Traditional and Electronic Cigarette Usage Patterns, Dependence, and Perceptions Among Ajman University Students

Round 1

Reviewer 1 Report (Previous Reviewer 3)

Comments and Suggestions for Authors

Investigating the characteristics of traditional and electronic cigarette use, perceptions of them, and addiction tendencies may be valuable. However, the study design and analysis presented in the submitted manuscript do not contribute academically or clinically. Therefore, I consider it unpublishable. The reasons for this are as follows:

 

1. A simple analysis of the characteristics of traditional and electronic cigarette use and perceptions of students at a specific university based on their basic characteristics has no academic or clinical value. While it may be useful as data for health education or guidance for students at a specific university, it is not a practical approach.

 

2. An in-depth analysis of traditional and electronic cigarette use, addiction, or dependence characteristics among students at a single university, yielding meaningful results, would be generalizable and contribute to academic and clinical research. However, analyzing information gathered through overly simple questions, as presented in the submitted manuscript, lacks significant value.

 

3. There are many things to comment on regarding the writing of the paper, such as the lack of references that could serve as a basis for the content of the first paragraph of the introduction, but I have omitted those comments because the above-mentioned matters are fatal to an academic paper.

Author Response

Dear Reviewer,

We thank the reviewer for taking the time to read and provide feedback on our manuscript. We respectfully acknowledge the concerns raised regarding the scope and perceived academic value of the study. However, we believe that the manuscript provides valuable insights into nicotine use, dependence, and perceptions among university students in the UAE, a region with limited existing data.

Reviewer 2 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

The authors have addressed my concerns. This has strengthened the manuscript considerably. 

Author Response

Dear Reviewer,
We sincerely thank the reviewer for their positive feedback and for acknowledging the improvements made to the manuscript. We appreciate the time and effort taken to review our work and are glad that the revisions have strengthened the clarity and quality of the study.

Reviewer 3 Report (New Reviewer)

Comments and Suggestions for Authors

Patterns, Dependence, and Perceptions of Traditional and Electronic Cigarettes among Ajman University Students Review

Introduction

Line 50 – 55 comes with factual statements, please add citations to all facts presented

Line 63: define the MENA region so all readers will understand what that stands for.

Line 65: define KSA region/country

Line 65-66: re write clearly and expand

Line 106 – 109 needs re write

Methods:

Line 144-146 needs re write

Ethics: Add a section on Ethics and explain how the study followed human subjects protocol

Was there an IRB approval process? If so, what #?

Was there an informed consent?

Were there any incentives provided?

Results:

Add data labels to Figure 1

Discussion:

Good, very brief

Conclusion:

Study limitations are presented, are there any study strengths?

Any policy recommendations for college students or college campuses?

Author Response

Dear Reviewer,
Thank you for you constructive feedback and suggestions! All comments have been addressed in the revised manuscript, with changes highlighted in yellow for clarity. Overview of the changes are as follows:

Introduction

• Line 50–55: An Appropriate reference was added to support the factual claim

• Line 63: “MENA” was defined as Middle East and North Africa at first mention.

• Line 65: “KSA” Kindogm of Saudi Arabia was changed to “Saudi Arabia” for clarity.

• Lines 65–66: The text was rewritten and expanded to better clarify the cited studies.

• Lines 106–109: The study aim was concisely rewritten for clarity.

Methods

• Lines 144–146: Methodology text regarding statiscal tests used was shortened and clarified.

• Ethics section: Added as a new subsection under Methods, including IRB approval (IRB number M-F-H-21-Aug), informed consent procedures, and statement that no incentives were provided.

Results

• Figure 1: Data labels for graph bar totals were added.

• Comparisions between studies table and paragraph was moved to the discussion

Discussion and Conclusion

• Discussion was subdivided into clear subsections, including a new section on study strengths and limitations.

• Study strengths added, highlighting the large representative sample, validated dependence instruments, and inclusion of both traditional and e-cigarettes with dual-use assessment.

• Policy recommendations were added in the Conclusion, suggesting that schools and universities focus on delaying nicotine initiation through early prevention and first-year interventions emphasizing behavioral skills, supported by smoke- and vape-free campus policies.

Much appreaciated!

Reviewer 4 Report (New Reviewer)

Comments and Suggestions for Authors

This article describes the results of a cross-sectional study conducted among students at Ajman University, located in the Middle East and North Africa region. The study provides valuable information on e-cigarette use and its relationship to traditional cigarettes among adolescents. Furthermore, the study results show that e-cigarettes do not appear to facilitate quitting; on the contrary, they may maintain nicotine addiction. Few studies have addressed this topic to date, making this article worthy of publication.

The introduction provides a comprehensive introduction to the topic addressed by the researchers. The authors also provide epidemiological data on the prevalence of tobacco smoking and e-cigarette use in the MENA region. The aim of the study is stated at the end of the introduction. The materials and methods include a description of the study protocol, which allows for its reproducibility. The section on the questionnaire could be improved. The description of the statistical analysis performed is adequate. The results are presented in tables, figures, and text. The discussion includes the most important results obtained, which are compared with the results of other studies. Limitations of the study are indicated. Conclusions were drawn appropriately based on the obtained results.

Minor comments:

Materials and Methods: Please describe in more detail the topics covered in the questionnaire (including the questions used in the Results section).

Please provide information about the JASP software (license, country).

Results: Please standardize the graphics in Table 1 with the other tables in the article.

Please standardize the notation of surnames and names in Table 2.

The Results section should present only the results obtained in the study, without comparisons with other studies or citations. Comparisons of your results with other studies should be included in the Discussion section (page 6).

Discussion: Limitations of the study should be included either as a paragraph in the Discussion section or as a separate section after the Discussion section. It is worth adding the strengths of the study.

 

Author Response

Dear Reviewer,

We sincerely thank the reviewer for their thoughtful and supportive comments. All suggestions have been addressed in the revised manuscript, with changes highlighted in yellow. Changes made are as follows:

Materials and Methods

• The questionnaire has been included in the supplementary materials.

• Information regarding the JASP software, including license type and country of origin, has been added.

Results

• Table 1 has been reformatted to match the style of other tables in the manuscript.

• Author surnames and names in Table 2 (now Table 8) have been standardized.

• Comparisons with other studies have been removed from the Results section and moved to the Discussion section, so the Results now present only findings obtained in this study.

Discussion

• The Discussion has been reorganized into clear subsections.

• A new section on study strengths and limitations has been added to highlight both methodological rigor and contextual limitations.

Much Appreaciated!

Round 2

Reviewer 1 Report (Previous Reviewer 3)

Comments and Suggestions for Authors

I believe highlighting these limitations will alleviate some of my concerns. If the editorial board considers these limitations and deems this manuscript worthy of publication in this journal, I believe it will be accepted.

Author Response

Dear reviewer,

Thank you for your thoughtful criticism and recommendations.

I believe we have answered your concerns in the discussion section, especially in the subsection "limitations".

Much appreciated!

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a well-designed study; it provides pertinent evidence on nicotine use among students in the UAE. This study fills in the gap in the literature on tobacco and nicotine use in the MENA region. However, there are a few concerns/suggestions.

Concerns/Suggestions

1. The authors need to retitle paper or revise introduction. Manuscript introduction focuses disproportionately on e-cigarettes compared to other nicotine products. Based on information provided in the introduction, authors can opt to compare e-cigarette users with users of other nicotine products (Revisions of study analysis and sections of the manuscript will need to be revised accordingly) OR keep as is but expand sections on conventional cigarettes, waterpipes, midwakh etc., to provide more details as provided on e-cigarettes OR refocus the paper on conventional and e-cigarette use only. This option corresponds to findings provided in manuscript i.e., it appears perceptions on these two products were assessed. Will need to change title of manuscript to show that perceptions were evaluated for conventional and e-cigarettes.
2. Is there a particular reason why midwakh was singled out. See line 38. Shisha for instance is flavored with molasses, glycerin etc. and has comparatively longer and deeper inhalations. If this is a nicotine product exclusively available in the MENA region, this distinction needs to be made in manuscript. Something along the lines: “In particular, midwakh is most commonly used in the MENA region…”
3. Rephrase pure cigarettes as conventional or traditional cigarettes.
4. Authors need to diligently review content included in manuscript with corresponding reference. For instance, reference #1 does not include information identifying different forms of nicotine as stated in Line37 nor does this reference discuss social or cultural determinants. See Line 43.
5. Need to use proper citation formation for reference #1 and #8. Reference #1 should be cited as: Münzel T, Hahad O, Kuntic M, Keaney Jr JF, Deanfield JE, Daiber A. Effects of tobacco cigarettes, e-cigarettes, and waterpipe smoking on endothelial function and clinical outcomes. European heart journal. 2020 Nov 1;41(41):4057-70. https://doi.org/10.1093/eurheartj/ehaa460. Need to review all other references.
6. Line 212: Change table 5 to table 6
7. Line 264: Change table X to appropriate table
8. Need to explain how cultural beliefs play a role in nicotine use among genders, particularly in MENA. See line 284. Need to include a section in introduction that discuss social and cultural factors that influence tobacco and nicotine use in the MENA region.
9. What other contributory factors may have impacted correlations with conventional and e-cigarettes. See line 298. Need to explain.
10. See Line 312: What other factors should be accounted for? Why did the present study not account for these factors. Some explanation is needed.
11. Need to revise line 317: “This showcases the importance and nuisance involved in the cofactors that affect nicotine dependence”. While confounders are regarded as nuisance variables, their impact on study findings can be limited in study design. This statement gives the impression of the authors complaining about confounding rather than account for them in their study.
12. The authors have merely reiterated their findings in their discussion, in comparison with similar studies in the literature. A more robust discussion of study findings and the implications of these findings with comparisons with available literature is needed.

 

Author Response

Dr. Khaldoun Tabbah
Clinical Associate Professor, Clinical & Medical Education Department
College of Medicine, Ajman University, Ajman, UAE
k.tabbah@ajman.ac.ae

14 October 2025

Re: Revised Manuscript Submission – “Prevalence, Dependence and Perceptions of Traditional and Electronic Cigarettes among Ajman University Students”

Dear Reviewer,

         We sincerely thank you for your constructive and detailed comments. Your feedback has significantly contributed to improving the clarity, focus, and scientific rigor of our manuscript. We have carefully revised the paper in accordance with your suggestions and addressed each comment as follows:

Comment 1:
The authors need to retitle paper or revise introduction. Manuscript introduction focuses disproportionately on e-cigarettes compared to other nicotine products. Based on information provided in the introduction, authors can opt to compare e-cigarette users with users of other nicotine products (Revisions of study analysis and sections of the manuscript will need to be revised accordingly) OR keep as is but expand sections on conventional cigarettes, waterpipes, midwakh etc., to provide more details as provided on e-cigarettes OR refocus the paper on conventional and e-cigarette use only. This option corresponds to findings provided in manuscript i.e., it appears perceptions on these two products were assessed. Will need to change title of manuscript to show that perceptions were evaluated for conventional and e-cigarettes.
Response 1:
The main focus of the paper is on traditional cigarettes and e-cigarettes. Accordingly, the title has been changed to reflect this focus clearly, and the introduction has been revised to align with the study’s scope.

Comment 2:
Is there a particular reason why midwakh was singled out. See line 38. Shisha for instance is flavored with molasses, glycerin etc. and has comparatively longer and deeper inhalations. If this is a nicotine product exclusively available in the MENA region, this distinction needs to be made in manuscript. Something along the lines: “In particular, midwakh is most commonly used in the MENA region…”
Response 2:
The introduction has been streamlined to focus primarily on traditional and electronic cigarettes; thus, the section on midwakh and similar details was removed.

Comment 3:
Rephrase pure cigarettes as conventional or traditional cigarettes.
Response 3:
We initially used the term “pure cigarettes” to indicate participants who used only cigarettes and no other nicotine products. However, to improve clarity and align with your suggestion, this term has been changed to “pure traditional cigarettes.”

Comment 4:
Authors need to diligently review content included in manuscript with corresponding reference. For instance, reference #1 does not include information identifying different forms of nicotine as stated in Line37 nor does this reference discuss social or cultural determinants. See Line 43.
Response 4:
We have thoroughly reviewed all references and their corresponding content. In addition to updating Reference #1, we have removed several irrelevant citations (CDC 2025; Heng et al., 2021; NIDA 2025). The reference by Ou et al., 2024 has been replaced with a more relevant one (Henn et al., 2023), and an archived reference (Muhammad & Sani, 2024) has been discarded.

Comment 5:
Need to use proper citation formation for reference #1 and #8. Reference #1 should be cited as: Münzel T, Hahad O, Kuntic M, Keaney Jr JF, Deanfield JE, Daiber A. Effects of tobacco cigarettes, e-cigarettes, and waterpipe smoking on endothelial function and clinical outcomes. European heart journal. 2020 Nov 1;41(41):4057-70. https://doi.org/10.1093/eurheartj/ehaa460. Need to review all other references.
Response 5:
We have carefully reviewed and corrected all reference formats according to MDPI style guidelines. Both references mentioned were manually checked and updated. Although Zotero was used to manage citations, final formatting was verified manually to ensure full compliance.

Comments 6 & 7:
Line 212: Change table 5 to table 6
Line 264: Change table X to appropriate table
Response 6 and 7:
All table and figure numbers, captions, and references have been reviewed and corrected accordingly.

Comment 8:
Need to explain how cultural beliefs play a role in nicotine use among genders, particularly in MENA. See line 284. Need to include a section in introduction that discuss social and cultural factors that influence tobacco and nicotine use in the MENA region.Response 8:
We have added a section in the introduction discussing relevant social and cultural influences on nicotine use within the MENA region and further expanded this theme in the discussion. (lines 42 and 319)

Comment 9:
What other contributory factors may have impacted correlations with conventional and e-cigarettes. See line 298. Need to explain.
Response 9:
This point has been addressed by expanding the relevant section to include a discussion of additional variables that may contribute to nicotine dependence and influence correlation strength. (line 350)

Comment 10: See Line 312: What other factors should be accounted for? Why did the present study not account for these factors. Some explanation is needed.
Comment 11: Need to revise line 317: “This showcases the importance and nuisance involved in the cofactors that affect nicotine dependence”. While confounders are regarded as nuisance variables, their impact on study findings can be limited in study design. This statement gives the impression of the authors complaining about confounding rather than account for them in their study.
Response 10 and 11:
The paragraph has been rewritten for clarity. It now highlights how frequency of use among dual users may determine whether they quit or continue with increased dependence. Our study could not further stratify dual users by frequency due to limited subgroup sizes. The phrasing regarding “nuisance” variables has been removed to avoid misinterpretation. (line 357)

Comment 12:
The authors have merely reiterated their findings in their discussion, in comparison with similar studies in the literature. A more robust discussion of study findings and the implications of these findings with comparisons with available literature is needed.
Response 12:
We have substantially revised the discussion to focus on the implications of our findings and their relevance to tobacco control policies and student health education. Figures and tables have been moved to the results section to enhance readability and flow.

        Once again, we sincerely thank the reviewer and editorial team for their valuable time and thoughtful feedback. Your insights have greatly strengthened the manuscript’s structure, clarity, and overall contribution to the literature. We hope the revised version fully addresses all comments and meets your expectations. We truly appreciate your consideration and look forward to your response.

Sincerely,
Dr Khaldoun Tabbah

Reviewer 2 Report

Comments and Suggestions for Authors

Please kindly read the attached file.

Comments for author File: Comments.pdf

Author Response

Dr. Khaldoun Tabbah
Clinical Associate Professor, Clinical & Medical Education Department
College of Medicine, Ajman University, Ajman, UAE
k.tabbah@ajman.ac.ae

14 October 2025

Re: Revised Manuscript Submission – “Prevalence, Dependence and Perceptions of Traditional and Electronic Cigarettes among Ajman University Students”

Dear Reviewer,

     We sincerely thank you for your valuable and constructive feedback. Your detailed comments have helped us significantly refine the clarity, focus, and rigor of our manuscript. We have carefully revised the paper in accordance with your recommendations and addressed each point as follows:

Comment 1:
In Section 2.2, please clarify the number Of participants more explicitly. For example, indicate both the total number invited and the final number included in the analysis.
Response 1:
Thank you for this suggestion. It is difficult to precisely estimate the number of students invited during in-person events. However, all 7,113 students were invited via email. We have added the following statement: “All 7,113 students were invited to participate in the survey. The final sample size was 1,713 students (24.1% response rate).”

Comment 2:
In Section 2.4, you reported using the Shapiro—Wilk test, While this test is suitable for relatively small to medium sample sizes, given the large sample in this study, I recommend reconsidering your approach to assessing normality.
Response 2:
We appreciate this observation. Upon reassessing the data distribution, kurtosis and skewness values were examined. The PS-ECDI score was found to be approximately normally distributed; thus, a Student’s t-test was used instead of the Mann–Whitney test. This did not result in any changes to the p-values. Other variables (participants’ age, perception scores, and ages of onset) remained non-normally distributed.

Comment 3:
Figures and tables should be included only when they convey information more effectively than text. In the current version, Figures I and 2 and Table 1, among others, take up considerable space, Please carefully evaluate whether each Of these visual elements is essential. If not, I recommend removing them and presenting the information more concisely in the text.
Response 3:
Following your advice, we removed several figures and tables that provided limited additional value, including both scatter plots comparing dependence and onset age, the PS-ECDI frequency table, and the gender–nicotine use bar chart.
We retained only the bar chart showing college distribution, as it demonstrates that the study sample is representative of the wider university population.

Comment 4:
 For Table 3, please include percentages (%) in addition to raw frequencies.
Response 4:
Percentages have been added to Table 3 alongside raw frequencies to enhance clarity.

Comment 5:
The statistical tables would benefit from improved readability. Given the large sample size, it may be more appropriate to examine skewness and kurtosis values and then proceed with parametric tests where justified.
Response 5:
We appreciate this feedback. The readability of the statistical tables has been improved following your advice, and percentages have been added where relevant.
Additionally, skewness and kurtosis values were calculated for all key variables as follows:

Variable	Skewness	Kurtosis
Age	2.402	8.911
Cigarette Dependence Scale (CDS) score	–0.222	–0.830
Penn State E-Cigarette Dependence Index (PS-ECDI) score	–0.179	–0.805
Cigarette harm perception	–2.295	7.198
E-cigarette harm perception	–1.723	3.255
Age of cigarette smoking onset	0.361	0.320
Age of e-cigarette smoking onset	1.279	7.974

 

Comment 6:
Figure 3 seems to provide limited additional insights. Consider whether it is truly necessary.
Response 6:
Both scatter graphs were removed as suggested.

Comment 7:
Table 6 could be summarized in a single line, and more fundamentally, its necessity should be reconsidered. Overall, the number of tables and figures appears somewhat redundant. It may strengthen the manuscript to streamline these and retain only the most essential.
Response 7:
We agree with this recommendation. The manuscript has been streamlined, reducing the number of figures to two and tables to four, focusing only on essential data.

Comment 8:
Based on the central limit theorem, it would be statistically justified to perform Pearson correlation analysis with your current sample. (Please also correct the duplication of Table 9, as two tables are labeled with the same number.)
Response 8:
Thank you for this insightful suggestion. The correlation analysis was changed to Pearson’s correlation, as justified by the sample size. Additionally, table numbering errors (including duplicate Table 9) have been corrected.

Comment 9:
It is recommended that no new tables or figures be introduced in the Discussion section. Instead, this section should focus on the authors' interpretation and arguments, drawing on the results already presented.
Response 9:
We have moved all tables and figures to the Results section and rewritten the Discussion to emphasize interpretation and implications of the findings. 

Comment 10:
In general, please revise the manuscript so that the tables and figures are concise, well-organized, and limited to only what is necessary.
Response 10:
We have removed the mean rank column from statistical tables, as it provided limited additional insight.

Comment 11:
The Discussion could be enriched by including comparisons with findings from other regions (e.g., the United States, Europe, Asia), beyond the Middle East.
Response 11:
The Results section has been expanded to include comparisons with studies from the United States, Europe, Asia, and global university samples, as well as population-based surveys.

Comment 12:
Finally, please expand on the policy implications of your findings. In particular, based on the results, what types of policies or programs would be most beneficial to introduce in the Middle Eastern context to better inform local public health strategies?
Response 12:
The discussion was revised to include cultural aspect and implications of the data on policies.

 

      Once again, we extend our sincere gratitude for your detailed and insightful review. Your comments have greatly enhanced the quality, precision, and overall impact of our manuscript. We hope that the revised version satisfactorily addresses all points raised and meets your expectations.

Sincerely,
Dr. Khaldoun Tabbah

Reviewer 3 Report

Comments and Suggestions for Authors

Smoking during adolescence can have significant implications not only for health at the time but also for health later in life, even in middle age and old age. Therefore, studying the prevalence and dependence of college students' smoking, as well as their perceptions of tobacco use and the variables that may influence it, is valuable.

However, while information on the prevalence, dependence, and perceptions of tobacco use among students at a specific university may be useful for health education at that university, the results of such analyses have no academic or clinical significance for publication in an academic journal. Analyzing factors that influence prevalence, dependence, and perceptions of tobacco use in a specific sample might be worth publishing. However, even without mentioning the limitations of generalizability, I believe such descriptive information is not suitable for publication in an academic journal.

Author Response

Dear Reviewer,

Thank you for your time and thoughtful feedback. We respectfully disagree with the assessment that the current study lacks academic or clinical significance.

While our data were collected from a single university, which may limit generalizability to the broader population, this focused approach enhances the internal validity of the study, increasing confidence in the accuracy of our findings within the sampled population. This is particularly important given that the study population is understudied in the MENA region. To our knowledge, very few regional studies have simultaneously assessed both conventional cigarette and e-cigarette dependence.

Furthermore, our analysis extends beyond simple prevalence reporting. We examined factors influencing dependence, including gender differences, age of initiation, and dual product use, and discussed how these determinants relate to cultural and behavioral influences within the MENA context. We have revised the Discussion section to emphasize these analytical aspects.

Sincerely,
Dr Khaldoun Tabbah

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Since there are no significant improvements, and the most concerning aspect of the first review is the one that is most detrimental to publication in the journal, I have decided that this manuscript cannot be published in the journal.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf