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A literature review addressing midwakh and e-cigarette use in the Gulf region


A notable decrease in conventional cigarette smoking has been witnessed on a global scale. However, this decrease has been accompanied by an equally striking global increase in the consumption of alternative tobacco products (ATPs), namely e-cigarettes and midwakh in the Arabian Gulf region. A literature review was used to outline the chemical composition of these two ATPs and review their impacts on health. The study was conducted using databases like PubMed, Google Scholar, MDPI, and WorldCat. The literature search included terms such as “e-cigarettes,” “midwakh,” “dokha,” “heath impacts,” “psychological effects,” “social influences,” and “cigarette smoking” with emphasis on literature from the Arabian Gulf region. Data shows that midwakh contains markedly high levels of tar, nicotine, and various compounds of notable effects on the human body. Similarly, it was found that e-cigarettes contain non-negligible amounts of nicotine and other chemical compounds that may not have been extensively investigated. Alarming reports of system-specific effects brought about by midwakh, and e-cigarette consumption, have been reported, although further research is needed to deduce the mechanism. We also discussed some of the social and psychological factors leading to their consumption within this population. Hence, this review raises questions around the safety of these two types of ATPs and encourages comprehensive studies globally and regionally.

1 Introduction

A recent decrease in the consumption of conventional cigarettes has been witnessed globally, with a variety of national and international studies confirming this trend [1,2,3,4,5]. Between 2009 and 2017, global cigarette smoking prevalence declined by 7.7% in men and 15.2% in women [6]. This can be explained by the control measures taken by countries against tobacco use including increasing awareness programs on its dangers and banning tobacco usage in public places [6]. Another potential explanation for this significant reduction is the reported correlation between higher cigarette pricing and smoking cessation [7]. At a first glance, this decrease may seem like a positive skew; however, the decrease in conventional cigarette smoking is coupled with an exponential increase in alternative tobacco products (ATPs) [8].

ATPs include midwakh (dokha), electronic nicotine delivery systems such as electronic cigarettes (e-cigarettes/vapes), smokeless tobacco (chewing tobacco), pipes, hookah (water pipes), and recently marijuana [9,10,11]. Despite the extensive list of ATPs, we will describe two products that prevail in the Gulf Cooperation Council (GCC) countries, namely e-cigarettes, which have seen a global rise [12,13,14,15], and midwakh, which is growing in popularity locally [12,13,14,15]. In the United Arab Emirates (UAE), 18.5% of the surveyed population disclosed trying midwakh, and 9% are current midwakh smokers [13]. According to Al Sharbatti et al., within 54.4% of midwakh smokers in Ajman, 48.9% of the participants were male adults between the ages of 26–35 [15]. Another study revealed that most participants were e-cigarette smokers of 40 years of age or less [16]. Also, out of 15.1% of students from three UAE universities who are current smokers, 44% are e-cigarette and midwakh consumers [17]. In Saudi Arabia, 7.9% of male college students have smoked midwakh, and 3.8% are current midwakh smokers [18]. Remarkably, 12.2% of medical students in Saudi Arabia are current e-cigarette smokers [19]. In Qatar, 14% of university students use e-cigarettes, and 4.7% of surveyed Qatari smokers use midwakh [20, 21]. In Kuwait, a study showed 26.4% of high school students are current e-cigarette users [22].

Although deemed as a growing public crisis, little is known about the health effects of ATPs [8, 23, 24]. Additionally, many e-cigarette consumers are not using ATPs to cesate smoking [25]. According to the World Health Organization (WHO), adolescents and children who use electronic nicotine delivery systems are more than twice as likely to use conventional cigarettes [11]. Compelling evidence implies that e-cigarette consumption may lead to eventual conventional cigarette smoking among youth [26]. This review aims to describe the chemical composition of e-cigarettes and midwakh, along with their health effects as well as some of their social and psychological impacts, especially within the Gulf region.

2 Methods

A literature review was conducted using multiple databases including WorldCat, PubMed, MDPI, and Google Scholar to gather relevant studies essential for this review. The search was conducted between March 2022 and March 2023 and focused mainly on studies underlying the effects of e-cigarettes and midwakh (dokha) on health within the Arabian Gulf regions. Keyword search was used to assist with the database search which included the following: “e-cigarettes,” “midwakh,” “dokha,” “Arabian Gulf,” “heath impacts,” “psychological effects,” “social influences,” and “cigarette smoking.” After extensive research, the current review incorporated 87 research and peer-reviewed papers focusing on the impact of e-cigarette and midwakh within the Gulf region.

3 Results

3.1 The chemical composition of ATPs

3.1.1 The chemical composition of dokha

Dokha is a blend of tobacco leaves with an array of spices, herbs, barks, dried fruits, or dried flowers and has gained its name from the pipe used to smoke the blend, the “midwakh” [12]. The array of available flavors misrepresents midwakh as a healthier cigarette counterpart among young people population. In fact, a few studies have investigated the role of toxicants and heavy metals in midwakh smoking-related diseases [27, 28]. Yet, studies that did analyze the chemical composition of midwakh report non-negligible findings [28]. As mentioned, midwakh is composed of fine dried green tobacco leaves collected without major processing. They retain high amounts of carbon monoxide, nicotine, and tar [29].

Additionally, midwakh is often smoked without a filter and rarely with a resin filter causing toxicants such as tar, carbon monoxide, hydrogen cyanide (HCN), nitrosamines, volatile organic compounds, and toxic heavy metals to immediately enter the lungs [29,30,31]. Tar, the sticky, aerosol residue of tobacco combustion, contains most of the toxic, carcinogenic, and mutagenic agents in tobacco [29]. Midwakh (dokha) has strikingly higher nicotine and tar levels than conventional cigarettes. A recent study reports that nicotine in different midwakh brands falls between 23.82 and 52.80 mg/g [29]. Furthermore, midwakh has 55.62% higher tar concentrations than cigarettes [29, 30]. CNS depressants and carcinogens such as acrylonitrile, benzene, and acrylamide have also been detected in midwakh [28, 29]. Moreover, concentrations of trace metals such as lead, cobalt, aluminum, nickel, copper, chromium, manganese, iron, potassium, calcium, zinc, magnesium, and strontium are markedly higher in midwakh than in cigarettes [27,28,29].

Alarmingly, metal content in midwakh is unregulated. A chemical analysis of midwakh smoke identified over 400 organic compounds including 22 irritants; 5 toxic compounds such as cycloheptatriene, 2-methylfuran, and m-xylene; and at least 3 carcinogens including benzene [28]. A midwakh tobacco brand was shown to have concentrations of aluminum, boron, cobalt, copper, lead, and zinc at 421.2 μg/g, 219.8 μg/g, 25.1 μg/g, 24.0 μg/g, 468.6 μg/g, and 342.7 μg/g, respectively [28]. These metals are in quantities equal or higher than in cigarettes. Interestingly, polycyclic aromatic hydrocarbons (PAHs), which are usually formed during incomplete combustion, were also detected in midwakh samples [31]. Two PAHs, naphthalene, and anthracene were found in trace amounts in raw dokha tobacco, while 12 PAHs were found in midwakh smoke at concentrations surpassing those detected in cigarettes [31].

3.1.2 The chemical composition of e-cigarettes

Formerly produced as a tobacco cessation facilitator, e-cigarettes are noncombustible electronic nicotine delivery systems containing flavoring agents [24, 25]. While e-cigarettes advanced from first-generation pods with disposable e-liquid cartridges to third-generation e-cigarettes with a refillable e-liquid tank and then to fourth-generation Joel brand, e-cigarette smoking essentially involves heating and aerosolizing an “e-liquid” made of nicotine, propylene glycol (PG), vegetable glycerine (VG), and flavor compounds using a battery-mediated device [32]. This resistance heating is done through a metallic coil, which is commonly Kanthal, comprised of iron, chromium, and aluminum or nichrome, a coil consisting of nickel and chromium [32]. Consequently, due to the thermal degradation of the e-liquid, e-cigarette gas and particle emissions consist of aerosolized PG, VG, flavors, nicotine, free radicals, and various carbonyls, and an array of hydroxycarbonyls were reported [32]. Carbonyl compounds including acetaldehyde and formaldehyde, which normally form after heating, have also been detected in e-cigarette vapor, in lower levels than cigarette smoke [33].

Unlike their conventional counterpart, no precise protocols have been established to test e-cigarettes, yet chemical analyses have been carried out, whereby 46 volatile and semi-volatile compounds were detected in e-liquid formulations and 55 compounds were found in e-cigarette aerosols [34]. A study investigating the presence of carbonyl compounds, volatile organic compounds (VOCs), tobacco-specific nitrosamines (TSNAs), and metals revealed that all tested e-cigarette samples contained three carbonyls with reported toxic properties: formaldehyde, acetaldehyde, and acrolein [35]. Almost all samples contained the volatile organic compounds toluene and m, p-xylene, and all generated vapors containing nickel, and lead, with some vapor samples containing traces of the carcinogenic nitrosamines: N′-nitrosonornicotine (NNN) and 4-(methylonitrosoamino)-1-(3-pirydyl)-l-butanone (NNK) [35].

An elemental analysis of thirty-six inorganic chemical elements revealed that e-cigarette aerosols include a variety of elements encompassing heavy metals at concentrations significantly higher than in conventional cigarettes [36]. Further analysis showed that e-cigarette fluid and aerosol contain nickel, chromium, copper, zinc, silver, and lead [37]. In order to compare metal concentrations in e-liquids from the refilling dispenser, e-liquids in the tank, and the inhaled aerosol, an analysis was carried out using samples from the devices of daily e-cigarette users. It revealed that concentrations of most metals were significantly higher in samples collected from tanks and the aerosols to be inhaled by the consumer than those from the refilling dispenser [37]. Concentrations of chromium, copper, nickel, lead, and zinc were also more than 25 times higher than in the dispenser samples, and the concentrations of aluminum, cadmium, and antimony were between 2.30 and 4.65 times higher in the tank and between 1.60 and 3.58 times higher in the aerosol in comparison with the dispenser samples [37].

Flavoring compounds contain diacetyl and various aldehydes including benzaldehyde, vanillin, ethyl vanillin, and cinnamaldehyde noting that many of the employed flavorants have been deemed as safe food additives. However, their consumption through inhalation has not been designated as safe by the Federal Food, Drug, and Cosmetic Act (FFDCA). Aldehydes are reactive and can produce adducts by forming covalent bonds with nucleic acids, cellular proteins, and other biomolecules [38]. Interestingly, detected concentrations of aldehydes vary greatly among commercial e-cigarettes liquids and can be as high as 34% as in the case of cinnamaldehyde in cinnamon flavored e-liquids [39]. Acetoin, diacetyl, and its structural analogue 2,3-pentanedione are used in various food flavorings such as butter, caramel, and strawberry, but they are also commonly employed in e-cigarette flavors with strong appeal such as cupcake, cotton candy, and Blue Water Punch [40]. In their study of 51 e-cigarette flavors, Allen et al. disclose that at least one of these three compounds was detected in 47 of different flavor samples, and that diacetyl, a chemical compound correlated with various severe respiratory pathologies in microwave popcorn-processing plant workers, was observed in concentrations above the laboratory limit in 39 of these flavors [40] (Table 1).

Table 1 The chemical composition of dokha [28,29,30,31] and e-cigarettes [32,33,34,35,36,37,38,39,40]

3.2 The health effects of ATPs

3.2.1 The health effects of dokha

Unlike the effects of tobacco smoking on health that have been very well documented, the effects of ATP consumption are poorly studied. Various authors report a scarcity in studies investigating the health effects of midwakh consumption [41,42,43]. One report shows that midwakh smoking has serious effects on blood pressure like other forms of smoking [12]. Notably, midwakh contains higher concentrations of nicotine and tar than other tobacco products [43, 44]. Since nicotine levels in midwakh (23.83–52.80 mg/g) are much higher than those in cigarettes (0.5–19.5 mg/g), they are expected to impose harmful health effects [29]. The alkaloid, nicotine, can permeate the blood-brain barrier; bind to nicotinic receptors in the central nervous system, promote adrenaline release; and, consequently, stimulate cardiac contractility and constrict blood vessels [44]. In chronic use, excessive sympathetic stimulation leads to continuous elevation of heart rate and cardiac output, causing flow turbulence and potentially damage to blood vessel lining [44].

A study investigating the effects of midwakh smoking on male UAE medical students revealed a significant mean increase in systolic blood pressure of 12 ± 1 mmHg, 20 ± 2 bpm in heart rate, and a nonsignificant mean decrease in diastolic blood pressures of 1 ± 1 mmHg [43]. In other words, midwakh smoking appears to increase heart rate and systolic pressure significantly. Shaikh and colleagues report that immediately after smoking midwakh, there was an observed increase of 4 ± 1 breaths/min in respiratory rate by (2 ± 2 breaths/min) [43]. This is higher than the increase (in respiration rate) brought about by waterpipe smoking. Given that midwakh smokers smoke dokha an average of 12 times per day, they are exposed to markedly high levels of nicotine and tar, increasing their risk of lung cancer [44, 45]. While not considered a carcinogen, nicotine has been associated with bronchial epithelial cell apoptosis [46]. Midwakh analyses revealed high toxin levels and five central nervous system depressants in its smoke [28]. A growing number of seizure cases following midwakh consumption have also been reported in the literature. For example, after a sustained seizure following midwakh consumption for the first time, a 17-year-old male was rushed into an emergency unit and presented with confusion, tachycardia, tachypnea, and a blood pressure of 180/100 mm Hg [42].

Other similar cases were reported by Alsaadi and colleagues [47]. Remarkably, seven male adolescents, who were otherwise healthy, were admitted to hospital for new onset tonic-clonic seizures after a few minutes of smoking midwakh [47]. While further research is required to pinpoint the mechanisms behind midwakh-induced seizures, the high nicotine content in addition to the potential effects of the additives may have brought these about [47]. Ultimately, these few studies point to a substantial psychological and health risks that should be properly evaluated.

3.2.2 The health effects of e-cigarettes

E-cigarettes have been regarded as the less harmful alternative to cigarettes [48]. Since conventional cigarette smoking is typically completed in 8–10 puffs over a 5–8-min period, most e-cigarette smoking is intermittent throughout the day, leading to lower and more stable nicotine levels with no arterial spikes [49]. Some studies report that e-cigarette consumption poses low cardiovascular risk, at least when it comes to short-term use in healthy users [48, 49]. Yet, other studies investigating the longer cardiovascular repercussions of e-cigarette smoking are limited and controversial since novel compounds in e-cigarette vapor, such as flavorings and fragrances, are mostly untested, and their cardiovascular effects are unexamined [50, 51].

Interestingly, a meta-analysis including studies published in 2000-2017 reported negative effects of e-cigarettes on endothelial function, an increase in arterial stiffness, and a greater long-term risk for coronary events [51]. Despite the reported negative effects of e-cigarettes on heart rate, diastolic and systolic blood pressure, one study reported that switching from conventional smoking to e-cigarettes had positive effects on blood pressure regulation [52]. However, dual smokers of e-cigarettes and combustible cigarettes were 36% more likely to suffer from cardiovascular disease [52]. An inhalation toxicology analysis revealed an absence of oxidative stress and inflammation in mice exposed to e-vapor aerosols, while high urinary markers were detected in mice exposed to conventional cigarette smoke [53]. E-cigarette vapor aerosols produced smaller atherosclerotic plaques, affected systolic and diastolic cardiac function, and endothelial function in significantly less severity than conventional cigarettes [54].

A recent case report disclosed that an otherwise healthy patient without any previous cardiopulmonary comorbidities developed a sudden severe, acute cardiomyopathy with e-cigarette use [54]. Another study reports the association of daily e-cigarette use, but not former or occasional e-cigarette use, with higher risks of myocardial infarction in comparison with conventional cigarette use [55]. E-cigarettes also release various compounds displaying pulmonary toxicity such as volatile carbonyls, reactive oxygen species, furans, and metals [56]. A few comprehensive studies investigated the long-term effects of e-cigarettes compounds such as vaporized nicotine and its associated solvents, PG, and VG [57, 58]. E-cigarette aerosol inhalation has been reported to produce enhanced airway reactivity, airway obstruction, inflammation, and emphysema [58]. After exposure to e-cigarettes, airway irritation, mucus hypersecretion, inflammatory response, systemic changes, and altered respiratory function were observed [59, 60].

Moreover, e-cigarette exposure could lead to alteration in gene and protein expression, inhibition of ciliary beating, inhibition of cystic fibrosis transmembrane conductance regulator, and increased cytokine expression in bronchial epithelia [57]. Similarly, the nasal epithelia display inhibited ciliary beating and downregulation of immune genes, while the bronchi display increased stiffness and impaired vasoconstriction [57]. In fact, e-cigarette consumption is linked with aggravated pathology in asthma, cystic fibrosis, and chronic obstructive pulmonary disease patients [60]. The most imminent of all e-cigarettes pulmonary risks is the e-cigarette-associated lung injury (EVALI) [60]. For instance, a case report disclosed that a 35-year-old female electronic nicotine delivery system user presented to the emergency department with sudden-onset dyspnea [61]. Bronchoscopy revealed an extensive pattern of potential airway chemical injury, implying vesicular bronchial injury ensuing e-cigarette use [61]. Another case of a healthy 31-year-old male presenting with lung damage met the CDC definition for potential e-cigarette smoking-associated lung injury [62]. Interestingly, these health hazards are reported to be independent of nicotine. Madison and colleagues [57] report that independent of nicotine, ENDS-exposed mice infected with influenza demonstrated enhanced lung inflammation and tissue damage, and impaired alveolar macrophage physiology, which may be mediated through PG/VG solvents, which are currently deemed safe. Hence, future studies should investigate the direct effects of PG and VG used in e-cigarettes.

Moreover, 35 seizure cases ensuing e-cigarette consumption were reported to the FDA and poison control centers between 2010 and early 2019, and since reporting is voluntary, there is a possibility that even more cases exist [63, 64]. In fact, as of March 2021, more than 250 reports on e-cigarette-associated seizures showed that about 2/3 of the cases were presented in adolescents [64]. Yet, these reports provide limited information on the medical evaluation of each case. Since correlation does not necessarily imply causation, the FDA has requested elaborate assessment of e-cigarette use in patients presenting with e-cigarette-associated seizures to decipher whether nicotine is the mediator of these neurological symptoms [64].

Since nicotine is present at higher concentrations in conventional cigarettes and no other nicotine intoxication has been mentioned, other compounds present in e-cigarettes may be the culprits, especially since many of e-cigarette liquids can be mixed with seizure inducers such as caffeine or synthetic cannabinoids [65]. Aside from this increase in reported seizures, little is known about e-cigarette effects and neurotoxicity [66, 67]. A murine study reported that e-cigarette exposure for 7 days downregulated GLUT1 and GLUT3 expressions and hence glucose uptake. This induced glucose deprivation could enhance ischemic brain injury and/or stroke risk [68]. E-cigarette smoking could therefore be a promoting factor for stroke onset, deterioration of postischemic brain injury, and loss of blood-brain barrier integrity [68].

E-cigarette consumption seems to expose adolescents to lifelong alterations in neuronal signaling, which affects behaviors ranging from emotional regulation to addiction [69]. In fact, e-cigarette smoking has been associated with various drug use and mental problems such attention-deficit/hyperactivity disorder, posttraumatic stress disorder, gambling disorder, anxiety, low self-esteem, and impulsivity [69, 70]. Recent studies reveal a correlation between depression and e-cigarette consumption and an association between greater depressive symptoms at the age of 14 and faster e-cigarette escalation [71, 72]. Of note, e-cigarette consumption may affect people surrounding the user. The mainstream vapor exhaled by the user contains vaporized particles and droplets that can have significant health effects on the passive inhaler. It is worth mentioning that indoor e-cigarette exposure potentially exposes nonusers to nicotine only and not toxic tobacco-specific combustion products [73]. Other studies [75,76,77,78,79] reported other physical and mental health effects with cancer as the most serious [77, 79] (Table 2). Interestingly, an e-cigarette health warning could potentially encourage users to quit e-cigarette smoking and discourage smoking [73, 74]. Future efforts should be directed towards clearing the misconceptions around the assumed safety of e-cigarettes.

Table 2 Reported health effects of cigarettes in comparison to e-cigarettes and midwakh

4 Discussion

Midwakh use in the UAE accounts for 15% of the total tobacco users [15]. The use of midwakh has been gaining interest, mainly because it is cheaper and easy to use. According to Shemmari et al., smoking dokha is considered appealing especially by the younger age groups because it is less expensive than smoking cigarettes, with a week’s supply costing around US $3 versus US $21 for cigarettes. In addition, the lack of odor, the absence of lip staining, and the speed at which the effects are felt allow the smoker to practice rapid smoking in a discreet manner [80]. In some countries, water pipes (also known as shisha) and midwakh are more socially acceptable types of tobacco use, and most of the people who smoke midwakh, according to a study in UAE, do so because of peer pressure, stress relief, or simply for the experience [76].

The lack of barriers and ease in ability to obtain tobacco, and the financial standing of the nation, all have sway over the potential to create new smokers, especially in the young population [81]. Moreover, Elobaid et al. [82] revealed that stress was the main factor to smoking midwakh (dokha) among male students, especially during examinations. The UAE has established various policies to regulate the selling and consumption of midwakh, by penalizing smoking in private cars in the presence of a child under 12 in confined public areas, worship areas, educational establishments, and sports and health facilities. This law also forbids selling tobacco products to those under 18, selling sweets or candies that have similar appearances to tobacco products, and creating automatic vending machines or devices that distribute tobacco across the country, in addition to forbidding advertising tobacco products [83].

In addition, Cabral, [84]. discloses that factors like loneliness, stress, and depression were linked with smoking e-cigarettes among university students as a coping mechanism, especially during COVID 19. Park et al. [85] measured psychological factors like depression, anxiety, and hopelessness, among e-cigarette and cigarette smokers. Results revealed that both had high levels of psychological stress during every smoking session [85]. The influence of a family member or friend was also one of the main reasons associated with the use of e-cigarettes, specifically among adolescents [86]. In a study among young adults in UAE, 27.1% of the surveyed e-cigarettes users had at least one parent that smokes one of the ATPs, and 44.6% had a friend that smokes [86]. A total of 34.4% of students surveyed, among three public UAE universities, mentioned that different flavors of e-cigarettes encouraged them to smoke, while others reported that e-cigarettes seemed like a healthier option than traditional smoking [17]. The abundance of flavors is linked to satisfaction and addiction among young adults, possibly encouraging both e-cigarettes and midwakh smoking between adolescents [87].

5 Conclusions

Theoretically, the ATPs purpose was to facilitate smoking cessation among the cigarette smoking population. In fact, its use has been predicted to encourage utilization of other substances. Yet, information on its chemical and physiological effects is alarming. Compelling evidence implies that e-cigarette consumption may lead to eventual conventional cigarette smoking with an alarming increase in e-cigarette consumption among youth. Of note, some studies reveal that ATPs were encouraged within social activity with peers. Smoking dokha and e-cigarettes, however, may be a coping mechanism underlying psychological stress. Depression was commonly found amid e-cigarette smokers and more likely to occur in e-cigarette smokers than nonsmokers, specifically among young adults. With social influences and emerging flavors being one of the main reasons behind smoking e-cigarettes and midwakh, there is a concerning growth in public health among adolescents. Despite many studies indicating the harmful effects of e-cigarettes and midwakh on physical and mental health, it is still a controversial topic that requires a lot more research and regulation.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.


  1. Conner M, Grogan S, Simms-Ellis R, Flett K, Sykes-Muskett B, Cowap L, et al. Do electronic cigarettes increase cigarette smoking in UK adolescents? Evidence from a 12-month prospective study. Tob Control. 2017;27(4):365–72.

    Article  PubMed  Google Scholar 

  2. Janik-Koncewicz K, Zatoński W, Zatońska K, Stępnicka Z, Basiak-Rasała A, Zatoński M, et al. Cigarette smoking in Poland in 2019: the continuing decline in smoking prevalence. J Inequal Appl. 2020;6(2):87–94.

    Article  Google Scholar 

  3. Janssen E, Le Nézet O, Shah J, Chyderiotis S, Brissot A, Philippon A, et al. Increasing socioeconomic disparities in tobacco smoking decline among French adolescents (2000–2017). J Public Health. 2019;42(4)

  4. Wei L, Muhammad-Kah RS, Hannel T, Pithawalla YB, Gogova M, Chow S, et al. The impact of cigarette and e-cigarette use history on transition patterns: a longitudinal analysis of the Population Assessment of Tobacco and Health (PATH) study, 2013–2015. Harm Reduct J. 2020;17(1)

  5. Gao W, Sanna M, Chuluunbaatar E, Tsai M-K, Levy DT, Wen CP. Are e-cigarettes reviving the popularity of conventional smoking among Taiwanese male adolescents? A Time-trend population-based analysis for 2004-2017. Tob Control. 2020;30(2):132–6.

    Article  PubMed  Google Scholar 

  6. Flor LS, Reitsma MB, Gupta V, Ng M, Gakidou E. The effects of tobacco control policies on global smoking prevalence. Nat Med. 2021;27(2):239–43.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  7. Mayne SL, Gordon-Larsen P, Schreiner PJ, Widome R, Jacobs DR, Kershaw KN. Longitudinal associations of cigarette prices with smoking cessation: the coronary artery risk development in young adults study. Nicotine Tob Res. 2018;21(5):678–85.

    Article  PubMed Central  Google Scholar 

  8. Bjurlin MA, Kamecki H, Gordon T, Krajewski W, Matulewicz RS, Małkiewicz B, et al. Alternative tobacco products use and its impact on urologic health – will the lesser evil still be evil? A commentary and review of literature. Cent European J Urol. 2021;74(2)

  9. Abdel Magid HS, Halpern-Felsher B, Ling PM, Bradshaw PT, Mujahid MS, Henriksen L. Tobacco retail density and initiation of alternative tobacco product use among teens. J Adolesc Health. 2020;66(4):423–30.

    Article  PubMed  Google Scholar 

  10. Al Kawas S, Al-Marzooq F, Rahman B, Shearston JA, Saad H, Benzina D, et al. The impact of smoking different tobacco types on the subgingival microbiome and periodontal health: a pilot study. Sci Rep. 2021;11(1)

  11. World Health Organization. WHO report on the global tobacco epidemic 2021: addressing new and emerging products. World Health Organization; 2021. Available from: Accessed 6 Jun 2023.

  12. Vupputuri S, Hajat C, Al-Houqani M, Osman O, Sreedharan J, Ali R, et al. Midwakh/dokha tobacco use in the Middle East: much to learn. Tob Control. 2014;25(2):236–41.

    Article  PubMed  Google Scholar 

  13. Jawad M, Al-Houqani M, Ali R, El Sayed Y, ElShahawy O, Weitzman M, et al. Prevalence, attitudes, behaviours and policy evaluation of midwakh smoking among young people in the United Arab Emirates: cross-sectional analysis of the Global Youth Tobacco Survey. PLoS ONE. 2019;14(4)

  14. Chehab M. Legislation related to e-cigarettes in the Gulf Cooperation Council countries. Asian Pac J Cancer Prev. 2020;21(12):3449–51.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Al Sharbatti S, Shaikh RB, Sreedharan J, Muttappallymyalil J, Weizman M. Predictors of nicotine dependence among adult male midwakh and cigarette smokers. Sultan Qaboos Univ Med J. 2021;

  16. Barakat M, Jirjees F, Al-Tammemi AB, Al-Qudah R, Alfoteih Y, Kharaba Z, et al. The era of e-cigarettes: a cross-sectional study of vaping preferences, reasons for use and withdrawal symptoms among current e-cigarette users in the United Arab Emirates. J Community Health. 2021;46(5):876–86.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Ahmed LA, Verlinden M, Alobeidli MA, Alahbabi RH, AlKatheeri R, Saddik B, et al. Patterns of tobacco smoking and nicotine vaping among university students in the United Arab Emirates: a cross-sectional study. Int J Environ Res Public Health. 2021;18(14):7652.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  18. Almogbel F, Almuqbil S, Rabbani U, Almogbel Y. Prevalence and predictors of midwakh smoking among male students of Qassim University, Al-Qassim, Saudi Arabia. Tob Induc Dis. 2020;18(September):73.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Habib E, Helaly M, Elshaer A, Sriwi D, Ahmad M, Mohamed M, et al. Prevalence and perceptions of e-cigarette use among medical students in a Saudi University. Fam Med Prim. 2020;9(6):3070.

    Article  Google Scholar 

  20. AlMulla A, Mamtani R, Cheema S, Maisonneuve P, Abdullah BaSuhai J, Mahmoud G, et al. Epidemiology of tobacco use in Qatar: prevalence and its associated factors. PLoS ONE. 2021;16(4)

  21. Kurdi R, Al-Jayyousi GF, Yaseen M, Ali A, Mosleh N, Abdul Rahim HF. Prevalence, risk factors, harm perception, and attitudes toward e-cigarette use among university students in Qatar: a cross-sectional study. Front Public Health. 2021:9.

  22. Esmaeil A, Alshammasi A, Almutairi W, Alnajem A, Alroumi D, Ali M, et al. Patterns of electronic cigarette, conventional cigarette, andhookah use and related passive exposure among adolescentsin Kuwait: a cross-sectional study. Tob Induc Dis. 2020;18

  23. Zhou S, Van Devanter N, Fenstermaker M, Cawkwell P, Sherman S, Weitzman M. A study of the use, knowledge, and beliefs about cigarettes and alternative tobacco products among students at one U.S. medical school. Acad Med. 2015;90(12):1713–9.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Herman M, Tarran R. E-cigarettes, nicotine, the lung and the brain: multi-level cascading pathophysiology. Physiol J. 2020;598(22):5063–71.

    Article  CAS  Google Scholar 

  25. Bhatt JM, Ramphul M, Bush A. An update on controversies in e-cigarettes. Paediatr Respir Rev. 2020;36:75–86.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Chao D, Hashimoto H, Kondo N. Social influence of e-cigarette smoking prevalence on smoking behaviours among high-school teenagers: microsimulation experiments. PLoS ONE. 2019;14(8)

  27. Mohammad AB, Mohammad SH, Mohammad MK, Khan AS, Al-Hajjaj MS. Quantification of trace elements in different dokha and shisha tobacco products using EDXRF. J Anal Toxicol. 2018;43(4)

  28. Elsayed Y, Dalibalta S, El Kouche M. Chemical Characterization and safety assessment of dokha: an emerging alternative tobacco product. Sci Total Environ. 2018;615:9–14.

    Article  PubMed  CAS  Google Scholar 

  29. Mahboub B, Mohammad AB, Nahlé A, Vats M, Al Assaf O, Al-Zarooni H. Analytical determination of nicotine and tar levels in various dokha and shisha tobacco products. J Anal Toxicol. 2018;42(7):496–502.

    Article  PubMed  CAS  Google Scholar 

  30. Varughese A, Pooboni S, Vinod V, Abusamra R. Midwakh associated acute lung injury (Mali): an emerging epidemic in the Middle East -a case report and review of literature. Authorea. 2020;

  31. Samara F, Alam IA, ElSayed Y. Midwakh: Assessment of levels of carcinogenic polycyclic aromatic hydrocarbons and nicotine in dokha tobacco smoke. J Anal Toxicol. 2021;46(3):295–302.

    Article  CAS  Google Scholar 

  32. Li Y, Burns AE, Tran LN, Abellar KA, Poindexter M, Li X, et al. Impact of e-liquid composition, coil temperature, and puff topography on the aerosol chemistry of electronic cigarettes. Chem Res Toxicol. 2021;34(6):1640–54.

    Article  PubMed  CAS  Google Scholar 

  33. Mallock N, Trieu HL, Macziol M, Malke S, Katz A, Laux P, et al. Trendy e-cigarettes enter Europe: chemical characterization of JUUL pods and its aerosols. Arch Toxicol. 2020;94(6):1985–94.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  34. Shah NH, Noe MR, Agnew-Heard KA, Pithawalla YB, Gardner WP, Chakraborty S, et al. Non-targeted analysis using gas chromatography-mass spectrometry for evaluation of chemical composition of E-vapor products. Front Chem. 2021:9.

  35. Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control. 2013;23(2):133–9.

    Article  PubMed  Google Scholar 

  36. Williams M, Bozhilov K, Ghai S, Talbot P. Elements including metals in the atomizer and aerosol of disposable electronic cigarettes and electronic hookahs. PLOS ONE. 2017;12(4)

  37. Olmedo P, Goessler W, Tanda S, Grau-Perez M, Jarmul S, Aherrera A, et al. Metal concentrations in e-cigarette liquid and aerosol samples: the contribution of metallic coils. Environ Health Perspect. 2018;126(2).

  38. Jabba SV, Diaz AN, Erythropel HC, Zimmerman JB, Jordt S-E. Chemical adducts of reactive flavor aldehydes formed in e-cigarette liquids are cytotoxic and inhibit mitochondrial function in respiratory epithelial cells. Nicotine Tob Res. 2020;22(Supplement_1):25–34.

    Article  CAS  Google Scholar 

  39. Eddingsaas N, Pagano T, Cummings C, Rahman I, Robinson R, Hensel E. Qualitative analysis of e-liquid emissions as a function of flavor additives using two aerosol capture methods. Int J Environ Res Public Health. 2018;15(2):323.

  40. Allen JG, Flanigan SS, LeBlanc M, Vallarino J, MacNaughton P, Stewart JH, et al. Flavoring chemicals in e-cigarettes: diacetyl, 2,3-pentanedione, and acetoin in a sample of 51 products, including fruit-, candy-, and cocktail-flavored e-cigarettes. Environ Health Perspect. 2016;124(6):733–9.

    Article  PubMed  CAS  Google Scholar 

  41. Vallès Y, Inman CK, Peters BA, Ali R, Wareth LA, Abdulle A, et al. Types of tobacco consumption and the oral microbiome in the United Arab Emirates Healthy Future (UAEHFS) pilot study. Sci Rep. 2018;8(1)

  42. Eid MM. Midwakh (pipe) and seizure: the overlooked link. J Emerg Pract.. 2021;7(2):140–2.

  43. Shaikh RB, Haque NM, Al Mohsen HA, Al Mohsen AA, Humadi MH, Al Mubarak ZZ, et al. Acute effects of dokha smoking on the cardiovascular and respiratory systems among UAE male university students. Asian Pac J Cancer Prev. 2012;13(5):1819–22.

    Article  PubMed  Google Scholar 

  44. Al-Houqani M, Ali R, Hajat C. Tobacco smoking using midwakh is an emerging health problem – evidence from a large cross-sectional survey in the United Arab Emirates. PLoS ONE. 2012;7(6)

  45. Middha P, Weinstein SJ, Männistö S, Albanes D, Mondul AM. Β-carotene supplementation and lung cancer incidence in the alpha-tocopherol, beta-carotene cancer prevention study: the role of tar and nicotine. Nicotine Tob. Res. 2018;21(8):1045–50.

    Article  PubMed Central  CAS  Google Scholar 

  46. Bodas M, Van Westphal C, Carpenter-Thompson R, Mohanty DK, Vij N. Nicotine exposure induces bronchial epithelial cell apoptosis and senescence via ROS mediated autophagy-impairment. Free Radic Biol Med. 2016;97:441–53.

    Article  PubMed  CAS  Google Scholar 

  47. Alsaadi T, Alkaddour AR, Shahrour TM, Shakra M, Turkawi L, Shatila A. Midwakh-induced seizures: case series from UAE. Epilepsy Behav. 2014;39:85–7.

    Article  PubMed  Google Scholar 

  48. Eltorai AE, Choi AR, Eltorai AS. Impact of electronic cigarettes on various organ systems. Respir Care. 2018;64(3):328–36.

    Article  PubMed  Google Scholar 

  49. Benowitz NL, Burbank AD. Cardiovascular toxicity of nicotine: implications for electronic cigarette use. Trends Cardiovasc Med. 2016;26(6):515–23.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  50. Münzel T, Hahad O, Kuntic M, Keaney JF, Deanfield JE, Daiber A. Effects of tobacco cigarettes, e-cigarettes, and waterpipe smoking on endothelial function and clinical outcomes. Eur Heart J. 2020;41(41):4057–70.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  51. Skotsimara G, Antonopoulos AS, Oikonomou E, Siasos G, Ioakeimidis N, Tsalamandris S, et al. Cardiovascular effects of electronic cigarettes: a systematic review and meta-analysis. Eur J Prev Cardiol. 2019;26(11):1219–28.

    Article  PubMed  Google Scholar 

  52. Osei AD, Mirbolouk M, Orimoloye OA, Dzaye O, Uddin SMI, Benjamin EJ, et al. Association between e-cigarette use and cardiovascular disease among never and current combustible-cigarette smokers. Am J Med. 2019;132(8)

  53. Szostak J, Wong ET, Titz B, Lee T, Wong SK, Low T, et al. A 6-month systems toxicology inhalation study in apoe−/− mice demonstrates reduced cardiovascular effects of E-vapor aerosols compared with cigarette smoke. Am J Physiol Heart. 2020;318(3)

  54. Amirahmadi R, Childress J, Patel S, Wagner L-A. Electric cigarette-related lung injury and cardiovascular insult. BMJ Case Rep. 2021;14(3)

  55. Alzahrani T, Pena I, Temesgen N, Glantz SA. Association between electronic cigarette use and myocardial infarction. Am J Prev Med. 2018;55(4):455–61.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Gotts JE, Jordt S-E, McConnell R, Tarran R. What are the respiratory effects of e-cigarettes? BMJ. 2019;366:l5275.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Madison MC, Landers CT, Gu B-H, Chang C-Y, Tung H-Y, You R, et al. Electronic cigarettes disrupt lung lipid homeostasis and innate immunity independent of nicotine. J Clin Investig. 2019;129(10):4290–304.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Tsai M, Byun MK, Shin J, Crotty Alexander LE. Effects of e-cigarettes and vaping devices on cardiac and pulmonary physiology. Physiol J. 2020;598(22):5039–62.

    Article  CAS  Google Scholar 

  59. Thirión-Romero I, Pérez-Padilla R, Zabert G, Barrientos-Gutiérrez I. Respiratory impact of electronic cigarettes and low-risk tobacco. Rev Investig Clin. 2019;71(1)

  60. Overbeek DL, Kass AP, Chiel LE, Boyer EW, Casey AM. A review of toxic effects of electronic cigarettes/vaping in adolescents and young adults. Crit Rev Toxicol. 2020;50(6):531–8.

    Article  PubMed  CAS  Google Scholar 

  61. Carter T, Tucker D, Kilic A, Papadimos T, Barlow A, Berry E. Life-threatening vesicular bronchial injury requiring veno-venous extracorporeal membrane oxygenation rescue in an electronic nicotine delivery system user. Clin Pract Cases Emerg Med. 2017;1(3):212–7.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Macias A, Garcia F, Saldana S. A patient from Mexico with vaping-associated lung injury,seizures and renal failure. Tob Induc Dis. 2019;17(9)

  63. Zolot J. Some young adult e-cigarette users report seizures. Am J Nurs. 2019;119(7):13.

    Article  PubMed  Google Scholar 

  64. Weidner A-S, Imoisili O, Rudy S. E-cigarette–associated seizure reports to Food and Drug Administration lack medical information. Ann Emerg Med. 2021;78(6):802–3.

    Article  PubMed  Google Scholar 

  65. Benowitz NL. Seizures after vaping nicotine in youth: a canary or a red herring? J Adolesc Health. 2020;66(1):1–2.

    Article  PubMed  Google Scholar 

  66. Kaisar MA, Villalba H, Prasad S, Liles T, Sifat AE, Sajja RK, et al. Offsetting the impact of smoking and e-cigarette vaping on the cerebrovascular system and stroke injury: is metformin a viable countermeasure? Redox Biol. 2017;13:353–62.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  67. Ruszkiewicz JA, Zhang Z, Gonçalves FM, Tizabi Y, Zelikoff JT, Aschner M. Neurotoxicity of e-cigarettes. Food Chem Toxicol. 2020;138:111245.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  68. Sifat AE, Vaidya B, Kaisar MA, Cucullo L, Abbruscato TJ. Nicotine and electronic cigarette (e-cig) exposure decreases brain glucose utilization in ischemic stroke. J Neurochem. 2018;147(2):204–21.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  69. Grant JE, Lust K, Fridberg DJ, King AC, Chamberlain SR. E-cigarette use (vaping) is associated with illicit drug use, mental health problems, and impulsivity in university students. U.S. National Library of Medicine; 2019. Available from: Accessed 6 Jun 2023

  70. Obisesan OH, Mirbolouk M, Osei AD, Orimoloye OA, Uddin SM, Dzaye O, et al. Association between e-cigarette use and depression in the behavioral risk factor surveillance system, 2016-2017. JAMA Netw Open. 2019;2(12)

  71. Moustafa AF, Testa S, Rodriguez D, Pianin S, Audrain-McGovern J. Adolescent depression symptoms and e-cigarette progression. Drug Alcohol Depend. 2021;228:109072.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Rom O, Pecorelli A, Valacchi G, Reznick AZ. Are e-cigarettes a safe and good alternative to cigarette smoking? Ann N. Y. Acad Sci. 2014;1340(1):65–74.

    Article  PubMed  CAS  Google Scholar 

  73. Brewer NT, Jeong M, Hall MG, Baig SA, Mendel JR, Lazard AJ, et al. Impact of e-cigarette health warnings on motivation to vape and smoke. Tob Control. 2019;28(e1):e64–70.

    Article  PubMed  Google Scholar 

  74. Saha SP, Bhalla DK, Whayne TF, Gairola CG. Cigarette smoke and adverse health effects: an overview of research trends and future needs. Int J Angiol. 2007;16(03):77–83.

    Article  PubMed  PubMed Central  Google Scholar 

  75. John LJ, Muttappallymyalil J. Dokha: An emerging public health issue as a form of tobacco smoking in the Middle East. Asian Pac J Cancer Prev. 2013;14(12):7065–7.

    Article  PubMed  Google Scholar 

  76. Aden B, Karrar S, Shafey O, Al Hosni F. Cigarette, water-pipe, and medwakh smoking prevalence among applicants to Abu Dhabi’s pre-marital screening program. U.S. National Library of Medicine; 2011. Available from: Accessed 6 Jun 2023.

  77. Xu Z, Qi F, Wang Y, Jia X, Lin P, Geng M, et al. Cancer mortality attributable to cigarette smoking in 2005, 2010 and 2015 in Qingdao, China. PLoS ONE. 2018;13(9)

  78. Livingston JA, Chen C-H, Kwon M, Park E. Physical and mental health outcomes associated with adolescent e-cigarette use. J Pediatr Nurs. 2022;64:1–17.

  79. Esteban-Lopez M, Perry MD, Garbinski LD, Manevski M, Andre M, Ceyhan Y, et al. Health effects and known pathology associated with the use of e-cigarettes. Toxicol Rep. 2022;9:1357–68.

  80. Shemmari NA, Shaikh RB, Sreedharan J. Prevalence of dokha use among secondary school students in Ajman, United Arab Emirates. Asian Pac J Cancer Prev. 2015;16(2):427–30.

    Article  PubMed  Google Scholar 

  81. Asfour LW, Stanley ZD, Weitzman M, Sherman SE. Uncovering risky behaviors of expatriate teenagers in the United Arab Emirates: a survey of tobacco use, nutrition and physical activity habits. BMC Public Health. 2015;15(1)

  82. Elobaid YE, Jabari AL, Al Hamiz A, Al Kaddour AR, Bakir S, Barazi H, et al. Stages of change, smoking behavior and acceptability of a textmessaging intervention for tobacco cessation among cigarette, dokha and shishasmokers: a qualitative research study. BMJ Open. 2019;9(9)

  83. The United Arab Emirates' Government portal. Tobacco provisions UAE; 2023. Available from: Accessed 6 Jun 2023.

  84. Cabral P. E-cigarette use and intentions related to psychological distress among cigarette, e-cigarette, and cannabis vape users during the start of the COVID-19 pandemic. BMC Psychol. 2022;10(1)

  85. Park SH, Lee L, Shearston JA, Weitzman M. Patterns of electronic cigarette use and level of psychological distress. PLoS ONE. 2017;12(3)

  86. Abbasi Y, Hout M-CV, Faragalla M, Itani L. Knowledge and use of electronic cigarettes in young adults in the United Arab Emirates, particularly during the COVID-19 pandemic. Int J Environ Res Public Health. 2022;19(13):7828.

  87. Landry RL, Groom AL, Vu T-HT, Stokes AC, Berry KM, Kesh A, et al. The role of flavors in vaping initiation and satisfaction among U.S. adults. Addict Behav. 2019;99:106077.

    Article  PubMed  PubMed Central  Google Scholar 

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SD, FS, and YE have made substantial contributions to the conception and design of the study, the acquisition and interpretation of the data, and have substantively revised the manuscript. ZM and LR drafted the original paper and made substantial contributions to the analysis of the data and formulation of tables. All authors have approved the submitted version of the study and any substantially modified version that involves the author’s contribution to the study and have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated and resolved and the resolution documented in the literature.

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Correspondence to Sarah Dalibalta.

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Dalibalta, S., Makhlouf, Z., Rabah, L. et al. A literature review addressing midwakh and e-cigarette use in the Gulf region. J. Egypt. Public. Health. Assoc. 98, 21 (2023).

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