Knowledge and Risk Perception of E-cigarettes and Hookah Among Youths in Anambra State, Nigeria

Knowledge and Risk Perception of E-cigarettes and Hookah Among Youths in Anambra State, Nigeria | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Knowledge and Risk Perception of E-cigarettes and Hookah Among Youths in Anambra State, Nigeria Nkem Hillary OKEKE, Ndubuisi Paris Obi, Chinomnso Chinanuekpere Nnebue This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5815292/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Jul, 2025 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background E-cigarettes and hookah have gained significant popularity, particularly among young people in recent years, despite limited research on their safety and efficacy. Advertisements for these products are widespread across various media platforms, further increasing their popularity and raising awareness among youths. This study aimed to assess the knowledge and risk perception of e-cigarettes and hookah among youths in Anambra State, Nigeria. Method This descriptive cross-sectional study was conducted in three tertiary institutions, selected through simple random sampling from the three Senatorial Districts of Anambra State. Participants (n = 272), aged 18–35 years, were recruited using a multi-stage stratified random sampling technique A self- administered, semi- structured questionnaires was shared amongst students of the three tertiary institutions that met the inclusion criteria. Descriptive statistics were generated, and chi-square tests were conducted to determine the level of significance at p < 0.05. Result The study showed that most participants (66.7%) reported the internet/media as their primary source of information about these substances. Majority (64.7%) perceived both e-cigarettes and hookah as equally harmful in terms of health risks, while 50.7% considered both substances equally addictive. Participants identified respiratory (65.4%) and cardiovascular (71.7%) diseases as the major health risks associated with e-cigarette and hookah use. Most users of these substances were within the 25–29 age group, and 7.4% of participants reported using both e-cigarettes and hookah. The majority of first-time users tried these devices in cafés/restaurants, followed by nightclubs. Conclusion This study demonstrates high awareness but limited comprehensive knowledge of the health risks associated with e-cigarette and hookah use among youths in Anambra State. The prevalence of use in social settings reveals the need for targeted education on their risks. Incorporating these products into smoke-free policies and regulating access in youth-centered environments are essential to curbing their growing use and associated health risks. E-cigarettes Hookah Knowledge Risk perception Anambra State Health hazards Introduction In recent years, the use of alternative smoking devices, such as e-cigarettes and hookah, has gained significant popularity worldwide, particularly among youths (1–5). Electronic nicotine delivery systems (ENDS), known as e-cigarettes or electronic cigarettes, are battery powered devices that deliver nicotine without burning tobacco (6). An electronic cigarette consists of three main components: a cartridge, an atomizer, and a battery. An e-cigarette cartridge usually contains a fluid composed of nicotine, ranging from 0 to 24 mg/ml, and humectants such as propylene glycol or glycerol and flavorings, an atomizer aerosolizes the fluid when heated by the battery (7). In a typical device configuration, instead of burning tobacco, a user draws air through the device; an airflow sensor or a physical power button activates a battery that powers an atomizer to produce an aerosol from liquid containing nicotine and flavorings (2,6,8). The vapor carries a dose of nicotine into the users lungs through inhalation, and a residual aerosol is released into the environment through exhalation (7,9). E-cigarette advertising appears in various media including television (TV), radio, print, online, and at retail point of sale, and has contributed to the popularity of the product and raised awareness among youth. The prevalence of e-cigarette use has been increasing among middle and high school students in the United States this is in accordance with Findings from the National Youth Tobacco Survey which showed that among all students grades 6–12, the number of those who had ever used e-cigarettes rose from 3.3–6.8%, and current use of e-cigarettes rose from 1.1–2.1% during 2011 and 2012 (10). This trend is not limited to Western nations; in Nigeria, and particularly in Anambra State, these devices have become more accessible and are gaining traction among young people. E-cigarettes and hookah are often marketed as safer alternatives to traditional cigarettes (2), but emerging evidence suggests that their health risks, particularly among young and impressionable populations, may be significant (11,12). Young people and teenagers are especially drawn to e-cigarettes (ECs) for a variety of reasons, such as curiosity, peer pressure, social standing, the abundance of delicious flavors and the fact that e-cigarettes are readily available at malls and convenience stores (13). This increasing prevalence of e-cigarette use among adolescents raises concerns about the possibility that ECs could lead to nicotine dependence or act as a gateway to traditional tobacco cigarettes, although it is still hotly contested (12,14). The higher incidence of mental health conditions like depression is another significant negative effect associated with EC use. EC is linked to anxiety disorders, which are characterized by excessive worry, fear, or anxiety that interferes with day-to-day functioning (15). The use of e-cigarettes is reported to be more common among individuals with depression or anxiety compared to those without mental health conditions (16). In fact, smoking rates among people with mental health conditions are estimated to be about 70% higher than in those without such conditions (16). Furthermore, there is evidence from international studies demonstrating a concerning connection between e-cigarette use and mental health issues. According to the research carried out on American college students, it was found that e-cigarette use was associated with depressive symptoms and other mental health problems, with students experiencing depression being more prone to use e-cigarettes than their non-depressed peers (17). However, in another study conducted in 2017 it was indicated that the link between e-cigarette use and depression in adolescents was minimal (18). These conflicting findings show the need for further research, particularly in different cultural and geographic contexts. Despite the increasing popularity of these devices, there is a paucity of data on young people's knowledge and risk perception associated with the use of e-cigarettes and hookah in Nigeria. (19). Therefore, this qualitative study sought to explore the knowledge and risk perception of e-cigarettes and hookah among youths in Anambra State, Nigeria, to better understand the potential health implications associated with their use. METHOD Study design This study employed a descriptive cross-sectional design to assess the knowledge and risk perception of e-cigarettes and hookah among youths in Anambra State, Nigeria, specifically targeting students from Nnamdi Azikiwe University Awka, Nwafor Orizu College of Education Nsugbe, and the College of Health Sciences, Nnamdi Azikiwe University Nnewi Campus. Study population Participants (n = 272) aged 18–35 years were recruited from three higher institutions across the three senatorial districts of Anambra State: Anambra Central, Anambra South, and Anambra North. The study targeted students who had been enrolled in their respective institutions for at least one year. Inclusion criteria . 1.Youths admitted in the selected Higher Institutions for at least one year. 2. Regular students Exclusion criteria 1. Those selected as above but were not present during the study. 2. Those who were present but declined assent or full informed consent. Sample Size Determination. Using Cochran formula: n = Z 2 x P x (1-p)/ d 2 Where: Z = 1.96 (corresponding to 95% confidence interval) P = 0.5 (50% prevalence used as no similar study exists within our region) d = 0.05 (Margin of error to be tolerated set to 5%) Therefore: n= (1.96) 2 x 0.5 x (1-0.5) / (0.05) 2 = 384.16 n = 384 Adjustment for the population < 10,000 the formula below is used (20), the finite population correction formula; nf = n/1 + n/N where n = 384 (calculated sample size) N = 500 (estimated population size) Therefore: nf = 384/[1+(384/500)] nf = 217.2 nf = 217 Anticipating a non-response of 10% (f) using the formula = n/1-f 217/1-0.1 = 217/0.9 = 241.1 = 241 To increase the power of the study, this is rounded up to 272 ( the Minimum total population size used for this study) . The sample size was adjusted to take care of non-response and improperly filled questionnaires. This was done by dividing the calculated Sample size by anticipated non response rate. Sampling Technique A multistage sampling technique was employed. Stage 1 : Selection of Senatorial Zones: The study was conducted across the three Senatorial Districts of Anambra State. Stage 2 : Selection of Higher Institutions: One institution was selected from each Senatorial Zone using simple random sampling through balloting. Stage 3 : Selection of Participants: Students aged 18 to 35 from the selected institutions were randomly chosen via balloting. Stage 4 A total of 272 participants were recruited using a simple random sampling technique. Data Collection Data were collected using a semi-structured, self-administered questionnaire adapted from a UK database survey which was developed according to the objectives of this study. The questionnaire comprised four sections (A-D). Section A contained socio-demographic data of respondents, while sections B, C, and D assessed knowledge and risk perception of e-cigarettes and hookah. Participants were assured of confidentiality, and informed consent was obtained prior to administering the questionnaires. Ethical consideration and consent to participate : Ethical approval was sought and obtained from the Ethics Review Committee of Nnamdi Azikiwe University. Participants were informed of the study's purpose, and unique codes were assigned to the questionnaires to ensure confidentiality. Statistical analysis The collected data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 25. Descriptive statistics were generated, and chi-square tests were conducted to determine the level of significance at p < 0.05. Results Table 1 presents summary of the socio-demographic profiles of the participants. From the table, it can be observed that a total of 272 participants (52.9% males) participated in the study, with a mean age of 23.19 ± 3.46 years. The majority of participants were single (94.1%), predominantly belonged to the Catholic denomination (47.8%), and identified as members of the Igbo tribe (87.1%). Over half of the participants (55.5%) attained post-secondary (tertiary) education, with 33.8% holding bachelor’s qualifications. Table 2 shows summary of the descriptive statistics of the knowledge and awareness of E-Cigarettes and Hookah Among Participants. Most participants (66.7%) reported the internet/media as their primary source of information about these substances. Despite this, a majority (58.5%) had not seen either e-cigarettes or hookah. When identifying health hazards, cardiovascular (71.7%) and respiratory (65.4%) issues were most frequently recognized as significant risks. Furthermore, the majority (64.7%) perceived both e-cigarettes and hookah as equally harmful in terms of health risks, while 50.7% considered both substances equally addictive. Table 3 shows the statistics of the usage of e-cigarettes and hookah among participants. Out of the participants, 6 (2.2%) reported using both substances, 2 (0.7%) were using only shisha, and 4 (1.5%) were using only hookah at the time of data collection. Among the current users, most hookah smokers (75.5%) smoked less than once a year. The age group with the highest proportion of first-time hookah users was 25–29 years, accounting for 7.0% of participants. A combined 9.2% of the participants were considering using any of traditional cigarette, smokeless tobacco, hookah, electronic cigarette or their combinations in the future Table 4 shows the summary of the statistics of the usage of e-cigarettes and hookah among relatives, friends, and significant others of participants. Approximately one-third of participants reported having one or more close friends (2.6%) and one or both parents (8.8%) who used hookah or e-cigarettes. The majority of users indicated they were with friends during their first experience with hookah. The most common locations for first use were cafés/restaurants (7.4%) and nightclubs (6.6%). Table 5 shows the association of awareness of E-Cigarettes and Hookah with Selected Socio-Demographic Variables. No significant associations were found between awareness of e-cigarettes and hookah and gender, marital status, religion, tribe, or educational qualifications (p > 0.05). Table 6 shows the association of usage of E-Cigarettes and Hookah with Selected Socio-Demographic Variables. A significant association was noted between gender and usage, with a higher proportion of males having used the substances compared to females (χ² = 17.04, p < 0.01). Additionally, tribe significantly influenced usage, with a greater proportion of Hausas using the substances compared to other tribes (χ² = 89.00, p < 0.01). Educational qualifications were also significantly associated with usage, showing that participants with higher educational attainment tended to indulge less in the use of e-cigarettes and hookah (χ² = 67.12, p < 0.01). Table 2 Knowledge about e-cigarettes and hookah among the participants Knowledge Questions Response options Frequency Percentage If yes, how did you get to hear about it? Internet / media 126 66.7 School 37 19.6 Books 27 14.3 Friends 105 55.6 Other 3 1.6 Which of them have you seen? None 159 58.5 Both 82 30.1 Other 31 11.4 Which among these do you identify as important health hazards of Hookah and e-cigarettes smoking? Respiratory problems 178 65.4 Cardiovascular impairments 195 71.7 Hematologic Impairments 122 44.9 Pregnancy Hazards 62 22.8 Diarrhea 99 36.4 Which among E-CIGARETTE and Shisha/Hookah are more addictive according to your perception? Shisha/Hookah (water-pipe) smoking is more addictive 51 18.8 e-Cigarette smoking is more addictive 51 18.8 Both are equally addictive 138 50.7 Where do you rate the health hazards of habitual hookah smoking in comparison to those of E-cigarette smoking? Cigarette smoking is more harmful 43 15.8 Water-pipe smoking is more harmful 28 10.3 Both are equal in terms of health risks 176 64.7 Table 3: Usage of e-cigarettes and hookah among the participants Usage Questions Response options Frequency Percentage If you are currently using any, specify Both 6 2.2 Shisha 2 0.7 Hookah 4 1.5 Which one of the following did you use first? Traditional cigarettes 23 8.5 Smokeless tobacco (snus or chewing tobacco) 8 2.9 Hookah (Water pipe tobacco smoking or Shisha) 17 6.3 Electronic cigarettes 3 1.1 None of these 221 81.3 Which of the following are you currently using? Traditional cigarettes 2 0.7 Smokeless tobacco (snus or chewing tobacco) 3 1.1 Hookah (Water pipe tobacco smoking or Shisha) 9 3.3 Electronic cigarettes 1 0.4 None of these 256 94.1 All of the above 1 0.4 Which are you likely to use in the future? Traditional cigarettes 5 1.8 Smokeless tobacco (snus or chewing tobacco) 4 1.5 Hookah (Water pipe tobacco smoking or Shisha) 6 2.2 Electronic cigarettes 7 2.6 None of these 248 90.8 All of the above 3 1.1 Please explain why to the answer in the future usage? Religion 90 33.1 Health 97 35.7 Personal 85 31.3 Pleasure 0 0.0 Have you ever used a hookah to smoke tobacco (even one or two puffs)? No 229 84.2 Yes 43 15.8 Which of the following choices best describes how often you smoke tobacco using a hookah? Less than once a year 17 6.3 At least once a year, but not monthly 23 8.5 At least once a month, but not weekly 8 2.9 At least once a week, but not daily 3 1.1 At least once a day, or most days each month 3 1.1 How old were you when you FIRST used a hookah? Younger than 9 years old 3 1.1 10-12 years old 2 0.7 13-15 years old 5 1.8 16-18 years old 7 2.6 19-21 years old 14 5.1 22-24 years old 0 0.0 25-29 years old 19 7.0 30 years old or older 4 1.5 Table 4: Usage of e-cigarettes and hookah among relatives, friends and significant orders of the participants Questions Response options Frequency Percentage Do one or more of your close friends use electronic cigarettes or Hookah? Yes 90 33.1 No 97 35.7 Don’t know 85 31.3 Does your mother or father (guardian) use electronic cigarettes or hookah? Yes both my mom and dad use 2 0.7 Yes, my mom uses 1 0.4 Yes, my dad uses 4 1.5 No, neither my mom nor dad use 265 97.4 Who else in your family use electronic cigarettes or hookah? Brother (s)/Sister(s) 24 8.8 Grandmother 4 1.5 Grandfather 0 0.0 Uncle 9 3.3 Aunt 0 0.0 Other, cousin 10 3.7 No one uses 0 0.0 I don’t know 139 51.1 8 82 30.1 9 4 1.5 Who were you with when you FIRST used a hookah? No one, I was alone 8 2.9 With one friend 21 7.7 With more than one friend 17 6.3 With a family member 5 1.8 With more than one family member 0 0.0 With a new acquaintance 1 0.4 Where were you when you FIRST used hookah? In a cafe or restaurant 20 7.4 In my own home (apartment, condo, house) 1 0.4 In the night club 18 6.6 At a family member's home 4 1.5 At a fraternity/sorority house 3 1.1 At a friend's or acquaintance's home 5 1.8 Table 5 Showing the association between awareness of e-cigarette and hookah and selected socio-demographic variables of the participants Variable Class Awareness (n(%)) X 2 P Yes No Maybe Gender Male 98(68.1) 38(26.4) 8(5.6) 1.11 0.58 Female 80(62.5) 38(29.7) 10(7.8) Marital status Single 165(64.5) 75(29.3) 16(6.3) 4.72 0.32 Married 12(80.0) 1(6.7) 2(13.3) Others 1(100.0) 0(0.0) 0(0.0) Religion Catholic 83(63.8) 41(31.5) 6(4.6) 15.07 0.06 Anglican 41(75.9) 9(16.7) 4(5.6) Pentecostal 45(63.4) 22(31.0) 4(5.6) Muslim 1(25.0) 2(50.0) 1(25.0) Others 8(61.5) 2(15.4) 3(23.1) Tribe Igbo 151(63.7) 70(29.5) 16(6.8) 8.10 Housa 15(88.2) 1(5.9) 1(5.9) Yoruba 5(100.0) 0(0.0) 0(0.0) Others 7(53.8) 5(38.5) 1(7.7) Qualifications NCE 23(71.9) 7(21.9) 2(6.3) 7.62 0.67 OND 13(72.2) 3(16.7) 2(11.1) HND 4(80.0) 1(20.0) 0(0.0) BSc 60(65.2) 23(25.0) 9(9.8) MSc 3(75.0) 1(25.0) 0(0.0) Others 75(62.0) 41(33.9) 5(4.1) Table 6 Showing the association between Usage of e-cigarette and hookah and selected socio-demographic variables of the participants Variable Class Usage (n(%)) X 2 P None Both Other Gender Male 109(75.7) 27(18.8) 8(5.6) 17.04 < 0.01* Female 120(93.8) 5(3.9) 3(2.3 Marital status Single 215(84.0) 30(11.7) 11(4.3) 0.88 0.32 Married 13(86.7) 2(13.3) 0(0.0) Others 1(100.0) 0(0.0) 0(0.0) Religion Catholic 106(81.5) 19(14.6) 5(3.8) 11.09 0.20 Anglican 43(79.6) 8(14.8) 3(5.6) Pentecostal 64(90.1) 5(7.0) 2(2.8) Muslim 3(75.0) 0(0.0) 1(25.0) Others 13(100.0) 0(0.0) 0(0.0) Tribe Igbo 210(88.6) 17(7.2) 10(4.2) 89.00 < 0.01* Housa 3(17.6) 14(82.4) 0(0.0) Yoruba 4(80.0) 1(20.0) 0(0.0) Others 12(92.3) 0(0.0) 1(7.7) Qualifications NCE 15(46.9) 17(53.1) 0(0.0) 67.13 < 0.01* OND 14(77.8) 4(22.2) 0(0.0) HND 5(100.0) 0(0.0) 0(0.0) BSc 82(89.1) 6(6.5) 4(4.3) MSc 4(100.0) 0(0.0) 0(0.0) Others 109(90.1) 5(4.1) 7(5.8) KEY: *= Significant at p < 0.05 DISCUSSION This study is among the few to qualitatively examine the knowledge and risk perceptions of e-cigarette and hookah use among young people in Nigeria. The present research aimed to assess the understanding and perceptions of risks associated with e-cigarettes and hookah among youths in Anambra State, Nigeria. This is particularly relevant given the alarming global rise in the use of these substances, which pose significant yet preventable health risks. As e-cigarettes and hookah become increasingly popular among young populations, it is crucial to explore how awareness and risk perceptions shape their usage patterns(21). Understanding these dynamics is essential for informing public health interventions aimed at reducing tobacco and nicotine consumption among vulnerable youth demographics. The youths were targeted in this study (as revealed by the mean age = 23.19 ± 3.46 years) because they have been reported as the group most liable to indulge in the usage of these substances, with more than 70% of cigarette and hookah smoking starting during adolescence (22). Majority of the participants were Igbo’s and Christians who were mainly Catholics and Anglicans. This is not surprising as Igbo’s are the natives of the setting of this study, and are mainly Christians of Catholic and Anglican denominations. Educational attainment of the participants was high as majority attained tertiary education. This is in line with previous reports that Igbo’s are one of the most educated tribes in Nigeria (23). Most of the participants reported to have heard of e-cigarettes and hookah with internet/media being the most frequent source of information. This may not be unexpected considering the fact that usage of internet and social media has unprecedentedly increased in recent times, and act as a medium for fast dissemination of information (24). However, over half of the participants had not seen any of e-cigarette and hookah suggesting that there awareness did not come from having direct contacts with the substances. The participants of the present study seemed to be knowledgeable about the health hazards (especially respiratory and cardiovascular) of e-cigarette and hookah. This might not be unconnected to their enlightenment from media or internet. Cigarette smoking has been reported to associate with development of several systemic conditions (including cancer, cardiovascular and pulmonary diseases), oral diseases (including oral cancer, periodontal diseases and peri-implantitis) and so on (25). Hookah users have actually been reported to be exposed to many of the same toxic compounds/by-products as conventional cigarette users, but at dramatically higher levels, which might lead to more severe negative health effects. Majority of the participants in the present study rated both e-cigarette and hookah as having equal addictive tendencies. The two substances have been reported to deliver the dependence-producing drug nicotine(25). 7.4% of the participants in the present study reported to have used e-cigarette and hookah while 3.7% were still using them at the point of data collection. Previous reports(Bunnell et al., 2015; Cahn & Siegel, 2011; Masjedi et al., 2020) have revealed that the use of e-cigarette and hookah had been an emerging trend especially among the youths. However, the recorded point prevalence (3.7%) of hookah use in the current study falls below 9–12% recorded in Syria (26), 30% in Jordan (27), 9.2% and 25.5% in Iran (22), 29% in Canada(28), 12–15% in the US, 12% in Estonia, 8% in the UK, 25% in Lebanon, 15% in Syria and 33% in Pakistan(26). This may be a pointer to the fact that hookah and e-cigarette use is not yet as rife in Nigeria as in many other countries. This is further buttressed by the fact that majority of the hookah smokers in this study indulged in the act only once a year unlike more frequent usage in other climes (22). The users of the substances were spread across different age groups between 10 and 30 years. Furthermore, a combined 4.8% prevalence of the participants grandparents, aunts and uncles were reported to be using hookah unlike a combined higher 12.5% prevalence of siblings and cousins (who are understandably younger than the previous group) of the participants that were using hookah. This may be supporting the previous reports that hookah usage are more popular among the youths (27). A combined 9.2% of the participants were considering using any of traditional cigarette, smokeless tobacco, hookah, electronic cigarette or their combinations in the future. This is similar to 7.9% pooled probabilities of cigarette initiation in never e-cigarette users reported in a systematic review(29), and may be a pointer to the increasing popularity of e-cigarette usage among young adults as reported in literature (25). This may be a cause for concern as e-cigarette smoking initiation had been reported to significantly associate with subsequent cigarette usage (29). This might have also highlighted the need for strong e-cigarette regulation in order to curb youths access to e-cigarette and hookah which are still easily accessible (29), and had probably contributed in making e-cigarette and hookah most popular form of tobacco smoking, overtaking the conventional cigarette in recent years(25). This increase in usage of hookah has also been partly attributed to misperception of hookah being less harmful than cigarettes and the availability of different but appealing flavors(30). The proportion of participants (33.1%) that reported having one/more close friends smoking e-cigarette and hookah is almost double the proportion (18.9%) of those that reported having a relative (parents, grandparents, siblings, cousins, aunts and uncles) smoking the substances. This may be highlighting the influence peer pressure may be having on initiation of e-cigarette and hookah smoking, as many participants would have been likelier to be persuaded to indulge in the act by their friends than by a relative. This assumption is supported by the fact that majority of the users reported being with their friend(s) when they first used hookah. Peer influence has been reported as a major factor in hookah smoking(21). Café/restaurant and night club were the most frequent locations where the users firstly used hookah in the present study. These substances have been reported to be commonly used in public places including social parties and cafés(21). This may be a wakeup call for the government of the day to save the populace from the menace of secondhand or passive smoking. There was significant association of gender with usage of e-cigarette and hookah among the participants of this study with more males having used the substances than their female counterparts. This is contrary to previous Iranian study (22) where more female high school students were smoking cigarette and hookah than their male counterparts. The fact that Igbo’s have a patriarchal culture where women are expected to be less adventurous than men might have discouraged Igbo female youths from indulging in hookah and e-cigarette smoking like the male youths. There was also a significant association between usage of e-cigarette and hookah and tribe with more proportion of Hausas having significantly used the substances than other tribes. Varied prevalence of e-cigarette and hookah smoking had been reported across different cultures and geographical locations with higher prevalence reported among Middle Eastern countries who are mainly Muslims(26). The fact that Hausa is a predominantly Muslim tribe who has imbibed the Arabic (Middle Eastern) cultures might have explained their higher usage of hookah and e-cigarette in this study. Qualifications of the participants also significantly associated with their usage of e-cigarette and hookah with those who had higher education attainment seeming to indulge less in the usage. This may be easily justified. More educated people might have been more enlightened on the health hazards of e-cigarette and hookah smoking than their less educated peers. This might have discouraged them from indulging in the usage of these substances. Strengths, weaknesses and limitations The main strengths of the present study were to the best of our knowledge, it is the first of its kind to investigate the knowledge and risk perception of e-cigarettes and hookah among youths in Southeastern Nigeria, addressing an important gap in public health research within the region. By employing a well-structured questionnaire and a multistage sampling technique, the study ensured robust data collection and representation across diverse participant demographics in Anambra State. Additionally, the findings provide valuable insights into sociodemographic factors, such as gender, education level, and cultural influences, that shape the usage patterns and perceptions of e-cigarettes and hookah among youths. Despite these strengths, the study has some limitations. The reliance on self-reported data may introduce social desirability bias, potentially leading to underreporting or overreporting of behaviors and perceptions. The cross-sectional design restricts the ability to establish causal relationships between knowledge, perceptions, and usage patterns. Furthermore, the study was conducted in a single state, which may limit the generalizability of the findings to other regions with varying cultural or sociodemographic characteristics. Finally, while the questionnaire was effective in assessing knowledge and perception, it may not have fully captured the nuanced motivations or psychological factors influencing e-cigarette and hookah use. Recommendations for Further Research Future research should consider using a longitudinal design to explore trends and causal relationships over time. Expanding the geographic scope of the study to include other states or regions in Nigeria, with an emphasis on urban-rural comparisons, would enhance the generalizability of findings. Additionally, Incorporating qualitative methods, such as focus group discussions or in-depth interviews, could provide deeper insights into the motivations, attitudes, and beliefs underlying youth behavior toward e-cigarettes and hookah. CONCLUSIONS This study provides valuable insights into the knowledge and risk perception of e-cigarettes and hookah among youths in Anambra State, Nigeria. The findings reveal that a substantial majority of participants were aware of these substances, with the internet and media identified as the primary sources of information. However, despite this awareness, many participants may underestimate the associated risks, potentially leading to addiction. The demographic of users predominantly included individuals aged 25–29 years. Notably, gender and educational qualifications were significantly associated with the usage of these substances; males were more likely to use e-cigarettes and hookah than females, while those with higher educational attainment tended to use them less frequently. These findings enrich our understanding of e-cigarette and hookah usage patterns among Nigerian youths and can inform public health interventions and awareness campaigns targeting smoking-related behaviors. They emphasize the urgent need for enhanced awareness campaigns about the adverse health effects of e-cigarettes and hookah to promote prevention and cessation. Additionally, these insights may act as a catalyst for the Nigerian government to reinforce tobacco control regulations, addressing not only cigarette smoking but also all forms of tobacco and nicotine use. Declarations ACKNOWLEDGEMENT The authors wish to express their sincere gratitude to the authorities of all the schools that participated in this research. We extend our appreciation to the various offices, teaching staff, and class coordinators whose assistance greatly facilitated the process of data collection. Special thanks to the students who generously participated in the study, as their willingness to engage made this research possible. Your contributions are deeply appreciated. AUTHORS’ CONTRIBUTIONS NHO and CCN designed the study and developed the methodology. HNO collected the data. NPO analyzed the data and wrote the first draft of the manuscript. All authors reviewed and approved the final draft of the manuscript FUNDING This work was not funded by any organization or body AVAILABILITY OF DATA AND MATERIALS The data presented in this study are available on request from the first author ( [email protected] ) Ethics approval and consent to participate Ethical approval for this study was obtained from the Health Research Ethics Committee of Nnamdi Azikiwe University. Informed consent was obtained from all participants prior to data collection. Participants were explicitly informed of their right to withdraw from the study at any stage without any consequences. All measures were taken to ensure confidentiality and the ethical treatment of participants throughout the research process. Competing interests The authors declare no competing interests. Consent for publication Not applicable References Fadus MC, Smith TT, Squeglia LM. The rise of e-cigarettes, pod mod devices, and JUUL among youth: Factors influencing use, health implications, and downstream effects. Vol. 201, Drug and Alcohol Dependence. Elsevier Ireland Ltd; 2019. p. 85–93. Cahn Z, Siegel M. Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or a repeat of past mistakes? J Public Health Policy. 2011 Feb;32(1):16–31. Centers for Disease Control and Prevention (US). Introduction, Conclusions, and Historical Background Relative to E-Cigarettes. E-Cigarette Use Among Youth and Young Adults . 2016. Daniels K, Roman N. A descriptive study of the perceptions and behaviors of waterpipe use by university students in the Western Cape, South Africa. Tob Induc Dis. 2013 Feb 8;11:4. Bunnell RE, Agaku IT, Arrazola RA, Apelberg BJ, Caraballo RS, Corey CG, et al. Intentions to smoke cigarettes among never-smoking US middle and high school electronic cigarette users: National youth tobacco survey, 2011-2013. Nicotine and Tobacco Research. 2015 Feb 1;17(2):228–35. Unger M, Unger DW. E-cigarettes/electronic nicotine delivery systems: A word of caution on health and new product development. Vol. 10, Journal of Thoracic Disease. AME Publishing Company; 2018. p. S2588–92. Trtchounian A, Williams M, Talbot P. Conventional and electronic cigarettes (E-cigarettes) have different smoking properties. Nicotine Tob Res. 2010 Sep 1;12:905–12. Cheng T. Chemical evaluation of electronic cigarettes. Tob Control. 2014 May 1;23 Suppl 2:ii11–7. Czogala J, Goniewicz ML, Fidelus B, Zielinska-Danch W, Travers MJ, Sobczak A. Secondhand exposure to vapors from electronic cigarettes. Nicotine and Tobacco Research. 2014;16(6):655–62. Chapman S, Wu LT. E-Cigarette Prevalence and Correlates of Use among Adolescents versus Adults: A Review and Comparison. J Psychiatr Res. 2014 Jul 1;54. Alotaybi M, Alzahrani SS, Algethmi AM, Alamri NS, Natto YS, Hashim ST, et al. E-cigarettes and Vaping: A Smoking Cessation Method or Another Smoking Innovation? Cureus. 2022 Dec 12; Rigotti NA. Balancing the Benefits and Harms of E-Cigarettes: A National Academies of Science, Engineering, and Medicine Report. Ann Intern Med [Internet]. 2018 Feb 13;168(9):666–7. Available from: https://doi.org/10.7326/M18-0251 Kong G, Morean ME, Cavallo DA, Camenga DR, Krishnan-Sarin S. Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults. Nicotine and Tobacco Research. 2015 Jul 1;17(7):847–54. Camenga DR, Delmerico J, Kong G, Cavallo D, Hyland A, Cummings KM, &, et al. Trends in use of electronic nicotine delivery systems by adolescents. . Addictive behaviors. 2014;39(1):338–40. Kaplan B, Thrul J, Cohen JE. Association of cigarette and electronic nicotine delivery systems use with internalizing and externalizing problems among US adults: Findings from wave 3 (2015–2016) of the PATH study. PLoS One. 2021 Jun 1;16(6 June). Obisesan OH, Mirbolouk M, Osei AD, Orimoloye OA, Uddin SMI, Dzaye O, et al. Association Between e-Cigarette Use and Depression in the Behavioral Risk Factor Surveillance System. JAMA Netw Open. 2016;2(12). Bandiera F, Loukas A, Li X, Wilkinson A, Perry C. Depressive Symptoms Predict Current E-Cigarette Use Among College Students in Texas. Nicotine Tob Res. 2017 Feb 13;19. Dunbar M, Tucker J, Ewing B, Pedersen E, Miles J, Shih R, et al. Frequency of E-cigarette Use, Health Status, and Risk and Protective Health Behaviors in Adolescents. J Addict Med. 2016 Nov 1;11:1. Osibogun O, Odukoya K, Odusolu Y, Osibogun A. Knowledge and risk perception of e-cigarettes and hookah amongst youths in Lagos State, Nigeria: An exploratory study. Niger Postgrad Med J. 2020 Nov 8;27:384–90. Adam A. Sample Size Determination in Survey Research. J Sci Res Rep. 2020 Jun 25;26:90–7. Hammal F, Wild TC, Nykiforuk C, Abdullahi K, Mussie D, Finegan B. Waterpipe (Hookah) Smoking Among Youth and Women in Canada is New, not Traditional. Nicotine Tob Res. 2015 Jul 17;18. Masjedi M, Ainy E, Zayeri F, Paydar R. Cigarette and Hookah Smoking in Adolescent Students using World Health Organization Questionnaire Global Youth Tobacco Survey (GYTS): A Pilot Study in Varamin City, Iran in 2016. Asian Pacific Journal of Cancer Prevention. 2020 Oct 1;21:3033–7. National Bureau of Statistics. The National Literacy Survey. Marketing Communications. 2010; Hadi Ashara B. Use of Social Media among Students of Nigerian Polytechnic. 2018 Oct 2; Ramôa C, Eissenberg T, Sahingur S. Increasing popularity of waterpipe tobacco smoking and electronic cigarette use: Implications for oral healthcare. J Periodontal Res. 2017 Apr 10;52. Akl EA, Gunukula SK, Aleem S, Obeid R, Jaoude PA, Honeine R, et al. The prevalence of waterpipe tobacco smoking among the general and specific populations: a systematic review. BMC Public Health [Internet]. 2011;11(1):244. Available from: https://doi.org/10.1186/1471-2458-11-244 Khabour O, Alzoubi K, Eissenberg T, Mehrotra P, Azab M, Carroll M V, et al. Waterpipe Tobacco and Cigarette Smoking Among University Students in Jordan. Int J Tuberc Lung Dis. 2012 Apr 16;16:986–92. Government of Canada. Canadian Tobacco Alcohol and Drugs Survey (CTADS) -22 Summary of results for 2013. Available at: http://healthycanadians.gc.ca/science23 research-sciences-recherches/data-donnees/ctads-ectad/summary-sommaire-2013- 24 eng.php. Accessed April 8, 2015. 2013; Adam A. Sample Size Determination in Survey Research. J Sci Res Rep. 2020 Jun 25;26:90–7. Aslam HM, Saleem S, German S, Qureshi W. Harmful effects of shisha: Literature review. Int Arch Med. 2014 Apr 4;7:16. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 25 Jul, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 17 Jan, 2025 Editor assigned by journal 14 Jan, 2025 Submission checks completed at journal 14 Jan, 2025 First submitted to journal 12 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5815292","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":402001904,"identity":"4bb44c50-d7ac-4c85-b49a-5f3858765628","order_by":0,"name":"Nkem Hillary OKEKE","email":"","orcid":"","institution":"Department of Community Medicine, Faculty of Basic Medical Sciences, Nnamdi Azikiwe University, Nigeria.","correspondingAuthor":false,"prefix":"","firstName":"Nkem","middleName":"Hillary","lastName":"OKEKE","suffix":""},{"id":402001905,"identity":"49dd418a-f6d5-4360-b843-1a077f3c48fa","order_by":1,"name":"Ndubuisi Paris Obi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYJCCA0DEw8/eAGQaWJCgRbLnAEiLBAkWGdxIADGI0GLOfvbhwR8Vd2QkZz6/uuFHgQQDf3t3Al4tlj3pBod5zjzj4ZfOKbvZA3SYxJmzG/BqMTiQxnCYse0wj+TsnLQbPEAtBhK5BLScf8Zw8CdQi8HNM2k3/xCl5UYawwFekJYb7MduE2WL5YxnDGC/SPbksN2WMZDgIegXc/405o/AELPnZz/+7OabPzZy/O29BByGYPKA2Tx4laNpYX9AUPUoGAWjYBSMTAAAxW9L3UnNjn0AAAAASUVORK5CYII=","orcid":"","institution":"Developmental Neurobiology and Forensic Anatomy Unit, Department of Anatomy, University of Ibadan, Ibadan 200212, Nigeria","correspondingAuthor":true,"prefix":"","firstName":"Ndubuisi","middleName":"Paris","lastName":"Obi","suffix":""},{"id":402001906,"identity":"4e796f52-3e13-4fd4-80ca-e7b380812a4e","order_by":2,"name":"Chinomnso Chinanuekpere Nnebue","email":"","orcid":"","institution":"Department of Community Medicine, Faculty of Basic Medical Sciences, Nnamdi Azikiwe University, Nigeria.","correspondingAuthor":false,"prefix":"","firstName":"Chinomnso","middleName":"Chinanuekpere","lastName":"Nnebue","suffix":""}],"badges":[],"createdAt":"2025-01-12 20:08:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5815292/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5815292/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-23790-1","type":"published","date":"2025-07-25T15:58:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88506315,"identity":"41c819f6-1b0c-4ae3-b79a-5df244456a94","added_by":"auto","created_at":"2025-08-07 07:32:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1013254,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5815292/v1/2abdd596-27bc-43b1-bd0a-08b61696daf3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eKnowledge and Risk Perception of E-cigarettes and Hookah Among Youths in Anambra State, Nigeria\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn recent years, the use of alternative smoking devices, such as e-cigarettes and hookah, has gained significant popularity worldwide, particularly among youths (1\u0026ndash;5). Electronic nicotine delivery systems (ENDS), known as e-cigarettes or electronic cigarettes, are battery powered devices that deliver nicotine without burning tobacco (6). An electronic cigarette consists of three main components: a cartridge, an atomizer, and a battery. An e-cigarette cartridge usually contains a fluid composed of nicotine, ranging from 0 to 24 mg/ml, and humectants such as propylene glycol or glycerol and flavorings, an atomizer aerosolizes the fluid when heated by the battery (7).\u003c/p\u003e \u003cp\u003eIn a typical device configuration, instead of burning tobacco, a user draws air through the device; an airflow sensor or a physical power button activates a battery that powers an atomizer to produce an aerosol from liquid containing nicotine and flavorings (2,6,8). The vapor carries a dose of nicotine into the users lungs through inhalation, and a residual aerosol is released into the environment through exhalation (7,9).\u003c/p\u003e \u003cp\u003eE-cigarette advertising appears in various media including television (TV), radio, print, online, and at retail point of sale, and has contributed to the popularity of the product and raised awareness among youth. The prevalence of e-cigarette use has been increasing among middle and high school students in the United States this is in accordance with Findings from the National Youth Tobacco Survey which showed that among all students grades 6\u0026ndash;12, the number of those who had ever used e-cigarettes rose from 3.3\u0026ndash;6.8%, and current use of e-cigarettes rose from 1.1\u0026ndash;2.1% during 2011 and 2012 (10). This trend is not limited to Western nations; in Nigeria, and particularly in Anambra State, these devices have become more accessible and are gaining traction among young people. E-cigarettes and hookah are often marketed as safer alternatives to traditional cigarettes (2), but emerging evidence suggests that their health risks, particularly among young and impressionable populations, may be significant (11,12).\u003c/p\u003e \u003cp\u003eYoung people and teenagers are especially drawn to e-cigarettes (ECs) for a variety of reasons, such as curiosity, peer pressure, social standing, the abundance of delicious flavors and the fact that e-cigarettes are readily available at malls and convenience stores (13). This increasing prevalence of e-cigarette use among adolescents raises concerns about the possibility that ECs could lead to nicotine dependence or act as a gateway to traditional tobacco cigarettes, although it is still hotly contested (12,14). The higher incidence of mental health conditions like depression is another significant negative effect associated with EC use. EC is linked to anxiety disorders, which are characterized by excessive worry, fear, or anxiety that interferes with day-to-day functioning (15). The use of e-cigarettes is reported to be more common among individuals with depression or anxiety compared to those without mental health conditions (16). In fact, smoking rates among people with mental health conditions are estimated to be about 70% higher than in those without such conditions (16).\u003c/p\u003e \u003cp\u003eFurthermore, there is evidence from international studies demonstrating a concerning connection between e-cigarette use and mental health issues. According to the research carried out on American college students, it was found that e-cigarette use was associated with depressive symptoms and other mental health problems, with students experiencing depression being more prone to use e-cigarettes than their non-depressed peers (17). However, in another study conducted in 2017 it was indicated that the link between e-cigarette use and depression in adolescents was minimal (18). These conflicting findings show the need for further research, particularly in different cultural and geographic contexts. Despite the increasing popularity of these devices, there is a paucity of data on young people's knowledge and risk perception associated with the use of e-cigarettes and hookah in Nigeria. (19). Therefore, this qualitative study sought to explore the knowledge and risk perception of e-cigarettes and hookah among youths in Anambra State, Nigeria, to better understand the potential health implications associated with their use.\u003c/p\u003e"},{"header":"METHOD","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study employed a descriptive cross-sectional design to assess the knowledge and risk perception of e-cigarettes and hookah among youths in Anambra State, Nigeria, specifically targeting students from Nnamdi Azikiwe University Awka, Nwafor Orizu College of Education Nsugbe, and the College of Health Sciences, Nnamdi Azikiwe University Nnewi Campus.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eParticipants (n\u0026thinsp;=\u0026thinsp;272) aged 18\u0026ndash;35 years were recruited from three higher institutions across the three senatorial districts of Anambra State: Anambra Central, Anambra South, and Anambra North. The study targeted students who had been enrolled in their respective institutions for at least one year.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e1.Youths admitted in the selected Higher Institutions for at least one year.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e2. Regular students\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e1. Those selected as above but were not present during the study.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e2. Those who were present but declined assent or full informed consent.\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size Determination.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing Cochran formula: n\u0026thinsp;=\u0026thinsp;Z\u003csup\u003e2\u003c/sup\u003e x P x (1-p)/ d\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWhere:\u003c/p\u003e\n\u003cp\u003eZ\u0026thinsp;=\u0026thinsp;1.96 (corresponding to 95% confidence interval)\u003c/p\u003e\n\u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.5 (50% prevalence used as no similar study exists within our region)\u003c/p\u003e\n\u003cp\u003ed\u0026thinsp;=\u0026thinsp;0.05 (Margin of error to be tolerated set to 5%)\u003c/p\u003e\n\u003cp\u003eTherefore:\u003c/p\u003e\n\u003cp\u003en= (1.96)\u003csup\u003e2\u003c/sup\u003e x 0.5 x (1-0.5) / (0.05)\u003csup\u003e2\u003c/sup\u003e = 384.16\u003c/p\u003e\n\u003ch3\u003en = 384\u003c/h3\u003e\n\u003cp\u003eAdjustment for the population\u0026thinsp;\u0026lt;\u0026thinsp;10,000 the formula below is used (20), the finite population correction formula;\u003c/p\u003e \u003cp\u003enf\u0026thinsp;=\u0026thinsp;n/1\u0026thinsp;+\u0026thinsp;n/N\u003c/p\u003e \u003cp\u003ewhere n\u0026thinsp;=\u0026thinsp;384 (calculated sample size)\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;500 (estimated population size)\u003c/p\u003e \u003cp\u003eTherefore:\u003c/p\u003e \u003cp\u003enf\u0026thinsp;=\u0026thinsp;384/[1+(384/500)]\u003c/p\u003e \u003cp\u003enf\u0026thinsp;=\u0026thinsp;217.2\u003c/p\u003e \u003cp\u003enf\u0026thinsp;=\u0026thinsp;217\u003c/p\u003e \u003cp\u003eAnticipating a non-response of 10% (f) using the formula\u0026thinsp;=\u0026thinsp;n/1-f\u003c/p\u003e\n\u003ch3\u003e217/1-0.1 = 217/0.9\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e=\u0026thinsp;241.1\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e=\u0026thinsp;241\u003c/h2\u003e \u003cp\u003eTo increase the power of the study, this is rounded up to 272 ( the Minimum total population size used for this study) .\u003c/p\u003e \u003cp\u003eThe sample size was adjusted to take care of non-response and improperly filled questionnaires. This was done by dividing the calculated Sample size by anticipated non response rate.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eSampling Technique\u003c/h3\u003e\n\u003cp\u003eA multistage sampling technique was employed.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStage 1\u003c/b\u003e: Selection of Senatorial Zones: The study was conducted across the three Senatorial Districts of Anambra State.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStage 2\u003c/b\u003e: Selection of Higher Institutions: One institution was selected from each Senatorial Zone using simple random sampling through balloting.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStage 3\u003c/b\u003e: Selection of Participants: Students aged 18 to 35 from the selected institutions were randomly chosen via balloting.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStage 4\u003c/strong\u003e \u003cp\u003eA total of 272 participants were recruited using a simple random sampling technique.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected using a semi-structured, self-administered questionnaire adapted from a UK database survey which was developed according to the objectives of this study. The questionnaire comprised four sections (A-D). Section A contained socio-demographic data of respondents, while sections B, C, and D assessed knowledge and risk perception of e-cigarettes and hookah. Participants were assured of confidentiality, and informed consent was obtained prior to administering the questionnaires.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eEthical consideration and consent to participate\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e was sought and obtained from the Ethics Review Committee of Nnamdi Azikiwe University. Participants were informed of the study's purpose, and unique codes were assigned to the questionnaires to ensure confidentiality.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe collected data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 25. Descriptive statistics were generated, and chi-square tests were conducted to determine the level of significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;1 presents summary of the socio-demographic profiles of the participants. From the table, it can be observed that a total of 272 participants (52.9% males) participated in the study, with a mean age of 23.19 ± 3.46 years. The majority of participants were single (94.1%), predominantly belonged to the Catholic denomination (47.8%), and identified as members of the Igbo tribe (87.1%). Over half of the participants (55.5%) attained post-secondary (tertiary) education, with 33.8% holding bachelor’s qualifications.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2 shows summary of the descriptive statistics of the knowledge and awareness of E-Cigarettes and Hookah Among Participants. Most participants (66.7%) reported the internet/media as their primary source of information about these substances. Despite this, a majority (58.5%) had not seen either e-cigarettes or hookah. When identifying health hazards, cardiovascular (71.7%) and respiratory (65.4%) issues were most frequently recognized as significant risks. Furthermore, the majority (64.7%) perceived both e-cigarettes and hookah as equally harmful in terms of health risks, while 50.7% considered both substances equally addictive.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;3 shows the statistics of the usage of e-cigarettes and hookah among participants. Out of the participants, 6 (2.2%) reported using both substances, 2 (0.7%) were using only shisha, and 4 (1.5%) were using only hookah at the time of data collection. Among the current users, most hookah smokers (75.5%) smoked less than once a year. The age group with the highest proportion of first-time hookah users was 25–29 years, accounting for 7.0% of participants. A combined 9.2% of the participants were considering using any of traditional cigarette, smokeless tobacco, hookah, electronic cigarette or their combinations in the future\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;4 shows the summary of the statistics of the usage of e-cigarettes and hookah among relatives, friends, and significant others of participants.\u003c/p\u003e\n\u003cp\u003eApproximately one-third of participants reported having one or more close friends (2.6%) and one or both parents (8.8%) who used hookah or e-cigarettes. The majority of users indicated they were with friends during their first experience with hookah. The most common locations for first use were cafés/restaurants (7.4%) and nightclubs (6.6%).\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;5 shows the association of awareness of E-Cigarettes and Hookah with Selected Socio-Demographic Variables. No significant associations were found between awareness of e-cigarettes and hookah and gender, marital status, religion, tribe, or educational qualifications (p \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003eTable 6 shows the association of usage of E-Cigarettes and Hookah with Selected Socio-Demographic Variables. A significant association was noted between gender and usage, with a higher proportion of males having used the substances compared to females (χ² = 17.04, p \u0026lt; 0.01). Additionally, tribe significantly influenced usage, with a greater proportion of Hausas using the substances compared to other tribes (χ² = 89.00, p \u0026lt; 0.01). Educational qualifications were also significantly associated with usage, showing that participants with higher educational attainment tended to indulge less in the use of e-cigarettes and hookah (χ² = 67.12, p \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1737006162.png\"\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eKnowledge about e-cigarettes and hookah among the participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eKnowledge Questions\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eResponse options\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003eIf yes, how did you get to hear about it?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInternet / media\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBooks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFriends\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e55.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eWhich of them have you seen?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e58.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003eWhich among these do you identify as important health hazards of Hookah and e-cigarettes smoking?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRespiratory problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e65.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCardiovascular impairments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e71.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHematologic Impairments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e44.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePregnancy Hazards\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiarrhea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eWhich among E-CIGARETTE and Shisha/Hookah are more addictive according to your perception?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eShisha/Hookah (water-pipe) smoking is more addictive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ee-Cigarette smoking is more addictive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth are equally addictive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eWhere do you rate the health hazards of habitual hookah smoking in comparison to those of E-cigarette smoking?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCigarette smoking is more harmful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWater-pipe smoking is more harmful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth are equal in terms of health risks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\u003cbr\u003e\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Usage of e-cigarettes and hookah among the participants\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"663\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUsage Questions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponse options\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eIf you are currently using any, specify\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShisha\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHookah\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eWhich one of the following did you use first?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTraditional cigarettes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSmokeless tobacco (snus or chewing tobacco)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHookah (Water pipe tobacco smoking or Shisha)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eElectronic cigarettes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNone of these\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e221\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e81.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eWhich of the following are you currently using?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTraditional cigarettes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSmokeless tobacco (snus or chewing tobacco)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHookah (Water pipe tobacco smoking or Shisha)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eElectronic cigarettes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNone of these\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e94.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAll of the above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eWhich are you likely to use in the future?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTraditional cigarettes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSmokeless tobacco (snus or chewing tobacco)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHookah (Water pipe tobacco smoking or Shisha)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eElectronic cigarettes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNone of these\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e248\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAll of the above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003ePlease explain why to the answer in the future usage?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHealth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePersonal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePleasure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eHave you ever used a hookah to smoke tobacco (even one or two puffs)?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e84.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eWhich of the following choices best describes how often you smoke tobacco using a hookah?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Less than once a year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAt least once a year, but not monthly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAt least once a month, but not weekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAt least once a week, but not daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAt least once a day, or most days each month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" valign=\"top\"\u003e\n \u003cp\u003eHow old were you when you FIRST used a hookah?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYounger than 9 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10-12 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13-15 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16-18 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19-21 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22-24 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25-29 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30 years old or older\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u0026nbsp;\u003cp\u003e\u003cstrong\u003eTable 4: Usage of e-cigarettes and hookah among relatives, friends and significant orders of the participants\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuestions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponse options\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eDo one or more of your close friends use electronic cigarettes or Hookah?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDon’t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eDoes your mother or father (guardian) use electronic cigarettes or hookah?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes both my mom and dad use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes, my mom uses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes, my dad uses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo, neither my mom nor dad use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e97.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"10\" valign=\"top\"\u003e\n \u003cp\u003eWho else in your family use electronic cigarettes or hookah?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBrother (s)/Sister(s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrandmother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrandfather\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUncle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAunt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOther, cousin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo one uses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI don’t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e51.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eWho were you with when you FIRST used a hookah?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo one, I was alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWith one friend\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWith more than one friend\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWith a family member\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWith more than one family member\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWith a new acquaintance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eWhere were you when you FIRST used hookah?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIn a cafe or restaurant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIn my own home (apartment, condo, house)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIn the night club\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAt a family member's home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAt a fraternity/sorority house\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAt a friend's or acquaintance's home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 5\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eShowing the association between awareness of e-cigarette and hookah and selected socio-demographic variables of the participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eClass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"7\"\u003e\n \u003cp\u003eAwareness (n(%))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaybe\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e98(68.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e38(26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8(5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e80(62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e38(29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e165(64.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e75(29.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e16(6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e4.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e12(80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e1(6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2(13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e83(63.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e41(31.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e6(4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003e15.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e41(75.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e9(16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e4(5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePentecostal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e45(63.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e22(31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e4(5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e2(50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e8(61.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e2(15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3(23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eTribe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIgbo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e151(63.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e70(29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e16(6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e8.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e15(88.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e1(5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1(5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYoruba\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e5(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e7(53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e5(38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1(7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003eQualifications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNCE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23(71.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e7(21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e2(6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003e7.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13(72.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e3(16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e2(11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e1(20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60(65.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e23(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e9(9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e1(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75(62.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e41(33.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e5(4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 6\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eShowing the association between Usage of e-cigarette and hookah and selected socio-demographic variables of the participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eClass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"7\"\u003e\n \u003cp\u003eUsage (n(%))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eNone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e109(75.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e27(18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8(5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e17.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt; 0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e120(93.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e5(3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e215(84.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e30(11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e11(4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e13(86.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e2(13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCatholic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e106(81.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e19(14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e5(3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003e11.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e43(79.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e8(14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3(5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePentecostal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e64(90.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e5(7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2(2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3(75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e13(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eTribe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIgbo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e210(88.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e17(7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e10(4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e89.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003e\u0026lt; 0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3(17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e14(82.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYoruba\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e4(80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e1(20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e12(92.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1(7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003eQualifications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNCE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15(46.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e17(53.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003e67.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003e\u0026lt; 0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14(77.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e4(22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82(89.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e6(6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e4(4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMSc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e109(90.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e5(4.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e7(5.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\"\u003eKEY: *= Significant at p \u0026lt; 0.05\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study is among the few to qualitatively examine the knowledge and risk perceptions of e-cigarette and hookah use among young people in Nigeria. The present research aimed to assess the understanding and perceptions of risks associated with e-cigarettes and hookah among youths in Anambra State, Nigeria. This is particularly relevant given the alarming global rise in the use of these substances, which pose significant yet preventable health risks. As e-cigarettes and hookah become increasingly popular among young populations, it is crucial to explore how awareness and risk perceptions shape their usage patterns(21). Understanding these dynamics is essential for informing public health interventions aimed at reducing tobacco and nicotine consumption among vulnerable youth demographics. The youths were targeted in this study (as revealed by the mean age\u0026thinsp;=\u0026thinsp;23.19\u0026thinsp;\u0026plusmn;\u0026thinsp;3.46 years) because they have been reported as the group most liable to indulge in the usage of these substances, with more than 70% of cigarette and hookah smoking starting during adolescence (22). Majority of the participants were Igbo\u0026rsquo;s and Christians who were mainly Catholics and Anglicans. This is not surprising as Igbo\u0026rsquo;s are the natives of the setting of this study, and are mainly Christians of Catholic and Anglican denominations. Educational attainment of the participants was high as majority attained tertiary education. This is in line with previous reports that Igbo\u0026rsquo;s are one of the most educated tribes in Nigeria (23).\u003c/p\u003e \u003cp\u003eMost of the participants reported to have heard of e-cigarettes and hookah with internet/media being the most frequent source of information. This may not be unexpected considering the fact that usage of internet and social media has unprecedentedly increased in recent times, and act as a medium for fast dissemination of information (24). However, over half of the participants had not seen any of e-cigarette and hookah suggesting that there awareness did not come from having direct contacts with the substances. The participants of the present study seemed to be knowledgeable about the health hazards (especially respiratory and cardiovascular) of e-cigarette and hookah. This might not be unconnected to their enlightenment from media or internet. Cigarette smoking has been reported to associate with development of several systemic conditions (including cancer, cardiovascular and pulmonary diseases), oral diseases (including oral cancer, periodontal diseases and peri-implantitis) and so on (25). Hookah users have actually been reported to be exposed to many of the same toxic compounds/by-products as conventional cigarette users, but at dramatically higher levels, which might lead to more severe negative health effects. Majority of the participants in the present study rated both e-cigarette and hookah as having equal addictive tendencies. The two substances have been reported to deliver the dependence-producing drug nicotine(25). 7.4% of the participants in the present study reported to have used e-cigarette and hookah while 3.7% were still using them at the point of data collection. Previous reports(Bunnell et al., 2015; Cahn \u0026amp; Siegel, 2011; Masjedi et al., 2020) have revealed that the use of e-cigarette and hookah had been an emerging trend especially among the youths. However, the recorded point prevalence (3.7%) of hookah use in the current study falls below 9\u0026ndash;12% recorded in Syria (26), 30% in Jordan (27), 9.2% and 25.5% in Iran (22), 29% in Canada(28), 12\u0026ndash;15% in the US, 12% in Estonia, 8% in the UK, 25% in Lebanon, 15% in Syria and 33% in Pakistan(26). This may be a pointer to the fact that hookah and e-cigarette use is not yet as rife in Nigeria as in many other countries. This is further buttressed by the fact that majority of the hookah smokers in this study indulged in the act only once a year unlike more frequent usage in other climes (22). The users of the substances were spread across different age groups between 10 and 30 years. Furthermore, a combined 4.8% prevalence of the participants grandparents, aunts and uncles were reported to be using hookah unlike a combined higher 12.5% prevalence of siblings and cousins (who are understandably younger than the previous group) of the participants that were using hookah. This may be supporting the previous reports that hookah usage are more popular among the youths (27).\u003c/p\u003e \u003cp\u003eA combined 9.2% of the participants were considering using any of traditional cigarette, smokeless tobacco, hookah, electronic cigarette or their combinations in the future. This is similar to 7.9% pooled probabilities of cigarette initiation in never e-cigarette users reported in a systematic review(29), and may be a pointer to the increasing popularity of e-cigarette usage among young adults as reported in literature (25). This may be a cause for concern as e-cigarette smoking initiation had been reported to significantly associate with subsequent cigarette usage (29). This might have also highlighted the need for strong e-cigarette regulation in order to curb youths access to e-cigarette and hookah which are still easily accessible (29), and had probably contributed in making e-cigarette and hookah most popular form of tobacco smoking, overtaking the conventional cigarette in recent years(25). This increase in usage of hookah has also been partly attributed to misperception of hookah being less harmful than cigarettes and the availability of different but appealing flavors(30).\u003c/p\u003e \u003cp\u003eThe proportion of participants (33.1%) that reported having one/more close friends smoking e-cigarette and hookah is almost double the proportion (18.9%) of those that reported having a relative (parents, grandparents, siblings, cousins, aunts and uncles) smoking the substances. This may be highlighting the influence peer pressure may be having on initiation of e-cigarette and hookah smoking, as many participants would have been likelier to be persuaded to indulge in the act by their friends than by a relative. This assumption is supported by the fact that majority of the users reported being with their friend(s) when they first used hookah. Peer influence has been reported as a major factor in hookah smoking(21). Caf\u0026eacute;/restaurant and night club were the most frequent locations where the users firstly used hookah in the present study. These substances have been reported to be commonly used in public places including social parties and caf\u0026eacute;s(21). This may be a wakeup call for the government of the day to save the populace from the menace of secondhand or passive smoking.\u003c/p\u003e \u003cp\u003eThere was significant association of gender with usage of e-cigarette and hookah among the participants of this study with more males having used the substances than their female counterparts. This is contrary to previous Iranian study (22) where more female high school students were smoking cigarette and hookah than their male counterparts. The fact that Igbo\u0026rsquo;s have a patriarchal culture where women are expected to be less adventurous than men might have discouraged Igbo female youths from indulging in hookah and e-cigarette smoking like the male youths. There was also a significant association between usage of e-cigarette and hookah and tribe with more proportion of Hausas having significantly used the substances than other tribes. Varied prevalence of e-cigarette and hookah smoking had been reported across different cultures and geographical locations with higher prevalence reported among Middle Eastern countries who are mainly Muslims(26). The fact that Hausa is a predominantly Muslim tribe who has imbibed the Arabic (Middle Eastern) cultures might have explained their higher usage of hookah and e-cigarette in this study. Qualifications of the participants also significantly associated with their usage of e-cigarette and hookah with those who had higher education attainment seeming to indulge less in the usage. This may be easily justified. More educated people might have been more enlightened on the health hazards of e-cigarette and hookah smoking than their less educated peers. This might have discouraged them from indulging in the usage of these substances.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrengths, weaknesses and limitations\u003c/h2\u003e \u003cp\u003eThe main strengths of the present study were to the best of our knowledge, it is the first of its kind to investigate the knowledge and risk perception of e-cigarettes and hookah among youths in Southeastern Nigeria, addressing an important gap in public health research within the region. By employing a well-structured questionnaire and a multistage sampling technique, the study ensured robust data collection and representation across diverse participant demographics in Anambra State. Additionally, the findings provide valuable insights into sociodemographic factors, such as gender, education level, and cultural influences, that shape the usage patterns and perceptions of e-cigarettes and hookah among youths.\u003c/p\u003e \u003cp\u003eDespite these strengths, the study has some limitations. The reliance on self-reported data may introduce social desirability bias, potentially leading to underreporting or overreporting of behaviors and perceptions. The cross-sectional design restricts the ability to establish causal relationships between knowledge, perceptions, and usage patterns. Furthermore, the study was conducted in a single state, which may limit the generalizability of the findings to other regions with varying cultural or sociodemographic characteristics. Finally, while the questionnaire was effective in assessing knowledge and perception, it may not have fully captured the nuanced motivations or psychological factors influencing e-cigarette and hookah use.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for Further Research\u003c/h2\u003e \u003cp\u003eFuture research should consider using a longitudinal design to explore trends and causal relationships over time. Expanding the geographic scope of the study to include other states or regions in Nigeria, with an emphasis on urban-rural comparisons, would enhance the generalizability of findings. Additionally, Incorporating qualitative methods, such as focus group discussions or in-depth interviews, could provide deeper insights into the motivations, attitudes, and beliefs underlying youth behavior toward e-cigarettes and hookah.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis study provides valuable insights into the knowledge and risk perception of e-cigarettes and hookah among youths in Anambra State, Nigeria. The findings reveal that a substantial majority of participants were aware of these substances, with the internet and media identified as the primary sources of information. However, despite this awareness, many participants may underestimate the associated risks, potentially leading to addiction. The demographic of users predominantly included individuals aged 25\u0026ndash;29 years. Notably, gender and educational qualifications were significantly associated with the usage of these substances; males were more likely to use e-cigarettes and hookah than females, while those with higher educational attainment tended to use them less frequently. These findings enrich our understanding of e-cigarette and hookah usage patterns among Nigerian youths and can inform public health interventions and awareness campaigns targeting smoking-related behaviors. They emphasize the urgent need for enhanced awareness campaigns about the adverse health effects of e-cigarettes and hookah to promote prevention and cessation. Additionally, these insights may act as a catalyst for the Nigerian government to reinforce tobacco control regulations, addressing not only cigarette smoking but also all forms of tobacco and nicotine use.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to express their sincere gratitude to the authorities of all the schools that participated in this research. We extend our appreciation to the various offices, teaching staff, and class coordinators whose assistance greatly facilitated the process of data collection. Special thanks to the students who generously participated in the study, as their willingness to engage made this research possible. Your contributions are deeply appreciated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHORS\u0026rsquo; CONTRIBUTIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNHO and CCN designed the study and developed the methodology. HNO collected the data. NPO analyzed the data and wrote the first draft of the manuscript. All authors reviewed and approved the final draft of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was not funded by any organization or body\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAVAILABILITY OF DATA AND MATERIALS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data presented in this study are available on request from the first author ([email protected])\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Health Research Ethics Committee of Nnamdi Azikiwe University. Informed consent was obtained from all participants prior to data collection. Participants were explicitly informed of their right to withdraw from the study at any stage without any consequences. All measures were taken to ensure confidentiality and the ethical treatment of participants throughout the research process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFadus MC, Smith TT, Squeglia LM. The rise of e-cigarettes, pod mod devices, and JUUL among youth: Factors influencing use, health implications, and downstream effects. Vol. 201, Drug and Alcohol Dependence. Elsevier Ireland Ltd; 2019. p. 85\u0026ndash;93. \u003c/li\u003e\n\u003cli\u003eCahn Z, Siegel M. Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or a repeat of past mistakes? J Public Health Policy. 2011 Feb;32(1):16\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eCenters for Disease Control and Prevention (US). Introduction, Conclusions, and Historical Background Relative to E-Cigarettes. E-Cigarette Use Among Youth and Young Adults . 2016. \u003c/li\u003e\n\u003cli\u003eDaniels K, Roman N. A descriptive study of the perceptions and behaviors of waterpipe use by university students in the Western Cape, South Africa. Tob Induc Dis. 2013 Feb 8;11:4. \u003c/li\u003e\n\u003cli\u003eBunnell RE, Agaku IT, Arrazola RA, Apelberg BJ, Caraballo RS, Corey CG, et al. Intentions to smoke cigarettes among never-smoking US middle and high school electronic cigarette users: National youth tobacco survey, 2011-2013. Nicotine and Tobacco Research. 2015 Feb 1;17(2):228\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eUnger M, Unger DW. E-cigarettes/electronic nicotine delivery systems: A word of caution on health and new product development. Vol. 10, Journal of Thoracic Disease. AME Publishing Company; 2018. p. S2588\u0026ndash;92. \u003c/li\u003e\n\u003cli\u003eTrtchounian A, Williams M, Talbot P. Conventional and electronic cigarettes (E-cigarettes) have different smoking properties. Nicotine Tob Res. 2010 Sep 1;12:905\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eCheng T. Chemical evaluation of electronic cigarettes. Tob Control. 2014 May 1;23 Suppl 2:ii11\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eCzogala J, Goniewicz ML, Fidelus B, Zielinska-Danch W, Travers MJ, Sobczak A. Secondhand exposure to vapors from electronic cigarettes. Nicotine and Tobacco Research. 2014;16(6):655\u0026ndash;62. \u003c/li\u003e\n\u003cli\u003eChapman S, Wu LT. E-Cigarette Prevalence and Correlates of Use among Adolescents versus Adults: A Review and Comparison. J Psychiatr Res. 2014 Jul 1;54. \u003c/li\u003e\n\u003cli\u003eAlotaybi M, Alzahrani SS, Algethmi AM, Alamri NS, Natto YS, Hashim ST, et al. E-cigarettes and Vaping: A Smoking Cessation Method or Another Smoking Innovation? Cureus. 2022 Dec 12; \u003c/li\u003e\n\u003cli\u003eRigotti NA. Balancing the Benefits and Harms of E-Cigarettes: A National Academies of Science, Engineering, and Medicine Report. Ann Intern Med [Internet]. 2018 Feb 13;168(9):666\u0026ndash;7. Available from: https://doi.org/10.7326/M18-0251\u003c/li\u003e\n\u003cli\u003eKong G, Morean ME, Cavallo DA, Camenga DR, Krishnan-Sarin S. Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults. Nicotine and Tobacco Research. 2015 Jul 1;17(7):847\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eCamenga DR, Delmerico J, Kong G, Cavallo D, Hyland A, Cummings KM, \u0026amp;, et al. Trends in use of electronic nicotine delivery systems by adolescents. . Addictive behaviors. 2014;39(1):338\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eKaplan B, Thrul J, Cohen JE. Association of cigarette and electronic nicotine delivery systems use with internalizing and externalizing problems among US adults: Findings from wave 3 (2015\u0026ndash;2016) of the PATH study. PLoS One. 2021 Jun 1;16(6 June). \u003c/li\u003e\n\u003cli\u003eObisesan OH, Mirbolouk M, Osei AD, Orimoloye OA, Uddin SMI, Dzaye O, et al. Association Between e-Cigarette Use and Depression in the Behavioral Risk Factor Surveillance System. JAMA Netw Open. 2016;2(12). \u003c/li\u003e\n\u003cli\u003eBandiera F, Loukas A, Li X, Wilkinson A, Perry C. Depressive Symptoms Predict Current E-Cigarette Use Among College Students in Texas. Nicotine Tob Res. 2017 Feb 13;19. \u003c/li\u003e\n\u003cli\u003eDunbar M, Tucker J, Ewing B, Pedersen E, Miles J, Shih R, et al. Frequency of E-cigarette Use, Health Status, and Risk and Protective Health Behaviors in Adolescents. J Addict Med. 2016 Nov 1;11:1. \u003c/li\u003e\n\u003cli\u003eOsibogun O, Odukoya K, Odusolu Y, Osibogun A. Knowledge and risk perception of e-cigarettes and hookah amongst youths in Lagos State, Nigeria: An exploratory study. Niger Postgrad Med J. 2020 Nov 8;27:384\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eAdam A. Sample Size Determination in Survey Research. J Sci Res Rep. 2020 Jun 25;26:90\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eHammal F, Wild TC, Nykiforuk C, Abdullahi K, Mussie D, Finegan B. Waterpipe (Hookah) Smoking Among Youth and Women in Canada is New, not Traditional. Nicotine Tob Res. 2015 Jul 17;18. \u003c/li\u003e\n\u003cli\u003eMasjedi M, Ainy E, Zayeri F, Paydar R. Cigarette and Hookah Smoking in Adolescent Students using World Health Organization Questionnaire Global Youth Tobacco Survey (GYTS): A Pilot Study in Varamin City, Iran in 2016. Asian Pacific Journal of Cancer Prevention. 2020 Oct 1;21:3033\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eNational Bureau of Statistics. The National Literacy Survey. Marketing Communications. 2010; \u003c/li\u003e\n\u003cli\u003eHadi Ashara B. Use of Social Media among Students of Nigerian Polytechnic. 2018 Oct 2; \u003c/li\u003e\n\u003cli\u003eRam\u0026ocirc;a C, Eissenberg T, Sahingur S. Increasing popularity of waterpipe tobacco smoking and electronic cigarette use: Implications for oral healthcare. J Periodontal Res. 2017 Apr 10;52. \u003c/li\u003e\n\u003cli\u003eAkl EA, Gunukula SK, Aleem S, Obeid R, Jaoude PA, Honeine R, et al. The prevalence of waterpipe tobacco smoking among the general and specific populations: a systematic review. BMC Public Health [Internet]. 2011;11(1):244. Available from: https://doi.org/10.1186/1471-2458-11-244\u003c/li\u003e\n\u003cli\u003eKhabour O, Alzoubi K, Eissenberg T, Mehrotra P, Azab M, Carroll M V, et al. Waterpipe Tobacco and Cigarette Smoking Among University Students in Jordan. Int J Tuberc Lung Dis. 2012 Apr 16;16:986\u0026ndash;92. \u003c/li\u003e\n\u003cli\u003eGovernment of Canada. Canadian Tobacco Alcohol and Drugs Survey (CTADS) -22 Summary of results for 2013. Available at: http://healthycanadians.gc.ca/science23 research-sciences-recherches/data-donnees/ctads-ectad/summary-sommaire-2013- 24 eng.php. Accessed April 8, 2015. 2013; \u003c/li\u003e\n\u003cli\u003eAdam A. Sample Size Determination in Survey Research. J Sci Res Rep. 2020 Jun 25;26:90\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eAslam HM, Saleem S, German S, Qureshi W. Harmful effects of shisha: Literature review. Int Arch Med. 2014 Apr 4;7:16. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"E-cigarettes, Hookah, Knowledge, Risk perception, Anambra State, Health hazards","lastPublishedDoi":"10.21203/rs.3.rs-5815292/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5815292/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eE-cigarettes and hookah have gained significant popularity, particularly among young people in recent years, despite limited research on their safety and efficacy. Advertisements for these products are widespread across various media platforms, further increasing their popularity and raising awareness among youths. This study aimed to assess the knowledge and risk perception of e-cigarettes and hookah among youths in Anambra State, Nigeria.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis descriptive cross-sectional study was conducted in three tertiary institutions, selected through simple random sampling from the three Senatorial Districts of Anambra State. Participants (n\u0026thinsp;=\u0026thinsp;272), aged 18\u0026ndash;35 years, were recruited using a multi-stage stratified random sampling technique A self- administered, semi- structured questionnaires was shared amongst students of the three tertiary institutions that met the inclusion criteria. Descriptive statistics were generated, and chi-square tests were conducted to determine the level of significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eThe study showed that most participants (66.7%) reported the internet/media as their primary source of information about these substances. Majority (64.7%) perceived both e-cigarettes and hookah as equally harmful in terms of health risks, while 50.7% considered both substances equally addictive. Participants identified respiratory (65.4%) and cardiovascular (71.7%) diseases as the major health risks associated with e-cigarette and hookah use. Most users of these substances were within the 25\u0026ndash;29 age group, and 7.4% of participants reported using both e-cigarettes and hookah. The majority of first-time users tried these devices in caf\u0026eacute;s/restaurants, followed by nightclubs.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study demonstrates high awareness but limited comprehensive knowledge of the health risks associated with e-cigarette and hookah use among youths in Anambra State. The prevalence of use in social settings reveals the need for targeted education on their risks. Incorporating these products into smoke-free policies and regulating access in youth-centered environments are essential to curbing their growing use and associated health risks.\u003c/p\u003e","manuscriptTitle":"Knowledge and Risk Perception of E-cigarettes and Hookah Among Youths in Anambra State, Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-17 06:09:21","doi":"10.21203/rs.3.rs-5815292/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-17T12:35:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-14T12:14:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-14T12:14:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-01-12T19:59:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"59d25504-23ee-46e0-a9f2-79fa4932c0e4","owner":[],"postedDate":"January 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-07T07:23:04+00:00","versionOfRecord":{"articleIdentity":"rs-5815292","link":"https://doi.org/10.1186/s12889-025-23790-1","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-07-25 15:58:14","publishedOnDateReadable":"July 25th, 2025"},"versionCreatedAt":"2025-01-17 06:09:21","video":"","vorDoi":"10.1186/s12889-025-23790-1","vorDoiUrl":"https://doi.org/10.1186/s12889-025-23790-1","workflowStages":[]},"version":"v1","identity":"rs-5815292","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5815292","identity":"rs-5815292","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}