Electronic cigarettes are devices that contain batteries to power the device and often contain nicotine in various flavors. A few of the many names that these devices have taken on as their popularity has grown are mods, e-hookahs, and “cig-a-likes” (1). E-cigarettes are currently a major threat to public health worldwide (2), having varying prevalence in different countries. In a study conducted in Qatar, 14% of college students vape (3), According to two Egyptian studies, between 10.6 and 16.5% of participants used e-cigarettes (4). According to Qanash et al. (5), in a sample of Saudi Arabian college students, 27.7% claimed they are currently using e-cigarettes. In the general public, 3.8% of people in the United Arab Emirates, 11.7 to 39.2% of people in Jordan, and 2.2% of people in Saudi Arabia use e-cigarettes (4). Further, in Palestine, 18.1% of a sample of university students reported vaping (6). Although debates about e-cigarettes as a tool for cessation versus a reason for tobacco use initiation continue (7), they are arguably detrimental to public health given the fact that they have been associated with a number of health problems, such as cardiovascular, pulmonary, and developmental effects (8).

Among the United States (US), United Kingdom (UK), Australia, and Canada, Australia has restrictive vaping products legislation, whereby vaping products are only available with a prescription from a doctor and cannot be legally marketed (9, 10). Importing any kind of vaping device into Australia is largely prohibited, although using vapes for the purpose of managing nicotine dependence and quit smoking is legal (11). Canada prohibits vaping products that contain nicotine concentrations above 20 mg/mL (12). According to federal law, to purchase tobacco products, including e-cigarettes, individuals in the United States must be at least 21 years old (13). There are vast differences in e-cigarette regulations in the Middle East (4). For example, in Qatar, the manufacture, importation, marketing, distribution, display, and manufacturing of e-cigarettes is prohibited, while the fact that they are legal for personal use (14). Contrarily, in Jordan, e-cigarette use is legal, and in Iraq, there is no clear law pertaining to e-cigarettes (4). Despite being prohibited by law, e-cigarettes are available for purchase in Egyptian markets (4).

There is evidence that indicates a high level of social acceptability for e-cigarette use—for instance, e-cigarette users consider themselves “committed” to use and not “addicted” (15). However, this social acceptability seems to be true for “social use” but not “daily” use, the latter of which is considered stigmatized by college students (16). Higher vaping identity intensity, the self-identification as a vaper, is associated with lower trust for regulations imposed against vaping by governments (17). When regulations prohibit vaping use, it can still be socially acceptable, in contexts where enforcement is perceived to be weak (18). Studies have even shown sub identities of vapers, “cloud chasers” are the devout vapers with a sense of belonging to a community of vapers, and “substitutes” are ex-tobacco users who aim to escape their previous stigmatized identity and for them vaping is the mechanism to escape their previous identity (19). In young adults, the support for government policy against vaping is far from unanimous, thereby indicating a high level of social acceptability for vaping (20). Holding beliefs that are centered on the idea that vaping is the norm is associated with higher vaping frequency (21, 22) and having strong social connections is associated with increased likelihood of vaping relative to not having any vapers in one’s close social circle (23).

Middle Eastern countries show differences in social acceptability perceptions towards e-cigarettes. For instance: 20.2 to 69% of individuals perceive e-cigarettes as useful aids for quitting smoking (24). According to Jirjees et al. (4), young individuals in Saudi Arabia report using e-cigarettes to quit smoking, while in Jordan, Lebanon, and Qatar, e-cigarettes are perceived as less dangerous than tobacco (3, 4). In Saudi Arabia, 71% of young adults perceived vaping as socially acceptable relative to tobacco smoking (41). In the UAE, e-cigarettes are favored for their variety of flavors and perceived safety (4). In Egypt, vaping is perceived as a fashion statement and a tool for quitting smoking (4).

The Middle East has a wide range of social concerns about e-cigarettes. In the Middle East, 36 to 60.8% of people believe that e-cigarettes are a public issue, with 91.5% acknowledging their harmfulness and 33.5 to 41.8% highlighting their ability to cause nicotine addiction (4, 24). In Saudi Arabia and Egypt, the safety concerns for e-cigarette use are significant (4). People in Egypt also perceive e-cigarettes as ineffective smoking cessation strategies and potentially harmful in the long term. According to Aaiz et al. (25), 32% of participants in Iraq strongly agreed that e-cigarettes are harmful and 92.1% would never encourage their use. In addition, middle school students express more negative feelings about e-cigarettes than traditional cigarettes (25). Younger adolescents often fear the possibility that their parents or another family member will find out they vape, indicating a low level of social acceptance of e-cigarettes (26).

According to Aleyan et al. (9), the degree of laws and regulations in different countries is correlated with the social acceptance of vaping products. Further, the impact of a number of social factors on vapers varies according to their sex and tobacco use status, including peer pressure, exposure to social media content, and product preferences (e.g., type of device used) (23). Although social norms regarding the use of e-cigarettes have been previously explored, social unacceptability (de-normalization) of e-cigarettes is less studied. Evidence suggests the importance of studying social unacceptability, as some users hide their vaping habits in public (26, 27). Therefore, this study aims to examine how regular e-cigarette users perceive the social unacceptability of e-cigarettes and compare three Middle Eastern nations: Qatar, Egypt, and Iraq, while taking into consideration important social and behavioral factors related to vaping. This examinations helps establish whether or not there is a link between the degree of perceived social unacceptability among vapers and the laws currently in place in these nations.

Table 1 shows the sociodemographic and vaping characteristics for the total sample (n = 428) as well as by levels of perceived social unacceptability. The majority of participants were males (91%), with 38.3% aged 18–24 years, 38.1% aged 25–36 years, and 34% aged 37 years or older. Most participants were from Egypt (45%), followed by Iraq (33%), and Qatar (12%), with approximately 10% from other Arab countries. A significant proportion were citizens of their residing country (90%) and were employed (60%). Nearly 90% of participants reported being ever-smokers, with 78% indicating they started smoking before vaping. About 85% reported vaping 5–7 days per week, and less than half (47%) reported using vape juice with a nicotine concentration below 20 mg/mL. Friend’s pressure to vape was reported by 15% of participants, and around 48% experienced negative side effects from vaping. Additionally, 41% reported exposure to vaping content on social media ads. Regarding device preference, the majority used pods (35%), followed by mods (34%) and vape pens (16%). Approximately 72% expressed a preference for flavored vape products, and nearly half (48%) reported having attempted to quit vaping at some point.

When analyzing vaper characteristics across levels of perceived social unacceptability, significantly higher proportions of females, individuals residing in Qatar, those who had never smoked, those who reported experiencing friend pressure to vape, vapers who primarily used e-cigarettes as their choice of vaping device, and those who encountered negative side effects from vaping were more likely to report higher levels of perceived social unacceptability (p < 0.05) (Table 1).

As can be seen in Table 2, male vapers and vapers who are past smokers of traditional cigarettes had lower odds of reporting higher levels of perceived social unacceptability towards vaping relative to female vapers and vapers who never smoked, respectively. Vapers residing in Qatar and vapers who experience pressure from their friends to vape had higher odds of reporting higher levels of perceived social unacceptability towards vaping relative to vapers residing in Egypt, and vapers who do not experience pressure from friends, respectively. Vapers who experienced negative health effects from vaping or do not know if they did we more likely to report higher levels of social unacceptability relative to counterparts that never experienced negative health effects. Finally, vapers who usually use mods or e-cigarettes were more likely to have higher levels of social unacceptability in comparison to those who use pods.

According to Amin et al. (42), earlier studies have mostly concentrated on understanding social unacceptability of non-vapers. This study adds to the literature by providing insights on the correlates of social unacceptability perceptions in the Middle East. This study specifically looked at the relationships between sociodemographic variables and the degree of social unacceptability of vaping among vapers in Egypt, Iraq, and Qatar, three Middle Eastern countries. In our study, vapers from Qatar were more likely than those from Egypt to perceive vaping as socially unacceptable. This likely stems from differences in legislation. Unlike Egypt (32) and Iraq (4, 33), Qatar has strict measures against the production and sale of vaping products (34). In addition, this finding aligns with earlier studies in terms of the connection between the social unacceptability of vaping products and the level of restrictiveness in the country’s legislation (9). The result of this study implies that legislation in this region should be harmonized in order to perhaps lower the social acceptability of vaping in countries like Egypt and Iraq that have less stringent regulations. To fully map the link between the strictness of laws and societal unacceptability, additional research is required to look at other Middle Eastern countries.

In our study, male vapers and vapers with a history of traditional tobacco use were less likely than female vapers and vapers who had never smoked to have high social unacceptability perspectives about vaping. According to earlier research, male tobacco users and vapers are less supportive of tobacco control measures (35). Our study adds to the past findings by showing that these two subgroups also have lower odds of social unacceptability perceptions for vaping. It also suggests that low social unacceptability and low support for policies are aligned. Further, it is aligned with past findings on vaping subcultures which show that “substitutes,” past smokers who are current vapers, use vaping as a way of escaping their stigmatized ex-smoker identity (19). Therefore, it is logical to expect vapers who are ex-smokers to be less likely to appraise vaping negatively from a social standpoint.

Individuals who reported feeling pressured to vape by their peers had higher odds of social unacceptability perceptions towards vaping. According to Groom et al. (26), peer pressure is linked to higher levels of vaping, but it additionally leads to higher odds of vaping being perceived negatively. This unexpected conclusion calls for more research in the future. One possible explanation is that while peer pressure may make vaping easier and less perceived as a behavioral control, it is also seen as an unacceptable behavior that raises feelings of social unacceptability.

Experiencing negative side effects from vaping increases odds of high social unacceptability perceptions in comparison to not experiencing them. This finding complements prior studies that revealed that experiencing negative side effects is one of the key reasons for e-cigarette cessation (36). Based on the literature review, one of the indicators of social unacceptability of e-cigarettes was the harm or the negative health consequences that are associated with it. For example, in Middle Eastern countries e-cigarettes were perceived as harmful (4, 24). Moreover, it was perceived to be harmful in the long term in Egypt (4). Additionally, participants in Iraq strongly agreed that e-cigarettes pose harms (25). Our study suggests that experiencing negative side effects could be related to the fact that they find it less socially acceptable to vape. However, to determine if social unacceptability is the mechanism behind the association between unfavorable side effects and decreased vaping behaviors, further research is necessary. Campaigns that highlight the harmful effects of vaping, however, may contribute to increased social unacceptability of vaping and support for cessation attempts.

In this study users of mods and e-cigarettes higher odds of perceiving high social unacceptability compared to those who used pods. This is logical given that pods are small, discrete and easier to conceal relative to mods (37), which makes mods more visible and therefore related to higher odds of social unacceptability. Further, e-cigarettes are closer in their look to a cigarette stick, and by association to cigarettes, e-cigarettes are associated with higher social unacceptability relative to pods. Our study relates to previous research which has documented a higher proportion of vapers who use pods relative to other products (38), which is consistent with our finding that vapers who use pods have lower odds of social unacceptability relative to other products. Social media interventions may be required to reduce pod social acceptability as they could hinder vaping intentions, especially among young adults (39). Social marketing strategies are required to counteract message that promotes vaping usage, especially in light of social media posts that target younger populations (40).

This study explored differences in levels of social unacceptability across country of residence as well as sociodemographic variables for a vaper sample from Qatar, Iraq, and Egypt. Results revealed an association between each of country of residency, friend pressure to vape, being offered a vaping device, and experiencing negative side effects after vaping with the level of social unacceptability. The study’s implications involve a call for implementing stricter laws in Egypt and Iraq, awareness initiatives about the negative consequences of vaping behavior, and refusal skill training as ways to reduce social unacceptability for using vaping devices.