Electronic nicotine delivery system use and its relation to waterpipe smoking among youth in seven Arab countries

Background: The increasing use of Electronic Nicotine Delivery Systems (ENDS) and Waterpipe Tobacco Smoking (WTS) highlights a growing tobacco epidemic among youth in the Arab world. This study aimed to estimate the prevalence of ENDS use among adolescents in seven Arab countries and to explore the bidirectional relationship between ENDS use and WTS.

Methods: Data from the World Health Organization’s Global Youth Tobacco Survey (GYTS 2014–2018) were analyzed, involving 18,536 schoolchildren aged 12–16 from Mauritania, Morocco, Oman, Qatar, Tunisia, Yemen, and Iraq. Weighted prevalence estimates were calculated for nationally representative data, and adjusted multilevel logistic regression models were employed to examine associations between ENDS use and WTS.

Results: The analysis included 18,536 participants from 216 schools, representing approximately 4,171,719 schoolchildren across the seven Arab countries. The pooled weighted prevalence rates were 9.5% for ENDS use and 10.0% for WTS. Significant associations were found between ENDS use and WTS (AOR: 5.26, 95% CI: 4.28–6.46), conventional cigarette smoking (AOR: 1.54, 95% CI: 1.23–1.94), and early tobacco initiation before age 12 (AOR: 1.40, 95% CI: 1.14–1.72). Lower odds of ENDS use were noted among females and adolescents who received education on tobacco dangers in school.

Limitations: The broad definition of smoking may include experimental users, which is consistent with existing literature that suggests irregular smoking can lead to habitual use. Additionally, the cross-sectional design limits the ability to establish causal and temporal relationships.

Conclusion: WTS was linked to a more than fivefold increase in the likelihood of ENDS use, and conventional cigarette smoking was identified as a common risk factor for both behaviors. Early tobacco consumption before age 12 correlated with higher odds of ENDS use but lower odds of WTS. Furthermore, females and those educated about tobacco risks were less likely to report ENDS use.

Dr. Maryam Burezq is a motivated pediatric registrar who is interested in volunteering and the research field and passionate about children’s physical and mental health. Dr. Maryam is enrolled in the Kuwaiti Board of Pediatrics at the Kuwait Institute for Medical Specializations (KIMS). Editorial Board Member of the American Journal of Pediatrics (2022-2024) & Journal of Advances in Medical Sciences. Reviewer in the A reviewer in the American Journal of Pediatric (JAMS) (2023-2025), the Orphanet Journal of Rare Diseases, and Children and Youth Services Review. Interested in the research field and passionate about children’s physical and mental health.