Knowledge and Attitudes Towards E-Cigarette Use in Lebanon and Their Associated Factors
Knowledge and Attitudes Towards E-Cigarette Use in Lebanon and Their Associated Factors
Knowledge and Attitudes Towards E-Cigarette Use in Lebanon and Their Associated Factors
Abstract
Background: Despite the misconceptions regarding E-cigarettes (ECs), only a few studies have been conducted in
the Middle East that focused on this topic. This study assesses the knowledge of and attitudes towards ECs in
Lebanon, determines how these two measures are associated, and identifies the variables that explain each of
these measures.
Methods: A cross sectional study was conducted on a convenience sample of Lebanese pedestrians aged between
18 and 64 inclusive. A structured self-administered questionnaire comprising of knowledge and attitude scales, and
questions on demographical, health and smoking characteristics was used.
Results: Scores for attitudes and knowledge of ECs were summed and dichotomized using a 75% cutoff, above
which the participant was considered to have a positive attitude and good knowledge. Among the 352 participants
(56.6% males, 43.3% females, mean age 30.3, 46.2% smokers), 63.3% exhibited a lower level of EC knowledge. More
than 50% erroneously thought that ECs are not associated with lung and bladder cancer or impair lung and heart
function. 65% falsely thought that it is harmless and not addictive. As for attitude, 43.3, 53.9, and 44.3% thought
that it is socially acceptable, helps in smoking cessation, and is a good replacement for cigarettes and an enjoyable
recreational device respectively. Our results revealed an inverse correlation between attitude and knowledge scores
(Spearman’s correlation = −.30, p < .001). Predictors of knowledge included health-related occupation (p = .010),
regular exercise (p = .016), healthy diet (p = .026), EC use (p = .026), perception that ECs are not harmful (p = .001),
and help in smoking cessation (p = .017). Predictors of attitude included EC use (p = .008), sex (p = .010), and
knowledge that most ECs are addictive (p = .006), harmful (p = .014), and impair heart and lung function (p = .047).
(Continued on next page)
* Correspondence: ms148@aub.edu.lb
†
Hanan Aghar and Nathalie El-Khoury contributed equally to the manuscript
and both are considered first authors.
†
Mahasen Reda and Wissam Hamadeh contributed equally to the manuscript
and both are considered second authors.
†
Hussein Krayem, Mohammad Mansour, and Hawraa Raouf contributed
equally to the manuscript and all are considered third authors.
2
Epidemiology and Population Health Department, Faculty of Health
Sciences, American University of Beirut, P.O.Box 11-0236 Riad El-Solh, Beirut
1107 2020, Lebanon
Full list of author information is available at the end of the article
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Aghar et al. BMC Public Health (2020) 20:278 Page 2 of 18
Table 1 Demographics, socioeconomic, smoking habits, and Table 1 Demographics, socioeconomic, smoking habits, and
lifestyle characteristics distribution of our study participants (N = lifestyle characteristics distribution of our study participants (N =
352) in Beirut, Lebanon between December 2018 and March 352) in Beirut, Lebanon between December 2018 and March
2019 2019 (Continued)
No. Valid % No. Valid %
Age (Mean ± SD) 30.29 ± 11.78 Medication 2 2.2
Sex Nicotine gum 1 1.1
Male 198 56.6 Other 29 31.9
Female 152 43.4 Have you ever thought of quitting smoking?
Level of education Yes 132 72.5
Bachelor’s degree 156 44.3 No 50 27.5
Graduate school 100 28.4 Lifestyle characteristicsa
High school level or equivalent 52 14.8 Do you exercise regularly?
Intermediate level or below 33 9.4 No 197 56.0
Technical /vocational study 7 2.0 Yes 155 44.0
No schooling completed 4 1.1 Do you believe you follow a healthy diet?
Is your occupation or major health related? No 191 54.3
Yes 228 78.1 Yes 161 45.7
No 64 21.9 Do you drink alcohol?
Smoking Habits No 195 55.4
Do you currently smoke? Yes 157 44.6
Yes 162 46.2 Do you drink coffee?
No (non-smokers) 151 43.0 Yes 281 80.5
Quit/quitting smoking 38 10.8 No 68 19.5
If you smoke, what do you smoke? (Circle all that apply) a
Hookah or waterpipe: “a smoking device that consists of a bowl mounted on
a vessel of water which is provided with a long tube and arranged so that
Cigarettes 137 52.7 smoke is drawn through the water where it is cooled and up the tube to the
Hookah a
68 26.2 mouth” [38]
b
Dokha: is tobacco blended with “barks, herbs, spices, dried flowers or dried
Cigars 13 5 fruit” and smoked in a particular pipe called “midwakh”. It has a high nicotine
content, around five times that of a normal cigarette [39]
E-cigarettes 30 11.5 c
Pipe: “a device for smoking usually consisting of a tube having a bowl at one
Dokhab 6 2.3 end and a mouthpiece at the other” [40]
d
The study did not provide standard definitions for “exercise regularly”,
Pipec 1 0.4 “healthy diet”, “drink alcohol”, or “drink coffee”; the participants answered
these questions based on their subjective interpretation of these terms
Other 5 1.9
What form of smoking did you quit/are you quitting? (Circle all that
apply) Arabic versions of the questionnaire. Full explanation of
Cigarettes 44 58.7
the validation studies is included in Additional file 1:
Appendix B.
Hooka 20 26.7
Our analysis was initiated by data cleaning whereby
Cigars 4 5.3 outliers and data entry errors were detected and recti-
Dokha 3 4 fied. Descriptive statistics, graphical and numerical, were
E-cigarettes 3 4 carried out to determine the frequency distribution of
Pipe 0 0 each variable. All variables, except for age, were
Other 1 1.3
measured on a categorical scale. The mean age with its
standard deviation (SD) and the count with valid percent
What methods of smoking cessation have you used/are you using?
(Circle all that apply) are presented in the descriptive tables shown in the
result section (Tables 1 and 2). Valid percentages were
Reducing number of cigarettes per day 39 42.8
used in the calculations and characteristic distribution
E-cigarettes 12 13.2
reports in Tables 1, 2, 3 and 4. Missing data was not an
Behavioral therapy 5 5.5 issue in this study because the maximum observed percent-
Nicotine patches 3 3.3 age of missing responses did not exceed 8% in any category
or subcategory. It is important to note that in the reported
Aghar et al. BMC Public Health (2020) 20:278 Page 7 of 18
Tables some counts do not add up to the total sample size predictor of EC smoking whereby participants who con-
of 352 (or corresponding subtotal), attributable to the fact sumed alcohol were three times more likely to take up
that some questions are not applicable to the respondent. EC smoking (unadjusted OR = 3.006, 95% CI = [1.426,
Observations with available non-missing values were in- 6.337], p = .004). However, drinking coffee was not a sig-
cluded automatically in the analysis. nificant predictor of the EC smoking habit.
Table 2 Frequency distribution of E-cigarette smoking habits among study participants (N = 352) in Beirut, Lebanon between
December 2018 and March 2019
E-cigarette Habit Question No. Valid %
Have you heard of E-cigarettes
Yes 318 90.3
No 34 9.7
If yes, where have you heard of E-cigarettes? (Circle all that apply)
Friends 232 34.0
Social media 172 25.2
Advertisements 117 17.2
Family 84 12.3
University/school 48 7.0
Doctor 20 2.9
Center for smoking cessation 9 1.3
Do you use E-cigarettes?
No 295 89.1
Yes 36 10.9
What flavor of E-cigarettes do you use? (Circle all that apply)
Fruit 27 45.8
Tobacco 10 16.9
Menthol/mint 9 15.3
Candy 7 11.9
Coffee 3 5.1
Other 3 5.1
#Does the E-cigarette you use contain nicotine?
Yes 30 83.3
No 6 16.7
How long have you been using E-cigarettes (months)? (Mean) 11.99
What made you start smoking E-cigarettes? (Circle all that apply)
Taste 20 28.6
Social smoking 12 17.1
Quit smoking 11 15.7
Healthier 11 15.7
Trend 10 14.3
Effects (relaxant, etc. …) 3 4.3
Other 3 4.3
Why do you not use E-cigarettes? (Circle all that apply)
I do not smoke 130 34.9
Never considered it 118 31.6
Harmful/unhealthy 73 19.6
Expensive 34 9.1
No access 18 4.8
Compared to regular cigarettes (or other tobacco products) how much satisfaction do you get from E-cigarettes?
Less 19 57.6
Same 8 24.2
More 6 18.2
Aghar et al. BMC Public Health (2020) 20:278 Page 9 of 18
Table 3 Frequency distribution of E-cigarettes knowledge Table 4 Frequency distribution of attitude towards E-cigarettes
responses of participants who have heard of E-cigarettes (N = responses of participants who have heard of E-cigarettes (N =
318) in Beirut, Lebanon between December 2018 and March 318) in Beirut, Lebanon between December 2018 and March
2019 2019
Knowledge question No. Valid % Attitude question No. Valid %
E-cigarettes are associated with bladder cancer Should E-cigarettes be recommended to a nonsmoker?
False - Wrong Answer 251 75.4 No - Negative Attitude 298 90.3
True - Correct Answer 82 24.6 Yes - Positive Attitude 32 9.7
E-cigarettes are FDA Approved
Do you think E-cigarettes are harmful for health?
True - Wrong Answer 247 74.4
Yes - Negative Attitude 272 84.2
False - Correct Answer 85 25.6
No - Positive Attitude 51 15.8
Some flavors of E-cigarettes are more harmful than others
Should the use of E-cigarettes be allowed in places that do not allow
False – Wrong answer 232 70.1 smoking?
True – Correct answer 99 29.9 No - Negative Attitude 259 79.7
Swallowing the liquid in E-cigarettes accidentally can cause poisoning Yes - Positive Attitude 66 20.3
that is potentially fatal
False - Wrong Answer 183 55.3 Would you consider someone who uses E-cigarettes a smoker?
True - Correct Answer 148 44.7 Yes - Negative Attitude 252 77.1
E-cigarettes are not associated with lung cancer No - Positive Attitude 75 22.9
True - Wrong Answer 181 54.4 Do you think the use of E-cigarettes can lead to reliance?
False - Correct Answer 152 45.6 Yes - Negative Attitude 243 76.4
E-cigarettes impair lung and heart functions No - Positive Attitude 75 23.6
False – Wrong answer 110 50.9 Do you think the government should regulate the use of E-cigarettes?
True – Correct answer 216 49.1 Yes - Negative Attitude 226 70.0
E-cigarettes do not contribute to second hand smoking No - Positive Attitude 97 30.0
True - Wrong Answer 153 46.2
Do you feel more comfortable using or openly talking about smoking E-
False - Correct Answer 178 53.8 cigarettes, compared to cigarettes?
E-cigarettes can have an effect on fetal development No - Negative Attitude 217 69.1
False - Wrong Answer 132 39.6 Yes- Positive Attitude 97 30.9
True - Correct Answer 201 60.4 Do you feel it is more socially acceptable to smoke E-cigarettes, com-
Nicotine is present in most E-cigarettes pared to cigarettes?
False - Wrong Answer 129 38.9 No - Negative Attitude 183 56.7
True - Correct Answer 203 61.1 Yes- Positive Attitude 140 43.3
Harmful flavorings and toxins are found in the E-cigarette aerosol Should E-cigarettes be used as a replacement for regular cigarettes?
False - Wrong Answer 125 38.0 No - Negative Attitude 180 55.7
True - Correct Answer 204 62.0 Yes - Positive Attitude 143 44.3
E-cigarettes are harmless Do you think it is acceptable to experiment with E-cigarettes for
True - Wrong Answer 114 34.7 pleasure?
False - Correct Answer 215 65.3 No - Negative Attitude 182 55.7
Some components of the liquid found in E-cigarettes can cause harmful Yes - Positive Attitude 145 44.3
lung conditions
Do you think using E-cigarettes would be an effective way to help in
False - Wrong Answer 111 33.5 smoking cessation?
True - Correct Answer 220 66.5 No - Negative Attitude 165 51.4
E-cigarettes are not addictive Yes - Positive Attitude 156 48.6
True - Wrong Answer 110 33.0
Do you think it is acceptable to use E-cigarettes as a smoking cessation
False - Correct Answer 223 67.0 method?
E-cigarettes are suitable for pregnant women No - Negative Attitude 159 49.2
True - Wrong Answer 35 10.5 Yes - Positive Attitude 164 50.8
False - Correct Answer 298 89.5 Do you think E-cigarettes can help people cut down on cigarettes or
E-cigarettes are suitable for children quit smoking?
True - Wrong Answer 22 6.6 No - Negative Attitude 147 46.1
False - Correct Answer 310 93.4 Yes - Positive Attitude 172 53.9
Aghar et al. BMC Public Health (2020) 20:278 Page 10 of 18
Fig. 1 Frequency distribution of: (a) Types of smoking (Hookah or waterpipe: “a smoking device that consists of a bowl mounted on a vessel of
water which is provided with a long tube and arranged so that smoke is drawn through the water where it is cooled and up the tube to the
mouth” [38]. Dokha: is tobacco blended with “barks, herbs, spices, dried flowers or dried fruit” and smoked in a particular pipe called “midwakh”. It
has a high nicotine content, around five times that of a normal cigarette [39]. Pipe: “a device for smoking usually consisting of a tube having a
bowl at one end and a mouthpiece at the other” [39]) used by the participants with N = 260 total count for this subcategory,
(b) Smoking cessation methods among participants who have quit or are in the process of quitting smoking with N = 91 total count
for this subcategory, (c) E-cigarette flavors used by the E-cigarette smokers among participants with N = 59 total count for
this subcategory
The participants’ gap in EC knowledge was made ap- scores ranging from zero to 13 (13 representing the
parent by several questions that were commonly an- maximum score and the most positive attitude). The
swered incorrectly (Fig. 2a). 46.2% of the respondents mean of 4.23 is lower than the positive attitude cutoff
falsely believed that ECs do not contribute to second point of 9. As depicted in Fig. 2b, a relatively good
hand smoking, 70.1% of the participants had the wrong percentage of participants exhibited a positive attitude
perception that flavorings do not differ in their extent of towards some aspects of ECs.
harm. More than half of all respondents showed a lack Our results, showed that 43.3% of the respondents felt
of knowledge concerning ECs’ association with lung can- it was more socially acceptable to smoke ECs compared
cer, bladder cancer, and an impaired lung and heart to regular cigarettes, and a good proportion of 44.3%
function (54.4, 75.4, and 50.9% respectively). The ques- deemed it acceptable to experiment with ECs for pleas-
tions in the knowledge scale and the distributions of the ure. 48.6% thought that ECs were effective as a smoking
answers are displayed in Table 3. cessation method, 53.9% believed that ECs could help
people cut down or quit smoking, and 44.3% believed
Level of attitude of the participants towards EC that ECs should replace regular cigarettes. The distribu-
The participants had a mean attitude score of 4.23 ± 2.95 tion of answers to all the questions included in the atti-
SD (Me = 4.00, Q1 = 2.00, Q3 = 6.00, IQR = 4.00) with tude scale are displayed in Table 4.
Aghar et al. BMC Public Health (2020) 20:278 Page 11 of 18
Fig. 2 Frequency distribution of questions on EC-cigarettes that participants had: (a) the least knowledge of, and (b) the most negative attitude towards
Objective 3: correlation between attitude towards ECs also carried out and the final multivariable analysis
and EC knowledge model for positive attitude was displayed in Table 5.
The EC attitude score was significantly inversely corre- Our multiple logistic regression model was adjusted for
lated with EC knowledge score with r = −.30 (Spearman’s age and sex (universal covariates) and other eligible vari-
rho since the two variables are not normally distributed), ables pertaining to EC knowledge (unadjusted p ≤ .20). In-
and p < .0001. This indicates that as EC knowledge in- cluding knowledge covariates into the multivariable model
creases, the positive attitude towards it decreases and is important to identify the EC knowledge variables
the inverse is also true. that were significantly associated with the attitude to-
wards ECs.
Objective 4: predictors of attitude towards ECs Our multivariable analysis identified several factors
Using the attitude score as a dichotomized binary out- that exhibited significant associations with attitude to-
come, simple logistic regressions were performed and wards EC. Our results showed that participants who
the corresponding results were displayed in Additional consumed ECs were six times more likely to have a posi-
file 1: Appendix C. Multiple logistic regressions were tive attitude (OR = 6.257, 95% CI = [1.604, 24.404.],
Aghar et al. BMC Public Health (2020) 20:278 Page 12 of 18
Table 5 Multiple logistic regression of the outcome attitude towards E-cigarettes showing adjusted associations with its covariates
Covariate No. (%) Adjusted 95% Confidence Interval for Odds Ratio P-value
Odds Ratio
Lower Limit Upper Limit
E-cigarettes are addictive 223 (67.0) .231 .080 .663 .006*
Use E-cigarettes 36 (10.9) 6.257 1.604 24.404 .008*
Sex Male (reference) 198 (56.6) .225 .072 .704 .010*
Female 152 (43.4)
E-cigarettes are harmful 215 (65.3) .245 .080 .756 .014*
E-cigarettes impair lung and heart function 216 (66.3) .301 .092 .984 .047*
* p ≤ .050 multivariable analysis was adjusted for age and adverse effects of nicotine smoking (effects on children, fetus, pregnant women, and risk of
bladder cancer)
Table 6 Multiple logistic regression of the outcome knowledge of E-cigarettes showing adjusted associations with its covariates Ŧ
Covariate No. (%) Adjusted 95% Confidence Interval for Odds Ratio P-value
Odds
Lower Limit Upper Limit
Ratio
Think E-cigarettes are not harmful for health 51 (15.8) .122 .035 .434 .001*
Occupation or major is health related 64 (21.9) 2.408 1.233 4.705 .010*
Believe to exercise regularly 155 (44.0) 2.173 1.158 4.077 .016*
Think E-cigarettes can help people cut down on cigarettes or quit smoking 172 (53.9) .501 .285 .882 .017*
Use E-cigarettes 36 (10.9) .304 .107 .865 .026*
Believe to follow a healthy diet 161 (45.7) .511 .272 .962 .026*
Ŧ
* p ≤ .050 multivariable analysis was adjusted for age and sex
Aghar et al. BMC Public Health (2020) 20:278 Page 13 of 18
95% CI = [1.233, 4.705], p = .010 and OR = 2.173, 95% menthol/mint, similar to the findings drawn by a previ-
CI = [1.158, 4.077], p = .016 respectively). ous study [25]. One possible explanation is that these
Aspects of the attitude scale that were associated with flavors resemble those found in the more commonly
less knowledge included the positive perception that ECs used cigarettes and hookah making them more familiar
can help people cut down on cigarette consumption or to EC users. The hookah is popular in our culture show-
quit smoking, whereby participants who harbored this ing the second highest frequency of use in our study
positive attitude were half as likely to have high know- (26.2%), following cigarettes (52.7%). The hookah is
ledge (OR = .501, 95% CI = [.285, .882], p = .017). More- enjoyed because of its variety of available flavors. ECs
over, participants who positively perceived that ECs are have the potential to be used as a portable hookah which
not harmful for health were eight times less likely to might justify our study’s conclusion that the most com-
have a high level of knowledge (OR = .122, 95% CI = mon reason to start EC smoking was its taste. Compared
[.035, .434], p = .001). Hence, these results suggest that to Middle Eastern countries, in the Western region the
participants with the previously specified positive atti- hookah is less popular and less culturally tied. Therefore,
tude towards ECs were less likely to have high levels of studies conducted in Western countries focused more
knowledge and be classified as knowledgeable in ECs. on health-related reasons of EC use [45]. In this regard,
This finding is supported by the inverse correlation the EC use among participants was attributed to its
detected between knowledge and attitude towards ECs. perceived reduced harmful effects compared to tobacco,
All other covariates in the bivariate analysis that were rather than to its flavors [45]. Given that the EC flavors
individually significant predictors of a high level of render it as an auxiliary to hookah, many users of ECs
knowledge (p ≤ .05) (Additional file 1: Appendix D), as compare the taste between these two smoking devices;
well as the factors that were eligible to enter the therefore, they could uphold a negative attitude to-
multivariable analysis (p ≤ .20) were no longer statisti- wards ECs if they do not get the same level of nicotine
cally significant when entered in the multivariable satisfaction or if its taste does not live up to that of
analysis (Table 6). hookah.
Most of the EC users that participated in our study
were of a young age (mean age 25.8); a factor substanti-
Discussion ated by Goniewicz et al.’s claim that “EC users tend to
We propose a novel study identifying factors associated be younger” [25]. Since ECs are relatively new devices, a
with the knowledge and attitude towards ECs among young age group would like to follow such emerging
Lebanese participants. This study explored the nature of trends. Moreover, the majority of the participants in our
the correlation between attitude and knowledge and de- study heard about ECs through their friends and family
termined the specific aspects of knowledge that affect (46.3%), followed by social media (25.2%) and advertise-
the participants’ attitudes towards ECs as well as aspects ments (17.2%). This could be attributed to peer pressure
of attitudes that affect their knowledge. A thorough lit- and the influence of friends, both of which are more
erature search revealed that there are no comprehensive common among the young population, the predominant
knowledge or attitude scales available and that can be age group of our study, particularly regarding popular
employed in the context of a Middle Eastern developing trends. Our findings were in line with those of a study
country like Lebanon. Hence, in order to achieve our ob- conducted on EC users in Atlanta, Georgia where most
jectives, we developed and validated our own scales. The participants reported hearing about ECs through friends
novelty of this study is twofold: 1- filling a regional gap and family and the minority through TV news stories
in the literature about this specific EC topic; 2- propos- and advertisements [8].
ing an EC attitude scale and a comprehensive and useful Concerning the attitudes of the participants towards
knowledge scale. ECs, our data was not congruent with other studies in the
Our study results revealed that there is an inverse sig- literature. While 88.9% of participants thought that EC
nificant correlation between knowledge of and attitude use should be allowed in places that do not allow regular
towards ECs, indicating that a higher level of knowledge smoking [8], the data in our study showed only 20.3% of
is associated with a more negative attitude. Those who such a positive attitude towards ECs. Moreover, while
are more knowledgeable about EC use would also know 80.6% thought that ECs help in quitting smoking [8], a
more about its potential harms and therefore, would comparative question in our study addressing its use as an
perceive it more negatively than those who lack know- effective smoking cessation method obtained a 48.6% posi-
ledge about it. tive response. Furthermore, there was a 27.8% belief that
Our study also showed that people started using ECs ECs should be FDA regulated [8], whereas our study
mostly because of its flavor. According to our data, the showed a 70% belief that it should be governmentally
most popular flavors for the EL were fruit, tobacco, and regulated.
Aghar et al. BMC Public Health (2020) 20:278 Page 14 of 18
E-cigarettes entered the Lebanese market almost 4 predictors for higher knowledge. Participants who used
years ago while it has been in the US market since the ECs proved to have less knowledge on the topic, a factor
mid-2000s and its sales rose rapidly in 2007 [31, 46]. that could possibly contribute to their choice of using
Additionally, in Lebanon, EC import and sale was regu- this device. Those who believed they followed a healthy
lated in 2013, even before its introduction to the market diet also had less knowledge as their perceived healthier
because it was deemed comparable in harm to cigarettes lifestyle could have made them disinterested with ECs
by the Ministry of Health [46]. On the other hand, in and therefore less likely to learn more about them. The
the US, the FDA officially regulated ECs in 2016, around perception that ECs are not harmful for health and that
10 years after their introduction into the market and its they are effective for smoking cessation are both positive
widespread use [31]. Hence, relative to the US popula- attitudes towards ECs and negative predictors for know-
tion, the Lebanese population did not have enough ex- ledge. This relationship is substantiated by the inverse
posure to enrich their knowledge in ECs and their correlation between knowledge and attitude, where those
attitudes could have been influenced by the govern- who know more about ECs and its harms are more likely
ment’s initial negative perception towards this smoking to view it negatively.
device. Furthermore, the recent anti-tobacco law Concerning the attitude model, there was one positive
enforced in 2012 in Lebanon could have contributed to and four negative predictors for a more positive attitude.
an overall negative outlook on smoking in general [46]. Those who used ECs possessed a more positive attitude
Therefore, the differences between our study and that as a way to justify their use of the device. The knowledge
conducted in Georgia [8] could be due to three reasons: that most ECs are addictive, harmful, and impair lung
1- EC’s relatively new introduction to the Lebanese market and heart function were all negative predictors of a posi-
and therefore, participants not knowing much about it and tive attitude reiterated by the inverse correlation be-
attributing their perception of tobacco smoking to EC tween knowledge of ECs and the attitude towards them.
smoking; 2- ECs being less socially acceptable in Lebanon In summary, there is a clear EC knowledge gap among
compared to its tobacco counterparts which have the participants especially pertaining to certain areas like
existed for longer; 3- the recent implementation of EL constituents’ hazards and ECs’ harmful effects on
the indoor smoking ban in Lebanon and consequently organ functions. In addition, there seems to be a gener-
peoples’ increased concern with smoking in general. ally negative attitude towards ECs among the respon-
Our study participants lack knowledge regarding the dents notwithstanding a more positive one towards its
harms of ECs where more than half of the participants incor- use for smoking cessation and experimentation for
rectly answered questions about ECs’ association with lung pleasure. Our study showed an inverse correlation be-
cancer, bladder cancer, and the impairment of lung and tween EC knowledge and attitudes towards ECs. Predic-
heart function. In addition, around 70% did not know that tors for both knowledge and attitude were identified.
some flavors were more harmful than others. A substantial Factors associated with correct knowledge of ECs include
percentage were unaware that ECs contribute to second regular exercise and health-related occupations/majors.
hand smoking (46.2%), that they have an effect on fetal de- Meanwhile, EC use, thinking ECs are not harmful for
velopment (38.9%), and that most of them contain nicotine health and that they could help in quitting smoking, and
(38.9%). Our study is the first to develop a knowledge score, following a healthy diet were associated with incorrect EC
therefore, our results could not be compared. knowledge. Predictors for positive attitude towards ECs in-
Our study produced two multivariable models, one for cluded EC use and male sex; whereas, the knowledge that
a higher level of knowledge and another for a more posi- most ECs are addictive, impair heart and lung function, and
tive attitude; these models accounted for confounders as are harmful were associated with a more negative attitude.
well as other predictors including those related to demo-
graphics. In the model for higher knowledge, two vari- Strengths and limitations of the present study
ables behaved as positive predictors. First, those who Efforts have been made to come up with scales that re-
admitted to a health-related major or occupation dis- flect the attitudes of participants towards EC [21], as
played a higher level of knowledge concerning ECs as well as their knowledge of specific aspects of this novel
their major and occupation must expose them to such smoking tool such as its constituents and regulation
knowledge related to ECs or equip them with the cap- [20]. These studies were limited in the variables they ad-
acity to make better informed judgments about health. dressed within EC knowledge and attitude. Moreover,
Second, participants who believed they exercised regu- no studies were conducted thus far to assess how know-
larly also portrayed more knowledge which can be ex- ledge of and attitudes towards ECs are associated, and
plained by their healthier lifestyle and thus their greater no scales were available to determine in a comprehen-
awareness of habits that could be harmful to one’s sive manner the knowledge of EC and attitude towards
health. On the other hand, we obtained four negative it. Therefore, this study is novel because it: 1- contains
Aghar et al. BMC Public Health (2020) 20:278 Page 15 of 18
an extensive EC knowledge scale as well as an equally participants scored lower on harm-related questions
exhaustive attitude scale and 2- examines how EC know- such as the effects of ECs on the heart, lungs, and blad-
ledge and attitude are interrelated, and 3- identifies fac- der. They were also less aware that ECs contribute to
tors that are associated with these two measures. This second-hand smoking. Therefore, it is necessary to edu-
study is significant not only in filling a knowledge gap in cate the population regarding ECs, specifically related to
this research area in Lebanon and the region, but also in their harms. Studies such as ours are imperative in pro-
generating the first useful knowledge and attitude scales viding data useful in guiding the initiation of effective
of ECs that are comprehensive and that can be adopted corrective measures regarding EC misconceptions. Re-
regionally and internationally to specifically assess the formatory actions should be undertaken through
level of knowledge pertaining to EC and attitude towards it. organization of awareness campaigns, drafting of policy
We acknowledge that our study population was briefs, and institutionalization of new and more stringent
skewed towards a younger and more educated popula- laws that regulate this new smoking device.
tion; however, given that these two factors (age and edu- Although restricting our study to Beirut limits its
cation) did not show any significant association with generalizability, its results lay the foundation for future
neither the knowledge nor the attitude scores obtained, studies which could be carried out at a national level
this skewness should not affect the generalizability of under the support of the Ministry of Health and other
our results. Nevertheless, despite our attempts to choose governmental agencies. This would garner a more holis-
districts representative of different demographics and so- tic and profound understanding of the awareness and
cioeconomic status, including participants solely from perception of the Lebanese community towards ECs and
Beirut poses some inevitable limitations on the smoking in general. Considering that the level of EC
generalizability and extrapolation of the results to other knowledge would be predictably lower had this study
urban and rural areas of Lebanon. been conducted in rural areas rather than in the capital
Using a convenience sample also limits the and largest city of Lebanon, efforts to increase awareness
generalizability of this study. To address this limitation, should take place at a national level to capture the di-
we made sure to maximize the number and variability of verse demographical characteristics of the Lebanese
the sampled areas in Beirut. We have also ensured that community.
the pedestrians were approached randomly with no cri- Awareness campaigns about ECs should target people
teria to our choice of responders other than the exclu- of different age groups, educational levels, and socioeco-
sion criteria, which we confirmed after approaching a nomic status. Educating the population about ECs allows
prospective participant. This left minimal room for se- individuals to make more informed decisions about its
lection bias. Notwithstanding the effect that the conveni- consumption. Our results singled out specific aspects of
ence sample may have had on the external validity of the misconceptions about ECs that could guide the mission
study, our sample population has shown to be compar- and objectives of national awareness campaigns [48]. At-
able to the Lebanese population as there was a small tempts should be focused on the young in order to in-
margin of difference with regards to sex distribution, form them about the harmful and addictive adverse
median age, and literacy [41–44]. effects of ECs when misused as devices for recreational
We did not have an objective measure for quitting purposes. This can be achieved by incorporating these
smoking, rather the participant answered subjectively. awareness campaigns into school and university curric-
Without a standard definition for this measure (e.g. ula as a mandated and integral component of general
smoked 100 cigarettes in a lifetime and currently do not health education courses [49, 50].
smoke), participants who quit smoking were grouped to- Recommendations for the aforementioned initiatives
gether regardless of how recently they quit or the fre- were inspired from the outcomes of previous studies. In
quency of their smoking habits prior to quitting [47]. this regard, smoking cessation interventions imple-
Therefore, the value of 10.8% of individuals who quit or are mented in classrooms were shown to be effective in re-
in the process of quitting smoking could be an overesti- ducing the prevalence of smoking among adolescents
mate. Nevertheless, this value was used to observe the over- and increasing the propensity for smoking cessation in
all pattern of smoking in our sample and does not affect the US and Australia [49, 50]. Additionally, mass media
the results of our EC knowledge and attitude analysis. smoking cessation campaigns ran at a national level in
the US succeeded in increasing the awareness regarding
Public health significance, implications, and the harms of smoking and the inclination for quitting
future direction this habit [48]. Therefore, such active measures should
ECs are relatively new devices; therefore, people are not be taken in order to enlighten the population about the
well-informed about their harms and benefits as was evi- adverse effects of EC use and correct any misconcep-
denced by the results of our study. For instance, tions about the safety of its consumption.
Aghar et al. BMC Public Health (2020) 20:278 Page 16 of 18
Health care providers should also play a role in spreading the outcome knowledge of E-cigarettes with its covariates. The un-
awareness in the community by educating their patients on adjusted odds ratios and their corresponding confidence intervals, along
the attributable risks of ECs on health. Hence, understand- with the P-values showing the unadjusted associations between the co-
variates and the outcome “knowledge” are tabulated and presented in
ing the attitude towards ECs and recognizing its miscon- Appendix D.
ceptions highlight the issues health care providers should
address when informing patients about the use of ECs rec- Abbreviations
reationally or for the purpose of smoking cessation. CI: Confidence interval; EC: Electronic cigarette; EL: E-liquid; FDA: The food
More awareness could lead to a more negative attitude and drug administration; IQR: Interquartile range; Me: Median; OR: Odds ratio;
Q1: Lower quartile; Q3: Upper quartile; SD: Standard deviation
towards ECs, supported by the inverse association be-
tween knowledge and attitude. This is crucial because in- Acknowledgments
dividuals displaying a positive attitude towards ECs could Not applicable.
become more easily inclined to take up this smoking Authors’ contributions
habit. Despite the small percentage of EC users in our HA, and NEK developed the knowledge and attitude scales, and MAJ revised.
study (11%), EC use was found to be significantly associ- HA, NEK, MR, WH, HK, MM, HR developed the questionnaire and MAJ revised.
HA, NEK, MR, WH, HK, MM, and HR were responsible for data collection and
ated with a more positive attitude and less knowledge data entry. HA, NEK, MR and MAJ conducted the data analysis. HA, NEK and
about ECs. This again suggests that individuals with a MR constructed the tables of results. HK, MM, HR, WH, HA, and NEK
positive attitude towards ECs tend to be less generated the Figs. HK and MM wrote the ethics section. WH and HA wrote
the methods section. HA, NEK and MAJ wrote, reviewed, and edited the
knowledgeable and more enticed to use it as a smoking manuscript. HA, NEK and MAJ revised the manuscript and addressed the
device. reviewers’ comments. All authors read and approved the final manuscript.
MAJ oversaw the development and implementation of the study.
Conclusions Funding
In light of the results of this study, actions to improve Not applicable.
the level of knowledge are necessary to shape the atti-
Availability of data and materials
tude towards ECs and mitigate their use, especially for The questionnaire and datasets used and/or analyzed during the current
recreational purposes. Moreover, the government should study are available from the corresponding authors upon reasonable request.
take proactive measures to attenuate the spread of un-
Ethics approval and consent to participate
justifiable EC use in order to mitigate the burden of EC Oral consent was employed as this study presented minimal to no risk to
related cancer and pulmonary and cardiovascular dis- the participants. In addition, the research involved no procedures requiring
eases. A lack of serious intervention from governmental consent outside the context of participation. Participants were not asked to
sign, provide a name or any form of identification; therefore, there was
agencies and relevant ministries, and absence of laws minimal risk of any kind of confidentiality breach. This study with the oral
such as the one that was recently introduced by the consent was approved by the Institutional Review Board (IRB) at the
Lebanese government banning smoking in enclosed American University of Beirut (IRB ID: SBS-2018-0608). Study participants were
approached, informed about the aim of this study, and asked for oral con-
public areas [46], will allow the misconceptions surround- sent. Once consented, the participants filled in the questionnaire.
ing ECs to propagate in the community leading to an ex-
acerbation in disease burden and health care expenditure. Consent for publication
Not applicable.
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