Journal of Community Health (2021) 46:803–807

https://doi.org/10.1007/s10900-020-00953-2

ORIGINAL PAPER

Electronic Smoking Behavior Among Adult Males in Jordan

Hamzeh Al‑Balas1   · Mahmoud Al‑Balas1 · Hasan Ibrahim Al‑Balas2 · Almu’atasim Khamees2 · Muna Talafha2 ·
Amjad Nuseir3

Accepted: 25 November 2020 / Published online: 2 January 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature 2021

Abstract
The use of Electronic cigarettes (E-cigarettes) has considerably expanded especially among adults. This paper highlights the
behavior regarding E-cigarettes uses among adult males in Jordan. Moreover, we studied the electronic cigarette devices,
the electronic cigarette liquids used in them, and the health-related complaints associated with e-smoking. Among smokers,
we studied the association between E-cigarette use and their interest in smoking cessation. A questionnaire-based study
regarding electronic cigarette prevalence and awareness among Jordanian individuals was conducted with a total sample
size of 1536 participants. The questionnaire was distributed using Facebook and WhatsApp social groups. In this study, we
included data of a total of 254 adult male participants after excluding non-E-cigarettes smokers, female smokers, and male
smokers younger than 18 years old from the previously published study (Electronic Cigarettes Prevalence and Awareness
among Jordanian Individuals) to describe electronic smoking behavior among adult males in Jordan. We described smoking
behavior, electronic smoking technologies and materials, source of knowledge, and believe regarding electronic smoking
among participants. A total of 254 E-cigarette smokers have participated in this study. 104 participants (40.9%) were found to
smoke both traditional and electronic cigarettes, 111 (43.7%) quit traditional cigarette smoking and switched to E-cigarettes,
and 39 (15.3%) individuals are exclusively e-smokers. More than half of the participants (n = 144; 56.7%) believe E-smoking
is not addictive, and 213 (83.8%) suppose that the overall health effects attributable to E-smoking are less severe and not as
serious as those related to traditional smoking. The use of E-cigarettes increased both nationally and globally in the past few
years and is considered an emerging modality of smoking among non-smokers. Social media and other internet websites
are the main sources of knowledge regarding E-cigarettes. Health-related issues and addiction are thought to be less than
traditional smoking in considerable percentages of E-smokers. A more comprehensive conception of E-smoking patterns
in Jordan is required to approach this phenomenon. Health authorities in collaboration with governmental policymakers are
obligate to adopt strict recommendations to control the promotion of E-smoking through social media and other internet
websites to limit its distribution among people especially youths.

Keywords  E-smoking · Smoking-cessation · Addiction

Introduction

In the twenty-first century, smoking is known to be the most

common cause of preventable disease, morbidity, and early
mortality [1] that was estimated to kill 1 billion of the popu-
lation [2]. Jordan is considered to be one of the countries
* Hasan Ibrahim Al‑Balas with high smoking rates, and it was found that the Jordanian
hasanalbalas@yahoo.com
population consumes between 10 and 20 cigarettes per day
1
Department of General and Special Surgery, Faculty [3]. The addiction to smoking, especially in young adults is
of Medicine, Hashemite University, Zarqa, Jordan due to nicotine, with additional harmful effects secondary
2
Faculty of Medicine, Yarmouk University, P.O Box 566, to other substances in tobacco products which might lead to
Irbid 21163, Jordan other diseases and early death [4].
3
Faculty of Medicine, Jordan University of Science
and Technology, Irbid, Jordan

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804
The conceptualization of electronic cigarettes came
to life to reduce the damaging side effects of traditional
smoking that had been rapidly uncovered through research
in the past few decades. Enthusiastically large numbers
of traditional smokers and even non-smokers adopted the
habit of E-smoking presuming it has a more friendly side
effects profile [5].
E-cigarettes are battery-powered devices that work by
heating a liquid into an aerosol which the user inhales and
exhales. The E-cigarette liquid typically contains nicotine,
propylene glycol, glycerin, flavorings, and other chemi-
cals. The majority of people stated they tried E-cigarettes
because these devices are modern, safe, less nicotine addic-
tive, cheaper, cleaner, smoked anywhere, and healthier than
tobacco smoking [6, 7]. However, there were some concerns
about e-smoking and its relation to addiction and smoking
cessation. As some researchers stated that, e-smoking can
lead to increase in the risk of addiction as well as the initia-
tion of cigarette smoking among young adults [8].
In this study, we tried to observe the E-cigarettes smoking
pattern amongst Jordanian adults, including the devices that
are used, the frequency of its use, the nicotine consumption,
the effect on health, and its impacts on a smoking pattern
among traditional cigarette smoker.
Method
A questionnaire-based study regarding electronic cigarette
prevalence and awareness among Jordanian individuals was
conducted with a total sample size of 1536 participants. The
questionnaire was designed and developed according to vari-
ous questionnaires in similar articles. The questionnaire was
distributed randomly using Facebook and WhatsApp social
groups, answers were limited to participants with Jordanian
nationality, and responses were limited to one per partici-
pant. All participants were informed about this study, and
they were included in the study only after they signed their
consent for participation.
In this study, we included data of a total of 254 adult male
participants after excluding non-smokers, female smokers,
and male smokers younger than 18 years old from the previ-
ous study to describe electronic smoking behavior among
adult males in Jordan. We described smoking behavior, elec-
tronic smoking technologies, smoking materials, source of
knowledge, and believe regarding electronic smoking among
participants.
Study approval from the ethics committee for scientific
research (IRB), Hashemite University, Jordan. “The Hash-
emite University Institutional Review Board (HU-IRB) (No.
2/10/2019-2020). The questionnaire is available as a sup-
plementary document upon request.
13
Journal of Community Health (2021) 46:803–807
Results
Among the 254 E-cigarette smokers who participated in this
study, 104 (40.9%) smoke both traditional and Electronic
cigarettes, while 111 (43.7%) quit traditional cigarette smok-
ing and had replaced it with E-cigarettes. The remaining 39
(15.3%) individuals had never smoked traditional cigarettes
and have always been exclusive e-smokers. The Majority of
smokers reported that they were encouraged to use E-Ciga-
rettes by their friends (n = 186; 73.2%), and 62 (24.4%) tried
it after being introduced through media platforms, 3 indi-
viduals (1.2%) reported trying it for the first time at smoking
shopping centers, 1 (0.4%) through TV and 2 (0.8%) via a
community social event.
To further understand the health-related complaints
associated with E-smoking as a sole factor, the 39 exclusive
E-smokers with a mean duration of smoking for 1.3 years
were asked to report any health related problem or symptom
arising not due to previous known medical conditions, and
the results were as in Table 1: The majority of exclusive
e-cigarette smokers (69.2%) did not have any symptoms,
while the rest (30.8%) developed symptoms like dry cough,
wet cough, Tachycardia, Sore throat, Dryness of the nose
and Allergic complaints.
It is crucial to see if there is a correlation between the
habitual E-smoking pattern among Jordanians and their per-
sonal beliefs, whether they think E-smoking is addictive or
not. Out of 254 people, 144 (56.7%) believe that E-smoking
is not addictive, while 109 (42.9%) stated the opposite, and
only one individual (0.4%) had no clue in regards to this
concept. While aiming to assess the understanding of the
participants concerning the effects of E-smoking on human
physical health, 22 (8.7%) believe that E-smoking has a
similar impact on overall health as traditional smoking, 19
individuals (7.5%) admit that it has no effects at all on the
overall health, and the remaining 213 (83.8%) suppose that
the overall health effects attributable to E-smoking are less
severe and not as serious as traditional smoking.
Table 1  Health related problems among 39 exclusive E-cigarettes
smokers
Symptom Number
Free of symptoms 27 (69.2%)
Dry cough 6 (15.4%)
Wet cough 1 (2.56%)
Respiratory symptoms (other than cough) 1(2.56%)
Tachycardia 1(2.56%)
Sore throat 1 (2.56%)
Dryness of the nose 1 (2.56%)
Allergic compliant 1 (2.56%)
Journal of Community Health (2021) 46:803–807 805
Table 2  Types of E-smoking devices used
Type Number
Rechargeable E-cigarette 111 (43.7%)
Large-size tank devices 57 (22.4%)
Medium-size tank devices 50 (19.7%)
Renovo zero 15 (5.9%)
E-cigar 14 (5.5%)
Disposable E-cigarette 6 (2.4%)
E-pipe 1 (0.4%)
About 111 participants (43.7%) used rechargeable
devices, while 57 (22.4%) used large size tank devices, 50
(19.7%) used medium size tank devices, 15 (5.9%) used Ren-
ova zero (i.e. refillable device of polycarbonate material), 14
(5.5%) used E-cigar, 6 (2.4%) used disposable E-cigarette
and only one (0.4%) used E-pipe Table 2. The amounts of
daily consumed nicotine vary among users, as 201 (79.1%)
reported using less than 10 ml, and 45 (17.7%) people stated
their consumption ranges between 10 and 20 ml, and only a
small minority of 8 (3.2%) exceeded 20 ml. Out of the 234
participants (92.1%), the use of nicotine flavored devices was
preferable, while the remaining preferred nicotine unflavored
ones.
According to the World Bank’s latest classification, Jor-
dan is considered a country of low-middle income, with a
gross national income (GNI)/capita range of 1006 to 3955$
[9]. The cost-effectiveness of this behavior should be consid-
ered as well; 177 people (69.7%) reported spending less than
1JDs (less than 1.41$) per day on their electronic devices.
While 66 (26%) reported a range of 1–2JDs (1.41–2.82$) per
day, and 11 people (4.3%) spend more than 2 JDs (2.82$) per
day to purchase, maintain or recharge their devices.
The overall satisfaction rate related to e-smoking among
some smokers is said to be affected adversely by certain fac-
tors such as low battery storage reported by 30 individuals
(11.8%), unavailable replacing instruments (20.1%), a com-
plete sudden stop of the device (2.0%), short-lived instru-
ments requiring frequent alterations and maintenance cost
(6.7%), an explosion of the device (n = 1; 0.4%). But the
majority of participants were satisfied with their e-smoking
experience as 148 (58.2%) did not report any problems at
all (Table 3).
Discussion
E-Smoking can cause multiple variable symptoms like; mild
headache, eye dryness, dizziness, gastrointestinal (GI) upset,
upper respiratory tract infections (URTI), burn injuries [10,
11], and some serious side effects reported by the FDA
like pneumonia and chest pain [11]. Moreover, commonly
Table 3  Problems with usage of E-smoking devices
Problem with usage Number
No problem at all 148 (58.2%)
Non available replacing instruments 53 (20.1%)
Low battery storage 30 (11.8%)
Short half-life of the instrument 17 (6.7%)
Complete stop of work 5 (2.0%)
Explosion of the machine 1 (0.4%)
reported negative effects of E-smoking include throat and
mouth irritation, and dry cough [12]. In our study; the
majority of participants (69.2%) hadn’t had any symptoms
or any health-related problems. Further prospective studies
are required to evaluate the long term effects of E-smoking
products.
About 83.8% of participants thought that the effects of
E-smoking on health are less severe than traditional smok-
ing, while 8.7% believed that it had the same effects as
traditional smoking, and 7.5% presumed that there are no
drawbacks on the overall health at all. Our figures were con-
sistent with, Adkison et al. [13], who stated that 79.8% of
their participants had used e-cigarette because it has a less
negative effect on health than traditional smoking.
Numerous companies with mega-brand names are respon-
sible for the production and distribution of E-cigarettes
which played a major role in exponential growth as millions
of individuals adopted these devices, about 30% to 50% of
E-cigarettes devices sold by the internet [14]. However, the
majority of our participants 73.2% tried E-smoking with
their friends, 24.4% by social media and the internet, 1.2%
at smoking shopping centers, 0.4% on TV, and 0.8% on a
social event. Whereas Cho et al. [15] reported that 46% of
their participants’ contact with e-smoking was attributed to
the internet, 27.9% to their friends, 11.0% from TV, 9.3%
from books. Based on the above figures, health authorities in
collaboration with governmental policymakers are obligate
to adopt strict recommendations to control the promotion of
E-smoking through social media and other internet websites
to limit its distribution among people especially youths.
56.7% of participants stated that E-smoking is not
addictive or less nicotine dependent than traditional smok-
ing while 42.9% stated that it leads to addiction or nicotine
dependence. Our results were in congruence with those
of Rass et al. [16] who found that 57% of their partici-
pants thought E-smoking was less addictive than tradi-
tional smoking. Likewise, Czogala et al. [17] reported that
the concentration of nicotine resulting from E-cigarette
smoking is 10 folds less than traditional smoking. Also,
many researchers suggest E-cigarette to reduce nicotine
addiction and cessation of traditional smoking [18–21]. On
the other hand, Jankowski et al. [6] found that exclusive
13

806
E-cigarette smoking was twofold more likely to cause nic-
otine dependence and addiction compared to traditional
smoking.
To maintain and recharge E-cigarettes devices, about
69.7% of participants stated they spend less than 1JDs
(1.41$) per day thus less than 30JDs (42.3$) per month
which is higher than the findings of Etter et al. [22] who
concluded in his paper that the average cost of daily E-cig-
arette smoking was 33$ per month. Also, a quarter of our
participants (26%) spend between 1 and 2JDs (1.41–2.82$)
per day which is equal to 30-60JDs (42.3–84.6$) per
month and only 4.3% spend more than 2JDs (2.82$) which
is more than 60JDs (84.6$) per month.
Conclusion
The use of E-cigarettes increased both nationally and glob-
ally in the past few years and is considered an emerging
modality of smoking among non-smokers. Social media
and other internet websites are the primary sources of
knowledge regarding E-cigarettes. Health-related issues
and addiction are thought to be less than traditional
smoking in considerable percentages of E-smokers. A
more comprehensive conception of E-smoking patterns
in Jordan is required to approach this phenomenon. Health
authorities in collaboration with governmental policy-
makers are obligate to adopt strict recommendations to
control the promotion of E-smoking through social media
and other internet websites to limit its distribution among
people especially youths.
Limitation of the Study
This study has potential limitation were participants in
this study were only males, however caution is needed to
be taken in the generalization of the results to females. We
adopted a convenient sampling in our approach, so another
limitation of the study was the relatively small sample size,
and for this reason, these findings cannot be generalized to
the broader Jordanian population based on this study alone.
Funding  This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Compliance with Ethical Standards  18. Farsalinos, K. E., Poulas, K., Voudris, V., & Le Houezec, J.
Conflict of interest  There are no conflict of interest to declare.
Ethical Approval  All authors have read and approved the manuscript,
and ensure that this is the case.
13
Journal of Community Health (2021) 46:803–807
References
1. Creamer, M. R., Wang, T. W., Babb, S., et al. (2019). Tobacco
product use and cessation indicators among adults—United States,
2018. Morbidity and Mortality Weekly Report, 68, 1013–1019.
2. Boyle, P., YasanthaAriyaratne, M., Barrington, R., Bartelink, H.,
Bartsch, G., Berns, A., & Zhao, P. (2006). Tobacco: Deadly in any
form or disguise. The Lancet, 367(9524), 1710–1712.
3. Ng, M., Freeman, M. K., Fleming, T. D., Robinson, M., Dwyer-
Lindgren, L., Thomson, B., et al. (2014). Smoking prevalence
and cigarette consumption in 187 countries, 1980–2012. JAMA,
311(2), 183. https​://doi.org/10.1001/jama.2013.28469​2.
4. Benowitz, N. L. (2010). Nicotine addiction. New England Journal
of Medicine, 362(24), 2295–2303.
5. Schraufnagel, D. E., Blasi, F., Drummond, M. B., et al. (2014).
Electronic cigarettes. A position statement of the forum of inter-
national respiratory societies. American Journal of Respiratory
and Critical Care Medicine, 190(6), 611–618.
6. Jankowski, M., Krzystanek, M., Zejda, J. E., et al. (2019). E-cig-
arettes are more addictive than traditional cigarettes—A study in
highly educated young people. International Journal of Environ-
mental Research and Public Health, 16(13), 2279.
7. Grana, R. A., & Ling, P. M. (2014). “Smoking revolution”: A
content analysis of electronic cigarette retail websites. American
Journal of Preventive Medicine, 46(4), 395–403.
8. Hammond, D., Reid, J. L., Cole, A. G., & Leatherdale, S. T.
(2017). Electronic cigarette use and smoking initiation among
youth: A longitudinal cohort study. Canadian Medical Association
Journal, 189(43), E1328–E1336.
9. https​: //www.world​b ank.org/en/count​r y/jorda​n /brief​/ qa-jorda​
n-count​ry-recla​ssifi​catio​n.
10. Meo, S. A., & Al Asiri, S. A. (2014). Effects of electronic cigarette
smoking on human health. European Review Medicine Pharma-
cology Science, 18(21), 3315–3319.
11. Chen, I. L. (2013). FDA summary of adverse events on electronic
cigarettes. Nicotine & Tobacco Research, 15(2), 615–616.
12. Polosa, R., Caponnetto, P., Morjaria, J. B., Papale, G., Campagna,
D., & Russo, C. (2011). Effect of an electronic nicotine delivery
device (E-cigarette) on smoking reduction and cessation: A pro-
spective 6-month pilot study. BMC Public Health, 11, 786.
13. Adkison, S. E., O’Connor, R. J., Bansal-Travers, M., et al. (2013).
Electronic nicotine delivery systems: International tobacco control
four-country survey. American Journal of Preventive Medicine,
44(3), 207–215. https​://doi.org/10.1016/j.amepr​e.2012.10.018.
14. Zhu, S. H., Sun, J. Y., Bonnevie, E., Cummins, S. E., Gamst,
A., Yin, L., & Lee, M. (2014). Four hundred and sixty brands
of e-cigarettes and counting: Implications for product regulation.
Tobacco Control, 23, 3–9.
15. Cho, J. H., Shin, E., & Moon, S. S. (2011). Electronic-cigarette
smoking experience among adolescents. Journal of Adolescent
Health, 49(5), 542–546.
16. Rass, O., Pacek, L. R., Johnson, P. S., & Johnson, M. W. (2015).
Characterizing use patterns and perceptions of relative harm in
dual users of electronic and tobacco cigarettes. Experimental and
Clinical Psychopharmacology, 23(6), 494–503.
17. Czogala, J., Goniewicz, M. L., Fidelus, B., Zielinska-Danch, W.,
Travers, M. J., & Sobczak, A. (2014). Secondhand exposure to
vapors from electronic cigarettes. Nicotine & Tobacco Research,
16(6), 655–662.
(2017). E-cigarette use in the European Union: Millions of
smokers claim E-cigarettes helped them quit. Addiction, 112(3),
545–546.
19. Knorst, M. M., Benedetto, I. G., Hoffmeister, M. C., & Gaz-
zana, M. B. (2014). The electronic cigarette: the new cigarette
Journal of Community Health (2021) 46:803–807 807

of the 21st century? Journal Brasileiro de Pneumologia, 40(5), 22. Etter, J. F., & Bullen, C. (2011). Electronic cigarette: Users profile,
564–572. utilization, satisfaction and perceived efficacy. Addiction, 106(11),
20. González Roz, A., Secades Villa, R., & Weidberg, S. (2017). 2017–2028.
Evaluating nicotine dependence levels in e-cigarette users Eval-
uación de los niveles de dependencia de la nicotina en usuarios Publisher’s Note Springer Nature remains neutral with regard to
de cigarrilloselectrónicos. Adicciones, 29(2), 136–138. jurisdictional claims in published maps and institutional affiliations.
2 1. Rahman, M. A., Hann, N., Wilson, A., Mnatzaganian, G., &
Worrall-Carter, L. (2015). E-cigarettes and smoking cessation:
Evidence from a systematic review and meta-analysis. PLoS ONE,
10(3), e0122544.

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