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Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 163-169

Electronic and regular cigarette use among king saud university students and their association with psychological distress

1 Department of Family and Community Medicine, King Saud University; King Saud University Medical City, Riyadh, Saudi Arabia
2 Department of College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission26-Aug-2021
Date of Decision25-Jan-2022
Date of Acceptance23-Feb-2022
Date of Web Publication28-Apr-2022

Correspondence Address:
Ruba Alsalem
College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsm.jnsm_111_21

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Background: The growing trend of electronic cigarette (e-cigarette) use among the youth is concerning. This behavior has not been well studied among Saudi young adults, let alone among females. Aims and Objectives: We measured the prevalence of e-cigarette and regular cigarette use among female university students, their association with psychological distress and student characteristics, and the reasons for smoking. Materials and Methods: We conducted a cross-sectional study among 616 female students at King Saud University, from January to March 2019. Self-administered questionnaires were used asking about regular and e-cigarette use behavior, and psychological distress measured by 6-item Kessler Psychological Distress Scale (K6). Results: The response rate was 91.5%, and 7.8% of students smoked regular cigarette, while only 2.6% smoked e-cigarettes. About 86.9% of students had K6 scores suggestive of high levels of stress. Students whose friends smoked had around 16 times the odds for e-cigarette use (odds ratio [OR]: 15.75; 95% confidence interval [CI] = 7.45, 33.31), and 11 times the odds for regular cigarette use (OR: 11.40; 95% CI = 5.31, 24.47) compared to those without friends who smoked. The reasons for smoking e-cigarettes were peer pressure (35.6%), believing they are safer than regular cigarettes (32.2%), for quitting regular cigarettes (25.4%), and out of curiosity (6.8%). Conclusion: Although e-cigarette use prevalence does not seem quite high in this study, the prevalence of regular cigarette smoking was surprisingly higher. Peer pressure and having friends who smoke are important predictors of cigarette use that should be targeted in tobacco prevention planning.

Keywords: Electronic-cigarette, psychological distress, smoking, tobacco, university-student

How to cite this article:
Dabbagh R, Barnawi R, Alrsheed A, Alsalem R, Alanzan S, Alhuthail A, Alhogail N. Electronic and regular cigarette use among king saud university students and their association with psychological distress. J Nat Sci Med 2022;5:163-9

How to cite this URL:
Dabbagh R, Barnawi R, Alrsheed A, Alsalem R, Alanzan S, Alhuthail A, Alhogail N. Electronic and regular cigarette use among king saud university students and their association with psychological distress. J Nat Sci Med [serial online] 2022 [cited 2022 Jul 7];5:163-9. Available from: https://www.jnsmonline.org/text.asp?2022/5/2/163/344200

  Introduction Top

Electronic cigarettes (e-cigarettes) are a form of electronic nicotine delivery systems. They are designed to deliver nicotine without the use of tobacco smoke, by inhaled aerosol or “vapour,” produced through heating of the liquid containing nicotine and other contents.[1],[2] It was invented in 2003 by a Chinese pharmacist called Lik.[2] The death of his father from lung cancer as a consequence of years of smoking inspired him to create a product that produced vapor instead of smoke, with the intention to reducing tobacco-smoke harm. The e-cigarette industry rapidly expanded, and it quickly gained popularity after increasing the variety of flavors and designs, in addition to its availability for purchase by the youth.[1],[3]

E-cigarette devices deliver nicotine without the combustion of tobacco. This may have influenced the common perception of them being less harmful than regular tobacco products. Although e-cigarettes may contain fewer carcinogens when compared to traditional cigarettes, they can still cause acute side effects such as vomiting, burn injuries, upper respiratory tract irritation, bradycardia, hypotension, or atrial fibrillation.[1],[4] In addition, even though users do not expose themselves or others to the many harmful regular tobacco smoke constituents and particles, they still experience the effects of tobacco on the central nervous system.[5],[6] This feature makes e-cigarettes attractive to many smokers. Clinical trials have reported that e-cigarettes deliver significant amounts of nicotine, yet the amount of nicotine produced from them reaches lower plasma concentrations than that produced from regular cigarettes.[7] Nevertheless, this observation cannot be generalized as the concentration of nicotine carried to the bloodstream relies on the frequency and intensity of use in addition to the e-cigarette brand.[8] On top of the many negative effects that e-cigarettes may have on the human body, some research suggests its positive association with psychological distress.[9],[10] Other evidence suggests that e-cigarette users may be more likely to have experienced mental health problems at some point in their lives.[11]

Although e-cigarettes have only recently reached the Saudi tobacco market, many local studies imply their popularity among young Saudi adults. The prevalence of daily e-cigarette use is variable depending on the population sample and the sampling strategy, where it ranges from 3.9% to 58.7%.[12],[13],[14],[15],[16],[17] For example, an online survey conducted among Saudi Facebook users in 2014 reported that 33.5% of the respondents had ever used e-cigarettes.[12] A subsequent social media survey conducted in 2017 reported that 58.7% of the adult respondents were daily e-cigarette users.[16] In addition, 56.8% of these respondents believed they were safer than regular cigarettes, and 70% believed that they help in smoking cessation.[16] A lower prevalence was reported in 2016, among King Saud University (KSU) students, where 25.6% reported ever experimenting with e-cigarettes, while only 3.9% reported using them in the past month.[13] However, in 2019, a different study among university students in Jeddah reported that 27.7% were daily e-cigarette users.[17] These students most frequently used e-cigarettes for the purpose of reducing symptoms of anxiety or depression.[17]

Other studies imply that students from health-related colleges may be less likely to practice e-cigarette smoking. One study conducted on medical students at a private university in Riyadh reported that only 7.2% were current e-cigarette users.[14] Similarly, another survey conducted among students from health colleges reported a 6.2% prevalence of current e-cigarette use.[15] The Saudi literature collectively suggests that the prevalence of e-cigarette use in Saudi Arabia is highest among young adults, males, people who are regular smokers, and individuals who have a friend using e-cigarettes.

The growing trend in reported e-cigarette use among university students is concerning. E-cigarettes are misconceived as safe alternatives to regular cigarette use and may help in smoking cessation, even though the clinical trials have not concluded their usefulness in quitting smoking.[1],[18],[19] Because regulations around public use of e-cigarettes are not as clearly defined in Saudi Arabia as they are for regular cigarettes, many young individuals use e-cigarettes in places where regular cigarettes are prohibited.[17] In addition, although many studies explored the use e-cigarette use among several Saudi populations, a wide variation in methodologies and sample sizes were used, with ambiguity of the target populations from which inferences could be drawn. Moreover, females were under-sampled in most of these studies. Furthermore, little attention was directed to the psychological correlates of e-cigarette use among Saudi university students. Thus, it is important to explore the relationship between e-cigarette use and the mental well-being of university students.

The aims of this study were three-fold. First, we measured the prevalence of regular cigarette and e-cigarette use among female KSU students in Riyadh. Second, we assessed the association of both types of cigarette use with psychological distress and other student characteristics. Third, we explored the frequency and attitudes toward smoking as well as the reasons that drove students to use e-cigarettes. Addressing these elements among our student population is important to direct educational strategies for reducing the use of such substances, as well as to further understand the triggers for e-cigarette use that can be targeted for control and prevention.

  Materials and Methods Top

Study population and sampling technique

A cross-sectional study was conducted among female KSU students, using a stratified cluster sampling approach. First, we stratified KSU colleges into “health colleges” and “other colleges” (science and humanities), after referring to the KSU Office of Registrar's college list. From that list, we randomly selected four health colleges (medicine, dentistry, pharmacy, and nursing), and four other colleges (science, computer science, law, and language and translation). Next, from each selected college, we randomly selected student levels to include in our study (from 1st to 6th year). Then, from each of the selected levels, a quota of students was specified, proportionate to that college's size. Data collection was conducted from January to March 2019. Students were approached at their designated colleges during their lunch breaks. Once the sample size was achieved at that level, sampling from that college was considered complete.

Assuming an average prevalence for e-cigarette use of 12.6%,[13],[15],[17] a confidence level of 95%, a width of 3%, and a response rate of 70%, the estimated sample size was 673. Any female student who was enrolled full-time in the selected college and was part of the selected level was included in the study. Because sampling from the male campus was not feasible, we excluded all male students from this study.

Study tool and measures

The study tool consisted of a questionnaire that inquired about socio-demographic characteristics, tobacco use, and psychological distress. Questions for the section about tobacco use were retrieved from the Arabic version of the Global Adult Tobacco Survey.[20] These included questions about ever using regular and e-cigarettes, age at first cigarette smoke, frequency of smoking, attitudes toward smoking regular and e-cigarettes, attitudes toward quitting, and having a friend, parent, or sibling who smokes. Ever regular cigarette smoking was identified by answering yes to the question: “have you ever tried cigarette smoking, even one or two puffs?” Current cigarette smoking was identified by responding with “every day” to the question: “do you now smoke cigarettes every day, some days or not at all?” The same approach was followed to define ever and current e-cigarette users. The final part of the tobacco use questions inquired about sources from where e-cigarettes were obtained, their flavors, their perceived harms, and reasons for using them.

We were also interested in measuring the relationship of psychological distress with regular cigarette and e-cigarette smoking. Psychological distress is known as “a state of emotional suffering characterized by symptoms of depression and anxiety.”[21] It is measured in many studies as a proxy for mental well-being.[21] One of the widely used tools for measuring psychological distress is the 6-item Kessler Psychological Distress Scale (K6).[22] Thus, we used the Arabic version of this tool. This is a six-item tool for which responses are recorded on a 5-point Likert scale (from 1 = None of the time to 5 = All of the time). The resulting measure is usually expressed as a score ranging from 6 to 30, with higher scores indicative of greater probability of suffering from mental illness.[23],[24] We used a cut-off point of 12 to dichotomize this construct into “high versus low levels of psychological distress” in order to facilitate meaningful interpretations of logistic regression analysis. According to Kessler and colleagues,[23] K6 scores >12 are correlated with a high probability of having a serious mental illness. Other covariates in the study included age (continuous), nationality, parents' monthly income (less than SAR 5000, SAR 5000 to SAR 10,000, SAR 11,000 to SAR 15,000, and more than SAR 150,000), marital status (married vs. not), field of study, academic year, having a parent or sibling who smokes (yes vs. no), and having a friend who smokes (yes vs. no).

Ethical considerations

This study was approved by the Institutional Review Board at the KSU College of Medicine Research Center. Verbal consent was obtained prior to participation in this study. Participation in this study was voluntary and all data were handled with strict confidentiality. IRB approved on 17 JAN, 2022, with reference NO. 22/07/IRB_SCFHS.

Statistical analysis

Frequencies and percentages were calculated for categorical variables, while means and standard deviations (SD) were calculated for continuous variables. We stratified descriptive results by college type (health colleges vs. other). We tested the association of both regular cigarette and e-cigarette use with psychological distress by fitting two logistic regression models, using each of regular cigarette and e-cigarette use as the dependent variable, and binary psychological distress as the independent variables. We controlled for college type, parent's income, and having a family or friend who smokes in both models. We reported odds ratios (OR) and 95% confidence intervals (CI) for logistic regression analyses. All analyses were conducted using SAS© 9.4 (SAS Institute, Cary, NC, USA).

  Results Top

Student characteristics and prevalence of smoking

Out of the 673 students approached for this study, 616 participated (response rate = 91.5%). The distribution of demographic characteristics was fairly similar across the two college groups, where the majority were Saudi, unmarried and had a parent's monthly income greater than SR 15,000 [Table 1]. In addition, around half of the students reported having a family member who smoked regular cigarettes, while approximately 1/3 reported having a friend who smoked. Surprisingly, a greater proportion of students reported regular cigarette smoking compared to e-cigarettes. Around 18.4% of students reported ever smoking regular cigarettes, while 9.8% reported ever smoking e-cigarettes. Similarly, 7.8% reported current regular cigarette use, while only 2.6% reported current e-cigarette use [Table 1]. Because the frequency of reported “current e-cigarette use” was very low in this study (only 16 patients), it was not efficient to use this measure in logistic regression analysis, so we used every e-cigarette use instead.
Table 1: Student characteristics and prevalence for regular cigarette and e-cigarette smoking, among female King Saud University students, 2019

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The frequency of cigarette and electronic cigarette use

The mean age for first experimenting with tobacco (in the form of regular cigarettes) was 16.4 years (SD = 3.6). The average number of cigarettes smoked per day among regular cigarette smokers was 7.5 (SD = 7.7). Among the 48 current cigarette smokers, only half (52.4%) were thinking about quitting. When asked about the frequency of using e-cigarettes among students who used them at least once in their life, 46.9% used <11 times, 9.4% used them between 11 and 20 times, 9.4% used them from 21 to 50 times, and 34.4% reported using them more than 50 times.

Attitudes and perceptions toward smoking and electronic cigarette harm

Overall, 94.3% of the students thought that e-cigarettes were harmful, and 98.7% thought they were addictive. When students who “never used e-cigarettes” were asked about considering using them in the future, 13.8% thought they would consider using them. When asked about the reason for using e-cigarettes, the most commonly reported reason was “peer pressure” (35.6%) [Figure 1]. With respect to sources from where e-cigarettes were obtained, 55.1% reported getting them from a friend, 30.6% purchased them on the internet, 10.2% bought them from a supermarket, while 2.0% got them from the gas station or another unspecified source (2.0%).
Figure 1: Reasons for using electronic cigarettes among female King Saud University students, 2019

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Association of psychological distress with cigarette and electronic cigarette use

The mean K6 score was lower for students from health colleges (17.5; SD = 5.32) compared to students from other colleges (19.4; SD = 5.14); (t-test = 4.47; P < 0.0001). After transforming the K6 scores to binary psychological distress levels (high vs. low), 86.6% of all students had high levels of psychological distress (83.6% and 90.0% for students from health colleges and other colleges, respectively).

Because the vast majority of students were married, Saudi and around the same age, we did not control for marital status, nationality, or age in logistic regression analyses. Monthly parents' income categories were collapsed to a binary variable because more than 50% of the students had a parent's income of greater than SR 15,000, and in order to avoid decreasing model efficiency. Contrary to what was anticipated, and although not statistically significant, high level of psychological distress seemed to be associated with reduced odds for ever using e-cigarettes or current cigarette use [Table 2]. Although the prevalence of current cigarette smoking and ever using e-cigarettes were fairly similar between the two college groups, the odds for ever using e-cigarettes (adjusted OR [AOR] = 1.37; 95% CI = 0.75, 2.53) and the odds for current cigarette smoking (AOR = 1.14; 95% CI = 0.60, 2.17) were both greater among students from health colleges compared to those from other colleges. The two most prominent predictors for ever-using e-cigarettes and current cigarette use in the two fitted models seemed to be having a family member who smoked and having a friend who smoked [Table 2]. However, the OR estimates for comparing individuals who have friends who smoke to those without friends who smoke showed wide CI, and should be interpreted with caution.
Table 2: The association of ever smoking e-cigarettes and current regular cigarette smoking with psychological distress*, among female King Saud University students, 2019

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  Discussion Top

This study assessed the prevalence of e-cigarette and regular cigarette smoking and their association with psychological distress among a group of female students from different colleges at KSU. Results for this study can be summarized in the following points. First, the prevalence of current cigarette smoking among this female population was 7.8%, while only 2.6% reported current e-cigarette smoking. Second, having a high level of psychological distress as measured by the K6 was associated with “lower” odds for ever using e-cigarettes and current regular cigarette use. Third, the odds for ever using e-cigarettes and that for currently smoking regular cigarettes were surprisingly greater among students from health colleges compared to those from other colleges. Fourth, having a family member or a friend who smoked regular cigarettes was associated with “greater” odds for ever using e-cigarettes and currently smoking regular cigarettes. Finally, the most common two reasons for using e-cigarettes were peer pressure (35.6%) and perceiving e-cigarettes as being safer than regular cigarettes (32.2%).

The estimate for e-cigarette use in the current study is lower than what was reported in the previous Saudi literature. A possible explanation for this would be the under-reporting of e-cigarette use among female students due to social desirability. Another would be the differences in type of sample and population representation in the current study compared to previous studies. For example, the study that reported a high prevalence of e-cigarette use had sampled from the social media.[16] When comparing our results with studies that sampled from university students, the Jeddah study reported daily e-cigarette use at 27%, but that prevalence represented both male and female students combined.[17] Regional variation in the prevalence of e-cigarette use may also explain the discrepancy. On the other hand, the previous study conducted among KSU students in Riyadh reported a closer prevalence of current e-cigarette use (3.9%), for males and females combined, compared to what we report in our study (2.6%).[13]

Most of the students in the study perceived e-cigarettes as “harmful”. This is reassuring as more and more scientific evidence is uncovering the unrecognized harms of these devices. Perceptions about e-cigarettes harm on nationwide U. S. surveys, a country that uses these devices in high frequency, have also shifted. Results from the Tobacco Products and Risk Perceptions Survey suggest that the proportion of U. S. adults who perceive e-cigarettes to be as harmful as regular cigarettes has increased from 11.5% to 36.4% in a course of 5 years.[25]

The estimate reported for regular cigarette smoking (7.8%) is greater than the pooled estimate for female college student cigarette use in Saudi Arabia (5%), which was based on a meta-analysis.[26] In addition, during 10 years, the overall prevalence of cigarette smoking among female KSU students seemed to have increased from 5.9% to 7.8%.[27] This change in trend warrants further exploration to understand the psychological, social, and behavioral aspects that may have induced such an increase.

In this study, the overall average psychological distress score for students from nonhealth colleges was 19.4 out of 30. This score is comparable to what has been reported for medical residents in training in a recent study conducted in Riyadh (average K6 score was 20.1).[28] It should also be noted that although many educators may have the perception that “health college” students generally experience greater levels of stress during their studies, our study suggested that students from other colleges reported higher levels of psychological distress. This agrees with a study conducted among undergraduate students in Jazan, which reported the highest levels of psychological distress among students from the college of sciences, followed by students from the college of business administration.[29]

Our results suggested that the majority of students had high psychological distress when the scores were dichotomized using a relatively cut-off point.[12] This may be an artificially high distress prevalence, for lower prevalence rates could be produced by reducing the sensitivity of this cut-off point. Therefore, this prevalence may not be reliable. Although the current study was not intended to focus on the assessment of the mental well-being of undergraduate students, we believe that the results of psychological distress scores can direct future researchers to study this mental health issue in further detail, and examine the impact of interventions, like student wellness programs, on enhancing students' coping skills.

The influence of friends and peer pressure on taking on unhealthy behaviors has been well established in the literature. Therefore, it was no surprise that “peer pressure” was the most common reason for smoking e-cigarettes. This comes in agreement with a previous Saudi study that considered friends' smoking the most influential factor for picking up this behavior.[15] It also agrees with a similar study conducted among KSU students in 2010, reporting the same observation.[27] Students should be educated about the strength of peer pressure on influencing smoking behavior, and this behavior must be taken into consideration when planning youth smoking cessation programs.

The current study has shed light on the practice of a rather emerging substance use behavior among the vulnerable Saudi youth. The methods used in our study can be expanded to conducting broader population-based e-cigarette use surveys that can help address the burden of this behavior on a more generalizable population. However, few noteworthy limitations should be mentioned. For example, the sample was restricted to female students. Therefore, we could not compare the e-cigarettes use between males and females. Additionally, 40.7% of the health colleges' sample were from Medicine, which may have skewed the results for this group toward the medical students. Moreover, results from this study can only be generalized to female university students in the Kingdom. Furthermore, the nature of the cross-sectional design did not allow an assessment of the temporal relationship between psychological distress and tobacco use. Although we used psychological distress as a predictor for tobacco use, we cannot be certain whether tobacco use was a coping mechanism for psychological distress or whether it was a consequence of tobacco use. Finally, even though a large sample was obtained for this study, some of the OR estimates had wide CI, which reflects wide uncertainty around those estimates. This may have resulted from sparse data due to stratification of tobacco use (i.e., low to begin with) across many predictors, which created sparse cell sizes, and in turn, led to reduced precision. In spite of these limitations, the results from the current study can be helpful in stimulating researchers to test new hypotheses and conduct more extensive research on e-cigarette use in Saudi Arabia.

  Conclusion Top

The current study suggests that the prevalence of regular cigarette use may be in increasing trend among female university students. The most common reason for experimenting with cigarettes among this young female adult population is peer pressure. The growing trend of cigarette use among young Saudi women should be addressed to help in planning tobacco control programs. In addition, these control programs should tackle the influence of friends and peers on smoking experimentation and initiation. We also recommend that future research focuses on larger population-based studies assessing the burden of e-cigarette use among the Saudi youth, to understand the scope of this problem at a wider and national level. Finally, the low prevalence of e-cigarette smoking in our study should not be taken lightly. The e-cigarette may be the new gateway to nicotine addiction.[5] Its use must be controlled at an early age to prevent the unknown harms of a relatively novel device on future generations to come.


We would like to acknowledge KSU for its research support. We would also like to acknowledge the help and support we received from the staff at the KSU Female College Office of Registrar. We are thankful to Professor Fatimah Al-Haidar, Vice-Dean of the College of Medicine, for facilitating the data collection process.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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