Early Initiation and Dual Patterns of Cigarette and E-Cigarette Use among Adults in the Eastern Province, Saudi Arabia: A Cross-Sectional Study

Summary

Objectives:

To explore the early initiation of cigarette and e-cigarette use and the dual patterns of usage among adults in the Eastern Province of Saudi Arabia.

Methods:

A cross-sectional survey was conducted from December 2024 to February 2025 among adults living in the Eastern Province. An online self-administered questionnaire collected data on sociodemographic characteristics, smoking behaviors, age of initiation, dual-use patterns, and quit attempts. Convenience sampling was applied, and a total of 551 participants were included. Descriptive statistics summarized distributions of smoking behavior and initiation age. Pearson's Chi-square tests were used to examine associations between smoking status, age of initiation, and product-use categories.

Results:

Among the 551 participants, 29.9% were current smokers. Cigarettes were the most used product (50.7%), followed by shisha (42.2%) and e-cigarettes (34.5%). More than half of smokers (52.7%) initiated smoking between 15–20 years of age, while 8.5% initiated before age 15. Tobacco-use patterns varied, with 26% reporting cigarette-only use, 13% e-cigarette-only use, and 32% shisha-only use. Dual-use patterns included cigarette + shisha (7%), cigarette + e-cigarette (6%), and e-cigarette + shisha (5%), while 11% reported triple-product use. Quit attempts were most common among cigarette-only users (42 attempts), followed by e-cigarette–only users (22) and dual users (14).

Conclusion:

Early initiation and diverse tobacco-use patterns including cigarette, shisha, and e-cigarette use are common in the Eastern Province. Dual and triple-product use further highlight evolving nicotine behaviors, emphasizing the need for targeted prevention and cessation strategies.

Introduction

Tobacco use is a major preventable cause of morbidity and mortality worldwide [1]. Electronic nicotine delivery systems (ENDS), including e-cigarettes, have expanded rapidly, with meta-analyses reporting increasing use among youth and young adults [2].

In Saudi Arabia, national and regional surveys indicate increasing experimentation with and use of e-cigarettes, particularly among adolescents and young adults [3,4]. Lower perceived risk and greater openness to novel nicotine products in these groups may contribute to evolving patterns of dependence and dual use [5].

Saudi Arabia ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2005, committing to comprehensive tobacco control measures [6]. Saudi Arabia enacted a comprehensive Anti-Smoking Law (Royal Decree No. M/56, 2015), regulating smoke-free public places, advertising bans, and sales restrictions [7]. National data from 2021 show that tobacco use remains prevalent in Saudi Arabia, with 15.6% reporting smoked tobacco use and 8.6% using smokeless tobacco. The persistence of higher use among men and middle-aged adults highlights the need for strengthened and targeted tobacco control efforts [8]. Evidence on e-cigarettes remains debated at the population level. Systematic reviews report high-certainty evidence that nicotine e-cigarettes improve smoking cessation in clinical trial settings, while the WHO highlights concern about youth uptake and dual use [9,10].

Early tobacco initiation is associated with higher nicotine dependence, lower cessation success, and greater likelihood of later multiple-product use. Research indicates that adolescents who begin smoking at a younger age transition more rapidly to dependence and have more difficulty quitting as adults [11].

Although international studies have examined links between e-cigarette initiation and later smoking behaviors, evidence from Middle Eastern contexts remains limited. In Saudi Arabia, most studies assess cigarette smoking or e-cigarette use separately, and comprehensive assessment of dual-use patterns is uncommon. Furthermore, to our knowledge, there is limited published data specifically examining early initiation and dual-use behaviors in the Eastern Province, despite its demographic and socioeconomic diversity. Addressing this regional gap is essential to provide context-specific evidence to guide tobacco control strategies and public health interventions.

Methods

A cross-sectional survey was conducted among adults living in the Eastern Province of Saudi Arabia. Data was collected over 2 months, from December 2024 to February 2025. An online self-administered questionnaire was distributed through WhatsApp and other social media platforms. The survey included users and nonusers of tobacco products to capture information on smoking initiation and cigarette, e-cigarette, and dual-use patterns.

A non-probability convenience sampling approach was applied. The survey link was disseminated via WhatsApp and other social media platforms, allowing voluntary participation. While this method facilitated broad and rapid distribution, it may have introduced selection bias, as participation depended on internet access, social media engagement, and individual willingness to respond.

Eligible individuals were aged 15–65, currently living in the Eastern Province, and able to understand Arabic or English. Exclusion criteria included being younger than 15, not residing in the region at the time of participation, and being unable to complete the survey due to cognitive or language-related limitations.

The minimum sample size was estimated using the formula where Z = 1.96 for a 95% confidence level, P = 0.5 to maximize variability, and E = 0.05 as the margin of error. The calculated sample size was 384 participants. To account for potential nonresponse and incomplete data, the target sample size was increased to 500.

The questionnaire included 44 items adapted from validated instruments addressing tobacco use and health behaviors. Public health experts reviewed the items for clarity and cultural relevance. Sociodemographic characteristics included age, sex, marital status, education, employment, and monthly income. Health-related variables included body mass index, chronic disease status, and physical active. Smoking behavior was assessed through questions on current and past use of cigarettes, shisha (waterpipe), and e-cigarettes. A current user was defined as a participant who reported using a specific tobacco product within the past 30 days. An exclusive cigarette user was defined as a participant who reported cigarette use in the past 30 days but no e-cigarette uses during the same period. An exclusive e-cigarette user was defined as a participant who reported e-cigarette use in the past 30 days but no combustible cigarette use. A dual user was defined as a participant who reported use of both cigarettes and e-cigarettes within the past 30 days. Shisha use was analyzed as a separate category and was not included in the dual-use classification.

Passive smoking exposure was assessed through self-reported regular exposure to second-hand smoke at home, workplace, or social settings. Age of initiation was defined as the age at which the participant first tried cigarettes or e-cigarettes, regardless of frequency. Smoking cessation behavior was assessed by asking participants whether they had attempted to quit smoking within the past 12 months.

Ethical approval

Ethical approval was obtained from the Institutional Review Board at King Saud University (Approval No. KSU-HE-24-1087). Participants were informed about the objectives and procedures of the study. Electronic informed consent was obtained before participation. No identifying information was collected, and all responses remained anonymous. Data were stored securely in a password-protected system accessible only to the research team.

Statistical analysis

The Statistical Package for the Social Sciences version 27 (IBM Corp., Armonk, NY, USA) was used for data analysis. Descriptive statistics were presented as frequencies and percentages. Pearson's chi-square tests were performed to examine associations between smoking status, age of initiation, product-use categories, and sociodemographic variables. A significance level of p < 0.05 was used.

Results

A total of 551 adults were included; Table 1 presents their sociodemographic and health characteristics by smoking status. Most participants were aged 30–44 (49%), followed by those aged 15–29 (31.8%). The majority were male (73.9%) and married (72.1%). Half of the sample held a bachelor's degree (50.5%), and nearly 3-quarters were employed (72.2%), with 61% working in the governmental sector. Regarding household composition, 44.3% lived in households with over 5 members, and 40.1% lived in households of 3 to 4 members. Approximately 31.2% of participants were overweight, and 27% were classified as obese. Chronic disease prevalence was relatively low, with 10.5% reporting hypertension and 5.3% diabetes.

Table 1.

Sociodemographic characteristics stratified by smoking status among adults in the Eastern Province (N = 551).

	Smoking status
	Current smoker		Non-smoker		Passive-smoker
Factors	n	%	n	%	No	%	P-value
Age in years
15–29	53	30.3%	108	61.7%	14	8.0%	.079^
30–44	83	30.7%	148	54.8%	39	14.4%
45–60	27	27.0%	68	68.0%	5	5.0%
>60	2	33.3%	4	66.7%	0	0.0%
Gender
Male	154	37.8%	208	51.1%	45	11.1%	.001*
Female	11	7.6%	120	83.3%	13	9.0%
Qualification
Secondary education	30	29.4%	69	67.6%	3	2.9%	.003*
Diploma	45	37.5%	67	55.8%	8	6.7%
Bachelor degree	81	29.1%	160	57.6%	37	13.3%
Post-graduate	9	17.6%	32	62.7%	10	19.6%
Marital status
Single	46	33.3%	83	60.1%	9	6.5%	.164
Married	115	29.0%	233	58.7%	49	12.3%
Divorced/widow	4	25.0%	12	75.0%	0	0.0%
Are you pregnant
Yes	2	25.0%	5	62.5%	1	12.5%	.971^
No	117	28.9%	240	59.3%	48	11.9%
Body mass index
Underweight	8	25.8%	19	61.3%	4	12.9%	.049*
Normal weight	47	23.6%	126	63.3%	26	13.1%
Overweight	65	37.8%	97	56.4%	10	5.8%
Obese	45	30.2%	86	57.7%	18	12.1%
Family size
Not living alone	4	28.6%	9	64.3%	1	7.1%	.402
2 persons	18	25.0%	47	65.3%	7	9.7%
3–4 persons	75	33.9%	118	53.4%	28	12.7%
>5 persons	68	27.9%	154	63.1%	22	9.0%
Employment
Unemployed	11	13.8%	64	80.0%	5	6.3%	.001*
Student	17	23.3%	49	67.1%	7	9.6%
Employed	137	34.4%	215	54.0%	46	11.6%
Nature of work
Governmental	63	26.1%	148	61.4%	30	12.4%	.001*^
Semi-governmental	6	25.0%	12	50.0%	6	25.0%
Private	63	50.8%	52	41.9%	9	7.3%
Free work	3	50.0%	2	33.3%	1	16.7%
Field of work
Health care filed	51	25.8%	115	58.1%	32	16.2%	.004*
Non-health care field	114	32.3%	213	60.3%	26	7.4%
Monthly income
<5000 SR	34	26.4%	85	65.9%	10	7.8%	.383
5000–10000 SR	46	34.8%	75	56.8%	11	8.3%
10000–15000 SR	52	30.2%	100	58.1%	20	11.6%
>15000 SR	33	28.0%	68	57.6%	17	14.4%
Chronic diseases
Yes	32	29.4%	68	62.4%	9	8.3%	.648
No	133	30.1%	260	58.8%	49	11.1%
Practice sports
Yes	100	31.3%	190	59.6%	29	9.1%	.371
No	65	28.0%	138	59.5%	29	12.5%

P: Pearson X² test,

^{^:}Exact probability test,

^*P < 0.05 (significant).

Smoking status is illustrated in Fig. 1A. Overall, 29.9% of participants were current smokers (95% CI: 26.1%–33.8%), 59.5% were non-smokers (95% CI: 55.4%–63.6%), and 10.5% identified as passive smokers (95% CI: 7.9%–13.1%). Among current smokers, cigarettes were the most used product (50.7%), followed by shisha (42.2%) and e-cigarettes (34.5%). More than one-third (37.6%) reported the presence of smokers in the household. Among passive smokers, exposure occurred most frequently 1–2 times per week (34.5%), while 19% reported daily exposure (Table 2).

Fig. 1.

Smoking status and age of smoking initiation among adults in the Eastern Province of Saudi Arabia (N = 551). (A) Prevalence of smoking status. (B) Age of smoking initiation among current smokers (N = 165).

Table 2.

Smoking behavior and passive exposure among adults in the Eastern Province of Saudi Arabia (N = 551).

Smoking data	n	%
Smoking status
Current smoker	165	29.9%
Non-smoker	328	59.5%
Passive-smoker	58	10.5%
Type of smoking
Cigarettes	113	50.7%
Shisha	94	42.2%
E-cigarettes	77	34.5%
Hookah	34	15.2%
If you are a passive smoker, what is your exposure to passive smoking?
Daily	11	19.0%
3–4 times/week	15	25.9%
1–2 times/week	20	34.5%
Rarely	12	20.7%
Are there smokers in the home?
Yes	62	37.6%
No	103	62.4%
How old were you when you started smoking?
<15 years	14	8.5%
15–20	87	52.7%
21–25	42	25.5%
26–36	22	13.3%
How did you get your first cigarette?
I took the initiative myself	95	57.6%
From relatives	46	27.9%
From friends/college	22	13.3%
Parents	2	1.2%
Number of cigarettes smoked/day
1–5 / day	77	46.7%
6–9 / day	30	18.2%
10–20 / day	47	28.5%
> 20 / day	11	6.7%
How often do you smoke tobacco products weekly? (Including hookah and molasses)
Daily	72	43.6%
5–6 times	13	7.9%
3–4 times	22	13.3%
1–2 times	58	35.2%

Fig. 1B displays the age distribution of smoking initiation among current smokers (N = 165). More than half (52.7%) reported initiating smoking between 15–20 years, while 25.5% began between 21–25 years. Early initiation (<15 years) was reported by 8.5% of smokers (95% CI: 4.3%–12.8%). Regarding the source of the first cigarette, 57.6% indicated that they initiated smoking on their own, while others obtained their first cigarette from relatives (27.9%) or friends/college peers (13.3%).

Fig. 2 illustrates the distribution of product-use patterns among tobacco users (N = 217). Shisha-only use was the most prevalent pattern (32%), followed by cigarette-only (26%) and e-cigarette-only (13%). Dual-use patterns were also evident, including cigarette + shisha (7%), cigarette + e-cigarette (6%), and e-cigarette + shisha (5%). Triple use (cigarettes, e-cigarettes, and shisha) accounted for 11% of users.

Fig. 2.

Mosaic plot illustrating the distribution of tobacco-use patterns among adults in the Eastern Province (N = 217). C = Cigarettes only, E = E-cigarettes only, S = Shisha only, C+E = dual cigarette and e-cigarette use; C+S = dual cigarette and shisha use; E+S = dual e-cigarette and shisha use; C+E+S = triple use.

Quit-attempt patterns by product type are shown in Fig. 3. Among cigarette-only users, 42 participants reported a quit attempt, compared with 22 among e-cigarette–only users and 14 among dual users. Across all groups, a greater number of exclusive cigarette users attempted to quit compared with those who used e-cigarettes or dual products.

Fig. 3.

Quit attempts among cigarette-only, e-cigarette–only, and dual users in the Eastern Province of Saudi Arabia (N = 100).

The results of the multivariable logistic regression analysis identifying independent predictors of current smoking are presented in Table 3. After adjusting for potential confounders, female participants had significantly lower odds of being current smokers compared to males (AOR = 0.18, 95% CI: 0.09–0.36, p < 0.001). Overweight individuals had higher odds of current smoking compared to those with normal weight (AOR = 2.03, 95% CI: 1.19–3.46, p = 0.009). Employment status was also independently associated with smoking; employed participants were more likely to be current smokers compared to unemployed individuals (AOR = 3.67, 95% CI: 1.78–7.58, p < 0.001). Participants working in the private sector had higher odds of smoking compared to those in governmental positions (AOR = 2.85, 95% CI: 1.67–4.86, p < 0.001). Additionally, individuals working in non-healthcare fields had increased odds of smoking compared to healthcare workers (AOR = 1.52, 95% CI: 1.01–2.28, p = 0.044).

Table 3.

Multivariable binary logistic regression analysis of factors associated with current smoking among study participants in the Eastern Province.

Variable	AOR	95% CI	P-value
Gender
Male	1 (Ref)	-	-
Female	0.18	0.09–0.36	<0.001*
Educational qualification
Secondary	1 (Ref)	-	-
Diploma	1.29	0.71–2.35	0.404
Bachelor	0.88	0.50–1.55	0.659
Postgraduate	0.42	0.16–1.10	0.078
Body mass index
Normal weight	1 (Ref)	-	-
Underweight	1.09	0.45–2.63	0.847
Overweight	2.03	1.19–3.46	0.009*
Obese	1.44	0.84–2.46	0.186
Employment status
Unemployed	1 (Ref)	-	-
Student	2.02	0.88–4.63	0.097
Employed	3.67	1.78–7.58	<0.001*
Nature of work
Governmental	1 (Ref)	-	-
Semi-governmental	1.18	0.40–3.46	0.765
Private	2.85	1.67–4.86	<0.001*
Free work	2.94	0.45–19.20	0.261
Field of work
Healthcare	1 (Ref)	-	-
Non-healthcare	1.52	1.01–2.28	0.044*

^*Statistically significant at p < 0.05, AOR: Adjusted odds ratio, CI: Confidence interval.

Discussion

The most striking finding of this study may be the high proportion of early smoking initiation among adults in the Eastern Province, with over half of current smokers reporting smoking their first cigarette aged 15–20. This early uptake is particularly significant, as adolescence is recognized as a critical period for increased nicotine sensitivity and long-term addiction risk. Numerous studies have shown that initiating smoking at a younger age is associated with higher levels of nicotine dependence and reduced likelihood of successful cessation in adulthood [12,13]. Furthermore, broader national data corroborate that youth and young adults in Saudi Arabia remain vulnerable to initiating cigarette and e-cigarette use, particularly in high-risk areas such as the Eastern Province [14,15].

Regarding the distribution of tobacco-use patterns, nearly one-third of participants were current smokers, with cigarettes being the most common product, followed by shisha and e-cigarettes. A substantial proportion of smokers also reported dual or polytobacco use. Although the present data represent a single time point, these findings align with those observed in longitudinal studies such as the PATH study, which consistently show that dual-use behaviors are often fluid and transitional [16,17]. Similarly, national and regional data from the Gulf region show comparable patterns of cigarette, shisha, and e-cigarette use, with increasing experimentation with ENDS among young adults [18,19]. One interpretation of these findings is that many dual users may not engage with e-cigarettes as a structured cessation tool but rather as a supplemental behavior a pattern supported by prior research. Studies show that contextual factors such as social setting, craving, and smoking restrictions strongly influence whether individuals choose cigarettes or e-cigarettes [20]. Behavioral economics research similarly reported that cigarettes and e-cigarettes are only partially substitutable, as users tend to maintain consumption of both products depending on situational factors such as convenience and price [21]. Evidence from large cohort studies indicates that most dual users continue smoking over time, using e-cigarettes situationally rather than transitioning completely to vaping [16].

Although two-thirds of smokers had attempted to quit at some point, only about one in five had attended a cessation clinic. This gap between intention and formal service use has been consistently reported in Saudi and regional studies. For instance, national data from the 2019 Global Adult Tobacco Survey indicated that while 60% of tobacco users were aware of fixed cessation clinics, only 9% had attended one [22]. Clinical evidence demonstrates that structured cessation programs combining counseling and pharmacotherapy markedly improve quit rates [23]. However, the persistently low uptake of such services, despite increased availability, underscores that supply alone is insufficient to change behavior—a finding echoed across Gulf countries, where motivation and perceived social norms strongly influence cessation outcomes [24].

In the present study, a substantial proportion of smokers reported smoking after meals (77%) and before breakfast (20%). Consistent with our results, a recent qualitative investigation reported that many smokers associate smoking with mealtimes, particularly after breakfast, lunch, and dinner [25]. Moreover, A 2023 national survey indicated that a large proportion of smokers initiate smoking early in the day, with 43% smoking within the first 30 minutes of waking and 57% smoking before midday [26]. Although many participants reported smoking in social contexts, most preferred to smoke alone. This pattern may reflect the impact of smoke-free policies and changing cultural norms in Saudi Arabia, where recent evidence indicates growing support for smoke-free environments [27].

In the present study, 10.5% of participants identified as passive smokers, and more than one-third reported the presence of smokers within the household. Although lower than the levels reported among adolescents in the Gulf region, these findings remain concerning. A recent multi-country analysis of Global Youth Tobacco Survey data across GCC countries reported substantially higher exposure among adolescents, with home exposure ranging from 12.7% to 39.4% and public-place exposure exceeding 40% in several countries [28]. Similarly, a school-based study conducted in Jeddah during the COVID-19 pandemic found that 48.8% of children reported exposure to second-hand smoke, with 23.8% exposed at home [29].

Several limitations should be considered when interpreting these findings. First, the cross-sectional design limits the ability to determine causal relationships or changes in tobacco-use patterns over time. Although early initiation was common, it cannot be concluded that it directly resulted in dual use, exclusive smoking, or attempts to quit. Second, the use of convenience sampling may limit generalizability, as individuals with greater interest in nicotine products or cessation may have been more likely to participate. Third, all outcomes were based on self-reports, which introduces the possibility of recall bias or underreporting, particularly for smoking inside the home or quit attempts. Finally, the classification of tobacco products did not include details of the device type, nicotine concentration, or frequency of e-cigarette use. Previous studies, including reports linking higher nicotine concentrations and pod or mod systems to increased dependence, have shown that these factors influence dependence and cessation outcomes [30]. Other evidence indicates that daily e-cigarette users with lower baseline dependence may be less likely to quit smoking and that high-nicotine, salt-based products are associated with more frequent use and stronger dependence symptoms [31,32].

Despite these limitations, the findings are consistent with prior research and have important implications for tobacco control. The high rate of early initiation and continued smoking highlights the need for stronger youth-focused prevention strategies, including marketing restrictions, taxation, and school-based programs. Additionally, the low utilization of cessation services despite frequent quit attempts suggests a gap between motivation and access to structured support. Addressing dual-use patterns specifically may improve cessation efforts in this population.

In conclusion, this study highlights the high prevalence of early smoking initiation in the Eastern Province, with more than half of smokers reporting first use between ages 15–20. Dual and multiple tobacco-product use were also common, reflecting a diversified pattern of nicotine consumption. Smoking behaviors frequently occurred in routine and social contexts. Longitudinal research is needed to better understand transitions between cigarette and e-cigarette use and their implications for dependence and cessation.

AI disclosure statement

Artificial intelligence tools (ChatGPT, OpenAI) were used for language editing and formatting. AI tools were not used for study design, data collection, analysis, or interpretation. The authors take full responsibility for the accuracy and integrity of the manuscript.

Conflict of interest

The authors declare no conflicts of interest.

Funding

The authors would like to thank the Ongoing Research Funding Program (ORF-2026-1594), King Saud University, Riyadh, Saudi Arabia, for financial support.

Preprint disclosure

We hereby confirm that this article has not been previously published or posted on any preprint servers.

Conference presentation disclosure

This study has not been presented at any scientific meeting or conference, nor published in any conference proceedings.

Disclosure of benefit

The authors have no financial or material support related to this study.

Ethical approval

King Saud University Institutional Review Board (Approval No. KSU-HE-24-1087).

Acknowledgment

The authors would like to thank the Ongoing Research Funding Program (ORF-2026-1594), King Saud University, Riyadh, Saudi Arabia, for financial support.