The impact of group cognitive behavioral therapy on stress and psychological adjustment among cigarette, e-cigarette, and hookah smokers

Abstract

BACKGROUND:

The tobacco epidemic remains one of the world’s major public health threats, causing preventable cancers and disabilities, and claiming over seven million lives each year. Over the past decade, the use of nicotine-containing electronic cigarettes has grown among adolescents and young adults. This study investigates the effectiveness of a group cognitive behavioral therapy program on stress and psychological adjustment among university students who want to quit smoking cigarettes or hookah.

MATERIALS AND METHODS:

The sample included 123 male students who smoked cigarettes and e-cigarettes and 134 students who smoked hookah, all of whom expressed a desire to quit smoking. Students who smoke both cigarettes and hookah were excluded from the study to ensure clear differentiation between the two groups of users. A nonprobability sampling method was used. Psychological stress and psychological adjustments were measured twice: before the group treatment program began and after the program was completed. The study employed an experimental pretest and posttest design to analyze data.

RESULTS:

The results indicated that the program had an effective impact on users of cigarettes, electronic cigarettes, and hookah in terms of stress management strategies and psychological adjustment. Specifically, the program had a positive effect on reducing psychological stress but a negative effect on psychological adjustment, meaning that while stress levels decreased, psychological adjustment also decreased. The program had a greater impact on stress management strategies and psychological adjustment among cigarette and e-cigarette smokers compared to hookah smokers.

CONCLUSION:

The findings suggest that smokers of cigarettes and e-cigarettes are more likely to use stress-coping strategies but have a reduced ability to maintain psychological adjustment, which may be due to their dependence on nicotine. Therefore, it is recommended that awareness be raised about the necessity of involving psychologists in future treatment programs at the national level to help reduce this phenomenon.

Introduction

The tobacco epidemic is one of the world’s biggest public health threats, causing preventable cancers and disabilities, and killing over eight million people each year.[1] The use of nicotine-containing electronic cigarettes (e-cigarettes) has risen among adolescents and young adults over the past decade. In 2021, e-cigarettes remained the most popular tobacco product, with 11.3% of high school students and 2.8% of middle school students.[2] E-cigarette use among young adults is especially concerning because, compared to older adults, the brains of adolescents and young adults are more vulnerable to the harmful health effects of nicotine, which is found in most e-cigarettes.[3] Additionally, recent e-cigarettes can deliver as much or more nicotine than tobacco cigarettes,[4] potentially increasing the risk of addiction.

Waterpipe tobacco smoking (hookah smoking) has also emerged as a new form of tobacco use, especially among the younger generation. According to a study by Elkalmi et al.,[5] 80.3% of the participants had smoked a hookah at least once in the previous 6 months, accounting for nearly half of the participants (49.3%). In their initial hookah smoking experience, over half of the participants (58%) were persuaded by their friends.

Elkalmi et al.[5] noted that the main factors attracting individuals to try hookah were its appealing flavor, aroma, and taste (30%, 29%, and 12%, respectively). However, the primary reasons for continued hookah use were enjoyment and satisfaction, stress relief, and boredom reduction. The vast majority of participants believed there was no link between hookah and lung cancer, asserting that it contained no harmful substances and did not irritate the bronchi. About half of the participants considered hookah to be less addictive, less dangerous, and to contain less nicotine than cigarettes. Sixty-five percent of the study participants strongly believe that hookah will grow increasingly popular over the next five years.[5] Limited knowledge about hookah use and peer pressure were associated with the high rate of hookah smoking. Another study from Pakistan found that the highest prevalence of hookah smoking was among university students from higher socioeconomic backgrounds.[6]

It is well known that people under stress are more likely to smoke cigarettes, which is considered an unhealthy behavior. Stress plays a major role in initiating cigarette smoking, increasing consumption, and reducing efforts to quit.[7] One reason smokers tend to smoke when stressed is the presence of nicotine in cigarettes, which can relieve stress, even if only temporarily. However, research indicates that stress relief can occur even before the first puff and even when cigarettes do not contain nicotine. Therefore, the impact of smoking may be more related to psychological dependence than to nicotine itself.[8] Nicotine use among youth has also been connected to a higher risk of developing nicotine dependence (ND) and progressing to combustible tobacco use.[9]

Estimates from 2020 show an increase in e-cigarette use compared to 2018, with 12.5% of eighth graders, 19.3% of 10^th graders, and 24.7% of 12^th graders reporting e-cigarette use.[10] Youth nicotine use likely continued to rise due to the increasing popularity of new flavored disposable products. This trend has raised concerns among public health advocates, schools, and parents.[11] In Jordan, smoking is considered an unhealthy behavior that harms both physical and mental health. As a result, many studies have been conducted to determine the prevalence of unhealthy habits like smoking among university students. Dhiab’s[12] study, which aimed to identify how common unhealthy behaviors are among university students, found that 22.7% of students smoked cigarettes, 25.3% smoked hookah, and 7.87% smoked both cigarettes and hookah. Regarding therapeutic methods for quitting smoking, these vary. Behavioral therapy techniques appeared first, followed by cognitive therapy.[13]

To better understand the psychological factors among cigarette, electronic cigarette, and hookah smokers, the current study developed a cognitive behavioral therapy group program aimed at examining the program’s effect on stress levels and psychological adjustment. The study also seeks to illuminate the psychological state of smokers during participation in the group cognitive behavioral therapy program, which is crucial for predicting their ability to quit smoking regular cigarettes, electronic cigarettes, or hookah. This insight can help improve the development of effective smoking cessation programs. Additionally, the study emphasizes the importance of learning stress management strategies, which can enhance smokers’ adaptation and self-improvement, helping them avoid compensatory behaviors such as smoking. The research contributes to creating a scientifically grounded training program that can be utilized in future studies.

Smoking tobacco has been practiced in Mesoamerica and South America since around 3000 BC.[14] Burning tobacco releases nicotine and other harmful chemicals, including nitrogen, carbon monoxide (CO), and tar. Nicotine addiction varies depending on how it is consumed, and cigarettes remain the primary way nicotine is delivered worldwide.[15] The biological effects of smoking include the release of about 6000 chemical particles, which are the main cause of health risks. Smoking kills millions of people each year worldwide, leading to diseases of the heart, lungs, stomach, and brain. It also affects fertility, sperm count, and increases the risk of miscarriage. Smoking is the leading cause of coronary heart disease, impacting people of all ages.[16]

Psychological aspects include smoking behavior and personality traits, with most smokers believing it helps them manage anxiety and depression. However, studies show that moderate and heavy smokers experience higher levels of depression, lower scores on emotional balance, and greater psychological alienation compared to nonsmokers.[17,41] A major barrier to quitting smoking is societal acceptance of its risks, with many studies indicating that inadequate enforcement of tobacco control policies contributes to normalizing smoking in public areas, workplaces, and communities. Peer pressure is often recognized as a key factor in encouraging young people to try nicotine early and continue smoking.[18] The economic aspects of smoking involve direct, indirect, and intangible costs. Direct costs include loss of productivity due to smoking-related illnesses, while intangible costs involve loss of life and suffering caused by smoking-related diseases.[19] Goodwin et al.[20] examined hookah usage rates and demographic features among freshmen, focusing on the connections between hookah use, substance abuse, mental health issues, and perceived stress levels. The study found that 14.1% of undergraduates reported using hookah in the past month, with the strongest links observed between hookah use and alcohol and cigarette consumption. However, no significant associations were found between hookah use and mental health problems or perceived stress levels.[20]

A growing body of research has explored various behavioral interventions and psychosocial factors related to nicotine use, including the effectiveness of cessation programs, the influence of stress and mental health, and patterns of e-cigarette use across different demographic and clinical groups. For example, Onyechi et al.[21] studied how a group-focused cognitive behavioral health education program (GCBHEP) affected cigarette smoking among Nigerian inmates. Their study used a pretest–posttest randomized controlled trial (RCT), showing that GCBHEP significantly impacted smoking patterns in the treatment group compared to the control group. The program’s effectiveness was moderate across different age groups and lower depending on educational level. Hajek et al.[22] conducted a multicenter pragmatic RCT with two groups to compare the effectiveness of e-cigarettes and nicotine replacement therapy (NRT) for smoking cessation, finding e-cigarettes to be more effective. Walker et al.[23] designed a three-arm pragmatic RCT comparing nicotine patches, nicotine e-cigarettes, and nicotine-free e-cigarettes. Their main outcome was exhaled CO verified continued abstinence 6 months after the quit date, confirmed by a Bedfont Smokerlyzer reading of nine ppm or lower. Secondary outcomes included 12 months of continuous abstinence, evaluated through 7-day point prevalence at the quit date and at 1, 3, and 6 months afterward.

Fatani et al.’s[24] study aimed to assess the relationship between ND and felt stress in patients with affective disorder (AD) visiting for psychiatric treatment at different clinical stages (initial visit or follow-up) and among various nicotine types (cigarette and waterpipe smokers). They also examined the willingness to stop smoking and its link to difficulties in quitting. This cross-sectional mixed-method study collected both quantitative and qualitative data from 57 individuals seeking treatment at multiple locations in Saudi Arabia. Validated quantitative measures were used to evaluate 70 symptoms of depression, anxiety, perceived stress, and ND. Qualitative questions explored the challenges faced in quitting smoking. ND showed a statistically significant association with felt stress. Participants in the follow-up group had higher ND scores than those in the initial visit group. One of the most frequently stated barriers to quitting was using nicotine as a stress management tool, indicating a readiness to stop. Boredom was more commonly cited as a barrier in the waterpipe group than in the cigarette group. ND had a significant connection with felt stress in individuals with AD, regardless of treatment status, highlighting the importance of assessing smoking cessation during the early phases of treatment for patients with AD and ND. It will be crucial for physicians to provide individuals with Alzheimer’s disease with alternative strategies for managing stress and boredom.[24]

Another study by Ahuja et al.[25] examined the connections between perceived stress, social support, self-esteem, and e-cigarette use among college students in the United States. Two hundred twenty students (aged between 18 and 24) were recruited to complete an online survey. The study focused on current and former e-cigarette users, considering factors such as perceived stress, social support, self-esteem, and sociodemographics. About 30.1% and 55.0% of participants were current and past e-cigarette users, respectively. Participants with high perceived stress were more likely to use e-cigarettes than those with low perceived stress. A one-unit increase in self-esteem lowered the risk of current e-cigarette use by 7%. Perceived stress and self-esteem are strongly associated with e-cigarette use among college-aged young adults.[25] Another study by Erhabor et al.[26] conducted a cross-sectional analysis of the social background of e-cigarette use in the United States, utilizing data from the All of Us research program’s COVID-19 Participant Experience survey. The study found that individuals who reported prior or current e-cigarette use had a greater incidence of psychological distress and drug use than those who had never used e-cigarettes. Current e-cigarette use was associated with higher odds of depressive symptoms, anxiety, suicidal ideation, stress, cannabis, opioids, stimulants, sedatives, hallucinogens, and cocaine use.[26]

Mohsen et al.[27] studied the presence and severity of withdrawal symptoms, along with changes in smoking or vaping behavior and their predictors during Ramadan fasting. A cross-sectional study was conducted during Ramadan in 2023, involving 251 individuals (96% male). Withdrawal symptoms were reported by 70.5%, but their severity was generally mild, both physically and psychologically. Factors, such as education, nationality, smoking duration, ND, and daily E-liquid intake, were independent predictors of withdrawal symptoms. Approximately 134.6% of participants reported attempting to quit smoking or vaping during Ramadan, with younger age and higher education levels linked to more quitting efforts. The severity of withdrawal symptoms during Ramadan fasting remains modest, and many smokers and vapers try to stop during the fast.[27] Ramadan provides an opportunity for smoking and vaping cessation with some behavioral support. Smith et al.[28] conducted a study where one group was given e-cigarettes and another received NRT. The primary goal was a 50% reduction in cigarette use, verified biochemically at 6 months, with sustained abstinence confirmed at the same interval. The generalized linear model with a binomial distribution and a logarithmic link was used to calculate the relative risk of e-cigarettes compared to NRT. In conclusion, the usage rates of hookah, e-cigarettes, and NRT have been studied and compared in various research. Future studies should focus on these factors to better understand their impact on smoking cessation. These findings can guide efforts to raise awareness about the factors associated with e-cigarette use.

Materials and Methods

Study design and setting

The study used an experimental research method, which involves examining the effect of an independent variable on a dependent variable, mainly focusing on quantitative control while isolating factors that could influence the results. This method was selected because it aligns well with the nature of this study.

Study participants and sampling

The study population included all male students in Jordan who smoked regular cigarettes, electronic cigarettes, or hookah. The study sample consisted of 123 cigarette and e-cigarette smokers and 134 hookah smokers, all of whom were males interested in quitting smoking.

Data collection tools and techniques

Two scales were used to collect data:

• Stress Level Scale: The scale was developed by reviewing theoretical literature and previous studies related to stress. The final version of the scale consisted of 32 items.

• Psychological Compatibility Scale: A scale consisting of 30 items in its final version was assessed for its psychometric properties and its suitability for the Jordanian environment.

Validity and reliability

The study tools were validated by presenting them to a group of psychology and measurement specialists to confirm the suitability of the items for assessing psychological stress and psychological compatibility. The scales were also reviewed by Arabic language experts to ensure linguistic accuracy and proper grammar. Some items were revised, but none were removed or added.

The reliability of both scales was confirmed by testing them on a pilot sample of 30 individuals from the study population and calculating the Cronbach’s alpha reliability coefficient. The Cronbach’s alpha for the psychological stress scale was 0.93, showing a high and acceptable reliability level for the study’s goals. To further assess the scale’s reliability, the correlation coefficient between each item and the total score was calculated, showing that all items had high reliability, with correlation coefficients above 0.3 and statistically significant.

The Cronbach’s alpha coefficient for the psychological compatibility scale was 0.95, also indicating a high and acceptable level of reliability. The correlation coefficients for each item with the total score were similarly above 0.3 and statistically significant, confirming the reliability of all items on the scale.

Study procedures

The program was extended to 10 weeks, consisting of 10 sessions, with one session per week. In each session, techniques, such as exposure and response prevention, delayed response, cognitive aversion methods, contemplation methods, self-control and self-monitoring techniques, and problem-solving strategies, were used. Both the psychological stress level scale and the psychological compatibility scale were administered before the group cognitive behavioral program began and after it was completed. The program was conducted with 123 male students who smoke cigarettes and e-cigarettes and 134 male students who smoke hookah, all of whom expressed a desire to quit smoking. Notably, those who smoked both types were excluded. The goal was to better understand the effects of psychological stress, how to manage it, and the participants’ psychological compatibility before and after the program. The primary aim was to reduce the use of cigarettes and hookah and to build psychological resilience that prevents relapse after the treatment program.

Measurement

Premeasurements

• Both stress levels and psychological compatibility were assessed before starting the program, after confirming the students’ consent and desire to quit smoking or hookah. This represents the premeasurement.

• Participants were divided into two groups: regular cigarette and e-cigarette smokers, and hookah smokers. Smokers who used both types were excluded from the study to ensure clear differentiation between the two groups of users.

• The program included 10 sessions, one session per week, each incorporating cognitive behavioral techniques. The smoker undergoing the program was introduced to each technique, which was then applied both inside and outside the session until the participant could master it independently.

Postmeasurements

After the completion of the program, both stress levels and psychological compatibility were remeasured, constituting the postmeasurement.

Statistical analysis

The means and standard deviations for psychological stress and psychological adjustment were calculated before and after the program using Statistical Package for the Social Sciences (SPSS) software. The differences in means between psychological stress and psychological adjustment, measured before and after, were analyzed using the independent samples t-test via SPSS software. Statistically significant differences in psychological stress and psychological adjustment between pre- and postmeasurements for cigarette smokers versus hookah smokers were compared using the effect size index (Eta square). The difference in Eta square was examined using the z-test.

Results

To answer the first question, “Are there statistically significant differences at the significance level (α = 0.05) in psychological adjustment among smokers of regular and electronic cigarettes before and after implementing a group program to quit smoking?” The average responses from a sample of regular and electronic cigarette smokers were calculated on the psychological adjustment scale before and after their participation in the smoking cessation program, as shown in Table 1.

Table 1.

Psychological adjustment scores of regular and e-cigarette smokers before and after the program

Application		Mean		Sample size		Standard deviation
Before the program		P. 0.0870		123		18.17569
After the program		59.2609		123		17.31583

It is noted that there are differences between the means on the psychological adjustment scale before the program, which was 0.087, and after the program, which decreased to 59.609. To examine the significance of these differences, a paired t-test was used, yielding a t-test value of 10.428 with 22 degrees of freedom and a P value of 0.000. This indicates that the differences in the mean responses of regular and electronic cigarette smokers on the psychological adjustment scale between the preprogram and postprogram applications are statistically significant. In other words, the smoking cessation program had an inverse effect on the level of psychological adjustment among regular and electronic cigarette smokers, as the level of psychological adjustment decreased after the program was implemented.

To answer the second question “Are there statistically significant differences at the significance level (α = 0.05) in psychological stress among regular and electronic cigarette smokers before and after implementing a group program to quit smoking?” the means of responses from a sample of regular and electronic cigarette smokers on the psychological stress scale before and after the smoking cessation program were calculated, as shown in Table 2.

Table 2.

Stress scores of regular and e-cigarette smokers before and after the program

Application		Mean		Number		Standard deviation
Before the program		103.3913		123		20.10142
After the program		55.0435		123		17.03333

The averages show that there are differences between the mean on the psychological stress scale before the program, which was (103.3913), and decreased after the program to (55.0435). To examine the significance of these differences, a t-test was used for related samples, where the t-test value reached (8.482) with a degree of freedom of 22 and a probability value of (0.000), indicating the significance of the differences in the mean of the responses of regular and electronic cigarette smokers on the psychological stress scale between the two measurements before and after the program. This means that the smoking cessation program had a significant effect on the level of psychological stress among regular and electronic cigarette smokers, as the level of psychological stress decreased after the program was implemented.

To answer the third question, which states, “Are there statistically significant differences at the significance level (α = 0.05) in psychological adjustment among hookah smokers before and after implementing a group program to quit smoking?” the averages of the responses from hookah smokers were calculated on the psychological adjustment scale before and after exposure to the smoking cessation program, as shown in Table 3.

Table 3.

Responses of hookah smokers on the psychological adjustment scale before and after the smoking cessation program

Application		Mean		Number		Standard deviation
Before the program		117.1481		134		19.92236
After the program		93.1852		134		37.91391

It is noted that there are differences between the mean scores on the psychological adjustment scale before the program, which was (117.1481), and after the program, which decreased to (93.1852). To examine the significance of these differences, a paired t-test was used, with a t-test value of 3.138 at 26 degrees of freedom and a P value of 0.004. This indicates that the differences in the mean scores of hookah smokers on the psychological adjustment scale between the two measurements—before and after the program—are statistically significant. In other words, the smoking cessation program had a negative impact on the level of psychological adjustment among hookah smokers, as their level of psychological adjustment decreased after the program was implemented. This result is statistically significant at a P value of less than 0.05.

To answer the fourth question, which states: “Are there statistically significant differences at the significance level (α = 0.05) in psychological stress among hookah smokers before and after implementing a group program to quit smoking?”, the mean scores of hookah smokers’ responses on the psychological stress scale were calculated both before and after participating in the smoking cessation program, as shown in Table 4.

Table 4.

Responses of hookah smokers on the psychological stress scale before and after the smoking cessation program

Measurement		Mean		Sample size		Standard deviation
Before program		83.0000		134		14.53378
After program		65.3704		134		21.34542

It is noted that there are differences between the means on the psychological stress scale before the program, which was (83.00), and decreased after the program to (65.3704). To examine the significance of these differences, a paired t-test was used, yielding a value of 3.699 with 26 degrees of freedom and a P value of 0.001. This indicates the significance of the differences in the mean of the responses of hookah smokers on the psychological stress scale between the two measurements, before and after the program. That is, the smoking cessation program affected the level of psychological stress among hookah smokers inversely, as the level of psychological stress decreased after the program was applied.

To answer the fifth question, which states, “To what extent does the smoking cessation program affect both psychological adjustment and psychological stress among smokers of regular and electronic cigarettes versus hookah smokers?” the effect size of the differences in responses (Eta squared: η²) was calculated for both the psychological adjustment scale and the psychological stress scale between the pre- and postapplication, depending on the smoking method (cigarettes, hookah), as shown in Table 5.

Table 5.

The effect size (eta squared) for differences between pre- and postapplication measurements of psychological adjustment and psychological stress by smoking method

Smoking method		Regular and electronic cigarettes		Hookah
Psychological adjustment (η²)		0.832		0.275
Psychological stress (η²)		0.766		0.345

The effect size values indicate that the impact of the program on both psychological adjustment and psychological stress is greater among smokers of electronic and regular cigarettes than among hookah smokers. To evaluate the significance of this difference, and since eta squared represents a weighted percentage of the explained variance, the z-test was used to compare the proportions for independent samples. The results of this analysis are shown in Table 6.

Table 6.

Z-test analyzing the difference in effect size (eta squared)

Measure		Cigarettes		Hookah		Estimated difference		Z-test value		P
Psychological adjustment		0.832		0.275		0.56		3.933		0.0001
Psychological stress		0.766		0.345		0.58		3.070		0.0021

The z-test indicates that the effect size of the smoking cessation program on both psychological adjustment and psychological stress is higher among smokers of regular and electronic cigarettes compared to hookah smokers. None of the P values for the z-test exceeded the statistical significance level (α = 0.05).

Discussion

The results indicated that the group program affected psychological adjustment among cigarette smokers, with a probability value of 0.000. Psychological compatibility decreased among these smokers. This decrease can be attributed to psychological dependence[8] or physical dependence on nicotine, which increases dopamine levels in the brain. This results in momentary happiness, accompanied by withdrawal symptoms and cravings for the substance.[9,29] Additionally, the easy accessibility of cigarettes and their availability in most places make it difficult for individuals to control their smoking behavior, despite therapeutic sessions aimed at increasing self-awareness. This difficulty in maintaining psychological compatibility leads to a decrease in compatibility.[30,31,32,33]

The results also showed an effect of the group program on psychological stress among both cigarette and electronic cigarette smokers, with a probability value of 0.000. The percentage of stress decreased, indicating an improved ability to cope with stress, as a result of the program’s focus on individual-level stress management strategies, based on the Lazarus and Folkman (1984) theory.[34] Stress management strategies were tailored to individual needs and driven by personal decisions, making it easier to cope with and adapt to stress.

Also, the results showed an effect of the program, with a probability value of 0.004, on psychological adjustment among hookah smokers. Although the level of psychological adjustment decreased, it was to a lesser extent compared to cigarette and electronic cigarette smokers. This may be due to the belief among hookah users that hookah is less harmful and less addictive than cigarettes.[5] Approximately half of the participants believed that hookah is less addictive, less detrimental, and contains less nicotine than cigarettes. Furthermore, the results showed an effect of the program, with a probability value of 0.001, on psychological stress among hookah smokers. However, the decrease in stress was less pronounced compared to cigarette smokers, indicating that their ability to cope with stress is lower due to group-based smoking and decisions stemming from personal will within group sessions.

The effect size of the smoking cessation program on both psychological adjustment and stress was greater among regular and electronic cigarette smokers than among hookah smokers. None of the P values from the z-test surpassed the significance threshold (α = 0.05). This can be attributed to psychological dependence or nicotine withdrawal symptoms and cravings after abstinence,[8,34,35,36] which hinder psychological adjustment. The impact on psychological adjustment was more significant among cigarette smokers compared to hookah smokers, likely due to easier access and availability of cigarettes and the greater discomfort caused by abstaining from them versus hookah, which is typically smoked in specific settings and times.[37,38] This indicates that hookah smoking is more of an urban trend.[39,40] There is also a common belief that hookah is less harmful than cigarettes, which may increase psychological acceptance and lessen the program’s impact.[5] Additionally, peer influence encouraging hookah use may also affect the results.

Conclusion

The study reveals differences in stress management and psychological adjustment among hookah and cigarette smokers undergoing a combined cognitive behavioral therapy program. Hookah smokers were more prevalent among participants compared to cigarette smokers. Although cigarette smokers showed a greater impact on stress management, they struggled to maintain psychological adjustment postprogram compared to hookah smokers. As such, there is a need for intensified efforts to combat cigarette, e-cigarette, and hookah smoking and to strengthen policies aimed at reducing their use. The results of this study are useful for improving instructional tactics in treatment programs as well as for creating programs to prevent and stop smoking. It is recommended that more research be done to elucidate the relationship between distinct characteristics of hookah smokers. National-level studies are needed to examine the determinants of hookah smoking to help mitigate this issue.

AI policy statement

This study was not created, executed, analyzed, or written with the aid of any artificial intelligence tools. The authors are fully responsible for the accuracy, integrity, and originality of the work presented.

Ethical approval

This study was carried out following the ethical guidelines of the Declaration of Helsinki. This study received ethical approval from the University of Jordan Institutional Review Board (IRB). Participants gave informed written consent before participating. The participants were given assurances of confidentiality and anonymity of responses and that they had the right to opt out of the study at any time without penalty.

Author contributions

FAMA: Conceptualization, study design, methodology, data analysis, interpretation of results, writing of the manuscript, and final approval. MAIR: Data gathering, statistical processing, manuscript editing, and finalization. SYR: Data collection, literature review, manuscript editing, and final approval. SZS: Data collection, literature review, and final approval. MMB: Supervision, methodology validation, interpretation of results, manuscript revision, and final approval. RM: Data collection, manuscript formatting, referencing, and finalization. All authors have read and approved the submitted manuscript and are accountable for the manuscript's content.

Data availability statement

The datasets used and/or analyzed in the current study can be reasonably obtained from the corresponding author (Feras Ali Mohammad Al-Habies, firas4400@yahoo.com) upon request. This is due to privacy and ethical concerns: data are not publicly accessible because the data include information that could compromise the privacy of research participants.

Conflicts of interest

The authors have no conflicts of interest to disclose. There are no financial or non-financial interests that are directly or indirectly related to the work submitted for publication. The authors do not have any connections with tobacco companies, e-cigarette manufacturers, pharmaceutical companies, or other organizations that may have affected the design, conduct, analysis, or interpretation of the study.

Funding Statement

The research was not funded by any particular grant from the public, commercial, or not-for-profit sectors. The authors funded all of the study costs.