Smoking among adolescents in Jordan: Prevalence, associated factors, and its relation to mental health outcomes.

Waterpipe (shisha) was the most prevalent form of tobacco use among adolescents in Jordan, followed by e-cigarettes and cigarettes.

• Study included 4,407 adolescents from a nationally representative school-based survey conducted between December 2022 and April 2023.
• Waterpipe prevalence was 19.2%, e-cigarette prevalence was 15.1%, and cigarette prevalence was 9.8%.
• Sample covered children and adolescents aged 8-18 years in both host and refugee populations in Jordan.
• A multi-stage stratified cluster sampling design was employed to ensure national representativeness.

Smoking odds increased significantly with age, with 18-year-olds having substantially higher odds of all forms of tobacco use compared to 12-year-olds.

• Compared with 12-year-olds, adolescents aged 18 had significantly higher odds of smoking cigarettes or waterpipe (OR = 5.9, 95% CI 3.8-9.2).
• Adolescents aged 18 also had significantly higher odds of using e-cigarettes compared to 12-year-olds (OR = 4.5, 95% CI 2.7-7.4).
• These findings were from multivariate analysis.

Maternal education level was associated with adolescent e-cigarette use, with lower maternal education linked to reduced odds of e-cigarette use.

• Adolescents whose mothers had less than a diploma had lower odds of e-cigarette use (OR = 0.8, 95% CI 0.6-0.9).
• This association was identified in multivariate analysis.

Geographic region within Jordan was significantly associated with smoking prevalence, with adolescents in the northern region less likely to smoke than those in the central region.

• Compared with adolescents in central Jordan, those in the northern region had significantly lower odds of cigarette/waterpipe use (OR = 0.8, 95% CI 0.6-0.9).
• Adolescents in the northern region also had significantly lower odds of e-cigarette use compared to those in central Jordan (OR = 0.7, 95% CI 0.6-0.9).

Palestinian camp refugees were significantly less likely than Jordanians to smoke cigarettes or waterpipe, but did not differ significantly in e-cigarette use.

• Palestinian camp refugees had significantly lower odds of cigarette or waterpipe use compared to Jordanians (OR = 0.4, 95% CI 0.2-0.9).
• No significant difference in e-cigarette use was found between Palestinian camp refugees and Jordanians.

Smoking cigarettes or waterpipe was significantly associated with higher levels of multiple mental and psychosocial problem symptoms.

• Cigarette or waterpipe smoking was associated with higher levels of separation anxiety, emotional symptoms, conduct problems, hyperactivity, relationship problems with peers, lower sociability, and general behavioral difficulties.
• Cigarette or waterpipe smoking was also significantly associated with PTSD symptoms.
• A higher risk of problematic Internet use was also found among cigarette or waterpipe smokers.
• These associations were assessed using internationally recognized and validated tools.

Smoking cigarettes or waterpipe was significantly associated with poorer quality of life across all measured dimensions.

• Poorer quality of life was observed across overall, physical health, psychosocial health, emotional functioning, social functioning, and school functioning dimensions.
• These associations were identified among adolescent cigarette or waterpipe smokers.

E-cigarette use was significantly associated with higher conduct problems, hyperactivity, total difficulties, lower prosocial behavior, and poorer school functioning.

• Adolescents who reported using e-cigarettes had significantly higher conduct problems and hyperactivity symptoms.
• E-cigarette users also had higher total difficulties scores and lower prosocial behavior scores.
• Poorer school functioning was also significantly associated with e-cigarette use.