Global prevalence of E-cigarette use among students: Systematic review and meta-analysis

Abstract

Background: The growing use of e-cigarettes among students is a major public health concern. Yet, global data on its prevalence and associated risk factors remain limited. Therefore, this study aimed to estimate the global prevalence of e-cigarette use among students and identify key predictors influencing usage patterns.

Methods: A systematic review and meta-analysis were conducted using articles retrieved from databases including Science Direct, Scopus, EMBASE, Google Scholar, and PubMed, between August 15 and September 21, 2024. Data were extracted using Excel and analyzed with STATA version 14. Heterogeneity was assessed using the I2 statistic, and publication bias was evaluated through forest plots and Begg and Egger's tests. Subgroup analyses were conducted by geographic region, World Bank income classification, and level of education. A pooled odds ratio was calculated to identify predictors of e-cigarette use.

Results: A total of 40 studies with 654,853 student participants were included in the final analysis. The global prevalence of e-cigarette use among students was 22.65%. Usage varied significantly by region and demographic factors, with the highest rates observed in the Western Pacific (32.13%) and among high school students (33.62%). Students in high-income countries reported the highest usage (23.15%) as well. Key predictors of e-cigarette use included being male (AOR = 3.22), smoking conventional cigarettes (AOR = 5.35), and consuming alcohol (AOR = 3.14).

Conclusion: This meta-analysis reveals a high global prevalence of e-cigarette use among students, especially among high school males in high-income and Western Pacific regions, with strong associations to conventional cigarette smoking and alcohol use. Prioritize region-specific school based interventions targeting high-risk students particularly high school males in high-income countries to curb e-cigarette use and associated behaviors like smoking conventional cigarettes and alcohol consumption.

Fig 1. A Prisma diagrammatic presentation used to show the selection of studies.

The inclusion criteria were all observational studies reported e-cigarette prevalence, student participants, published in English studied globally, and availability of full text. Studies were excluded if they were qualitative studies, letters to the editor, review articles, expert opinions, case studies, case series, and randomized controlled trials.

Fig 2. Forest plot of global prevalence of e-cigarette with the height of the diamond is the overall effect size (22.65% while the width is the confidence interval at (95% CI: 18.32, 26.92),The y-axis shows the standard error of each study while the x-axis the estimate of effect size of the each study.

The verticalline denotes the no effect. The box represents the effect size of each study and the line across the box is confidence interval of each study.

Fig 3. Funnel plot showing asymmetrical distribution of studies indicating the presence of publication bias.

The Y-axis is thestandard error and the X-axis is the study result or effect size. The dotted diagonal lie of the funnel is the 95% confidence interval and the vertical. The vertical line is the line of no-effect and dots are included studies reporting electronic cigarette use.

Fig 4. The funnel plot for trim-and-fill method was used to correct the result eleven potential missing studies were requiredin the left side of the funnel plot to ensure symmetry.

The enclosed circles represent the dummy studies and the free circles are genuine studies.

Fig 5. Counter-enhanced funnel plot suggestions of missing studies on the bottom left-hand-side of the plot.

Since the majority of this area contains regions of high statistical significance (P < 0.01), this reduces the plausibility that publication bias is the underlying cause of this funnel asymmetry. Various shaded regions indicate statistical significance. In particular, thewhite shaded region in the middle corresponds to p-values greater than.10, the dark gray-shaded region corresponds to p-values between.10 and.05, the medium gray-shaded region corresponds to p-values between.05 and.01, and the region outside of the funnel corresponds to p-values below.01.

Fig 6. Pooled odds ratio displaying the association between being male and electronic cigarette use.

Males were 3.22 times using electronic cigarette smoking than females 95%CI: (2.32, 4.47).

Fig 7. Pooled odds ratio displaying the association between convenient cigarette use and e-cigarette use.

Students who utilized convient cigarette use were 5 times more likely to use electronic cigarette 5.35 (2.21, 12.91).

Fig 8. Pooled odds ratio displaying the association between current alcohol consumption and electronic cigarette use.

Study participants who used alcohol were 3 times more likely to use electronic cigarette as compared to those who didn’t use 3.14 (2.24, 4.39).