Document Type : Original Article


1 Hawler Medical University, College of Health Sciences, Public Health Department, Erbil City, Kurdistan region, Iraq

2 Tishk International University, Faculty of Applied Sciences, Medical Analyses Department, Erbil City, Kurdistan region, Iraq


Introduction: Using of electronic cigarettes is on the increase all over the world, in particular, among young people. Vaping regularly resulted in health complications with substantial proof. The study was to evaluate university students’ prevalence and perceptions in terms of E-cigarettes.
Materials and methods: An online cross-sectional survey was utilized to conduct the research from June 4th, 2023 to November 15th, 2023 at Hawler Medical University, Kurdistan Region in Erbil, Iraq. The questionnaire was filled up by 629 students. The features, prevalence, and perception of the participants were assessed using descriptive statistics. The chi-square test was used with the statistical significance fixed at p <0.05.
Result: The prevalence of electronic cigarettes was 99 (15.7%) The majority of the participants 277 (44%) age group (20-21) years old, in more than half of the participants were female 382 (60.7%), the academic year of the participant were 211 (33.5%) of them first year and 156 (24.8%) of them from the College of Medicine at Hawler Medical University. Approximately one-third (74.6%) of the samples demonstrated fair alertness regarding the damaging effects of smoking hookah, while only 6.4% exhibited marvelous alertness.
Conclusion: The usage of extraordinary prevalence of E-cigarettes was identified. It leads to an upturn of attractiveness and habit of E-cigarettes among students of college. The study recommends that the relevant governmental offices take the findings into consideration. Systematic activities should be performed to stop prevalence of E-cigarettes usage and to rise the peoples’ knowledge regarding nicotine products.               

Graphical Abstract

Prevalence and Perceptions toward Electronic Cigarettes (Vaping) Use among Medical Students: A New Public Health Challenge in Kurdistan Region, Iraq


Main Subjects


Electronic cigarettes (E-cigarettes) are tools warming up a watery solution and produce a mist that people inhale. The solution usually contains glycerol and propylene glycol, and may also have nicotine and flavors [1]. Many young adults, including medical students, have been using e-cigarettes more frequently in recent years. The usage of E-cigarettes/vaping among medical students becomes a bigger problem for communal health in the region.

E-cigarettes have quickly become widely available in the market, even though there are still many uncertainties surrounding their safety, effectiveness in reducing harm and helping people quit smoking, and overall impact on public. The landscape of E-cigarette products is evolving rapidly, and the data from research on older products may not apply to the evaluation of newer products that have the potential to be safer and more efficient as nicotine delivery systems. Furthermore, marketing strategies and other external factors can differ by country, leading to variations in patterns of usage and potential impacts on public health. The inherent risks and advantages of these products must be considered within the ongoing presence of traditional cigarettes and other tobacco items, as well as the common practice of using e-cigarettes and conventional cigarettes simultaneously among both adults.

It is important to assess e-cigarette toxicant exposure and individual risk, as well as the health effects, of e-cigarettes as they are actually used to ensure safety and to develop an evidence-based regulatory scheme that protects the entire population- children and adults, smokers and nonsmokers- in the context of how the tobacco industry is marketing and promoting these products. Health claims and claims of efficacy for quitting smoking are unsupported by the scientific evidence to date. To minimize the potential negative impacts on prevention and cessation and the undermining of existing tobacco control measures, E-cigarette use should be prohibited where tobacco cigarette use is prohibited and the products should be subject to the same marketing restrictions as tobacco cigarettes. The first documented reference to an electronic cigarette (E-cigarette) is dated back to 1930, but a patent was obtained for the first non-tobacco, smokeless cigarette device in the USA by Herbert A. Gilbert in 1965. However, it is not commercialized till 1980s on a limited scale while Hon Lik, a pharmacist, invented the first-generation E-cigarettes in 2003. The nicotine liquid was diluted and vaporized using a piezoelectric element in a propylene glycol solution. E-cigarette progressively has entered the USA and European market in 2006 then the infection passed to all other countries [2]. The vaping business has industrialized gradually since its start, producing goods that are more appealing and efficient through innovation, and E-cigarettes come in a wide range of styles, forms, and dimensions [3]. Some E-cigarettes have a visual resemblance to traditional cigarettes, while others may take the form of fountain pens or miniature flashlights. There are also those designed to resemble cigars or pipes. Some are non-rechargeable single-use disposables, while others feature prefilled cartridges or refillable cartridges (modular systems) which users can replenish with E-liquids or E-juices [4].

So many brands of E-cigarette have been produced in the world. However, they share similar parts which are a battery, a reservoir comprising the liquid and a vaporization chamber with warming element the e liquid contains a solvent (propylene glycol or vegetable glycerin), flavorings (tobacco, mint, fruit, and bubblegum), and often, nicotine in various doses typically ranging from 3-50 mg/ ml [5]. The frequency with which medical students use e-cigarettes varies across different studies.

An investigation carried out at Saudi Arabia's Qassim University found that approximately 10% of medical Students admitted to using E-cigarettes [6]. Another study in Jeddah, Saudi Arabia, involving three different universities reported that 27.7% of participants smoked electronic cigarettes [7]. In contrast, an investigation carried out at the University of Minnesota explored that 14.7% of medical students had ever tried e-cigarettes [8]. In France, the popularity of E-cigarette ever use among college students was available to be 23.0%, which is consistent with rates in Poland, the USA, and Romania. The occurrence of existing E-cigarette use among college students in France was 5.7% lower than in the USA [9]. A current epidemic of lung harm interrelates to vaping products or E-cigarettes. More than 2600 cases and 60 losses have been registered so far in the USA and other parts of the world [10, 11]. E-cigarettes that contain cannabis have been linked to lung harm in almost 80% of documented cases involving vaping products or e-cigarettes, while products containing nicotine and cannabinoids have been utilized in about 58% of reported cases, only nicotine has been used in 13% of cases [12, 13].

In the United States, E-cigarette usage has become a domestic epidemic among high/middle schools pupils, with prevalence rates of 27.5% and 10.5%, respectively [14]. Among college students in the US, opinions about how harmful and addicting E-cigarettes were found to be lower paralleled to conventional cigarettes. This insight of lower harm and addictiveness was also observed among high-class and dual users of E-cigarettes [15].

Materials and Methods

The purpose of this cross-sectional study is to dictate undergraduate students at Hawler Medical University regarding the prevalence and attitudes of E-cigarette usage as well as the health hazards that go along with it. The students were updated with the purpose of the research and guaranteed that their response was only used for the study. The involvement was optional. The duration of the study was from June 4th 2023 to November 15th 2023. The questionnaire was designed as a google form and handed out to the contributors by means of a text message. The questionnaire embraced three different parts. Sociodemographic characteristics covered the first part. Part two stood for smoking status and part three represented the perception towards health-related risks of E-cigarettes use. Only the undergraduates at Hawler Medical University encountered the inclusion necessities. The data were analyzed via SPSS V.27.0. The frequency and percentages were determined in descriptive analysis. Moreover, the relations between variables were tested through chi-square test, and the statistical significance was installed at p <0.05.

Table 1: Socio-demographic characteristics of the participants

Table 2: Study sample distribution by general information of smoking habits

Results and Discussion

The majority of the participant 277 (44%) age group (20-21) years old, in which more than half of the participant are female 382 (60.7%), regarding the academic year of the participant were 211 (33.5%) of them first year and 156 (24.8%) of them from college of medicine at Hawler Medical University (Table 1).

Table 2 indicates that 99 (15.7%) of the study sample were regularly use e-cigarette (vape) smokers, while only 55 (8.7%) of them smoked occasionally, more than half 475 (75.5%) of them were non-E-cigarette smoking. Concerning smoking conventional cigarette, 40 (6.4%) of the study sample were regularly smokers, while only 27 (4.3%) of them smoked occasionally, more than three quarter 562 (89.3%) of them were never smoked cigarette smoking. Concerning smoking hookah, Table 2 shows that 39(6.2%) of the study sample were regularly smokers, while only 31 (4.9%) of them smoked occasionally but not regularly, more than three quarter 559 (88.9%) of them were never hookah smoking.

As can been seen in Tables 3 and 4, participants’ awareness was poor (19.1%) with regard to harmful of smoking hookah. One-third (74.6%) had a fair understanding of the hazards associated with hookah smoking showing the overall awareness of the participants about harmful of smoking hookah was poor (19.1%). About one-third (74.6%) of them were had fair awareness about the harmful of smoking hookah. Merely 6.4% possessed marvelous awareness.

To the best empathy, this is the foundational work examining the prevalence of vaping among students enrolled in medical universities in the Kurdistan Region. The vaping is going to a public health challenge because the number of users increase rapidly furthermore the use of E-cigarette should take consideration among population and especially among health professional and more specifically among medical student. The prevalence of college students use E-cigarettes is different across different countries. The study investigated the prevalence of electronic cigarette usage by Students in medical universities. Ever-use of e-cigarettes was 15.7% in the current study. The findings of this study was highly compared with a study conducted at Umm AlQura University, Makkah, Saudi Arabia, declared that 31% of respondents are currently smoking e-cigarettes [16]. A study conducted in medical schools at University of Minnesota discovered that a prevalence of 14.7% [8]. Further investigation indicated that 9.5% of Jordanian university medical students acknowledged using e-cigarettes. The sample was a nationwide cross-sectional one that involved 1819 medical students from five medical colleges in Jordan. Many research works, from meta-analyses to longitudinal and cross-sectional studies, have consistently supported the idea that young individuals who use E-cigarettes are more likely to later smoke traditional cigarettes [17,18]. Findings of this study indicated that the majority of the research sample for age group was between 20-21 years old, they were female, first year medical student and from college of medicine respectively.

Table 3: Study sample distribution by their E-cigarettes awareness

Table 4: Overall responses about E-cigarette awareness (vaping)

The existent research displayed that majority of the study participant mentioned that smoking E-cigarette is not less harmful than conventional cigarette and also not less addictive. A survey by the Center for Environmental Health of 97 different E-cig products showed the chemical acetaldehyde to be present. Acetaldehyde is associated with asthma and cancer. In addition, they found lead, cadmium, nickel, tin, and other heavy metals that are associated with nervous-system and respiratory problems [19]. E-cigarette users who use nicotine-containing products might develop a dependence on them; nonetheless, e-cigarettes are usually thought to be less addictive than traditional cigarettes [20, 21]. Professionals express hesitation concerning the potential addictiveness of E-cigarettes, as they encompass nicotine, a substance known to induce addiction [22]. The rising misconception that E-cigarettes are just as deadly as regular combustible cigarettes, if not more so, exacerbates this worry [23]. In this current study, more than half of the participant thought that the E-cigarette contains chemical substance and highly risk for cancer. This result agree with a study was founded that Particularly in the mid and high ranges of observed values, E-cigarette liquids and aerosols stand out as a notable and remarkably changeable source of metals, contributing to unduly elevated risks of both cancer and non-cancer outcomes [24]. Lead, manganese, arsenic, cadmium, and nickel are small contributors to these dangers, although chromium and nickel are the main culprits, despite the point that E-cigarette vapours are verified to have far fewer carcinogenic toxicants than regular tobacco [25].

Concerning the possibilities of taking drugs such as cannabis or marijuana in E-cigarettes near two third of the participant believed that there’s a possibility of using drugs in E-cigarettes. There are difficulties associated with youth E-cigarette usage because some studies show a link between E-cigarette use and the use of other drugs, such as cannabis [26, 27]. The discovery of the existent study shows that most of the participants thought that E-cigarette cause lung injury and decreasing pulmonary function. The finding of the current work agree with a study was conducted in United States of America they found that a vital fraction of hospitalized patients with lung injuries related to vaping products or E-cigarettes have needed to be admitted to the intensive care unit, and up to one-third of them required mechanical ventilation [5].

Table 5: Associations between socio-demographics of electronic cigarette and their awareness

The outcomes of the existent study specified a moderate stage of knowledge with respect to e-cigarettes among medical students. A total of 473 contributors, constituting 75.2% of the sample, were knowledgeable about the fact that E-cigarettes consist of nicotine, are regarded as tobacco products, and have the potential to cause cancer. The knowledge level observed in this study surpasses that reported at Hangzhou University in China, where approximately 58% of students were certain about E-cigarettes containing nicotine, and over 68% of students failed to recognize E-cigarettes as tobacco products [14]. The findings of the present study illustrate the variability in the overall knowledge of medical students. Medical students appear to possess a heightened awareness of the adverse health effects and addictive properties associated with E-cigarettes. Most students well knowing that E-cigarettes cannot be used in closed or public places may indicate that they are using E-cigarettes (or observing its use) in these places, or that they are unaware that E-cigarettes are prohibited in Brazil [28]. Interestingly, the low level of knowledge about e-cigarettes seems to be common among health colleges students reflected by reports of Habib et al. and Guckert et al., where 69.4% of medical students and 81.6% of dental students believed e-cigarettes were less harmful compared to conventional cigarettes, respectively [6, 28].  Moreover, the present study indicates an association between knowledge about e-cigarettes and their existing usage, both for E-cigarettes and traditional cigarettes. It reveals a trend where smokers exhibit less alertness of the damages and addictiveness linked with E-cigarettes. Similar observations were noted in a study conducted in Thailand, in which participants with lower awareness of the detrimental effects of e-cigarettes were more inclined to use them [29].


The present study show that the Hawler Medical University students consume a high prevalence of use e-cigarette, their level of perception regarding E-cigarettes was fair, even though they are medical students. This implies that E-cigarette use is becoming more common and popular among college students. It is recommended that the government and other relevant authorities take note of the present study's findings as well as those from earlier research, since they indicate a concerning trend toward the widespread use of e-cigarettes and a lack of awareness regarding these nicotine products.


The authors would like to acknowledge all the subjects who participated in the study, everyone who contributed to the completion of the study.

Disclosure Statement

No potential conflict of interest was reported by the authors.


This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.


Sangar Muhammad Ahmed




Sangar Muhammad Ahmed, Prevalence and Perceptions toward Electronic Cigarettes (Vaping) Use among Medical Students: A New Public Health Challenge in Kurdistan Region, Iraq. J. Med. Chem. Sci., 2024, 7(5) 720-728.




©2024 The author(s). This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit:


Sami Publishing Company remains neutral concerning jurisdictional claims in published maps and institutional affiliations.


Sami Publishing Company

[1]. Hutzler C., Paschke M., Kruschinski S., Henkler F., Hahn J., Luch A., Chemical hazards present in liquids and vapors of electronic cigarettes, Archives of Toxicology, 2014, 88:1295 [Crossref], [Google Scholar], [Publisher]
[2]. Holt A.K., Poklis J.L., Peace M.R., The history, evolution, and practice of cannabis and E-cigarette industries highlight necessary public health and public safety considerations, , 2022 [Crossref], [Google Scholar], [Publisher]
[3]. Trucco E.M., Fallah-Sohy N., Hartmann S.A., Cristello J.V., Electronic cigarette use among youth: understanding unique risks in a vulnerable population, Current addiction reports, 2020, 7:497 [Crossref], [Google Scholar], [Publisher]
[4]. Wamamili B.M., Assessing the prevalence of use and perceptions of university students in New Zealand on vaping, cigarette smoking, and the Smokefree 2025 goal, 2020, [Crossref], [Google Scholar], [Publisher]
[5]. Cherian S.V., Kumar A., Estrada-Y-Martin R.M., E-cigarette or vaping product-associated lung injury: a review, The American journal of medicine, 2020, 133:657 [Crossref], [Google Scholar], [Publisher]
[6]. Habib E., Helaly M., Elshaer A., Sriwi D., Ahmad M.S., Mohamed M.I., Obeidat A., Prevalence and perceptions of e-cigarette use among medical students in a Saudi University, Journal of family medicine and primary care, 2020, 9:3070 [Crossref], [Google Scholar], [Publisher]
[7]. Almutham A., Altami M., Sharaf F., AlAraj A., E-cigarette use among medical students at Qassim University: Knowledge, perception, and prevalence, Journal of family medicine and primary care, 2019, 8:2921 [Crossref], [Google Scholar], [Publisher]
[8]. Hinderaker K., Power D.V., Allen S., Parker E., Okuyemi K., What do medical students know about e-cigarettes? A cross-sectional survey from one US medical school, BMC medical education, 2018, 18:1 [Crossref], [Google Scholar], [Publisher]
[9]. Tavolacci M.P., Vasiliu A., Romo L., Kotbagi G., Kern L., Ladner J., Patterns of electronic cigarette use in current and ever users among college students in France: a cross–sectional study, BMJ open, 2016, 6:e011344 [Crossref], [Google Scholar], [Publisher]
[10]. Jatlaoui T.C., Wiltz J.L., Kabbani S., Siegel D.A., Koppaka R., Montandon M., Adkins S.H., Weissman D.N., Koumans E.H., O’Hegarty M., Update: interim guidance for health care providers for managing patients with suspected e-cigarette, or vaping, product use–associated lung injury—United States, November 2019, Morbidity and Mortality Weekly Report, 2019, 68:1081 [Crossref], [Google Scholar], [Publisher]
[11]. Itoh M., Aoshiba K., Herai Y., Nakamura H., Takemura T., Lung injury associated with electronic cigarettes inhalation diagnosed by transbronchial lung biopsy, Respirology case reports, 2018, 6:e00282 [Crossref], [Google Scholar], [Publisher]
[12]. Lozier M.J., Wallace B., Anderson K., Ellington S., Jones C.M., Rose D., Baldwin G., King B.A., Briss P., Mikosz C.A., Update: demographic, product, and substance-use characteristics of hospitalized patients in a Nationwide outbreak of E-cigarette, or Vaping, product use–associated lung injuries—United States, December 2019, Morbidity and Mortality Weekly Report, 2019, 68:1142 [Crossref], [Google Scholar], [Publisher]
[13]. Perrine C.G., Pickens C.M., Boehmer T.K., King B.A., Jones C.M., DeSisto C.L., Duca L.M., Lekiachvili A., Kenemer B., Shamout M., Characteristics of a multistate outbreak of lung injury associated with e-cigarette use, or vaping—United States, 2019, Morbidity and Mortality Weekly Report, 2019, 68:860 [Crossref], [Google Scholar], [Publisher]
[14]. Fang J., Ren J., Ren L., Max W., Yao T., Zhao F., Electronic cigarette knowledge, attitudes and use among students at a university in Hangzhou, China, Tobacco induced diseases, 2022, 20 [Crossref], [Google Scholar], [Publisher]
[15]. Cooper M., Loukas A., Harrell M.B.,Perry C.L., College students' perceptions of risk and addictiveness of e-cigarettes and cigarettes, Journal of American College Health, 2017, 65:103 [Crossref], [Google Scholar], [Publisher]
[16]. Alshanberi A.M., Baljoon T., Bokhari A., Alarif S., Madani A., Hafiz H., Altayyar A., Abo-Ali E.A., The prevalence of E-cigarette uses among medical students at Umm Al-Qura University; a cross-sectional study 2020, Journal of family medicine and primary care, 2021, 10:3429 [Crossref], [Google Scholar], [Publisher]
[17]. Soneji S., Barrington-Trimis J.L., Wills T.A., Leventhal A.M., Unger J.B., Gibson L.A., Yang J., Primack B.A., Andrews J.A., Miech R.A., Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: a systematic review and meta-analysis, JAMA pediatrics, 2017, 171:788 [Crossref], [Google Scholar], [Publisher]
[18]. Barrington-Trimis J.L., Berhane K., Unger J.B., Cruz T.B., Urman R., Chou C.P., Howland S., Wang K., Pentz M.A., Gilreath T.D., The e-cigarette social environment, e-cigarette use, and susceptibility to cigarette smoking, Journal of Adolescent Health, 2016, 59:75 [Crossref], [Google Scholar], [Publisher]
[19]. Johar R.S., E-Cigarettes: Safer Than Tobacco?, Missouri Medicine, 2016, 113:342 [Google Scholar], [Publisher]
[20]. Cooper M., Harrell M.B., Perry C.L., Comparing young adults to older adults in e-cigarette perceptions and motivations for use: implications for health communication, Health education research, 2016, 31:429 [Crossref], [Google Scholar], [Publisher]
[21]. Etter J.F., Eissenberg T., Dependence levels in users of electronic cigarettes, nicotine gums and tobacco cigarettes, Drug and alcohol dependence, 2015, 147:68 [Crossref], [Google Scholar], [Publisher]
[22]. Ferkol T.W., Farber H.J., La Grutta S., Leone F.T., Marshall H.M., Neptune E., Pisinger C., Vanker A., Wisotzky M., Zabert G.E., Electronic cigarette use in youths: a position statement of the Forum of International Respiratory Societies, European Respiratory Journal, 2018, 51 [Crossref], [Google Scholar], [Publisher]
[23]. Majeed B.A., Weaver S.R., Gregory K.R., Whitney C.F., Slovic P., Pechacek T.F., Eriksen M.P., Changing perceptions of harm of e-cigarettes among US adults, 2012–2015, American journal of preventive medicine, 2017, 52:331 [Crossref], [Google Scholar], [Publisher]
[24]. Fowles J., Barreau T., Wu N., Cancer and non-cancer risk concerns from metals in electronic cigarette liquids and aerosols, International journal of environmental research and public health, 2020, 17:2146 [Crossref], [Google Scholar], [Publisher]
[25]. Alzahrani S.H., Alghamdi R.A., Almutairi A.M., Alghamdi A.A., Aljuhani A.A., ALbalawi A.H., Knowledge and attitudes among medical students toward the clinical usage of e-cigarettes: a cross-sectional study in a university hospital in Saudi Arabia, Risk Management and Healthcare Policy, 2021, 1969 [Google Scholar], [Publisher]
[26]. Audrain-McGovern J., Stone M.D., Barrington-Trimis J., Unger J.B., Leventhal A.M., Adolescent e-cigarette, hookah, and conventional cigarette use and subsequent marijuana use, Pediatrics, 2018, 142 [Crossref], [Google Scholar], [Publisher]
[27]. Cullen K.A., Ambrose B.K., Gentzke A.S., Apelberg B.J., Jamal A., King B.A., Notes from the field: use of electronic cigarettes and any tobacco product among middle and high school students—United States, 2011–2018, Morbidity and Mortality Weekly Report, 2018, 67:1276 [Crossref], [Google Scholar], [Publisher]
[28]. Guckert E.C., Zimmermann C., Meurer M.I., Level of knowledge of undergraduate dental students about electronic cigarettes, Rev ABENO, 2021, 21:1099 [Crossref], [Google Scholar], [Publisher]
[29]. Chudech S., Janmaimool P., Effectiveness of warning graphic labels on cigarette packs in enhancing late-teenagers’ perceived fear of smoking-related harms in Bangkok, Thailand, Journal of Public Health Research, 2021, 10:1912 [Crossref], [Google Scholar], [Publisher]