Introduction

The use of electronic cigarettes, commonly known as vaping, has gained significant popularity worldwide in recent years.¹ Vaping devices deliver aerosolized nicotine and other solvents like propylene glycol, tobacco-specific nitrosamines (TSNAs), and volatile organic compounds in a non-traditional way, presenting a potential alternative to traditional combustible tobacco products.² While some perceive vaping as a less harmful option,^3-6 concerns have risen regarding its long-term health effects, particularly with regard to cardiovascular health and its impact on public health.^7-10 While studies have indicated that vaping is helpful for people trying to quit traditional cigarettes^11-13, it has also invariably generated a generation of smokers who would not have been introduced to nicotine otherwise.⁵ Given the rising popularity, there is a pressing need to comprehensively understand the epidemiology of vaping, including its prevalence, patterns of use, and potential health risks.

The prevalence of vaping has seen a drastic surge, particularly among young adults and adolescents, and Bahrain is experiencing a notable increase in use. A study by the Center for Disease Control¹⁴ assessed E-cigarette youth amongst youth. The study found that in the United States, vapes are the most widely used tobacco product among adolescents and that E-cigarette marketing is influencing youth to start or continue with this habit. In 2023, 2.1 million students in the United States used e-cigarettes.¹⁴ Of the 2.1 million, 1.56 million were high-school students, and 550,000 were middle school students. Concerningly, the study also reports that “nearly 1 in 2 U.S. youth who have tried e-cigarettes report current use”. These findings are similar to the previous year¹⁵, however, there has been a notable isolated spike in the number of middle school students who vape (380,000 in 2022). In England, the number of 11–18-year-old students who reported vaping has doubled from 3.3% in 2021 to 7.6 in 2023.¹⁶ As such, this rising trend warrants comprehensive analysis to further understand the epidemiology of vaping amongst this population in Bahrain. This rise in popularity can be attributed to various factors, including aggressive marketing campaigns, the perception of vaping as a fashionable trend, and the belief that it is a safer alternative to smoking.^17-20 However, limited research has been conducted to investigate the extent of this phenomenon. To date, no nation-wide studies have been conducted to look at the impact of vaping regarding different population groups and various socioeconomic backgrounds.

This pilot study aims to bridge the gap in the literature to better understand the factors impacting the use of ENDS (Electronic Nicotine Delivery Systems) in adolescents. By initiating this pilot study, the researchers aim to lay the groundwork for future larger-scale investigations and policy interventions. This approach allows for initial data collection, exploratory analyses, and refinement of research methodologies in hopes of providing insights into the multifactorial nature of vaping behaviors and addiction.

The study aimed to estimate the prevalence of vaping among different demographic groups, including age and gender. Additionally, it explored patterns and determinants of vaping behavior, such as frequency, duration, and factors associated with initiation and chronic use. This study also looked at the level of understanding of the potential health risks associated with vaping among adolescents. It explored the effectiveness of video intervention in understanding the health risks of vaping among participants.

This pilot study's findings will contribute to the existing body of knowledge through exploratory analysis of the root causes of using ENDS. The results will inform future research endeavors, policy formulation, and targeted interventions aimed at harm reduction associated with vaping. Additionally, this study will serve as a crucial step toward understanding the evolving landscape of tobacco and nicotine consumption, helping public health officials and policymakers make evidence based, informed decisions to protect the well-being of Bahraini adolescents.

Methodology

To achieve the above objectives, a cross-sectional survey was conducted among students from grades 6-12, aged 12-20, from an international school in the Kingdom of Bahrain in June 2023. The study utilized a modified survey from the Centre for Disease Control (CDC) - The National Youth Tobacco Survey.²¹ The survey included questions about vaping prevalence, use patterns, motivations, and perceived benefits or harms. Students were also shown a video made by the authors that discussed vaping as a problem in today’s society and highlighted the harmful effects of nicotine on the developing brain.^22-25

Study design

This study adopted a cross-sectional design to evaluate the prevalence of vaping among Bahraini adolescents.

Sample selection

Students in middle and high school, ages 12-20, were recruited from an international school in the Kingdom of Bahrain. The school for this pilot study was chosen out of convenience and availability. All students present whose parents had given consent were allowed to participate in the study. The study did not include students who declined or whose parents had declined consent.

Data collection

A structured questionnaire was developed to collect data on the various aspects of vaping. The questionnaire included demographic data, vaping behaviors (frequency, duration, and types of vaping products used), reasons for vaping initiation, and perceived risks. Students were asked to complete a preliminary survey, watch the video, and complete a post-intervention survey. A barcode was made available for the students to scan to access the surveys. All surveys were conducted through Microsoft Forms. Two researchers were present to aid students. To ensure anonymity, faculty members were restricted from being present at the hall throughout the study.

Ethical considerations

Ethical approval was obtained from the Bahrain Defense Force- Royal Medical Services Ethics Review Board. Informed consent was obtained from the participants and their parents or legal guardians. Emphasis was made on the principle of voluntary participation. Both students and their parents/ guardians were allowed to ask the researchers questions. Confidentiality and anonymity of participants were prioritized and emphasized throughout the study.

Data analysis

Descriptive statistics were used to summarize the sample's demographic characteristics and the prevalence of vaping. Chi-square tests were conducted to examine associations between demographic factors and vaping behaviors. Additionally, analyses were conducted to study the effectiveness of informative videos as an intervention to properly educate youth about the harms associated with vaping. All analyses were done through IBM SPSS Statistics version 29.0.1.1 (244).

Results

Both pre and post-video survey results are summarized in Table 1. 540 students were present when conducting the study, and 531 students responded to the survey (98.4% response rate). Most students, approximately 90%, reported never vaping. Amongst those who have tried vaping, 45.7% vape daily, 17.1% vape weekly, and 37.1% monthly. Amongst the 10% of students who do smoke, 32% of them are unaware of the concentration of nicotine used in their vapes. About 15% used nicotine greater than or equal to 50 mg.

Before showing the students the video, when asked about the adverse effects of vaping, about 12% of students thought that there were no harmful effects, 7.5% of students said they were unaware of the harmful effects, and the rest agreed that there were adverse health effects associated with smoking. Post-video, the survey revealed that amongst students who vape, 66.7% of them wanted to quit vaping after learning the consequences of vaping. 88.3% of all students had learned of at least two consequences of vaping, and 80.8% of them said that they were unlikely to use a vape. 72.9% of all students also said that they would advise against vaping. 71.6% of students agree that there should be more awareness with regard to vaping in schools

Discussion

The results of this pilot study provide valuable insights into the epidemiology of vaping among youth and shed light on the prevalence, patterns, and associated factors of this behavior. The study f irst assessed the 10% of students who admitted to vaping. Almost 46% of those students who vape do so daily, with 17% vaping weekly and 37% monthly. Also, among that cohort, 15% of them used nicotine concentrations greater than or equal to 50 mg. There are no official laws prohibiting the sale of 50 mg/mL nicotine pods, and they are readily available at many local online and retail stores.²⁶ The prevalence of current vapers in the age demographic studied is higher than that in the USA (7.7%) in 2023¹⁴, and the UK (3.6%) for the same year.²⁷ In the UK, there was a 50% growth in experimentation with vaping devices from 2022 to 2023.²⁷ There are no previous statistics for Bahrain to compare, and the prevalence of vaping among adolescents in regional countries has not yet been studied. However, studies looking at the prevalence of university students are equally concerning. 23% of students in the United Arab Emirates, 27.7% in Saudi Arabia, and 14% in Qatar admitted to using E-cigarettes.²⁸

The demographic characteristics of age and gender were explored to identify potential variations in vaping prevalence. Of the students who have tried e-cigarettes, 55.1% identified as males, and 44.9% identified as females. Research by Tehrani et al. (2022) found that worldwide, the lifetime prevalence of e-cigarette vaping was higher among men than women, 22% and 16%.¹ This gender discrepancy highlights the importance of considering gender factors in prevention efforts. About 60% of participants fell within the 12-14-year age group (see Table 2). However, the highest percentage of smokers (50.9%) were amongst the 14-16-year age group. The increase in use among older children has been demonstrated in several studies and may be due to increased exposure to e-cigarettes with age.²⁹ Although the highest percentage of smokers were amongst the 14-16-year age group, it should be noted that only two students from 531 were in the 16-18 and 18-20 age groups. This reflects the need to conduct more extensive studies to further examine the relationship between age and vaping. Previous studies have shown that among students who vape, the highest percentage of vapers belong to high school students, particularly in the United States, 4.6% out of 7.7%.¹⁴ Since 2019, the legal age for purchasing tobacco products in the United States has changed from 18 to 21 years old.³⁰ Although the sale of E-cigarettes to those under the age of 18 is prohibited in Bahrain³¹, it is clear that it has not prevented the students from obtaining these devices. The reasons and methods behind obtaining vapes illegally in the study population are beyond the scope of this study. However, it is reasonable to blame the ease of online purchasing at least partially as a contributor.

This study also looked at reasons for vaping initiation. In this study, from the students who have tried e-cigarettes, the three most common answers as to why they started were “to try something new” (38.3%), “Because my friends/family do it” (27.7%), “It seems cool and fun” (27.7%). A comparable study conducted by Wang et al. (2019)³², reported higher prevalence rates of youth vaping in the United States. However, when exploring the reasons for e-cigarette initiation, similar results were observed. In both studies, one of the three most common reasons as to why they started vaping was “because my friends/ family do it” (27.7% and 30.8%, respectively). Research by Kong et al. (2015)³³, similarly revealed that curiosity motivated adolescents to vape (54.4%). Recognizing the motivations behind e-cigarette initiation is crucial to understanding the underlying factors driving its popularity and for the development of prevention strategies such as comprehensive education programs. These programs should focus on understanding the motivating factors by providing information about the risks associated with vaping, and the impact friends and family have on this impressionable population.

One of the study’s objectives was to explore the students’ understanding of potential health risks associated with vaping. When asked about the adverse effects of vaping before showing the video, about 12% of student responders thought that there were no harmful effects, 7.5% of students said they were unaware of the harmful effects, and the rest agreed that there are adverse health effects associated with smoking. This is a dangerously false perception, as the health consequences of vaping are continuously being revealed. These include the effects of nicotine on the developing brain and its ability to decline cognition and affect memory impairment in adolescents.¹⁵ The flavorings and additives also harm adolescents, and they have been proven to contain carcinogens and harness the ability to impair mucociliary function in bronchial epithelial cells.¹⁵ Countries like the USA have also reported an epidemic of E-cigarette or Vaping Product-use Associated Lung Injury (EVALI) that started in 2019.³⁴ According to Zulfikar, Sankari, and Rahman³¹, EVALI is an “acute or subacute respiratory illness characterized by a spectrum of clinicopathologic findings mimicking various pulmonary diseases.” Although Vitamin E acetate, a condensing agent, is seemingly the culprit behind EVALI,^31,34 the etiology remains unclear. These harmful consequences were highlighted in the video shown to the students after completing the preliminary survey.

This study assessed the perceptions of the students with regard to e-cigarette use after watching the informative video discussing the harms of vaping. With regards to the 10% of e-cigarette users, 66.7% reported wanting to quit vaping after learning about the consequences vaping had on their health. 88.3% of all students had learned of at least 2 consequences of vaping, and 80.8% of them said that they were unlikely to use a vape. 72.9% of all students also said that they would advise against vaping. Additionally, 71.6% of all students believed schools should have more vaping awareness programs. This highlights the impact education can have on addressing this global health concern. According to a study by Jones et al. (2020)³⁵, it appears that adolescents obtain vaping-related information from social media platforms and their peers. This study additionally found that while parents rely on schools to educate their children on e-cigarettes, students continue to receive minimal resources about this topic. This emphasizes how crucial it is to use social media platforms to spread focused anti-vaping initiatives and correct information to offset the impact of false content. A study published in 2020 by Chaplin et al.36 similarly assessed the effectiveness of video intervention in improving high school student's knowledge of the health effects of vaping and concluded the intervention was successful.

In summary, this pilot study adds to the body of research on the epidemiology of juvenile vaping by shedding light on prevalence rates, related factors, initiation reasons, and information sources. This study is, as expected, consistent with similar research published, and highlights the need to expand on vaping in our youth, especially in the region. A more thorough understanding of juvenile vaping can enable the creation of more efficient preventative and intervention plans to combat this public health issue. By addressing the reasons for vaping initiation and continuation, the study serves as a foundation to further expand on the issue of adolescent vaping and the urgent need for public health campaigns to address this matter.

Limitations and Future Considerations

The study's limitations include self-reported data, which may be subject to recall and social desirability biases. These biases potentially lead to under- or over-reporting of vaping behaviors. Moreover, these biases have resulted in minor inconsistencies across the data collected. Across both surveys, some inconsistencies were noted across the data collected (i.e., the student selected I have never vaped/Not applicable for one question, but the reason for vaping was to quit smoking for a different question). Inconsistent entries were considered in the survey summary tables but removed from the final data analysis.

Second, the generalizability of the findings may be limited to the socioeconomic demographic and specific age group studied, as the population was limited to students attending a privately funded school. However, this pilot study provides a valuable foundation for future research on the epidemiology of vaping among Bahraini youth. The results contribute to the existing literature and can inform evidence-based interventions and policies aimed at reducing vaping prevalence and protecting the health of young individuals. Future research should aim to include diverse populations and expand the sample size to enhance generalizability.

Conclusion

In conclusion, this pilot study highlights the importance of understanding the epidemiology of vaping among adolescents. By investigating the prevalence, patterns, and associated factors of vaping, this study provides valuable insights that can guide future research and targeted interventions. It is crucial to continue studying this issue to develop comprehensive strategies that effectively address the public health concerns associated with youth vaping. Ultimately, this study serves as a critical foundation for future endeavors and policy development to address the complexity of vaping patterns. In fostering a deeper understanding of the epidemiology of vaping, this body of research contributes to the collective efforts to safeguard public health and protect adolescents’ well-being in the face of evolving patterns of substance abuse and their associated health implications.

By conducting this pilot study, we aim to lay the foundation for future larger-scale research on the epidemiology of vaping among youth. The findings will contribute to developing evidence based interventions and policies to reduce vaping prevalence and protect the health of young individuals in society.