Electronic Nicotine Delivery Systems Use Among Students in the Eastern Mediterranean Region: A Systematic Review and Meta-Analysis of 60 Studies on Prevalence and Socioeconomic Determinants.

BACKGROUND: The rapid global increase in Electronic Nicotine Delivery Systems (ENDS) use among youth is a pressing public health concern. However, comprehensive data for the Eastern Mediterranean Region (EMRO) remains sparse. This study aimed to conduct a systematic review and meta-analysis to determine the pooled prevalence of ENDS use among student populations in EMRO countries. METHODS: Following PRISMA guidelines, a systematic search was conducted across PubMed, Scopus, Web of Science, and Embase for studies published up to August 2025. Observational studies reporting the prevalence of current or lifetime ENDS use in EMRO countries were included. A random-effects meta-analysis model was employed to calculate pooled prevalence estimates. Meta-regression analysis was performed to assess the association between the Human Development Index (HDI) and ENDS prevalence. RESULTS: Sixty studies (n = 92,636) were included. 81.7% of the included studies were rated as high quality on the Newcastle-Ottawa Scale. The overall pooled current prevalence of ENDS use was 21% (95% CI: 17.0-24.0), while the lifetime prevalence was 24% (95% CI: 20-29). A significant sex disparity was observed, with current use higher in males (28%) than females (14%). Meta-regression revealed a statistically significant inverse relationship between a country's HDI and both current (slope: -1.81, p < 0.01) and lifetime (slope: -3.11, p < 0.001) ENDS prevalence. CONCLUSION: ENDS use is highly prevalent among students in the EMRO region, particularly among males. The strong negative correlation with HDI suggests higher use is associated with lower socioeconomic development. These findings highlight an urgent need for targeted regulatory and public health interventions tailored to the region's specific socioeconomic context.