Prevalence, Risk Factors, Harm, Perception and Attitudes Toward E-Cigarette Use Among Athletes in Lebanon:A Cross-Sectional Study

Prevalence, Risk Factors, Harm, Perception and Attitudes Toward E-Cigarette Use Among Athletes in Lebanon:A Cross-Sectional Study | 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 Prevalence, Risk Factors, Harm, Perception and Attitudes Toward E-Cigarette Use Among Athletes in Lebanon:A Cross-Sectional Study Elichia Bou Akar, Clara Khalil, Andress Youssef, Omar Houchaimy, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5685024/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The rising prevalence of e-cigarette use among athletes globally and in the Middle East and North Africa (MENA) region including Lebanon, poses significant public health concerns. Objective This study investigates e-cigarette use patterns, knowledge, perceptions, and influences among athletes in Lebanon. Methods A cross-sectional survey was conducted in Arabic and English among 563 athletes aged 19–22 years, from July to December 2024. A self-reported questionnaire was adapted. Descriptive univariate analyses were performed, followed by bivariate analyses to examine the association between e-cigarette use and the variables of interest. Additionally, binary logistic regression analysis was conducted to identify the determinants of e-cigarette use among the students. Results E-cigarette use was predominantly social, occurring in homes and cafes. While most of the participants recognized that e-cigarettes could cause lung cancer, only a few believed they were less harmful than traditional cigarettes. Key influences on use included peer pressure, advertisements, stress relief, and curiosity. Conclusion Despite awareness of health risks, e-cigarette use remains widespread among athletes, emphasizing the need for targeted awareness campaigns and stricter regulations to address misconceptions and reduce usage rates in this high-risk population. E-cigarettes athletes smoking behavior knowledge and perception peer influence public health tobacco use Lebanon Background Tobacco smoking remains one of the leading causes of preventable morbidity and mortality worldwide. According to the World Health Organization (WHO), smoking-related diseases, including lung cancer, chronic obstructive pulmonary disease (COPD), and cardiovascular diseases, account for over 8 million deaths annually [ 1 ]. In Lebanon, smoking prevalence remains alarmingly high, contributing significantly to the national burden of non-communicable disease [ 6 ]. The increasing rates of tobacco consumption underscore the urgent need for strengthened tobacco control measures to reduce the associated health risks including most importantly lung disorders [ 21 ] and economic burden. Lebanon has taken steps toward tobacco control, particularly after becoming a signatory to the WHO Framework Convention on Tobacco Control (FCTC) in 2005 . The country has made efforts to implement some of the MPOWER measures, which include monitoring tobacco use, protecting individuals from tobacco smoke, offering cessation support, warning about the dangers of tobacco, enforcing bans on advertising, and raising tobacco taxes. Law 174 , enacted in 2011 , marked a significant milestone in Lebanon’s tobacco control efforts by introducing smoking bans in public spaces and restrictions on tobacco advertising. However, enforcement challenges have limited the full effectiveness of these regulations. Strengthening compliance with existing policies and implementing additional measures remain crucial to curbing Lebanon’s tobacco epidemic. The prevalence rates reported in this study—59% of respondents using e-cigarettes socially—are higher than those documented in broader MENA populations [ 2 ]. This discrepancy could be attributed to the unique social dynamics within athletic circles, where peer behaviors and social settings may amplify the normalization of e-cigarette use. Additionally, Lebanon's relatively lenient tobacco control policies compared to stricter regulations in Gulf countries may contribute to higher usage rates. E-cigarettes have emerged as a popular alternative to traditional cigarettes, marketed as less harmful and socially acceptable [ 3 ]. Among athletes, the use of e-cigarettes raises concerns due to the potential impact on physical performance and long-term health [ 4 ] as well as periodontal health [ 18 ]. Previous studies highlight that athletes often perceive e-cigarettes as a safer choice, influenced by peer behavior, advertisements, and accessibility [ 5 ]. In Lebanon, where smoking prevalence is already high (48.6% males and 21.5% females in a 1680 sample of Lebanese people above 18) [ 6 ], this study aims to explore e-cigarette use patterns, knowledge, and perceptions among athletes, shedding light on a growing public health issue. The surge in e-cigarette popularity coincides with aggressive marketing campaigns that portray them as trendy and less harmful alternatives to conventional tobacco products [ 7 ]. This perception has been further amplified by their easy availability and a variety of flavors that appeal to younger demographics, including athletes [ 8 ]. However, evidence suggests that e-cigarette use may pose unique risks to athletes, as the vapor can impair cardiovascular and respiratory functions of the smoker as well as secondhand ones [ 26 ]—an effect that is particularly concerning given their high physical demands [ 9 ]. Furthermore, research highlights the presence of toxic materials such as heavy metals (lead, cadmium, and nickel), volatile organic compounds, and other carcinogenic substances in e-cigarette aerosols [ 10 , 25 ]. These compounds can lead to cellular damage, oxidative stress, and inflammation, posing long-term health risks even for individuals with high physical fitness levels, such as athletes who have significantly higher respiratory and cardiovascular demands compared to the general population, making them more susceptible to the harmful effects of e-cigarette toxins. The inhalation of harmful substances can exacerbate inflammation and oxidative stress, potentially reducing oxygen uptake and impairing endurance performance. Furthermore, the added cardiovascular strain from vaping may negatively impact heart function and blood vessel integrity, particularly in athletes who regularly push their limits [ 11 ]. These factors underscore the importance of examining e-cigarette use specifically within the athletic community, as their physiological demands amplify the potential health risks. The COVID-19 pandemic, coupled with severe economic inflation and ongoing regional conflicts in Lebanon, has significantly strained public health infrastructure and increased daily stress levels among citizens, including athletes who must navigate limited resources and heightened financial pressures. In this challenging environment, e-cigarettes may be considered by some athletes as a potential stress relief method, offering an alternative to traditional smoking while mitigating some of the respiratory risks associated with combustion-based tobacco products. Athletes are often viewed as role models who exemplify health-conscious behaviors. Therefore, their smoking habits can influence broader social norms, particularly among younger audiences. In regions like Lebanon, where tobacco use is deeply embedded in social and cultural contexts, understanding the factors driving e-cigarette adoption among athletes is critical. Peer pressure, social acceptance, and stress relief are frequently cited motivators, but the interplay between these factors and the existing tobacco culture remains underexplored. This research not only addresses a gap in the literature concerning athletes—a group that has received limited attention in tobacco-related studies—but also highlights the broader implications for public health interventions in Lebanon and similar settings. By examining the attitudes, knowledge, and behaviors of this high-risk demographic, the study aims to inform targeted strategies that could mitigate the rising trend of e-cigarette use and its associated health risks. Materials and Methods Participants and recruitments In this study, participants were recruited through a combination of online and in-person methods. Social media platforms were utilized to distribute the survey link, allowing for broad outreach to individuals engaged in various levels of physical activity. Additionally, QR codes linking to the survey were distributed in sports facilities after obtaining consent from the facility management. These QR codes were strategically placed in high-traffic areas such as entrances, locker rooms, and common spaces to maximize participant engagement. This study was conducted among athletes in Lebanon between the ages of 17 and 45, with a total sample size of n = 563. The majority of respondents who filled out the survey were between the ages of 19 and 22. This dual approach ensured a diverse sample of respondents, including both recreational and competitive athletes, while maintaining ethical research practices. Survey and measures This is a cross-sectional study utilizing a self-reported recall survey. The study utilized a structured questionnaire to gather comprehensive data on participant demographics, sports involvement, and e-cigarette use, including questions on age, sex, household size, and income level. Additionally, participants were asked about the type of sport they played to examine potential variations in e-cigarette use across different athletic disciplines. The questionnaire also explored e-cigarette consumption patterns, including frequency, substances used, and reasons for usage. Furthermore, it assessed participants’ perceptions of the potential harms of e-cigarettes and the factors influencing their use, providing insight into the social and psychological drivers behind e-cigarettes use among athletes. The questionnaire was provided to students in both English and Arabic. The questions were derived from previously validated questionnaires [ 30 , 31 , 32 ]. Items related to tobacco use were adapted from the Global Adult Tobacco Survey [ 33 ] and the American Cancer Society’s Tobacco-Free Generation Campus Initiative: Cohort 5 Student Survey (2020–2021) [ 28 ]. As for the Arabic version a pre-tested and validated questionnaire in Arabic from prior research conducted among university students in Qatar was adapted [ 34 ]. The questionnaire in both languages was as well adapted by a study conducted in Lebanon where English and Arabic versions of the questionnaire were available to satisfy the participants’ language of preference. Two validation studies were conducted: one for the translation of the entire questionnaire to ensure reliability and consistency in the Arabic and English versions, and the second for the knowledge scale alone to validate its effectiveness in correctly reflecting the know ledge level of E-cigarettes among participants [ 35 ] Statistical analysis In this study, data were analyzed using IBM SPSS Statistics software. Descriptive statistical analysis was performed to summarize the prevalence and patterns of e-cigarette use among athletes in Lebanon. Frequencies and percentages were used to report categorical variables, including e-cigarette usage, reasons for use, places of use, and knowledge about cigarettes. Measures of central tendency, such as standard deviation, was applied to continuous variables like age, income, and household size. Additionally, cross-tabulations were conducted to explore potential relationships between e-cigarette use and demographic or lifestyle factors. To assess associations between categorical variables, the Chi-square test was used. This statistical approach ensured a comprehensive assessment of e-cigarette prevalence and its potential influencing factors among the surveyed athletes. Ethics approval and consent to participate The study received ethical approval from The Research Ethics Committee (REC) of the Higher Center for Research (HCR) at Holy Spirit University of Kaslik (approval number and date: HCR/EC 2024-045 Kaslik, 16/07/2024. ). The research followed the principles outlined in the Declaration of Helsinki (World Medical Association, 2013). Participants were thoroughly informed about the study’s objectives and procedures prior to their involvement. Informed consent was obtained electronically, and participation was completely voluntary. We ensured that data confidentiality and anonymity were rigorously maintained to safeguard participants’ privacy. Results Table 1: Demographics of Participants Variable Frequency (%) Count Age (19-22 years) 54.6 307 Gender (Male) 56.7 319 Household size (4-5 members) 65.3 368 Marital Status (Single) 80.1 451 Educational Qualification (Bachelor’s) 27.1 152 Household Income (< $4,000/month) 48.0 270 The study sample consisted predominantly of young adults, with 54.6% of participants aged between 19 and 22 years. A slightly higher proportion of respondents identified as male (56.7%). Most participants (65.3%) reported living in households with 4-5 members, and the majority (80.1%) were single. Regarding educational background, 27.1% had attained a bachelor’s degree. Household income varied, with nearly half (48.0%) reporting an income of less than $4,000 per month. (Table 1) Table 2: Prevalence of E-Cigarette Use Among Athletes participating in the study Usage Frequency Count Frequency (%) never 207 53.7 Daily 164 29.1 Twice a week 34 6 Once a month 23 4.1 Once a week 19 3.4 Biweekly 16 2.8 Once per week 5 0.9 E-cigarette use patterns among participants revealed that more than half (53.7%) had never used e-cigarettes, while 29.1% reported daily use. Less frequent usage varied, with 6% vaping twice a week, 4.1% using them monthly, and 3.4% reporting weekly use. Biweekly use was noted among 2.8% of respondents, and a smaller proportion (0.9%) used e-cigarettes once per week. These findings highlight diverse usage behaviors, with a substantial portion abstaining while others engage in different levels of use. (Table 2) Table 3: E-Cigarette Use by Gender Variable Male Female Number of Participants 319 244 E-cigarettes use 35.4% 24.6% A notable gender disparity was observed in e-cigarette use. Among male participants, 35.4% reported vaping, compared to 24.6% of females. This suggests that males in the study were more likely to use e-cigarettes than their female counterparts, indicating potential behavioral or social factors influencing vaping habits. (Table 3) Table 4: Participants’ opinions on e-cigarettes Variable Agree (%) Disagree (%) Count Standard Error Chi-Square p-value E-cigarettes cause lung cancer 84.6 15.4 476 0.008 55.12 <0.001 E-cigarettes cause cardiovascular problems 82.1 17.9 462 0.007 52.34 <0.001 E-cigarettes are less harmful 37.3 62.7 210 0.009 18.23 <0.001 E-cigarettes are addictive 88.9 11.1 501 0.007 70.23 <0.001 Participants' knowledge and perceptions of e-cigarettes varied significantly. The majority acknowledged the health risks, with 84.6% agreeing that e-cigarettes can cause lung cancer and 82.1% recognizing their link to cardiovascular problems. Additionally, 88.9% of respondents identified e-cigarettes as addictive. However, misconceptions persisted, as only 37.3% believed e-cigarettes are less harmful than traditional cigarettes, suggesting a gap in awareness regarding their relative risks. These findings underscore the need for targeted educational campaigns to address misconceptions and enhance public understanding of e-cigarette-related health risks. (Table 4) Table 5: Reasons for E-Cigarette Use Reason Frequency (%) Count Standard Error Chi-Square p-value Stress Reduction 45.1 254 0.007 28.34 <0.001 Curiosity 40.2 226 0.008 25.12 <0.001 Safer Alternative 38.5 217 0.008 22.45 <0.001 Peer Influence 33.7 190 0.009 20.34 <0.001 Accessibility 29.4 165 0.010 18.56 <0.001 Participants cited multiple reasons for using e-cigarettes, with stress reduction being the most frequently reported factor (45.1%). Curiosity was another significant motivator, with 40.2% of respondents indicating they tried e-cigarettes out of interest. Additionally, 38.5% of participants perceived e-cigarettes as a safer alternative to traditional cigarettes. Social influences also played a role, as 33.7% of users reported peer influence as a contributing factor. Accessibility was mentioned by 29.4% of respondents, suggesting that ease of obtaining e-cigarettes may facilitate usage. These findings highlight the diverse motivations behind e-cigarette use and suggest the need for targeted interventions to address misconceptions and social influences. (table 5) Table 6: Influence on E-Cigarette Use Variable `Strongly Agree (%) Neutral (%) Strongly Disagree (%) Count Standard Error Chi-Square p-value Influence of parents who smoke 36.2 25.4 38.4 204 0.008 15.23 <0.001 Influence of advertisements 40.1 21.6 38.3 226 0.009 18.12 <0.001 Influence of peers 45.2 19.5 35.3 254 0.007 22.45 <0.001 Participants identified various external influences on their decision to use e-cigarettes. Peer influence emerged as the most significant factor, with 45.2% strongly agreeing that their peers played a role in their vaping behavior. Advertisements were also impactful, as 40.1% strongly agreed that exposure to marketing influenced their perception of e-cigarettes. Additionally, 36.2% of respondents acknowledged the influence of parents who smoke, though opinions were more divided, with 38.4% strongly disagreeing with this notion. These findings suggest that social and environmental factors, particularly peer pressure and advertising, play a substantial role in shaping e-cigarette usage behaviors among young adults. Addressing these influences through awareness campaigns may help mitigate their impact. (table 6) Table 7: Percentage of E-Cigarette Use Among athletes Category Count Frequency (%) Has not used e-cigarettes 287 51 Has used e-cigarettes 276 49 The prevalence of e-cigarette usage among surveyed athletes revealed an almost equal distribution. While 51% of participants reported never using e-cigarettes, 49% indicated current use. This near-even split suggests a substantial adoption of e-cigarette use within this population. These findings emphasize the need for further investigation into the factors contributing to vaping behaviors among athletes and the potential implications for their health and performance. (Table 7) Table 8: Most Common Type of Tobacco Product Used Category Count Frequency (%) I do not consume tobacco 282 50 E-cigarettes 175 31.1 Traditional cigarettes 60 10.7 Chewable tobacco Waterpipe/ Shisha 43 7.6 Chicha 1 0.2 Cigarillos 1 0.2 Rolling tobacco 1 0.2 Among the participants, half (50%) reported not consuming any form of tobacco. However, e-cigarettes were the most commonly used tobacco product, with 31.1% of respondents indicating usage. Traditional cigarettes were reported by 10.7% of participants, while 7.6% used chewable tobacco or waterpipes/shisha. Less commonly used tobacco products included chicha (0.2%), cigarillos (0.2%), and rolling tobacco (0.2%). These findings highlight the predominance of e-cigarettes among tobacco users in the sample, underscoring the shift away from traditional cigarettes and the need to further explore the factors driving these preferences. (Table 8) Table 9: Frequency of E-Cigarette Use Variable Frequency (%) Count Standard Error Chi-Square p-value Social Use 59.0 332 0.008 40.23 <0.001 Use During Stressful Situations 34.2 192 0.009 22.45 <0.001 Place of Use (Home) 88.0 496 0.007 71.34 <0.001 Place of Use (Cafe) 85.2 480 0.007 68.12 <0.001 E-cigarette consumption was most commonly reported in social settings, with 59% of participants indicating social use as a primary reason for vaping. Additionally, 34.2% of respondents used e-cigarettes during stressful situations, highlighting stress-related motivations. Regarding the locations of use, homes (88%) and cafes (85.2%) were the most frequently reported places where participants engaged in vaping. These findings suggest that e-cigarettes are often used in familiar and social environments, contributing to their normalization in everyday life. The results underscore the importance of addressing social influences and stress-related factors in awareness campaigns aimed at reducing e-cigarette use among young adults. (table 9) Discussion This study's findings on e-cigarette use among athletes in Lebanon align with and diverge from trends observed in other regions, particularly in the Middle East and North Africa (MENA) and globally. Comparing our results to other studies offers valuable insights into the broader context of e-cigarette use and highlights cultural, social, and regulatory factors that influence behaviors. In the MENA region, studies have consistently reported a growing prevalence of e-cigarette use among young adults and adolescents, mirroring our findings [11]. For example, research conducted in Saudi Arabia and the United Arab Emirates indicates that e-cigarettes are increasingly popular among university students and young professionals, driven by peer influence, curiosity [12], and perceptions of reduced harm compared to traditional cigarettes [23]. Similarly, our study found that 45.2% of athletes in Lebanon cited peer influence as a key factor for initiating e-cigarette use, reflecting a regional pattern where social acceptance plays a pivotal role. In addition, our findings, which indicate that men use e-cigarettes at higher rates than women, align with the results of a study conducted in the US, which also reported greater e-cigarette use among male adolescents in the U.S [37]. This similarity suggests that gender differences in e-cigarette use persist across different populations and time periods, reinforcing the need for targeted public health interventions that consider these patterns. Globally, e-cigarette use among athletes and young adults shares similar driving factors but presents nuanced differences. In Western countries, such as the United States and European nations, e-cigarettes are often marketed as smoking cessation tools [24]. Studies from these regions have shown that many users perceive e-cigarettes as a way to quit traditional smoking [13,35,37]. In contrast, only 38.5% of respondents in our study identified "safer alternative" as a reason for use, suggesting that harm-reduction messaging may not be as prominent or effective in Lebanon. Instead, stress relief (45.1%) and curiosity (40.2%) were leading motivators, aligning with findings from other MENA studies but differing from Western trends. Notably, the global literature also emphasizes the impact of targeted advertising on e-cigarette use. Our results, suggesting that 40.1% of respondents were influenced by advertisements, align with international studies, particularly those from high-income countries where aggressive marketing campaigns have normalized e-cigarette use as a modern and fashionable lifestyle choice [14]. This commonality underscores the global nature of advertising's impact, transcending cultural and regional boundaries. Despite shared patterns, cultural and regulatory differences significantly influence the context of e-cigarette use. For instance, Western countries often have robust public health campaigns and stricter regulations on tobacco and e-cigarette advertising [15]. These measures have been effective in curbing youth use in certain regions. In contrast, Lebanon and many MENA countries face challenges such as limited enforcement of existing regulations and insufficient public health education, which likely exacerbate the rise of e-cigarette use. This study reveals that e-cigarettes cause lung cancer, cardiovascular problems, and addiction (88.9%), with only 37.3% viewing them as less harmful. In parallel a study conducted in Qatar found that e-cigarette users were less likely to agree that e-cigarettes can cause lung cancer (46.4%) and cardiovascular disease (42.9%) compared to non-users. While most athletes in the study demonstrated an understanding of the health risks associated with e-cigarette use, this awareness did not necessarily translate into lower usage rates. Peer influence, social norms within sports communities, sponsorship or marketing by vaping brands, and stress management needs may contribute to continued use despite recognizing the potential harm. This suggests that behavioral choices are not solely dictated by knowledge but are also influenced by the broader social and environmental context, reinforcing the need for targeted interventions that address these external pressures. [16] Moreover, the perception of athletes as role models in health-conscious societies may contribute to the unique findings of this study. Globally, athletes are less commonly studied as a distinct population for e-cigarette use, making this research an important contribution to understanding the intersection of sports, health, and smoking behaviors. The normalization of e-cigarette use among Lebanese athletes raises concerns about its potential influence on broader youth populations who look up to athletes for inspiration as well as the elderly because even though cancer, cardiovascular disease and chronic obstructive pulmonary disease are rare among the youth, they largely occur at older ages. [20, 27] In summary, while the factors driving e-cigarette use among athletes in Lebanon are consistent with trends observed in the MENA region and worldwide, cultural and regulatory contexts create distinct patterns. Peer influence, stress relief, and misconceptions about harm reduction are pervasive motivators, but higher usage rates in Lebanon highlight the need for targeted public health interventions. Comparing these findings with global trends underscores the importance of strengthening education and regulation to address this emerging public health issue effectively. Strengths and Limitations This study's strengths include its focus on athletes, an under-researched group, and the use of a bilingual questionnaire for inclusivity. Robust statistical analysis enhances reliability, while its regional focus adds valuable insight into e-cigarette use in the MENA region. However, limitations include its cross-sectional design, reliance on self-reported data, and limited generalizability beyond Lebanese athletes. Despite these, the study provides a strong foundation for future research on e-cigarette use in health-conscious populations. Conclusion E-cigarette use among athletes in Lebanon remains a pressing public health concern. Despite a significant level of awareness regarding the dangers associated with e-cigarette use, many athletes continue to smoke, influenced by social norms, peer pressure, and advertisements. This gap between knowledge and behavior underscores the normalization of e-cigarette use in athletic and social contexts. Addressing this issue requires comprehensive awareness campaigns tailored to athletes and young adults, aiming to correct misconceptions about e-cigarettes and emphasize their long-term health risks. Furthermore, initiatives promoting smoke-free environments in athletic settings and enforcing stricter regulations on e-cigarette advertising can help curb this trend. It is crucial to bridge the gap between knowledge and behavior to protect athletes' health and performance from the adverse effects of e-cigarettes. Declarations Acknowledgements: We thank the support of the Holy Spirit University of Kaslik. We are also grateful for Professor Hanan F. Abdul Rahim at Qatar University, department of public health for providing us with the Arabic version of the questionnaire used. (29) Funding: Not applicable Competing Interest: Not applicable Ethical approval and consent to participate/ consent for publication The study received ethical approval from The Research Ethics Committee (REC) of the Higher Center for Research (HCR) at Holy Spirit University of Kaslik (approval number and date: HCR/EC 2024-045 Kaslik, 16/07/2024. ). The research followed the principles outlined in the Declaration of Helsinki (World Medical Association, 2013). Participants were thoroughly informed about the study’s objectives and procedures prior to their involvement. Informed consent was obtained electronically, and participation was completely voluntary. We ensured that data confidentiality and anonymity were rigorously maintained to safeguard participants’ privacy. Availability of data and materials Data were collected anonymously after the consent form was complete and securely stored and is available upon request. A statistical analysis is conducted using SPSS version 26 and chi-square, p values, standard error, frequency, count. 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E-cigarette use and respiratory disorders: an integrative review of converging evidence from epidemiological and laboratory studies. Eur Respir J. 2021 Jan 21;57(1):1901815. doi: 10.1183/13993003.01815-2019. PMID: 33154031; PMCID: PMC7817920. Namwase AS, Gyimah EA, Carothers BJ, Combs TB, Harris JK. Changes in Harm Perception for E-Cigarettes Among Youth in the United States, 2014-2019. Am J Health Promot. 2023 May;37(4):471-477. doi: 10.1177/08901171221133805. Epub 2022 Oct 19. PMID: 36263457. Qureshi MA, Vernooij RWM, La Rosa GRM, Polosa R, O'Leary R. Respiratory health effects of e-cigarette substitution for tobacco cigarettes: a systematic review. Harm Reduct J. 2023 Oct 4;20(1):143. doi: 10.1186/s12954-023-00877-9. Erratum in: Harm Reduct J. 2024 Mar 13;21(1):60. doi: 10.1186/s12954-024-00968-1. PMID: 37794458; PMCID: PMC10552385. Collins L, Glasser AM, Abudayyeh H, Pearson JL, Villanti AC. E-Cigarette Marketing and Communication: How E-Cigarette Companies Market E-Cigarettes and the Public Engages with E-cigarette Information. Nicotine Tob Res. 2019 Jan 1;21(1):14-24. doi: 10.1093/ntr/ntx284. PMID: 29315420; PMCID: PMC6610165. Marques, P., Piqueras, L. & Sanz, MJ. An updated overview of e-cigarette impact on human health. Respir Res 22 , 151 (2021). https://doi.org/10.1186/s12931-021-01737-5 Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation. 2014 May 13;129(19):1972-86. doi: 10.1161/CIRCULATIONAHA.114.007667. PMID: 24821826; PMCID: PMC4018182. Hamann SL, Kungskulniti N, Charoenca N, Kasemsup V, Ruangkanchanasetr S, Jongkhajornpong P. Electronic Cigarette Harms: Aggregate Evidence Shows Damage to Biological Systems. Int J Environ Res Public Health. 2023 Sep 22;20(19):6808. doi: 10.3390/ijerph20196808. PMID: 37835078; PMCID: PMC10572885. American Cancer Society . Tobacco-Free Generation Campus Initiative: Cohort 5 Student Survey (2020-2021). Available online at: https://www.cancer.org/health-care-professionals/center-for-tobacco-cont... (accessed February 18, 2020). Puteh SEW, Manap RA, Hassan TM, Ahmad IS, Idris IB, Sham FM, et al. The use of e-cigarettes among university students in Malaysia. Tob Induc Dis. (2018) 16:57. doi: 10.18332/tid/99539 Almutham A, Altami M, Sharaf F, AlAraj A. E-cigarette use among medical students at Qassim university: knowledge, perception, and prevalence. J Family Med Prim Care. (2019) 8:2921–26. doi: 10.4103/jfmpc.jfmpc_567_19 Almutham A, Altami M, Sharaf F, AlAraj A. E-cigarette use among medical students at Qassim university: knowledge, perception, and prevalence. J Family Med Prim Care. (2019) 8:2921–26. doi: 10.4103/jfmpc.jfmpc_567_19 Awan KH. Experimentation and correlates of electronic nicotine delivery system (electronic cigarettes) among university students- a cross sectional study. Saudi Dent J. (2016) 28:91–5. doi: 10.1016/j.sdentj.2015.12.002 GATS.Global Adult Tobacco Survey. (2013). Available online at: https://www. psa.gov.qa/en/statistics/Surveys/GATS-BOOK.pdf (accessed April 25, 2020). Kurdi R, Al-Jayyousi GF, Yaseen M, Ali A, Mosleh N, Abdul Rahim HF. Prevalence, Risk Factors, Harm Perception, and Attitudes Toward E-cigarette Use Among University Students in Qatar: A Cross-Sectional Study. Front Public Health. 2021 Aug 20;9:682355. doi: 10.3389/fpubh.2021.682355. PMID: 34490180; PMCID: PMC8417713. Aghar, H., El-Khoury, N., Reda, M. et al. Knowledge and attitudes towards E-cigarette use in Lebanon and their associated factors. BMC Public Health 20 , 278 (2020). https://doi.org/10.1186/s12889-020-8381-x Kulik MC, Lisha NE, Glantz SA. E-cigarettes Associated With Depressed Smoking Cessation: A Cross-sectional Study of 28 European Union Countries. Am J Prev Med. 2018 Apr;54(4):603-609. doi: 10.1016/j.amepre.2017.12.017. Epub 2018 Feb 12. PMID: 29449132; PMCID: PMC5860982. Kong G, Kuguru KE, Krishnan-Sarin S. Gender Differences in U.S. Adolescent E-Cigarette Use. Curr Addict Rep. 2017 Dec;4(4):422-430. doi: 10.1007/s40429-017-0176-5. Epub 2017 Nov 4. PMID: 29545987; PMCID: PMC5847300. Additional Declarations No competing interests reported. Supplementary Files englishquestionnaire.pdf Cite Share Download PDF Status: Posted Version 1 posted 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-5685024","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":433443989,"identity":"44327c9e-cb30-4498-90e0-1ae83ef83129","order_by":0,"name":"Elichia Bou Akar","email":"","orcid":"","institution":"Holy Spirit University of Kaslik","correspondingAuthor":false,"prefix":"","firstName":"Elichia","middleName":"Bou","lastName":"Akar","suffix":""},{"id":433443990,"identity":"d4a0552c-e863-4d10-ac84-bc52c7b56d54","order_by":1,"name":"Clara Khalil","email":"","orcid":"","institution":"Holy Spirit University of Kaslik","correspondingAuthor":false,"prefix":"","firstName":"Clara","middleName":"","lastName":"Khalil","suffix":""},{"id":433443992,"identity":"05653fc6-338a-42c9-bfc4-e969e0d32aba","order_by":2,"name":"Andress Youssef","email":"","orcid":"","institution":"Holy Spirit University of Kaslik","correspondingAuthor":false,"prefix":"","firstName":"Andress","middleName":"","lastName":"Youssef","suffix":""},{"id":433443994,"identity":"d9cd9958-bf70-4acb-abf8-5f2ec74b872d","order_by":3,"name":"Omar Houchaimy","email":"","orcid":"","institution":"Holy Spirit University of Kaslik","correspondingAuthor":false,"prefix":"","firstName":"Omar","middleName":"","lastName":"Houchaimy","suffix":""},{"id":433443995,"identity":"32222aeb-ee0f-4fbd-9967-5088257c5bae","order_by":4,"name":"Georges Al Maalouf","email":"","orcid":"","institution":"Holy Spirit University of Kaslik","correspondingAuthor":false,"prefix":"","firstName":"Georges","middleName":"Al","lastName":"Maalouf","suffix":""},{"id":433443996,"identity":"3a11d30e-4af4-45a3-8ee4-4faea7b60a7a","order_by":5,"name":"Theresa Boulos","email":"","orcid":"","institution":"Holy Spirit University of Kaslik","correspondingAuthor":false,"prefix":"","firstName":"Theresa","middleName":"","lastName":"Boulos","suffix":""},{"id":433443997,"identity":"fe9a15e4-0b49-485d-9354-a7300edb493b","order_by":6,"name":"Elie Bou Akar","email":"data:image/png;base64,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","orcid":"","institution":"Holy Spirit University of Kaslik","correspondingAuthor":true,"prefix":"","firstName":"Elie","middleName":"Bou","lastName":"Akar","suffix":""},{"id":433443998,"identity":"b61293b8-b57f-4559-928e-d202c6e6eeb7","order_by":7,"name":"Shafika Assaad","email":"","orcid":"","institution":"Holy Spirit University of Kaslik","correspondingAuthor":false,"prefix":"","firstName":"Shafika","middleName":"","lastName":"Assaad","suffix":""}],"badges":[],"createdAt":"2024-12-20 14:53:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5685024/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5685024/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84299364,"identity":"1154c486-0faa-4db9-8036-11e473860ecc","added_by":"auto","created_at":"2025-06-10 10:17:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1069845,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5685024/v1/a9400524-9b6f-4d2c-951d-849d58b26b43.pdf"},{"id":79270726,"identity":"1e89b45d-c4de-4338-96d3-46839a948ccd","added_by":"auto","created_at":"2025-03-26 11:08:43","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":283509,"visible":true,"origin":"","legend":"","description":"","filename":"englishquestionnaire.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5685024/v1/02106a9e26615bcaa8b73006.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePrevalence, Risk Factors, Harm, Perception and Attitudes Toward E-Cigarette Use Among Athletes in Lebanon:A Cross-Sectional Study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eTobacco smoking remains one of the leading causes of preventable morbidity and mortality worldwide. According to the World Health Organization (WHO), smoking-related diseases, including lung cancer, chronic obstructive pulmonary disease (COPD), and cardiovascular diseases, account for over 8\u0026nbsp;million deaths annually [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In Lebanon, smoking prevalence remains alarmingly high, contributing significantly to the national burden of non-communicable disease [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The increasing rates of tobacco consumption underscore the urgent need for strengthened tobacco control measures to reduce the associated health risks including most importantly lung disorders [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and economic burden.\u003c/p\u003e \u003cp\u003eLebanon has taken steps toward tobacco control, particularly after becoming a signatory to the WHO Framework Convention on Tobacco Control (FCTC) in \u003cb\u003e2005\u003c/b\u003e. The country has made efforts to implement some of the MPOWER measures, which include monitoring tobacco use, protecting individuals from tobacco smoke, offering cessation support, warning about the dangers of tobacco, enforcing bans on advertising, and raising tobacco taxes. Law \u003cb\u003e174\u003c/b\u003e, enacted in \u003cb\u003e2011\u003c/b\u003e, marked a significant milestone in Lebanon\u0026rsquo;s tobacco control efforts by introducing smoking bans in public spaces and restrictions on tobacco advertising. However, enforcement challenges have limited the full effectiveness of these regulations. Strengthening compliance with existing policies and implementing additional measures remain crucial to curbing Lebanon\u0026rsquo;s tobacco epidemic.\u003c/p\u003e \u003cp\u003eThe prevalence rates reported in this study\u0026mdash;59% of respondents using e-cigarettes socially\u0026mdash;are higher than those documented in broader MENA populations [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This discrepancy could be attributed to the unique social dynamics within athletic circles, where peer behaviors and social settings may amplify the normalization of e-cigarette use. Additionally, Lebanon's relatively lenient tobacco control policies compared to stricter regulations in Gulf countries may contribute to higher usage rates.\u003c/p\u003e \u003cp\u003eE-cigarettes have emerged as a popular alternative to traditional cigarettes, marketed as less harmful and socially acceptable [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Among athletes, the use of e-cigarettes raises concerns due to the potential impact on physical performance and long-term health [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] as well as periodontal health [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Previous studies highlight that athletes often perceive e-cigarettes as a safer choice, influenced by peer behavior, advertisements, and accessibility [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In Lebanon, where smoking prevalence is already high (48.6% males and 21.5% females in a 1680 sample of Lebanese people above 18) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], this study aims to explore e-cigarette use patterns, knowledge, and perceptions among athletes, shedding light on a growing public health issue.\u003c/p\u003e \u003cp\u003eThe surge in e-cigarette popularity coincides with aggressive marketing campaigns that portray them as trendy and less harmful alternatives to conventional tobacco products [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This perception has been further amplified by their easy availability and a variety of flavors that appeal to younger demographics, including athletes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, evidence suggests that e-cigarette use may pose unique risks to athletes, as the vapor can impair cardiovascular and respiratory functions of the smoker as well as secondhand ones [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u0026mdash;an effect that is particularly concerning given their high physical demands [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, research highlights the presence of toxic materials such as heavy metals (lead, cadmium, and nickel), volatile organic compounds, and other carcinogenic substances in e-cigarette aerosols [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These compounds can lead to cellular damage, oxidative stress, and inflammation, posing long-term health risks even for individuals with high physical fitness levels, such as athletes who have significantly higher respiratory and cardiovascular demands compared to the general population, making them more susceptible to the harmful effects of e-cigarette toxins. The inhalation of harmful substances can exacerbate inflammation and oxidative stress, potentially reducing oxygen uptake and impairing endurance performance. Furthermore, the added cardiovascular strain from vaping may negatively impact heart function and blood vessel integrity, particularly in athletes who regularly push their limits [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These factors underscore the importance of examining e-cigarette use specifically within the athletic community, as their physiological demands amplify the potential health risks.\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic, coupled with severe economic inflation and ongoing regional conflicts in Lebanon, has significantly strained public health infrastructure and increased daily stress levels among citizens, including athletes who must navigate limited resources and heightened financial pressures. In this challenging environment, e-cigarettes may be considered by some athletes as a potential stress relief method, offering an alternative to traditional smoking while mitigating some of the respiratory risks associated with combustion-based tobacco products.\u003c/p\u003e \u003cp\u003eAthletes are often viewed as role models who exemplify health-conscious behaviors. Therefore, their smoking habits can influence broader social norms, particularly among younger audiences. In regions like Lebanon, where tobacco use is deeply embedded in social and cultural contexts, understanding the factors driving e-cigarette adoption among athletes is critical. Peer pressure, social acceptance, and stress relief are frequently cited motivators, but the interplay between these factors and the existing tobacco culture remains underexplored.\u003c/p\u003e \u003cp\u003eThis research not only addresses a gap in the literature concerning athletes\u0026mdash;a group that has received limited attention in tobacco-related studies\u0026mdash;but also highlights the broader implications for public health interventions in Lebanon and similar settings. By examining the attitudes, knowledge, and behaviors of this high-risk demographic, the study aims to inform targeted strategies that could mitigate the rising trend of e-cigarette use and its associated health risks.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and recruitments\u003c/h2\u003e \u003cp\u003eIn this study, participants were recruited through a combination of online and in-person methods. Social media platforms were utilized to distribute the survey link, allowing for broad outreach to individuals engaged in various levels of physical activity. Additionally, QR codes linking to the survey were distributed in sports facilities after obtaining consent from the facility management. These QR codes were strategically placed in high-traffic areas such as entrances, locker rooms, and common spaces to maximize participant engagement. This study was conducted among athletes in Lebanon between the ages of 17 and 45, with a total sample size of n\u0026thinsp;=\u0026thinsp;563. The majority of respondents who filled out the survey were between the ages of 19 and 22. This dual approach ensured a diverse sample of respondents, including both recreational and competitive athletes, while maintaining ethical research practices.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurvey and measures\u003c/h3\u003e\n\u003cp\u003eThis is a cross-sectional study utilizing a self-reported recall survey. The study utilized a structured questionnaire to gather comprehensive data on participant demographics, sports involvement, and e-cigarette use, including questions on age, sex, household size, and income level. Additionally, participants were asked about the type of sport they played to examine potential variations in e-cigarette use across different athletic disciplines. The questionnaire also explored e-cigarette consumption patterns, including frequency, substances used, and reasons for usage. Furthermore, it assessed participants\u0026rsquo; perceptions of the potential harms of e-cigarettes and the factors influencing their use, providing insight into the social and psychological drivers behind e-cigarettes use among athletes. The questionnaire was provided to students in both English and Arabic. The questions were derived from previously validated questionnaires [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Items related to tobacco use were adapted from the Global Adult Tobacco Survey [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and the American Cancer Society\u0026rsquo;s Tobacco-Free Generation Campus Initiative: Cohort 5 Student Survey (2020\u0026ndash;2021) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. As for the Arabic version a pre-tested and validated questionnaire in Arabic from prior research conducted among university students in Qatar was adapted [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The questionnaire in both languages was as well adapted by a study conducted in Lebanon where English and Arabic versions of the questionnaire were available to satisfy the participants\u0026rsquo; language of preference. Two validation studies were conducted: one for the translation of the entire questionnaire to ensure reliability and consistency in the Arabic and English versions, and the second for the knowledge scale alone to validate its effectiveness in correctly reflecting the know ledge level of E-cigarettes among participants [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eIn this study, data were analyzed using IBM SPSS Statistics software. Descriptive statistical analysis was performed to summarize the prevalence and patterns of e-cigarette use among athletes in Lebanon. Frequencies and percentages were used to report categorical variables, including e-cigarette usage, reasons for use, places of use, and knowledge about cigarettes. Measures of central tendency, such as standard deviation, was applied to continuous variables like age, income, and household size. Additionally, cross-tabulations were conducted to explore potential relationships between e-cigarette use and demographic or lifestyle factors. To assess associations between categorical variables, the Chi-square test was used. This statistical approach ensured a comprehensive assessment of e-cigarette prevalence and its potential influencing factors among the surveyed athletes.\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received ethical approval from The Research Ethics Committee (REC) of the Higher Center for Research (HCR) at Holy Spirit University of Kaslik (approval number and date: \u003cem\u003eHCR/EC 2024-045 Kaslik, 16/07/2024.\u003c/em\u003e). The research followed the principles outlined in the Declaration of Helsinki (World Medical Association, 2013). Participants were thoroughly informed about the study’s objectives and procedures prior to their involvement. Informed consent was obtained electronically, and participation was completely voluntary. We ensured that data confidentiality and anonymity were rigorously maintained to safeguard participants’ privacy.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1: Demographics of Participants\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCount\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (19-22 years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e307\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender (Male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e319\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHousehold size (4-5 members)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e368\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMarital Status (Single)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e451\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEducational Qualification (Bachelor’s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHousehold Income (\u0026lt; $4,000/month)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e270\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe study sample consisted predominantly of young adults, with 54.6% of participants aged between 19 and 22 years. A slightly higher proportion of respondents identified as male (56.7%). Most participants (65.3%) reported living in households with 4-5 members, and the majority (80.1%) were single. Regarding educational background, 27.1% had attained a bachelor’s degree. Household income varied, with nearly half (48.0%) reporting an income of less than $4,000 per month. (Table 1)\u003cbr\u003e \u003cstrong\u003e\u003cem\u003eTable 2: Prevalence of E-Cigarette Use Among Athletes participating in the study\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"233\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eUsage Frequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Count\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003enever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e53.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e29.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eTwice a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOnce a month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOnce a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eBiweekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOnce per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eE-cigarette use patterns among participants revealed that more than half (53.7%) had never used e-cigarettes, while 29.1% reported daily use. Less frequent usage varied, with 6% vaping twice a week, 4.1% using them monthly, and 3.4% reporting weekly use. Biweekly use was noted among 2.8% of respondents, and a smaller proportion (0.9%) used e-cigarettes once per week. These findings highlight diverse usage behaviors, with a substantial portion abstaining while others engage in different levels of use. (Table 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 3: E-Cigarette Use by Gender\u003c/em\u003e\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\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e319\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e244\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eE-cigarettes use\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eA notable gender disparity was observed in e-cigarette use. Among male participants, 35.4% reported vaping, compared to 24.6% of females. This suggests that males in the study were more likely to use e-cigarettes than their female counterparts, indicating potential behavioral or social factors influencing vaping habits. (Table 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 4: Participants’ opinions on e-cigarettes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAgree (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDisagree (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCount\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStandard Error\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eChi-Square\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eE-cigarettes cause lung cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e476\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eE-cigarettes cause cardiovascular problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e82.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e462\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eE-cigarettes are less harmful\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eE-cigarettes are addictive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e88.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e501\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e70.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eParticipants' knowledge and perceptions of e-cigarettes varied significantly. The majority acknowledged the health risks, with 84.6% agreeing that e-cigarettes can cause lung cancer and 82.1% recognizing their link to cardiovascular problems. Additionally, 88.9% of respondents identified e-cigarettes as addictive. However, misconceptions persisted, as only 37.3% believed e-cigarettes are less harmful than traditional cigarettes, suggesting a gap in awareness regarding their relative risks.\u003c/p\u003e\n\u003cp\u003eThese findings underscore the need for targeted educational campaigns to address misconceptions and enhance public understanding of e-cigarette-related health risks. (Table 4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 5: Reasons for E-Cigarette Use\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eReason\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCount\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStandard Error\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eChi-Square\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eStress Reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e254\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCuriosity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSafer Alternative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e217\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePeer Influence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAccessibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eParticipants cited multiple reasons for using e-cigarettes, with stress reduction being the most frequently reported factor (45.1%). Curiosity was another significant motivator, with 40.2% of respondents indicating they tried e-cigarettes out of interest. Additionally, 38.5% of participants perceived e-cigarettes as a safer alternative to traditional cigarettes. Social influences also played a role, as 33.7% of users reported peer influence as a contributing factor. Accessibility was mentioned by 29.4% of respondents, suggesting that ease of obtaining e-cigarettes may facilitate usage.\u003c/p\u003e\n\u003cp\u003eThese findings highlight the diverse motivations behind e-cigarette use and suggest the need for targeted interventions to address misconceptions and social influences. (table 5)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 6: Influence on E-Cigarette Use\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e`Strongly Agree (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNeutral (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Disagree (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCount\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStandard Error\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eChi-Square\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eInfluence of parents who smoke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eInfluence of advertisements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eInfluence of peers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e254\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eParticipants identified various external influences on their decision to use e-cigarettes. Peer influence emerged as the most significant factor, with 45.2% strongly agreeing that their peers played a role in their vaping behavior. Advertisements were also impactful, as 40.1% strongly agreed that exposure to marketing influenced their perception of e-cigarettes. Additionally, 36.2% of respondents acknowledged the influence of parents who smoke, though opinions were more divided, with 38.4% strongly disagreeing with this notion.\u003c/p\u003e\n\u003cp\u003eThese findings suggest that social and environmental factors, particularly peer pressure and advertising, play a substantial role in shaping e-cigarette usage behaviors among young adults. Addressing these influences through awareness campaigns may help mitigate their impact. (table 6)\u003cem\u003e\u003cbr\u003e \u003cstrong\u003eTable 7: Percentage of E-Cigarette Use Among athletes\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCount\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHas not used e-cigarettes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e287\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHas used e-cigarettes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e276\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe prevalence of e-cigarette usage among surveyed athletes revealed an almost equal distribution. While 51% of participants reported never using e-cigarettes, 49% indicated current use. This near-even split suggests a substantial adoption of e-cigarette use within this population. These findings emphasize the need for further investigation into the factors contributing to vaping behaviors among athletes and the potential implications for their health and performance. (Table 7)\u003cstrong\u003e\u003cbr\u003e \u003cem\u003eTable 8: Most Common Type of Tobacco Product Used\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCount\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 \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI do not consume tobacco\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e282\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eE-cigarettes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTraditional cigarettes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChewable tobacco Waterpipe/ Shisha\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\u003e7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChicha\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\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCigarillos\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\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRolling tobacco\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\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAmong the participants, half (50%) reported not consuming any form of tobacco. However, e-cigarettes were the most commonly used tobacco product, with 31.1% of respondents indicating usage. Traditional cigarettes were reported by 10.7% of participants, while 7.6% used chewable tobacco or waterpipes/shisha. Less commonly used tobacco products included chicha (0.2%), cigarillos (0.2%), and rolling tobacco (0.2%).\u003c/p\u003e\n\u003cp\u003eThese findings highlight the predominance of e-cigarettes among tobacco users in the sample, underscoring the shift away from traditional cigarettes and the need to further explore the factors driving these preferences. (Table 8)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 9: Frequency of E-Cigarette Use\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCount\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStandard Error\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eChi-Square\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSocial Use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUse During Stressful Situations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e192\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePlace of Use (Home)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e88.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e496\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePlace of Use (Cafe)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e85.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e480\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eE-cigarette consumption was most commonly reported in social settings, with 59% of participants indicating social use as a primary reason for vaping. Additionally, 34.2% of respondents used e-cigarettes during stressful situations, highlighting stress-related motivations.\u003c/p\u003e\n\u003cp\u003eRegarding the locations of use, homes (88%) and cafes (85.2%) were the most frequently reported places where participants engaged in vaping. These findings suggest that e-cigarettes are often used in familiar and social environments, contributing to their normalization in everyday life.\u003c/p\u003e\n\u003cp\u003eThe results underscore the importance of addressing social influences and stress-related factors in awareness campaigns aimed at reducing e-cigarette use among young adults. (table 9)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study\u0026apos;s findings on e-cigarette use among athletes in Lebanon align with and diverge from trends observed in other regions, particularly in the Middle East and North Africa (MENA) and globally. Comparing our results to other studies offers valuable insights into the broader context of e-cigarette use and highlights cultural, social, and regulatory factors that influence behaviors.\u003c/p\u003e\n\u003cp\u003eIn the MENA region, studies have consistently reported a growing prevalence of e-cigarette use among young adults and adolescents, mirroring our findings [11]. For example, research conducted in Saudi Arabia and the United Arab Emirates indicates that e-cigarettes are increasingly popular among university students and young professionals, driven by peer influence, curiosity [12], and perceptions of reduced harm compared to traditional cigarettes [23]. Similarly, our study found that 45.2% of athletes in Lebanon cited peer influence as a key factor for initiating e-cigarette use, reflecting a regional pattern where social acceptance plays a pivotal role.\u003c/p\u003e\n\u003cp\u003eIn addition, our findings, which indicate that men use e-cigarettes at higher rates than women, align with the results of a study conducted in the US, which also reported greater e-cigarette use among male adolescents in the U.S [37]. This similarity suggests that gender differences in e-cigarette use persist across different populations and time periods, reinforcing the need for targeted public health interventions that consider these patterns.\u003c/p\u003e\n\u003cp\u003eGlobally, e-cigarette use among athletes and young adults shares similar driving factors but presents nuanced differences. In Western countries, such as the United States and European nations, e-cigarettes are often marketed as smoking cessation tools [24]. Studies from these regions have shown that many users perceive e-cigarettes as a way to quit traditional smoking [13,35,37]. In contrast, only 38.5% of respondents in our study identified \u0026quot;safer alternative\u0026quot; as a reason for use, suggesting that harm-reduction messaging may not be as prominent or effective in Lebanon. Instead, stress relief (45.1%) and curiosity (40.2%) were leading motivators, aligning with findings from other MENA studies but differing from Western trends.\u003c/p\u003e\n\u003cp\u003eNotably, the global literature also emphasizes the impact of targeted advertising on e-cigarette use. Our results, suggesting that 40.1% of respondents were influenced by advertisements, align with international studies, particularly those from high-income countries where aggressive marketing campaigns have normalized e-cigarette use as a modern and fashionable lifestyle choice [14]. This commonality underscores the global nature of advertising\u0026apos;s impact, transcending cultural and regional boundaries.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite shared patterns, cultural and regulatory differences significantly influence the context of e-cigarette use. For instance, Western countries often have robust public health campaigns and stricter regulations on tobacco and e-cigarette advertising [15]. These measures have been effective in curbing youth use in certain regions. In contrast, Lebanon and many MENA countries face challenges such as limited enforcement of existing regulations and insufficient public health education, which likely exacerbate the rise of e-cigarette use. This study reveals that e-cigarettes cause lung cancer, cardiovascular problems, and addiction (88.9%), with only 37.3% viewing them as less harmful. In parallel a study conducted in Qatar found that e-cigarette users were less likely to agree that e-cigarettes can cause lung cancer (46.4%) and cardiovascular disease (42.9%) compared to non-users.\u003c/p\u003e\n\u003cp\u003eWhile most athletes in the study demonstrated an understanding of the health risks associated with e-cigarette use, this awareness did not necessarily translate into lower usage rates. Peer influence, social norms within sports communities, sponsorship or marketing by vaping brands, and stress management needs may contribute to continued use despite recognizing the potential harm. This suggests that behavioral choices are not solely dictated by knowledge but are also influenced by the broader social and environmental context, reinforcing the need for targeted interventions that address these external pressures. [16]\u003c/p\u003e\n\u003cp\u003eMoreover, the perception of athletes as role models in health-conscious societies may contribute to the unique findings of this study. Globally, athletes are less commonly studied as a distinct population for e-cigarette use, making this research an important contribution to understanding the intersection of sports, health, and smoking behaviors. The normalization of e-cigarette use among Lebanese athletes raises concerns about its potential influence on broader youth populations who look up to athletes for inspiration as well as the elderly because even though\u0026nbsp;cancer, cardiovascular disease and chronic obstructive pulmonary disease are rare among the youth, they largely occur at older ages. [20, 27]\u003c/p\u003e\n\u003cp\u003eIn summary, while the factors driving e-cigarette use among athletes in Lebanon are consistent with trends observed in the MENA region and worldwide, cultural and regulatory contexts create distinct patterns. Peer influence, stress relief, and misconceptions about harm reduction are pervasive motivators, but higher usage rates in Lebanon highlight the need for targeted public health interventions. Comparing these findings with global trends underscores the importance of strengthening education and regulation to address this emerging public health issue effectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study\u0026apos;s strengths include its focus on athletes, an under-researched group, and the use of a bilingual questionnaire for inclusivity. Robust statistical analysis enhances reliability, while its regional focus adds valuable insight into e-cigarette use in the MENA region. However, limitations include its cross-sectional design, reliance on self-reported data, and limited generalizability beyond Lebanese athletes. Despite these, the study provides a strong foundation for future research on e-cigarette use in health-conscious populations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eE-cigarette use among athletes in Lebanon remains a pressing public health concern. Despite a significant level of awareness regarding the dangers associated with e-cigarette use, many athletes continue to smoke, influenced by social norms, peer pressure, and advertisements. This gap between knowledge and behavior underscores the normalization of e-cigarette use in athletic and social contexts.\u003c/p\u003e\n\u003cp\u003eAddressing this issue requires comprehensive awareness campaigns tailored to athletes and young adults, aiming to correct misconceptions about e-cigarettes and emphasize their long-term health risks. Furthermore, initiatives promoting smoke-free environments in athletic settings and enforcing stricter regulations on e-cigarette advertising can help curb this trend. It is crucial to bridge the gap between knowledge and behavior to protect athletes\u0026apos; health and performance from the adverse effects of e-cigarettes.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the support of the Holy Spirit University of Kaslik. We are also grateful for Professor Hanan F. Abdul Rahim at Qatar University, department of public health for providing us with the Arabic version of the questionnaire used. (29)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate/ consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received ethical approval from The Research Ethics Committee (REC) of the Higher Center for Research (HCR) at Holy Spirit University of Kaslik (approval number and date: \u003cem\u003eHCR/EC 2024-045 Kaslik, 16/07/2024.\u003c/em\u003e). The research followed the principles outlined in the Declaration of Helsinki (World Medical Association, 2013). Participants were thoroughly informed about the study\u0026rsquo;s objectives and procedures prior to their involvement. Informed consent was obtained electronically, and participation was completely voluntary. We ensured that data confidentiality and anonymity were rigorously maintained to safeguard participants\u0026rsquo; privacy.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected anonymously after the consent form was complete and securely stored and is available upon request. \u0026nbsp;A statistical analysis is conducted using SPSS version 26 and chi-square, p values, standard error, frequency, count.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed equally to design of the work, the acquisition analysis, interpretation of data, and to the revision of work\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e-Elichia Bou Akar, EBA\u003c/p\u003e\n\u003cp\u003e-Clara Khalil, CK\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e-Andress Youssef, AY\u003c/p\u003e\n\u003cp\u003e-Omar Houchaimy, OH\u003c/p\u003e\n\u003cp\u003e-Georges Al Maalouf, GAM\u003c/p\u003e\n\u003cp\u003e-Theresa Boulos, TB\u003c/p\u003e\n\u003cp\u003e-Elie Bou Akar, EBA\u003c/p\u003e\n\u003cp\u003e-Shafika Assaad, SA\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePan American Health Organization. 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PMID: 29545987; PMCID: PMC5847300.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"E-cigarettes, athletes, smoking behavior, knowledge and perception, peer influence, public health, tobacco use, Lebanon","lastPublishedDoi":"10.21203/rs.3.rs-5685024/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5685024/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe rising prevalence of e-cigarette use among athletes globally and in the Middle East and North Africa (MENA) region including Lebanon, poses significant public health concerns.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study investigates e-cigarette use patterns, knowledge, perceptions, and influences among athletes in Lebanon.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA cross-sectional survey was conducted in Arabic and English among 563 athletes aged 19\u0026ndash;22 years, from July to December 2024. A self-reported questionnaire was adapted. Descriptive univariate analyses were performed, followed by bivariate analyses to examine the association between e-cigarette use and the variables of interest. Additionally, binary logistic regression analysis was conducted to identify the determinants of e-cigarette use among the students.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eE-cigarette use was predominantly social, occurring in homes and cafes. While most of the participants recognized that e-cigarettes could cause lung cancer, only a few believed they were less harmful than traditional cigarettes. Key influences on use included peer pressure, advertisements, stress relief, and curiosity.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eDespite awareness of health risks, e-cigarette use remains widespread among athletes, emphasizing the need for targeted awareness campaigns and stricter regulations to address misconceptions and reduce usage rates in this high-risk population.\u003c/p\u003e","manuscriptTitle":"Prevalence, Risk Factors, Harm, Perception and Attitudes Toward E-Cigarette Use Among Athletes in Lebanon:A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-26 11:08:38","doi":"10.21203/rs.3.rs-5685024/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fabb9ca6-37c7-4c99-9dd0-2d2fd5b5477e","owner":[],"postedDate":"March 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-10T10:08:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-26 11:08:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5685024","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5685024","identity":"rs-5685024","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}