eCommons@AKU Section of Pulmonary & Critical Care Department of Medicine January 2018 Awareness, use and perceptions about E-cigarettes among adult smokers in Karachi, Pakistan. Maryam Sarfraz Aga Khan University Hamza Abdur Rahim Khan Aga Khan University Amna Urooba Aga Khan University Zainab Manan Aga Khan University Omar Irfan Aga Khan University See next page for additional authors Follow this and additional works at: https://ecommons.aku.edu/ pakistan_fhs_mc_med_pulm_critcare Part of the Critical Care Commons, and the Pulmonology Commons Recommended Citation Sarfraz, M., Khan, H. A., Urooba, A., Manan, Z., Irfan, O., Nadeem, R., Baqir, H., Farooq, S., Khan, Z., Khan, J., saleem, S. (2018). Awareness, use and perceptions about E-cigarettes among adult smokers in Karachi, Pakistan.. JPMA. The Journal of the Pakistan Medical Association, 68(1), 147-153. Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_pulm_critcare/53 Authors Maryam Sarfraz, Hamza Abdur Rahim Khan, Amna Urooba, Zainab Manan, Omar Irfan, Ramlah Nadeem, Huma Baqir, Saad Farooq, Zarrar Khan, Javaid Khan, and Sarah saleem This article is available at eCommons@AKU: https://ecommons.aku.edu/pakistan_fhs_mc_med_pulm_critcare/53 147 STUDENTS CORNER KAP STUDY Awareness, use and perceptions about E-cigarettes among adult smokers in Karachi, Pakistan Maryam Sarfraz, 1 Hamza Abdur Rahim Khan, 2 Amna Urooba, 3 Zainab Manan, 4 Omar Irfan, 5 Ramlah Nadeem, 6 Huma Baqir, 7 Saad Farooq, 8 Zarrar Khan, 9 Javaid Ahmed Khan, 10 Sarah Saleem 11 Abstract Objective: To estimate the prevalence of awareness, current use and intention to use of e-cigarettes among adult smokers. Methods: This cross-sectional survey was carried out at the Aga Khan University Hospital, Karachi, from July to August 2016, and comprised people aged above 18 years who had smoked more than 100 cigarettes in their lifetime. Convenience sampling method was used. A self-administered questionnaire was used to collect data. SPSS 22 was used for data analysis. Results: Of the 387 participants, 359(92.8%) were male. The overall mean age was 32.4±12.6 years. Moreover, 215(55.5%) respondents belonged to the middle socio-economic class. Besides, 249(64.3%) respondents were aware of e-cigarettes while 39(10.1%) used them, and 81(20.9%) wanted to use them. Socio-economic status was the best predictor for awareness about e-cigarettes (p<0.001), while gender (p=0.001), occupation (p<0.001) and current smoking status (p=0.009) were significantly associated with the use of e-cigarettes. E-cigarettes were perceived as less harmful than tobacco cigarettes by 175(45.3%) respondents, helpful in quitting smoking by 138(35.6%), associated with chronic diseases by 158(40.9%), addictive 142(36.7%), and not safe during pregnancy by 197(50.8%) participants. Conclusion: The percentage of e-cigarette usage was low despite the higher than expected awareness among the subjects. Keywords: Electronic cigarettes, Smoking, Awareness, Usage, Perception, Pakistan. (JPMA 68: 147; 2018) Introduction potentially attributed to the lack of the psychological Electronic cigarettes (e-cigarettes) are battery-operated stimulus of smoke itself, 4 and the habit of cigarette portable devices that deliver nicotine via a vaporised, holding in the hand (habits which e-cigarettes can cater flavoured liquid consisting of proylene glycol, glycerol to in addition to providing nicotine replacement); thus and nicotine. 1 Marketed as healthier alternatives to their potential superiority over other therapies despite a tobacco smoking and a means to quit - claims not fully lack of evidence about their safety profile and established yet — e-cigarettes are becoming a popular effectiveness. 5 means to bypass smoke-free laws, enabling users to Indeed, e-cigarette revenues have doubled every year 1 "smoke anywhere". since 2008, demonstrating the potential to render Nicotine replacement therapy (NRT), though widely used tobacco smoking obsolete, 6 as they are projected to to help smokers with withdrawal symptoms via nicotine surpass tobacco cigarettes by 2021. 6 A 2013 report from gums, patches, and inhalers since 1992 2 has helped less the Centres for Disease Control and Prevention (CDC) than 5% of smokers to quit smoking successfully. found that e-cigarette use among middle- and high- Although proven safe, NRTs are not as satisfying and school students increased from 3.3% to 6.8% between smokers find it hard to break the bio-behavioural 2011 and 2012, equating to an estimated 1.78 million feedback and hobby element. 3 The addiction is youths who have tried e-cigarettes. 7 One review article failing to link short-term e-cigarette 1-9 Medical College, Aga Khan University, 10 Department of Pulmonology, use with any serious health risks, demonstrated weak 11 Department of Community Health Sciences, Aga Khan University Hospital, evidence to suggest that e-cigarettes helped smokers to Karachi. quit. 8 Similarly, World Health Organisation's (WHO) Correspondence: Hamza Abdur Rahim Khan. demonstration of a weak association of e-cigarettes with Email: [email protected] smoking cessation suggests e-cigarettes should be Vol. 68, No. 1, January 2018 148 M. Sarfraz, H. A. R. Khan, A. Urooba, et al recommended only for smokers who refuse conventional revolutionary. 19 The exponential rise in popularity of e- treatment, or who have undergone failed trials. 9 cigarettes worldwide may represent the future of smoking cessation. It was therefore crucial to explore this The global use of e-cigarettes has been rising avenue. exponentially since 2007, generating increased interest among researchers. 1 Studies conducted in the developed The current study was planned to estimate the prevalence world show a high level of awareness about, and the use of awareness, current use and intention to use of e- of, e-cigarettes as a means of smoking cessation. 10 cigarettes among adult Pakistani smokers while exploring However, studies from the developing world show a less the association of socio-demographic factors and past encouraging response. 11 Since no such studies have been smoking history with e-cigarette use. We also explored conducted in Pakistan so far, our study is the first to do so. the perceptions of the respondents about e-cigarettes, and their sources of information. Tobacco smoking is a rising problem in Pakistan; an estimated 1.3% women and 27.6% men smoke cigarettes, Subjects and Methods while as many as 6.4% women and 44.6% men use This cross-sectional survey was carried out at the Aga tobacco regularly. 12 This is contributing to an increased Khan University Hospital (AKUH), Karachi, from July to burden of disease, since the link between smoking and August 2016. Convenience sampling technique was used lung cancer, coronary artery disease, and tuberculosis has to enrol the subjects from the waiting area of a private been indubitably established. tertiary care hospital and three shopping malls. The sample size was calculated using EpiInfo software, A four-country survey conducted by the International assuming a prevalence of 50%, 95% confidence interval Tobacco Control (ITC)studied awareness about electronic (CI), and a bound on error of ± 5%. The estimated nicotine delivery systems (ENDS) among current and minimum sample size was found to be 385. Approval was former smokers in the United States, United Kingdom, obtained from the institutional review board. Informed Canada and Australia. 13 The study showed that younger, consent was also taken from all the participants before male, and current smokers were more likely to have heard asking them to fill out our forms (Appendix). Subjects of ENDS than older, female, former smokers. 13 older than 18 years of age and who had smoked more However, there is still considerable variation in e- than 100 cigarettes in their lifetime were included. cigarettes awareness and usage amongst various Subjects with missing information or refusal to answer countries. A study published in 2013 estimated global e- particular questions were excluded. cigarette use to range from 0.05% to 14% in China and Knowledge, attitude, and practices regarding the use of e- Malaysia, respectively and, awareness about e-cigarettes cigarettes among smokers and former smokers were ranged from 31% to 88% in China and the Netherlands, assessed via a self-administered questionnaire after respectively. 14 Other studies have reported high written informed consent. Awareness was assessed by awareness and usage in high-income countries, while e- asking if the patients had heard about e-cigarettes while cigarettes still remain widely underused in developing use was appraised by asking if they had ever used an e- countries. 10,15 A study in Egypt reported no usage of e- cigarette. The Kuppuswamy scale, which has been cigarettes in the sample population, even though validated for use in Pakistan, 20 was used to assess socio- awareness about them was 51.7%. 11 E-cigarette usage has economic status of the participants. They were offered also been associated with a higher socio-economic status, both the English and the Urdu-translated questionnaire. smoking more cigarettes, and attempting to quit within the past one year. 16 While the most popular reasons for The information was asked on demographics, existing co- using e-cigarettes appear to be avoiding health-related morbids, general tobacco consumption, smoking history, adverse effects of tobacco smoke, cutting down on attempts to quit smoking, and e-cigarette use, as well as current cigarette consumption, and quitting, 16 even on awareness and perceptions about e-cigarettes. The never-smokers have reported using e-cigarettes. 17 questionnaire was pretested on a small group of participants before collection of data for the study. According to the World Bank, an estimated 180 million premature deaths can be prevented if cigarette smoking E-cigarettes was defined as a cigarette consisting of a is cut to half by 2025, making it imperative to focus on battery and an atomiser containing volatile liquid promoting smoking cessation using established method, composed of propylene glycol, glycerol, distilled water, and developing new ones.