that most participants believed e-cigarettes are more socially acceptable than smoking traditional cigarettes, encouraging smokers to continue smoking but possibly using a low nicotine dose⁴³.

In the Hamadneh et al.³⁷ 2021 study conducted among pregnant women (n=436), smoking was high (10.3% for e-cigarettes alone and 55.8% for dual users). The level of awareness regarding the long-term consequences of tobacco use was found to be low among the participants. Non-smoking pregnant women believed that e-cigarettes were as bad for their health as cigarettes, while smoking pregnant women believed that e-cigarettes were less hazardous than cigarettes.

Finally, only one study assessed beliefs toward smoking and COVID-19 infection (n=2424), which included e-cigarette users (9.4%) and 12.9% were dual users. More than a third of respondents (38.2%) believed that e-cigarette use is associated with a risk of contracting COVID-19 infection. A low percentage of participants (21.6%) indicated that e-cigarettes are a safer alternative to other forms of tobacco products during the COVID-19 pandemic⁵⁷.

UAE

The use of e-cigarettes was legalised in the UAE in April 2019⁵⁸. The prevalence of e-cigarette use among the general population in the UAE was 3.8% in 2020⁵⁹. The prevalence was higher (8.8%) among university students, including dual users, and males were more common users of e-cigarettes than females⁴⁶. In another study conducted among current and former e-cigarette users, more than a quarter of participants were dual users⁴⁷. The main reasons for using e-cigarettes were the belief in their safety and enjoyment due to the availability of a wide range of e-liquid flavors^46,47.

Egypt

Although e-cigarettes are not officially legalised in the Egyptian market, they can be purchased in Egypt. In a study conducted between 2015 and 2017 among young adults who had a history of waterpipe use in Egypt (n=2014), e-cigarettes were used by 10.4% of the participants. In addition, young female waterpipe smokers who also used electronic nicotine delivery systems (ENDS) were more than ten times the young males (51.2% vs 4.1%)⁶⁰. Another two studies conducted among university students reported that e-cigarette prevalence was between 10.6 and 16.5%^48,61. At the same time, more than half of those who vaped also used other smoking products⁶¹.

Studies related to knowledge and beliefs about e-cigarettes among non-users of e-cigarettes were also conducted in Egypt. In a study among healthcare providers and the general population, the participants believed that e-cigarettes were not safe, not an effective smoking cessation strategy, and can encourage smoking habits. They also believed that e-cigarettes contained chemicals that may cause health issues in the long-term. However, the general population arm of the study showed low awareness of the potential harms of e-cigarettes among participants⁴⁹. A study by Abo-Elkheir and Sobh⁵⁰, which included the general population, revealed a high level of awareness and positive perception among participants about using e-cigarettes as a smoking cessation device.

In a university study (n=368), the prevalence of vaping was 10.6%. Moderate to high knowledge regarding e-cigarettes with male predominance was shown, and the most frequent reason was keeping with fashion followed by the influence of peers. Only 4.90% of smokers ever tried to quit smoking e-cigarettes⁴⁸.

Kuwait

The use of e-cigarettes was reported in two studies among the adolescent population aged 16–18 years (with n=1525 and n=1345, respectively) in Kuwait^62,63. In these two studies, more than a quarter of the participants were found to be e-cigarette users. In addition, a high percentage of the smokers (84.8%) were dual users, and male adolescents were more likely to use e-cigarettes than females⁶². In Kuwait, the sales of e-cigarettes are banned⁶⁴.

Lebanon

In 2015, regulations for e-cigarette imports were put in place in Lebanon by the Ministry of Finance⁶⁵. A study by Aghar et al.⁵¹ reported that the use of the e-cigarettes among participants (n=352) was 11.5%, and most participants (>80%) believed that using e-cigarettes is less harmful or not harmful compared with traditional cigarettes. In addition, more than half of the participants also thought that e-cigarettes could help people cut down on cigarettes or quit smoking⁵¹. In another study, most participants believed that e-cigarettes were less harmful than traditional cigarettes⁵², and in another study, 8% of the participants reported current use of e-cigarettes⁶⁶.

Qatar

Although the personal use of e-cigarettes is not prohibited in Qatar, the sale, distribution and/or possession of e-cigarettes in large quantities are illegal⁶⁷.

In two studies about e-cigarette use among the general population in Qatar, the prevalence of e-cigarette users was almost similar at 1.6% and 2.0%, and the majority of those who vaped (>82%) were dual users^53,68. In the third study, among university students, the prevalence was higher (14.0% of the participants)⁵⁴. Furthermore, the overall prevalence of using e-cigarettes was higher among males than females. As per the published articles in Qatar, e-cigarette users perceived e-cigarettes to be less harmful than other tobacco smoking. In addition, e-cigarette users believed that e-cigarettes could help reduce smoking, and quitting smoking was a reason to use e-cigarettes by the participants^53,54. Moreover, the availability of various flavors and the lack of restrictions on using e-cigarettes in public places were reported in a study as factors that may increase this type of smoking among the population⁵⁴.

Tunisia

There were two published conference abstracts on the use of e-cigarettes in Tunisia. In the first abstract in 2020, among healthcare workers (n=414), 4.8% of the participants were e-cigarette users. Their reasons to use e-cigarettes were for pleasure and to reduce smoking or quit smoking⁶⁹. Furthermore, a study by Maalej et al.⁷⁰ demonstrated that 20.5% of high school students (aged 15–20 years) were e-cigarette users. They mentioned that the main reason for using e-cigarettes was feeling more sociable. They were more confident in using such a modern smoking method and perceived less harmful effects than traditional smoking products by lowering the nicotine doses⁷⁰.

Sales and consumptions regulations of e-cigarettes in the Arab countries

Various regulatory approaches to the use of e-cigarettes have been implemented in Arab countries. Several countries, such as Bahrain, Lebanon, Oman, and Qatar, have banned the sale of e-cigarettes (Table 2)^50,67,71-74. However, in some of these Arab countries, it is legal to consume e-cigarettes, but it is illegal to sell e-cigarettes⁷⁵. In addition, there are many shops, such as in Bahrain and Kuwait, that sell e-cigarettes to people, as noted when searching through Google (Online shops).

Only three countries, Jordan, Saudi Arabia and the UAE, have passed regulations to control the sales and use of e-cigarettes^56,57,76. These regulations controlled the use of e-cigarettes similar to traditional tobacco products by applying taxes on products, standard manufacturing procedures, smoke-/vape-free areas, and restricting the sales of e-cigarettes to adults aged >18 years.

Some countries such as Bahrain, UAE, Kuwait, and Saudi Arabia have introduced a 100% excise tax on e-cigarettes, while Lebanon and Jordan have introduced a 150% excise tax^65,77-81. In addition, there is a tax on e-cigarette products in some countries, such as Egypt (44% of its value) and Morocco^82,83.

In other Arab countries, although there are regulations regarding the trade and sale of tobacco products (including traditional cigarettes, tobacco for hookah, etc.), to our knowledge, there are no specific regulations relating to e-cigarette sales. There are also internet websites for selling e-cigarettes in some of these countries. In other countries, regulations regarding smoking treat users of e-cigarettes in the same way as smokers of traditional cigarettes. They banned the sale of e-cigarettes to minors and/or restricted public use of e-cigarettes⁸⁴. Some of these smoking regulations specify that e-cigarette tools are under the same rule, or the regulations are applied to all types of smoking products with no particular policy for e-cigarettes^85-89. In addition, all published smoking regulations in Arab countries ban advertising any nicotine products, including e-cigarettes^{56,57,76,84,85}.

Reasons for using e-cigarettes among Arab communities

Overall, e-cigarettes are becoming popular among Arab communities. Prevalence of using e-cigarettes, for instance, was particularly high (>25%) among smokers in countries such as Jordan, Lebanon, Egypt and Saudi Arabia^{20,24,41,51,60}. In the Arab countries, the main reason for using e-cigarette devices among participants in most studies (Table 1) was positive perceptions of e-cigarette safety with minimal harmful health effects. So, e-cigarettes were considered a safer alternative compared with other methods of tobacco smoking, despite the lack of evidence on the long-term effects of e-cigarettes.

Although the long-term abstinence versus relapse among those who quit smoking with the help of e-cigarettes is debated, the desire to quit smoking among the participants (in 20 studies) was one of the main reasons for using e-cigarettes. Another reason was related to the characteristics e-liquids of e-cigarettes, such as flavors and smell, including the fact that e-cigarettes do not leave an unpleasant odor like traditional cigarettes, and nicotine content. Non-smoker participants also thought that e-cigarettes were less harmful than smoking and could help to quit smoking.

Most of the studies in this review reported that the social media were one of the main sources of information regarding e-cigarettes among the participants^{21,24,27,28,32,39,41,43,47,51,88}. This was reported in many studies worldwide⁹¹. This is mainly due to the high level of social media use among adolescents and young adults, mainly related to the increased promotion of e-cigarette use. In addition, e-cigarette use among friends was a significant factor in using this device, as many participants reported peer influence in their initiation of e-cigarette use^{24,25,27,28,30,32,35,39,43,65,87}. The peer influence was significantly associated with an increased probability of e-cigarette use among adolescents^6,91. The cost of e-cigarettes was not assessed in most of the studies. However, three studies stated that the lower cost of e-cigarettes compared with other cigarette types might be a motivation factor for e-cigarette use^27,30,51.

Age and gender

The prevalence of e-cigarette use was high in several studies among participants aged <25 years^{21,24,25,27-33,38,45,48,61}. In many of these studies, e-cigarette use among young adults (<25 or <30 years) was higher than among older people^{19,20-22,39,41,50,60}. There are similarities in these findings according to the data reported in several published reviews^6,90,91.

In all Arab countries, males smoke traditional cigarettes more than females^2,17. The included studies in the current review indicate that e-cigarette use was more prominent in males than females^{19,21,24,26,30,31,36,39,47,51,53,55,62}. Only one study, conducted in Qatar, showed no difference between males and females in e-cigarette use⁵⁴. Generally, knowledge about e-cigarettes was found to be higher among males than females in several studies. This knowledge and awareness related to less harm than traditional cigarettes and as a smoking cessation aid. The differences in knowledge and awareness were mainly related to more adult males using this form of smoking in the studies. Most of them were educated at college level or higher. In addition, males, to a greater extent, use e-cigarettes as a tool for helping them to quit smoking tobacco cigarettes.

Dual users

E-cigarettes have been marketed as healthy alternatives to traditional cigarettes or as a smoking cessation aid. However, most e-cigarette users do not stop smoking and instead use both e-cigarettes and traditional cigarettes or hookah (dual users). Dual users were reported in many of the included studies in this review^{20-22,24,26,36-38,41,46-48,51,53,60,61,68}. The use of e-cigarettes with other types of tobacco was more common than the use of e-cigarettes alone. In many cases, smokers might switch to e-cigarettes and quit traditional cigarettes, but they might fail in that and become dual users^92,93.

Recent studies have shown that dual users are associated with an increased risk of cardiovascular diseases compared to cigarette smokers⁹⁴. However, participants in several studies reported that they tried to quit using e-cigarettes and considered e-cigarettes safer than conventional cigarettes. This is mainly because most people have low smoking experience and have a low level of knowledge regarding the dangers of nicotine smoking and smoking cessation plans.

Limitations

The findings are limited by the quality of studies and methods/surveys, mainly cross-sectional electronic surveys, used in the included studies. Therefore, the data extracted from these studies were limited to the time of studies. The electronic distribution of surveys in several studies likely limits the generalizability of the findings as the main individuals who have access to the internet would respond to the survey. In addition, many studies included in the review did not provide information about the psychometric properties of the instruments used in the surveys. Thus, they did not capture the participants’ true prevalence and awareness of e-cigarette use.

A lack of a unified definition of variables such as the economic status of participants, smoking status, including the daily use volume of e-liquid, and nicotine content in using these devices and presenting other variables, made it difficult to find more information related to e-cigarette users. Furthermore, the wording of questions assessing e-cigarette use may differ in several studies, potentially introducing misclassification bias. For example, in some populations, the term ‘vape’ is more popular than e-cigarettes.