Electronic cigarette use in Tunisian adolescents: patterns, adverse effects, and associated factors: a cross-sectional study

Abstract

Tobacco use remains a major public health concern, with adolescents being a vulnerable group. Electronic cigarettes (e-cigarettes) have become increasingly popular worldwide, including in Tunisia, yet data on their prevalence and usage patterns are scarce. Our study aimed to determine the prevalence, patterns, and adverse effects of e-cigarette use as well as to identify its main determinants. We conducted a cross-sectional study from September to October 2024, during the 2024-2025 academic year, among a representative sample of adolescents enrolled in middle and high school institutions in Sfax, Tunisia. Data were collected using an anonymous, self-administered questionnaire and analysed using SPSS version 26. Descriptive statistics and multivariable logistic regression were conducted, with statistical significance set at p < 0.05. A total of 980 adolescents were enrolled, with a sex ratio (male/female) of 0.64 and a median age of 15 years (Interquartile Range (IQR) = [14–17] years). The prevalence of current e-cigarette use was equal to 20.2% (95% CI = [17.9%-22.9%]; n = 198). Regarding reasons for trying e-cigarettes, curiosity (84.2%, n = 202) and flavors (30.4%, n = 73) were the most commonly cited. Several adverse effects were reported by e-cigarette users, represented mainly by cough (25.9%, n = 53) and headaches (24.9%, n = 51). Among adolescents who reported an accident related to e-cigarette use, ingestion of e-liquid was the most frequent (41.7%). Multivariable analysis showed that factors independently associated with current e-cigarette use among adolescents were the current use of conventional cigarettes (Adjusted Odds Ratio (AOR) = 23.8; p < 0.001), current use of shisha (AOR = 5.35; p < 0.001), former conventional cigarette use (AOR = 3.75; p = 0.004), and male gender (AOR = 3.57; p = 0.002). In addition, higher paternal educational level (AOR = 1.66; p = 0.003) and exposure to tobacco product advertisements at the point of sale (AOR = 1.73; p = 0.044) were also independent factors associated with current e-cigarette use. E-cigarette use was prevalent among Tunisian adolescents and was associated with the use of other tobacco products and advertising exposure. Therefore, targeted prevention strategies and regulatory actions should be implemented to reduce initiation and protect adolescent health.