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RESEARCH ARTICLE
Perceptions, symptoms, and practices of
electronic cigarette users: Descriptive analysis
and validation of Arabic short form vaping
consequences questionnaire
Reema KarasnehID 1*, Sayer Al-Azzam2, Mohammad Nusair3, Sahar Hawamdeh2
1 Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan, 2 Clinical
Pharmacy Department, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan,
3 Department of Pharmacy Practice, Faculty of Pharmacy, Yarmouk University, Irbid, Jordan
Abstract
Background
E-cigarette (EC) use is increasing worldwide. Understanding the practices and perceptions
of e-cigarette users and profiling the symptoms they experience is essential for regulating
the use of such products. This study aims to investigate the practices and perceptions of e-
cigarette users in Jordan and examine the symptoms (e.g. respiratory) they associate with
e-cigarette use.
Methods
A cross-sectional online survey was conducted to assess EC use and tobacco smoking
behaviors and the corresponding health symptoms among EC users in Jordan. EC use
expectancies were also assessed using the Short Form Vaping Consequences Question-
naire, which was first translated into Arabic and tested for validity and reliability.
Results
Out of the 400 EC users surveyed, 95.5% were male, 76.2% used nicotine-containing juice,
and 56.8% were concurrent tobacco smokers. Further, the participants had a mean age of
28.9 years (±10.2). Among dual EC/cigarette users, 88.6% reported that they tried to quit cigarette smoking, with e-cigarette use being the most commonly tried method of smoking
cessation. The smoking-related symptoms reported by regular cigarette smokers mainly
included sputum production (77.5%). The participants reported that using e-cigarettes
instead of tobacco cigarettes had led to improvements in their sputum production (60.8%),
breathing (59%), and general wellbeing (52%). Pleasant taste, enjoyable taste sensation,
and flavor were significantly stronger (P-value < 0.05) among e-cigarette users compared to dual users. Dual EC/cigarette users reported stronger perceptions in the negative conse-
quences scale, particularly with regards to the hazardous effects of smoking on health (P-
value < 0.05).
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Citation: Karasneh R, Al-Azzam S, Nusair M,
Hawamdeh S (2021) Perceptions, symptoms, and
practices of electronic cigarette users: Descriptive
analysis and validation of Arabic short form vaping
consequences questionnaire. PLoS ONE 16(1):
e0245443. https://doi.org/10.1371/journal.
pone.0245443
Editor: Stanton A. Glantz, University of Calfornia
San Francisco, UNITED STATES
Received: February 15, 2020
Accepted: December 31, 2020
Published: January 22, 2021
Copyright: © 2021 Karasneh et al. This is an open access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the Figshare repository at DOI: 10.6084/m9.
figshare.13526270.
Funding: Funding for this study was provided to
RK by the Deanship of Scientific Research at
Yarmouk University (grant number 6/2019). The
funders had no role in study design, data collection
and analysis, decision to publish, or preparation of
the manuscript.
Conclusion
Dual daily use of e-cigarettes and regular cigarettes is a common practice among EC users.
We recommend that further research is conducted on dual EC/cigarette use and the poten-
tial health risks this may have (e.g. higher nicotine intake as compared to the single use of
either products).
Introduction
In recent years, there has been a marked increase in e-cigarette (EC) use globally. The e-cigarette
market has witnessed notable growth over the past few years, reaching a value of around $2.5 bil-
lion, a number which is yet expected to rise [1,2]. In light of this rapid growth, many controversies
have emerged concerning the safety and health issues associated with e-cigarette use.
An e-cigarette is an electronic nicotine delivery system where, unlike conventional ciga-
rettes, no tobacco combustion takes place. Rather, a special solution that may or may not con-
tain nicotine, in addition to flavorings and other ingredients such as propylene glycol and
glycerine, is heated to form an aerosol or ’vapor’ that is inhaled by the user. The product is
designed to mimic the psychological experience of conventional cigarette smoking and is
claimed to cause less harm and exposure to toxic constituents [3]. However, there is no conclu-
sive evidence to strongly support these claims [4]. Although many of the harmful chemicals
found in tobacco smoke are not present in significant amounts in EC solutions, the Food and
Drug Association (FDA) argues that detectable levels of certain carcinogens have been mea-
sured [5]. The toxic constituents in EC solutions reported by the FDA include nitrosamines
and diethylene glycol, among many others. Moreover, with the emergence of EC-associated
acute lipoid pneumonia case reports, the possible deleterious effects of EC use have recently
received public attention [6,7]. Furthermore, EC use has been suggested to impact cardiovas-
cular health, as users of nicotine-containing e-cigarettes have been observed to experience an
increase in systolic blood pressure and heart rate for about 45 minutes following EC use [8].
With tobacco smoking being a major risk factor for a myriad of diseases and a leading
cause of preventable death worldwide, the use of e-cigarettes as a tool for reducing the harm
associated with tobacco smoking is often perceived to be justifiable [9]. This calls for a clear
understanding of the practices, benefits, and risks associated with EC use. Further, the issue of
EC safety is not confined to the presence or lack of toxic constituents, as it can be argued that
tobacco morbidity and mortality do not justify the replacement of one method of nicotine
delivery with another. Rather, efforts should be focused on nicotine abstinence altogether [10].
Several studies have shown the majority of EC users to be former or current tobacco smokers
[11–13]. In these studies, the reported motives behind engaging in EC use have varied, includ-
ing the desire to reduce the harmful effects of cigarette smoking, decrease cigarette consump-
tion, or quit smoking. Other reasons have included the reduced environmental harm and
second-hand smoking effects caused by EC use as compared to conventional cigarette smoking.
There has also been a considerable spread of EC use among never-smokers, a trend particu-
larly prominent among youth [14]. In a study by Sutfin et al., 216 out of 4444 surveyed college
students reported being current or former EC users, and whilst EC use was more common
among former cigarette smokers, 12% of EC users were never-smokers. Users may also find e-
cigarettes to be convenient in allowing them to smoke in smoke-free areas [15]. Other motiva-
tions for EC use include the belief that they are healthier and cheaper than cigarettes [16].
It is important to understand EC users’ perceptions and patterns of EC use in order to
address the health impacts associated with EC use and guide EC sale regulations. Studies in the
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Competing interests: The authors have declared
that no competing interests exist.
literature have mainly been based on online surveys targeted at EC website visitors, and little is
known about the population of EC users in the Middle East. A very recent study in Lebanon
investigated EC-related knowledge and attitudes among a cross-sectional sample [17]. How-
ever, despite the high prevalence of EC use in the region, no studies have assessed the practices
of EC users in the Middle East. Recent studies have reported that in Jordan, where the current
study was conducted, the prevalence of EC use ranges between 11.7%-18% [18,19]. Further, in
a study conducted among college students in Saudi Arabia, an EC use prevalence of 27.7% was
reported [20]. Therefore, the present study aimed to investigate the demographic characteris-
tics, usage patterns, and EC-related health perceptions among EC users in Jordan. The findings
of this study can be used to guide future research related to EC use in the Middle East, as well
as ultimately guiding EC regulation in the region.
Methods
Study design
A cross-sectional survey was conducted from February to May 2019 among adult EC users in
Jordan. An online self-administered questionnaire was adapted from the Short Form Smoking
Consequences Questionnaire (S-SCQ) [21]. The S-SCQ was reworded to S-VCQ to reflect EC
expectancies [22]. Ethical approval for conducting this study was obtained from the Institu-
tional review boards of King Abdullah University Hospital (reference number 35/120/2019).
All performed procedures were in accordance with the ethical standards of the institutional
research committee and with the 1964 Helsinki declaration and its later amendments or com-
parable ethical standards. Electronic informed consent for participation in this study was
obtained from the participants, whilst no personally identifiable information was obtained.
Survey instrument
The online survey consisted of four sections. The first section comprised six items related to
the demographic characteristics of the respondents, while the second section comprised 11
questions aimed at identifying the respondents’ EC and tobacco smoking behaviors. The third
section was aimed at identifying the symptoms that the respondents experienced as a result of
smoking regular cigarettes and whether these symptoms had improved after they had started
using e-cigarettes. Finally, the fourth section included the S-VCQ, which comprises 21 items
aimed at assessing EC use outcome expectancies and which has been evidenced to be valid and
reliable for use among adults and adolescents [21,22]. In order for it to be usable among adults
in Jordan, the S-VCQ was translated into Arabic following ISPOR’s Principles of Good Prac-
tice for Translation and Cultural Adaptation [23]. In the cognitive debriefing phase of the
translation, the Arabic S-VCQ was tested on a sample of 18 adults, an essential step for ensur-
ing the understandability, interpretation, and cultural relevance of the translated survey. Dur-
ing this stage, the participants reported that some questions were similar in meaning and thus
needed to be eliminated to avoid confusion. Therefore, in the cognitive debriefing review, the
authors removed four items, resulting in a total of 17 questions in the final version of the Ara-
bic S-VCQ. A review of the final version of the S-VCQ was then conducted by a professor spe-
cialized in the Arabic language in order to check for any typographical or grammatical
mistakes (S1 File).
Data collection
To this date, e-cigarettes are not legally allowed to be sold in Jordan, and the majority of EC
and EC accessory sales are thus conducted through social media networks. Therefore,
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participants were invited to take part in this study through social media EC groups and pages.
The survey was administered using Survey Monkey, an online survey collection tool, and had
a required completion time of approximately 10 minutes. In order to ensure that there were
no missing data, all of the survey items were “required”. At the beginning of the survey, all
respondents were informed about the study purposes and assured that their participation was
completely voluntary and anonymous, and that all data would be treated as confidential. The
anonymous survey model was implemented to ensure confidentiality and to remedy the
potential effect of social desirability bias.
Data analysis
The survey responses were analyzed using the Statistical Package for the Social Sciences (SPSS)
version 25. Confirmatory factor analysis was performed to assess the construct validity of the
adapted Arabic S-VCQ. Cronbach’s alpha coefficient was used to assess the reliability of the
adapted survey, with an alpha value of � 0.7 considered satisfactory [24]. Furthermore,
descriptive statistical analyses were used to compare between the results of the tobacco smoker
and nonsmoker groups. Statistical significance was tested using the Chi-square test for the cat-
egorical variables and unpaired t-test for the continuous variables.
Results
A total of 400 EC users participated in this study, with a median age of 28 years (range 18–47
years) among the participants. The majority of the participants (95.5%) were male (Table 1),
and all participants were former tobacco cigarette smokers. Most of the participants did not
suffer from any chronic medical conditions (92.2%, n = 369).
Regular cigarette smoking
Of the participating EC users, 56.8% (n = 227) were dual cigarette smokers (i.e., tobacco and
EC). Most dual smokers reported smoking regular cigarettes on a daily basis, with the majority
Table 1. Participants’ characteristics.
Demographic Variables (n = 400) N (%)
Gender
Male 382 (95.5)
Female 18 (4.5)
Education
Secondary 61 (15.8)
Post-Secondary 339 (84.2)
Employment
Employed 288 (72)
Unemployed 112 (28)
Chronic Conditions
Yes 31 (7.8)
No 369 (92.2)
E-Cigarette Smoking Style
Dual smoker (tobacco and e-cigarette) 227 (56.8)
E-cigarette only 173 (43.2)
Age
Median (range) 28 (18–47)
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smoking one or more packs per day (Table 2). Further, most of the participants (87.3%) had
previously attempted to quit cigarette smoking, with 62% having tried to quit more than once.
The reported methods adopted for quitting regular cigarettes included EC use (66.8%), nico-
tine gums (2.6%), nicotine patches (2.6%), prescription medications (e.g., bupropion) (0.9%),
and going cold turkey (27.1%). The overwhelming majority of the participants reported that
they planned to quit smoking at the time of the survey (89.4%, n = 203).
E-cigarette use patterns
The participants’ EC use patterns were assessed (Table 3). Most of the participants (77.8%)
reported using e-cigarettes on a regular basis, whilst 22.2% reported using e-cigarettes occa-
sionally or socially. Further, 67% reported having used e-cigarettes for six months or less. The
results showed that on a typical day, EC-only users had significantly more puffs than did dual
cigarette users (P = 0.049). Moreover, EC-only users used nicotine free juices significantly
more often than did dual cigarette users (P<0.001; Table 3).
The most common type of juice used among the participants was nicotine-containing juice
(76.2%). However, only 15% of EC users reported using both nicotine-containing and nico-
tine-free juices. A considerable percentage of the participating EC users (21.5%) reported tak-
ing their first EC puff as soon as they woke up, although 43.8% reported that they waited at
least an hour after waking up. The most commonly used type of EC among the participating
EC users was the mini EC (59%), with customizable EC mods being significantly (P<0.001)
more preferable to EC-only users (48.6%, n = 84).
Table 2. Cigarette smoking habits among dual users.
Cigarette Smoking Habits (n = 227)
Cigarette Smoking Frequency
Daily 190 (83.0)
Occasionally/Socially 39 (17.0)
Number of Cigarettes/Day
<5 cigarettes 34 (14.8)
5–9 cigarettes 13 (5.7)
10–14 cigarettes 21 (9.1)
15–19 cigarettes 19 (8.3)
One pack 81 (35.4)
More than one pack 61 (26.7)
Tried to Quit
Never 29 (12.7)
Once 58 (25.3)
More than once 142 (62)
Smoking Cessation Method
Nicotine gum 6 (2.6)
Nicotine patches 6 (2.6)
Prescription medications 2 (0.9)
E-cigarette 153 (66.8)
Cold turkey 62 (27.1)
Planning to Quit
Yes 203 (89.4)
No 24 (10.6)
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Symptoms
The smoking-related symptoms experienced by the participants were assessed (Table 4). Spu-
tum production was the symptom that was most commonly reported to be experienced by the
participants when they smoked regular cigarettes. Interestingly, 12% of the participants who
smoked tobacco cigarettes reported experiencing no cigarette-associated symptoms, such as
coughing. Further, participants who had transitioned from smoking tobacco cigarettes to
using e-cigarettes reported that they had experienced improvements in sputum production
(60.8%), breathing (59%), and general wellbeing (52%).
Validity and reliability
In order to ensure that the Arabic S-VCQ would yield constructs similar to the original
S-VCQ, the construct validity of the Arabic S-VCQ was assessed using confirmatory factor
analysis [25]. Four factors emerged from the factor analysis: positive reinforcement, negative
reinforcement, appetite/weight control, and negative consequences (Table 5). The cumulative
variance of the four-factor solution was 68.34%. The Kaiser-Meyer Olkin (KMO) test and
Table 3. E-cigarette use patterns among the study participants (n = 400).
Practice N (%) Dual cigarette users
N (%)
E-cigarette only users N(%) P-value
How long have you been
using e-cigarettes
3 months or less 198 (49.5) 142 (62.6) 56 (32.4) <0.001
6 months 70 (17.5) 35 (15.4) 35 (20.2)
12 months 33 (8.3) 13 (5.7) 20 (11.6)
More than 12 months 99 (24.8) 37 (16.3) 62 (35.8)
How often do you use e-
cigarettes
On a regular basis 311 (77.8) 177 (78) 134 (77.5) 0.904
Occasionally/Socially 89 (22.2) 50 (22) 39 (22.5)
Number of puffs/days
< 50 93 (23.3) 60 (26.4) 33 (19.1) 0.049
50–99 140 (35.0) 78 (34.4) 62 (35.8)
100–150 77 (19.2) 48 (21.2) 29 (16.8)
> 150 90 (22.5) 41 (18.1) 49 (28.3)
Type of juice
With Nicotine 305 (76.2) 193 (85) 112 (64.7) <0.001
Nicotine Free 35 (8.8) 10 (4.4) 25 (14.5)
Both 60 (15.0) 24 (10.6) 36 (20.8)
First e-cigarette puff
As soon as I wake up 86 (21.5) 51 (22.5) 35 (20.2) 0.104
30–60 minutes after I
wake up
139 (34.8) 87 (38.3) 52 (30.1)
> 60 minutes after I wake
up
175 (43.8) 89 (39.2) 86 (49.7)
Type of e-cigarette
Mini EC 263 (59) 162 (71.4) 101 (58.4) 0.008
Mid-size EC Mods 39 (8.7) 18 (7.9) 21 (12.1%) 0.109
Customizable EC Mods 144 (32.3) 60 (26.4) 84 (48.6%) <0.001
� Pearson’s Chi-squared test and Fisher’s exact test were used.
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Bartlett’s test of sphericity were used to verify the adequacy of the sampling and examine the
appropriateness of the factor analysis. The Arabic S-VCQ obtained a good KMO measure
(0.842), with a significant Bartlett’s test of sphericity result (P <0.001) [26]. The Cronbach’s
alpha coefficients for the four factors ranged from 0.718 to 0.909, indicating that the Arabic
S-VCQ had acceptable to excellent internal reliability [27].
Perceptions
The validated Arabic S-VCQ was used to assess dual cigarette users and EC-only users’ percep-
tions towards EC use (Table 5). In the positive reinforcement scale, perceptions regarding
good taste, enjoyable taste sensation, and EC flavor were significantly stronger (p-
value < 0.05) among EC-only users. On the other hand, dual cigarette users reported stronger
perceptions in the negative consequences scale than did EC-only users, particularly regarding
the hazardous effects of EC use on health (P = 0.025). Meanwhile, no differences were identi-
fied between dual cigarette users and EC-only users in the negative reinforcement and appe-
tite/weight control scales.
Discussion
The majority of the EC users in the current study were also tobacco smokers who smoked
both regular cigarettes and e-cigarettes on a daily basis. This finding is similar to the findings
reported in other studies conducted among EC users, although the percentage of dual users
was higher in our study [11–13, 29, 30]. Whilst 56.8% of the EC users in our study were also
cigarette smokers, two similar studies reported percentages of 11.5% and 18% [28,29]. Consid-
ering that many of the participants reported having previously used e-cigarettes to aid tobacco
cessation, dual use may have resulted from failed cessation attempts. Other researchers have
proposed that reduction in costs and the ability to use e-cigarettes in smoke-free areas may be
motives for the dual use of regular cigarettes and e-cigarettes [30]. In addition, dual users may
desire to achieve a balance between the ’real’ experience of tobacco smoking and the reduced
harm of EC use [30]. However, we believe that this is not the case among our sample, as dual
use was associated with a stronger perception that EC use is hazardous to health. Further, we
Table 4. Self-reported symptoms that were aggravated by regular cigarette smoking and self-reported symptoms that had improved after the participants had
started EC use (n = 400).
Symptoms that the participants suffered from when they smoked regular cigarettes N (%) Dual cigarette users
N (%)
E-cigarette only users
N (%)
P-value
Chest wheezing 155 (38.8) 101 (44.5) 54 (31.2) 0.007
Shortness of breath 211 (52.8) 130 (57.3) 81 (46.8) 0.043
Sputum production 268 (67.0) 176 (77.5) 92 (53.3) <0.001
Cough 218 (54.5) 138 (60.8) 80 (46.2) 0.005
Nothing 48 (12.0) 26 (11.5) 22 (12.7) 0.757
Other symptoms (i.e., chest discomfort, headaches, blurred vision, and stomach upset) 8 (2.0) 4 (1.8) 4 (2.3) 0.731
Symptoms that had improved after the participants had started EC use N (%)
Cough 192 (48.0) 112 (49.3) 80 (46.2) 0.546
General well-being 210 (52.5) 118 (52.0) 92 (53.2) 0.840
Breathing 224 (56.0) 134 (59.0) 90 (52.0) 0.186
Sputum production 228 (57.0) 138 (60.8) 90 (52.0) 0.046
Other symptoms (i.e., increased appetite was reported) 1 (0.3) 1 (0.4) 0 (0.0) 1.000
� Pearson’s Chi-squared test and Fisher’s exact test were used.
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found that dual use had detrimental effects on the participants, whereby dual users reported
experiencing chest wheezing, sputum production, and cough more often than did EC-only
users. Similarly, a study among 7505 males found dual users to be more nicotine-dependent as
compared to cigarette-only smokers [31].
In terms of EC juice preference, most of our study participants reported using nicotine-con-
taining EC juices. However, EC-only users used nicotine-free juices significantly more often
than did dual users, which supports the idea that dual use is not always a temporary phase that
leads to the ultimate goal of quitting tobacco cigarettes. Rather, dual use may often end up being
a long-term practice. The majority of EC users in similar studies have also been reported to pre-
fer nicotine-containing solutions [11,12,32], with tobacco smokers and heavy EC users prefer-
ring medium to high nicotine concentrations [33,34]. This preference of nicotinic juices raises
concerns regarding the safety of EC use. According to the American Heart Association, the
harmful effects of nicotine addiction may include "hemodynamic effects, endothelial dysfunc-
tion, thrombogenesis, systemic inflammation, and other metabolic effects" [35].
Flavor was also found to be an important factor impacting the participants’ choice of EC
juice, as certain flavors may encourage usage or be associated with increased or reduced harm
Table 5. Dual cigarette users and e-cigarette only users’ perceptions towards e-cigarette use and factor analysis of the Arabic S-VCQ.
Item Total
(mean ± SD) Dual cigarette users
(mean ± SD) E-cigarette only users
(mean ± SD) P-value �
Factor
1 2 3 4
Positive Reinforcement Scale (Cronbach α = 0.831)
E-cigarettes taste good 8.3±1.93 8.1±2.1 8.7 ± 1.63 0.003 0.625 I enjoy the taste sensation I experience while
using e-cigarettes
8.4 ±1.69 8.1±1.86 8.8 ± 1.36 <0.001 0.832
When I use e-cigarettes, the taste is pleasant 8.1 ± 1.98 8.1 ± 1.91 8.2 ± 2.07 0.627 0.723 I enjoy the flavor of e-cigarettes 8.5 ± 1.66 8.3 ± 1.7 8.8 ± 1.56 0.001 0.890 I enjoy feeling the e-cigarette on my tongue
and lips
8.0 ± 2.14 7.9 ± 2.14 8.0 ± 2.15 0.565 0.760
Negative Reinforcement Scale (Cronbach α = 0.909)
E-cigarettes help me deal with my anxiety 5.5±2.81 5.5±2.78 5.6 ± 2.86 0.817 0.694 E-cigarettes help me deal with my depression 4.5 ± 2.98 4.4±2.93 4.8 ± 3.04 0.191 0.670 0.328 E-cigarettes help me reduce or handle tension 4.5 ± 2.74 4.5 ± 2.72 4.5 ± 2.8 0.884 0.754 When I am upset with someone, the e-
cigarette helps me cope
4.9 ± 2.74 4.8 ± 2.72 5.1 ± 2.77 0.321 0.825
E-cigarette use calms me down when I feel
nervous
5.5 ±2.66 5.4 ± 2.6 5.6 ± 2.75 0.558 0.900
When I am angry, an e-cigarette can calm me
down
5.4 ± 2.61 5.3 ± 2.51 5.5 ± 2.73 0.308 0.912
Appetite/Weight Control Scale (Cronbach α = 0.718)
E-cigarette use helps me control my appetite 4.8± 3.07 4.9±3.07 4.6 ± 3.08 0.478 0.760 E-cigarette use keeps me from eating more
than I should
4.0 ± 2.67 4.1 ± 2.62 3.8 ± 2.72 0.249 0.386 0.769
E-cigarette use helps me keep my weight
down
3.6 ± 2.55 3.6 ± 2.42 3.5 ± 2.72 0.655 0.401 0.691
Negative Consequences Scale (Cronbach α = 0.814)
E-cigarette use puts me at risk of heart disease
and lung cancer
4.0 ± 2.81 4.1 ± 2.85 3.8 ± 2.76 0.371 0.857
E-cigarette use is hazardous to my health 4.8 ± 2.88 5.1 ± 2.9 4.5 ± 2.76 0.025 0.841 E-cigarette use is taking years off my life 3.7 ± 2.77 3.8 ± 2.8 3.5 ± 2.73 0.235 0.830
� The unpaired t-test was used to compare the mean scores between the ‘dual cigarette users’ group and the ‘e-cigarette only users’ group
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perception [32]. A study by Kroemer et al. also showed sweet-flavored e-cigarette juices to be
associated with increased brain cue-reactivity and the potentiation of the reinforcing effects of
nicotine, thus increasing appeal [36]. Our findings indicate that good taste and flavor have
strong positive reinforcement effects among EC users, particularly EC-only users. Flavor plays
a role in creating the sensory effect of EC use, which may increase appeal for EC use among
never-smokers [37]. In fact, the fact that EC juices come in different flavors was reported as
being a main reason for EC use by 81% of youth in a study conducted between 2013 and 2014
[38]. Therefore, it is important to consider flavor when regulating the sales and availability of
EC products and accessories in the market.
The participants in our study reported improvement in health outcomes as a result of switch-
ing from regular cigarettes to e-cigarettes, particularly with regards to sputum production,
breathing, coughing, and general wellbeing. Similarly, respondents to a previous internet survey
listed better health outcomes as an advantage of switching from tobacco smoking to EC use [39]
This improvement in general health may have an impact on EC users’ health perceptions. Our
findings are consistent with the findings of several studies that reported improvement in health
perceptions among smokers who had switched from conventional cigarettes to e-cigarettes or
who were using e-cigarettes for smoking reduction. In a study by Van et al., which targeted
online EC shop customers, 84% of EC users reported that they had experienced improvements
in their general health after switching to EC products [40]. Similarly, another survey among EC
users revealed a significant association between switching to EC use and better-perceived health,
especially when cigarette use is reduced by more than 2 packets/month [28]. Additionally, EC
use was believed to aid weight control among the respondents in our study, and no significant
differences were found between dual and single users in the appetite/weight control scale. This
is similar to the findings of several studies, including a study in the United Kingdom which
reported that e-cigarettes are often used to replace a meal or a snack [41–44].
The present study is one of few studies conducted among EC users in the Middle East,
where EC use is on the rise. The study also captures the overlap between tobacco cigarette
smoking and EC use and provides useful data on EC use patterns, especially dual use. How-
ever, there are a few limitations to the current study. For example, online recruitment may
have led to selection bias in favor of younger EC users who regularly use social media plat-
forms. However, considering the fact that most EC sales in Jordan are conducted through
social media platforms, this may not have affected our findings. Finally, since this study used a
self-reported questionnaire, certain parameters could not be verified, such as the presence of
chronic conditions.
Conclusion
With the global rise in EC use and the ambiguity surrounding the safety profiles of such products,
it is of paramount importance to explore EC use patterns, perceptions, and attitudes among users.
Our findings have revealed that there is a high prevalence of the dual use of tobacco cigarettes and
e-cigarettes in Jordan. Further, concerning practices were identified among the participants, such
as the daily use of both tobacco cigarettes and e-cigarettes by most users and the preference for
nicotine-containing e-juices. Future studies with extended follow-up periods are required to
investigate the transition from regular cigarettes to e-cigarettes or vice versa.
Supporting information
S1 File. Arabic short form vaping consequences questionnaire.
(DOCX)
PLOS ONE Perceptions, symptoms, and practices of electronic cigarette users
PLOS ONE | https://doi.org/10.1371/journal.pone.0245443 January 22, 2021 9 / 12
Author Contributions
Conceptualization: Reema Karasneh, Sayer Al-Azzam, Mohammad Nusair, Sahar
Hawamdeh.
Data curation: Reema Karasneh, Sayer Al-Azzam, Mohammad Nusair, Sahar Hawamdeh.
Formal analysis: Mohammad Nusair.
Funding acquisition: Reema Karasneh.
Investigation: Reema Karasneh, Sayer Al-Azzam, Mohammad Nusair, Sahar Hawamdeh.
Methodology: Reema Karasneh, Sayer Al-Azzam, Mohammad Nusair.
Project administration: Reema Karasneh, Sayer Al-Azzam, Mohammad Nusair.
Resources: Sayer Al-Azzam.
Software: Mohammad Nusair.
Supervision: Reema Karasneh, Sayer Al-Azzam.
Validation: Reema Karasneh, Sayer Al-Azzam, Mohammad Nusair, Sahar Hawamdeh.
Visualization: Reema Karasneh, Sayer Al-Azzam, Mohammad Nusair, Sahar Hawamdeh.
Writing – original draft: Reema Karasneh, Sayer Al-Azzam, Mohammad Nusair, Sahar
Hawamdeh.
Writing – review & editing: Reema Karasneh, Sayer Al-Azzam, Mohammad Nusair, Sahar
Hawamdeh.
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