The Effectiveness of Electronic Cigarettes in Quitting Smoking in the Kingdom of Saudi Arabia (KSA).

Abstract

Background: Electronic cigarettes were popular in Saudi Arabia for a number of reasons, including quitting smoking. Its efficacy is still unknown, though. Using varying dosages and flavors, this study evaluated whether they aid in smoking cessation in a different way than other strategies.

Methods: This is a descriptive cross-sectional study, and a survey was administered to people who have used e-cigarettes and traditional cigarettes. The research focused on current and ex-smokers in Saudi Arabia. Nonsmokers and occasional smokers were omitted from the study since they did not represent the demographic of interest.

Results: Total feedbacks were 700. However, only 362 of the participants finished the survey. The findings show a significant difference in stopping regular cigarettes across subjects who smoked for varying lengths of time (p-value = 0.004). Those who had smoked for less than a year were more likely to quit. Participants who used electronic cigarettes with low nicotine concentration had a statistically significant tendency to use them five or more times per day (OR = 1.56, 95% CI:1.08-2.27, p=0.066). Participants who used a variety of flavors, particularly fruit flavors, had a significantly increased chance of quitting both traditional cigarettes and electronic cigarettes (OR = 1.24, 95% CI:1.00-1.54, p = 0.043).

Furthermore, 53% of individuals stopped smoking cigarettes after using an electronic cigarette.

Conclusion: A significant number of people have had to start the use of e cigarettes especially as a way of quitting to smoking. The efficacy of electronic cigarettes appears to vary based on the flavors and nicotine concentrations. As a result, people who tried different fruit flavors were more likely to succeed in stopping smoking using electronic cigarettes. In contrast, people who utilized low nicotine doses were less likely to quit smoking.

Keywords

Electronic cigarettes (EC); Nicotine replacement therapy; Nicotine concentrations; Regular cigarette; Smoking cessation; Assortments of flavor

Introduction

Tobacco smoking is a chronic illness caused by inhaling burning tobacco. premature mortality and disability as a result may occur globally (Yang et al., 2022). However, according to the World Health Organization (WHO), one billion people smoked tobacco in 2020, accounting for some 22.3% of the global population (Sinha & Haider, 2024). In addition, men were more likely to smoke than women; 36.7 percent of all men were smokers, compared with 7.8 percent of all women (Kumari et al., 2024). Unfortunately, annually 8 million people die because of using tobacco (Burki, 2021). In Saudi Arabia, smoking kills almost 5,000 people a year, or 71 men and 21 women each week. Various major disease states were attributing to smoking including lung cancer and cardiovascular disease (Thandra et al., 2021). There has also been the observation that it causes poor physical activity and mental changes leading to anxiety or sadness (Firth et al., 2020). Passive smoking is a practice that the smoker puts others at risk of health dangers by inhaling in a smoking environment (Juraybi et al., 2021). While smoking is frequently considered the foremost preventable cause of illness, kicking the habit is exceptionally difficult because addictive substances were used for the purpose (Chapman, 2022). As a result, nicotine withdrawal syndrome may develop as a quitting side effect (Klemperer et al., 2021). The condition is distinguished by symptoms such as anxiety, despair, mood frustration, and wrath.

Nicotine replacement therapy (NRT) is the most common treatment for smoking cessation (Haokip et al., 2021). It is usually combined with behavioral therapy and emotional support, which were two other major treatments for smoking cessation (Rigotti et al., 2022). The Food and Drug Administration (FDA) has approved nicotine gum, inhalers, nasal spray, or patches as medications to help people quit smoking (DiSilvio et al., 2021). In addition to that, clonidine and nortriptyline can also be used as medications to aid in quitting smoking (Patel et al., 2023). There were many clinical guidelines recommend using NRT as a first line treatment to help decrease the motivation to smoke and withdrawal symptoms that happen during attempts at quitting smoking (Giulietti et al., 2020). In the last two decades, the reports showed a significant increase in e-cigarette use especially by adolescents as alternative to conventional cigarettes in the world (Althobaiti & Mahfouz, 2022). They were created in the early 2000s, but were not widely pushed until a few years ago (Marques et al., 2021). In Saudi Arabia, a research found that 26.3% of participants had tried e-cigarettes at least once. Furthermore, e-cigarette users were more likely to smoke tobacco (p-value = 0.002). Males smoked more e-cigarettes than females (p value < 0.001), had greater educational levels (p value < 0.001), and were aged 18-24 years old(Althobaiti & Mahfouz, 2022).

Electronic cigarettes were small devices powered by battery, and people referred to this usage as vaping (Wylie et al., 2021). These devices can heat a liquid solution to generate an inhalable mist within minutes (Choi et al., 2021). Electronic cigarettes were composed of nicotine, water, flavoring, glycerin and propylene glycol (Li et al., 2020). In use, the liquid is sprayed into an aerosol (sometimes referred to as vapor), injected, heated by the injector and activates a pressure sensitive switch on breathing (Mallock, 2022). Some e-cigarettes have a button that the user can press to manually heat; these also have a danger that if the button was pressed in a way that is not intended (due to a mistake or disturbance) then the device can heat successfully (Hampsher-Monk et al., 2024). Nicotine cartridges for e-cigarettes generally contain less of the harmful chemicals such as tar and carbon monoxide (CO) than does traditional cigarettes (Son et al., 2020). Electronic cigarette products contain a key component of nicotine (Gholap et al., 2020). Nicotine addiction is the result of nicotine allowing pleasure-producing chemicals to remain in the brains of users for as long as they were present (Gholap et al., 2020). Because of this addiction, the body displays both psychological and physical symptoms of nicotine withdrawal when it stops getting nicotine (Le Foll et al., 2022). The more you become addicted, the more severe will be the withdrawal symptoms (Le Foll et al., 2022). Also, the symptoms of withdrawal when stopping from smoking electronic cigarettes were not as severe as if you were surrendering a daily cigarette (Palmer et al., 2022; Ponzoni et al., 2020). Nonetheless, there were numerous grounds to think that the variety of tastes and nicotine levels in the e-liquid used in electronic cigarettes significantly influenced the user's ability to stop smoking.

Smoking remains prevalent when treatments were available in forms such as behavioral therapy, and nicotine replacement (Patel et al., 2021; Rigotti et al., 2022). Besides, using electronic cigarettes or vaping has become one of the newer challenges especially among the youth (Trucco et al., 2020). As a relatively recent phenomenon, there were only limited ideas of what related health effects vaping might eventually have (Snoderly et al., 2021). Different fragrances, concentrations, sizes, and intensities of nicotine cartridges to produce the best feeling for the consumer, and the chance to regulate the length of an inhale by the time the button at the top of the gadget is pressed down on, all contributed to the popularity of the use of e-cigarettes (Sapru et al., 2020). Despite this, the matter is one of debate, and the research will have value. It might be beneficial.

1.1 Aims and Objectives of the Study

In this study, we aim to determine the effectiveness of electronic cigarettes in the smoking cessation in the Kingdom of Saudi Arabia. In addition, we aim to determine whether nicotine concentrations and flavors in electronic cigarettes help in quitting smoking and evaluate whether electronic cigarettes were more effective than nicotine replacement therapy.

2. Methodology

A cross sectional survey design was utilized in this study to investigate the effectiveness of e – cigarettes in smoking cessation in the Kingdom of Saudi Arabia. This approach we chose because it would allow us to collect data from a large and diverse sample at a single point in time and run a comprehensive analysis of the relationship between e-cigarette use and smoking cessation. The primary research question guiding this study was: Does the use of e-cigarettes influence smoking cessation?

2.1 Sample Collection

Current and former KSA residents who have used e-cigarettes were the study's target demographic. Because they had no bearing on the research issue, nonsmokers and occasional smokers were not included in the study. A 95% confidence level and a 5% margin of error were used to get a sample size of 362. Participants were gathered using a convenience sample technique on social media sites including WhatsApp, Twitter, and Telegram. The response rate was 100%; 362 replies (excluding missing values) were received within the six weeks between 25 February 2023 and 8 April 2023.

2.2 Collection of Data

A 32 questions, self-administered, online survey was the data gathering instrument used. The poll was broken up into three types of stimulus: one for regular cigarette (RC) users, one for EC users, and one for demographic information. The questionnaire was made after subject matter experts and literature reviewed. Validity, reliability, and clarity of the questionnaire were assessed by a small group of 60 people in a pilot study. Reliability analysis was judged sufficient enough with a Cronbach’s alpha of 0.92 and validated the study’s dependability. The questionnaire was revised and improved based on the input from the pilot test before going live online. The questionnaire was sent with a cover letter to alert participants that the study would include these things. In addition, they were assured that their data would be used only for research and assured that they would not be identified in the data. They agreed to take part in the research by filling out and sending in the questionnaire.

2.3 Analysis of Data

The data collected from the questionnaire was analyzed using SPSS software version 26. Characteristics of the sample and their response to the questions were summarized using descriptive statistics such as frequencies and percentage. Associations and differences between these variables were tested using inferential statistics (e.g. chi-square tests and multinomial logistic regression analysis) to see if figures predicted e-cigarette use behavior and interest in smoking cessation. 

2.4 Ethical considerations

The Institutional Review Board (IRB) of Imam Abdul-Rahman bin Faisal University approved this study protocol (registration number IRB-UGS-2023-03-072) and the study was conducted in accordance with the ethics standards of it. Before starting the study, the participants know their rights and obligations as a research subject. Moreover, they had the impunity to terminate the research at any time without penalty.

3. Results

362 people in Saudi Arabia who were already or had previously smoked responded to an electronic poll. Regular cigarette (RC) smokers, EC users, and demographic data were the three categories into which the survey was separated. The participants' demographic profile is shown in Table 1, where the majority of respondents were between the ages of 18 and 30 (64.92%) and male (68.23%). Smoking electronic cigarettes was the most popular among the various smokers (30.66%), followed by smoking regular cigarettes only (27.22%), smoking regular cigarettes and electronic cigarettes (25.14%), and smoking both regular cigarettes and electronic cigarettes (16.57%) (Figure 1). The social influence of friends, family, or other co-workers was the essential reason for most of the participants (96.26%) started using e-cigarettes, while only three (1.15%) reported being influenced by marketing. The majority of participants (41.22%) used electronic cigarettes with an average nicotine content of 50 mg, and 69.43% of them preferred fruit flavors, according to our data. 186 consumers of electronic cigarettes also reported using them more than five times a day. While 18.58% of participants experienced coughing and dry mouth, 17.43% reported breathing difficulties, and 22.48% reported no symptoms, 56.11% of participants thought that smoking electronic cigarettes was safer than smoking traditional cigarettes. (Table 2)

Table 1. Demographic characteristics of participants and their daily smoking frequency.

Variables	N(%)
Age:
Less than 18	13(3.59%)
18-30 year	235(64.92%)
31-40 year	78(21.55%)
41-50 year	28(7.73%)
51-60 year	6(1.66%)
Greater than 60	2(0.55%)
Gender:
Male	247(68.23%)
Female	115(31.77%)
Educational level:
Middle school	4(1.10%)
Secondary school	24(6.63%)
University	136(37.57%)
Unemployed	50(13.81%)
Employee	148(40.88%)
Relevant who smokes:
Family	152 (29.86%)
Friends	211 (41.45%)
Working place	Figure 1 Figure 2 Figure 3 Figure 4