Early Initiation and Dual Patterns of Cigarette and E-Cigarette Use among Adults in the Eastern Province, Saudi Arabia:

Objectives: To explore the early initiation of cigarette and e-cigarette use and the dual patterns of usage among adults in the Eastern Province of Saudi Arabia. Methods: A cross-sectional survey was conducted from December 2024 to February 2025 among adults living in the Eastern Province. An online self-administered questionnaire collected data on sociodemographic characteristics, smoking behaviors, age of initiation, dual-use patterns, and quit attempts. Convenience sampling was applied, and a total of 551 participants were included. Descriptive statistics summarized distributions of smoking behavior and initiation age. Pearson's Chi-square tests were used to examine associations between smoking status, age of initiation, and product-use categories. Results: Among the 551 participants, 29.9% were current smokers. Cigarettes were the most used product (50.7%), followed by shisha (42.2%) and e-cigarettes (34.5%). More than half of smokers (52.7%) initiated smoking between 15-20 years of age, while 8.5% initiated before age 15. Tobacco-use patterns varied, with 26% reporting cigarette-only use, 13% e-cigarette-only use, and 32% shisha-only use. Dual-use patterns included cigarette + shisha (7%), cigarette + e-cigarette (6%), and e-cigarette + shisha (5%), while 11% reported triple-product use. Quit attempts were most common among cigarette-only users (42 attempts), followed by e-cigarette-only users (22) and dual users (14). Conclusion: Early initiation and diverse tobacco-use patterns including cigarette, shisha, and e-cigarette use are common in the Eastern Province. Dual and triple-product use further highlight evolving nicotine behaviors, emphasizing the need for targeted prevention and cessation strategies.