Use of e-Cigarettes and Tobacco Products Among Youth in Turkey

Abstract

Objective:
The aim of this study was to determine high school students' views about tobacco products and e-cigarettes and e-cigarette smoking prevalence in one of Turkey's western provinces.

Materials and methods:
This cross-sectional study included 286 students. The data collection form consisted of 18 questions related to sociodemographic features and tobacco and e-cigarette use.

Results:
Of the 286 participants, 32.2% reported having used a tobacco product in the past month, 1.02% reported having used e-cigarettes, and 15.2% have tried e-cigarettes at least once. Of those who tried e-cigarettes, 19.2% of them did so because of curiosity. A positive correlation was found between e-cigarette trial and tobacco use, with age. Smoking/e-cigarette use status was significant with "e-cigarettes are harmful" (P=.034), "e-cigarette smoke is harmful" (P = .003), and "selling and advertising e-cigarettes is prohibited" (P =.043).

Conclusion:
This study determined that 3 out of 10 youths used tobacco products, and 1 used e-cigarettes. There is a need to raise awareness among high school students and youth regarding the dangers of e-ciga- rettes and tobacco products.

Full text

Content of this journal is licensed under a Creative
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Tobacco Use and e-Cigarette Experiences of the Youth
Kurtuluş and Can.
ABSTRACT
Objective: The aim of this study was to determine high school students’ views about tobacco products
and e-cigarettes and e-cigarette smoking prevalence in one of Turkey’s western provinces.
Materials and Methods: This cross-sectional study included 286 students. The data collection form consisted
of 18 questions related to sociodemographic features and tobacco and e-cigarette use.
Results: Of the 286 participants, 32.2% reported having used a tobacco product in the past month,
1.02% reported having used e-cigarettes, and 15.2% have tried e-cigarettes at least once. Of those who
tried e-cigarettes, 19.2% of them did so because of curiosity. A positive correlation was found between
e-cigarette trial and tobacco use, with age. Smoking/e-cigarette use status was significant with “e-cigarettes
are harmful” (P = .034), “e-cigarette smoke is harmful” (P = .003), and “selling and advertising e-cigarettes is
prohibited” (P =.043).
Conclusion: This study determined that 3 out of 10 youths used tobacco products, and 1 used e-cigarettes.
There is a need to raise awareness among high school students and youth regarding the dangers of e-ciga-
rettes and tobacco products.
Keywords: Addiction, e-cigarette, smoking, youth
Introduction
The youth are an important target group for the tobacco industry. According to the 2017 Global
Youth Tobacco Survey of Turkey, in total, among young people aged 13-15 years, smoking preva-
lence is 7.7%, 9.9% in men, and 5.3% in girls.1 Other studies involving high school students in
Turkey reported the prevalence of smoking between 13.4% and 35.7%.2-4 The tobacco industry
tries to maintain dependency on the new products it introduces to the market.5 One of these
products is Electronic Nicotine Delivery Systems (ENDS), known as e-cigarettes. e-Cigarettes
cause addiction due to their nicotine content.5,6 It is claimed that in causing addiction, e-ciga-
rettes may be a “gateway” in the transition to tobacco smoking. In other words, the previous
use of “lighter” substances is a step in the transition to stronger substances.6,7 Studies on the
long-term health outcomes of e-cigarette use are limited. However, research supports that the
e-cigarette is a harmful product.8 e-Cigarettes contain many toxic substances, including nicotine,5
which have harmful eects on brain development in adolescents and teenagers due to the toxic
substances they contain.5,7 In fact, studies in the literature suggest that the nicotine solution,
heavy metals, glass fibers, and flavoring chemicals in e-cigarettes may have potentially negative
eects that may contribute to the pathogenesis of adolescent respiratory tract symptoms and
asthma.9,10 Studies show that e-cigarette use has become widespread in many European coun-
tries, and especially in the United States. In the United States, in 2019, a study reported that
10.5% of secondary school students and 27.5% of high school students had used e-cigarettes in
the last 30 days.11 A study conducted in Canada reported the frequency of e-cigarette use as
6.5%.12 In a study involving 14 352 university students from Belarus, Lithuania, Poland, Russia, and
Slovakia, it was reported that 1.1% of the participants used e-cigarettes.13 In a study conducted
in China, the frequency of e-cigarette use is reported to be 2.1% and 3.6% among vocational
high school students.10
Use of e-Cigarettes and Tobacco Products Among Youth in Turkey
Şerif Kurtuluş1, Remziye Can2
2
54
Original Article
Original Article
Eurasian J Med 2022; 54(2): 127-132
Eurasian J Med 2022; 54(2): 127-132
This article has been accepted by Turkish
Thoracic Society and presented at the
23rdannual congress.
Cite this article as: Kurtuluş Ş, Can R. Use of
e-cigarettes and tobacco products among youth in
Turkey. Eurasian J Med., 2022;54(2)2:127-132.
1Department of Chest Diseases, Harran
University Faculty of Medicine, Şanlıurfa, Turkey
2Mustafa Kemal Atatürk Vocational and Technical
Anatolian High School, Eskişehir, Turkey
Received: June 11, 2020
Accepted: February 14, 2021
Corresponding author: Şerif Kurtuluş,
e-mail: drkurtulus1@gmail.com
DOI 10.5152/eurasianjmed.2022.20168
General Chest Diseases

128 • Kurtuluş and Can. Tobacco Use and e-Cigarette Experiences of the Youth Eurasian J Med 2022; 54(2): 127-132
E-cigarette was started to be sold to the
public trough both media and direct market-
ing in Turkey in 2007.5 However, studies on
e-cigarettes in Turkey usually cover the adult
age group.14,15 Studies have shown that the
frequency of e-cigarette use among Turkish
students is 2.9% and 19% among people over
18 years old.16,17 In the literature, no study was
found to examine the frequency and use of
e-cigarettes among adolescents in Turkey. The
aim of this study was to determine the fre-
quency of use of e-cigarettes and other tobacco
products and the views on the extent of
e-cigarette use among students in a high school
in 1 city in western Turkey.
Materials and Methods
Study Design
This cross-sectional study was conducted at a
vocational school in the city of Eskişehir in the
western part of Turkey (n = 286). Eskişehir is
an industrial zone where the research is carried
out, and its population is 887 475. Eskişehir is
considered among liveable cities with its location
and socio-economic level.18
Sample
The high school in which the study was con-
ducted consisted of graduate students in the
health field. The universe of the research was
724 students enrolled in the 2019-2020 aca-
demic year. The sample size calculated for the
population of 724 students with a 95% CI and 5%
margin of error is 251. Students were informed
about the study by the researcher. Written
informed consent was obtained from all parents
of individual participants. Of these students,
315 provided the signed forms and confirmed
that they wanted to participate in the study.
Twenty-nine of the forms were incomplete or
incorrectly coded in the questionnaire; thus, 286
students completed the study between 1 and
December 31, 2019. Of the group, 158 (45.3%)
were female. The participants consisted of indi-
viduals who reported that they were at most
15 years old (33.21%). Maximum participation
was from the 11th-grade level. The majority of
respondents reported that their income level
was moderate (54.54%). In this study, 92 partici-
pants (32.2%) reported that they had used any
tobacco product in the last one, and 44 students
(15.2%) have tried e-cigarettes at least once.
The number of respondents who have been
e-smokers within the last 30 days is 3 (3.2%).
The product used by the participants consisted
mostly of rolled tobacco (34.8%). Of the study
group, 194 (67.8%) reported that they bought
tobacco product from neighborhood markets.
Of the participants, 246 (86.0%) have individu-
als using tobacco products in their environment
(Table 1).
Ethical Issue
The study was approved by the Harran
University Ethical Committee (December 30,
2019; session: 08; decision no: 15).
Data Collection
The data collection form consisted of 18 ques-
tions with 4 questions about sociodemographic
characteristics (age, gender, family income sta-
tus, grade level), 3 questions about tobacco
use characteristics and prevalence (Do you
know the tobacco products listed below? Do
you use tobacco products? Where do you buy
tobacco products?), and 11 questions on e-cig-
arettes categorized as true/false/do not know
(e-cigarettes are addictive, e-cigarettes help to
quit smoking, e-cigarettes are harmful to health,
e-cigarettes contain nicotine, e-cigarettes are
at risk of explosion, swallowing the liquid in an
e-cigarette cartridge is harmful, e-cigarettes
are harmful, e-cigarettes are prohibited in our
country, use of e-cigarettes is forbidden in our
country, e-cigarettes are produced by tobacco
companies), and what are your reasons for
trying e-cigarettes?
Statistical Analysis
Using the IBM 23.0 program (IBM SPSS Corp.;
Armonk, NY, USA), sociodemographic charac-
teristics, tobacco use features and prevalence,
and the percentage and frequency distribu-
tions of the questions related to e-cigarettes are
given. Tobacco product use status was catego-
rized as yes/no, and the prevalence of the par-
ticipants’ tobacco product use was determined.
Questions regarding e-cigarette use were
compared in terms of statistical significance by
chi-square analysis in 2 groups. A Spearman’s
correlation analysis was performed between
the age variable and the status of tobacco prod-
uct use and trying e-cigarettes. The reasons for
using e-cigarettes are shown in a pie chart.
Results
Our study determined that a positive relation-
ship existed between the participants’ age vari-
able and tobacco use and trying e-cigarettes
(Table 2).
When the reasons for trying e-cigarettes at least
once in their life are listed to participants, the
most frequent reason for trying was curiosity
(19.2%). In terms of other reasons for trying,
16.4% of the participants reported that the taste
of e-cigarettes was good, 15.7% of participants
stated they smelled good, 14.0% stated they
Main Points
• The results of this study show that 3 out of
10 youth in Turkish society use tobacco products,
and 1 out of 10 youth try e-cigarettes.
• Although Turkish laws prohibit the use of e-ciga-
rettes, the frequency of use among youth is 3.2%.
Young people try e-cigarettes most often because
of curiosity.
• This frequency is important for the continuity of
nicotine addiction in young people and the risks
that may arise.
• Also, our study determined that tobacco use and
e-cigarette experience increased with age.
Table 1. Distribution of Some Features
Related to Tobacco Use
N %
Gender
Female 158 45.3
Male 128 44.7
Age
14 36 12.58
15 95 33.21
16 91 31.83
17 and above 64 22.37
Level of education
933 11.54
10 105 36.71
11 96 33.57
12 52 18.18
Family income
Low 72 25.18
Middle 156 54.54
High 58 20.28
Do you use any tobacco
products?
Yes 92 32.2
No 194 67.8
Have you tried
e-cigarettes in your life?
Yes 44 15.4
No 242 84.6
Type of tobacco product
used
Not used 194 67.8
Cigarette 42 14.7
Wrapping tobacco 32 11.1
Wrapping tobacco + cigarette 15 5.2
E-cigarette 3 1.2
Presence of smoking in
the near environment
Yes 246 86.0
No 40 14.0

Eurasian J Med 2022; 54(2): 127-132 Kurtuluş and Can. Tobacco Use and e-Cigarette Experiences of the Youth • 129
were available everywhere, and 10.5% were try-
ing to quit smoking (Figure 1).
Of the participants, 251 (87.8%) reported that
e-cigarettes are harmful, 239 (83.6%) stated
e-cigarettes contain nicotine, 252 (88.1%)
reported that e-cigarettes have a risk of explo-
sion, 250 (87.4%) reported that swallowing or
inhaling the liquid in the e-cigarette cartridge
causes poisoning, and 237 (82.9%) reported
that the smoke from the e-cigarette is harm-
ful. There was a statistically significant dier-
ence between the participants’ use of any
tobacco product and e-cigarettes being harmful
(P = .034) and the smoke from the e-cigarette
being harmful (P= .003). Of the participants,
146 (51.0%) reported that e-cigarette advertise-
ment and sales are prohibited in our country. A
statistically significant dierence was determined
between the participants’ tobacco use and their
knowledge that e-cigarettes are forbidden to be
sold and advertised in our country (P = .043). Of
the participants, 205 (71.7%) know that using
e-cigarettes is prohibited in our country, and
229 (80.1%) of them know that e-cigarettes
are produced by cigarette companies. There
was no statistically significant dierence
between the participants’ cigarette/e-cigarette
use and the status of knowing that e-ciga-
rette use is prohibited in our country and
that e-cigarettes are produced by cigarette
companies (Table 3).
Discussion
In this study, the opinions of Turkish youth about
tobacco products, e-cigarette use prevalence,
and their views on e-cigarettes were examined.
Ninety-two of the participants reported that
they use tobacco products, 44 reported they
had tried e-cigarettes at least once, and 3 were
e-cigarette smokers in the last 30 days (Table 1).
It was found that those who tried e-cigarettes
did so mostly out of curiosity (Figure 1). The
majority of participants (87.8%) think that
e-cigarettes are harmful. The frequency of those
who know that e-cigarettes contain nicotine is
83.6%. The frequency of those who know that
the smoke from e-cigarettes is harmful is 82.9%.
In internal documents, the tobacco industry
refers to youth as “replacement smokers” or
“learners.”19 It is known that around the world,
the frequency of tobacco product use, which
is increasing especially among youth, will bring
addiction in older age and the subsequent bur-
den of diseases that may develop.20 This situa-
tion, which requires taking significant measures,
will have a negative impact on both the national
economy and health data. The prevalence of
use of any tobacco product in this study was
determined to be 32.2%. Our study, which
is similar to the literature,7,13,20 unfortunately,
shows that 3 out of 10 youth are on their way
to being addicted.
The e-cigarettes launched by the tobacco indus-
try in 2007 may lead to regular smoking due to
both their nicotine content and the structure
that mimics cigarette smoking (bringing it to
the mouth and holding it).21 In our study, it was
determined that 44 (15.4%) of 286 students had
tried e-cigarettes at least once. This frequency
may indicate that at least 1 person will switch
to regular smoking. In our study, the number of
participants who reported that they were regu-
lar e-cigarette users in the last 30 days was 3
(1.2%). In the literature, studies report that the
frequency of e-smokers varies between 1.6%
and 11.8%.22-24 In a study comparing the smok-
ing and e-smoking habits of Spanish and Turkish
students in 2019, 2.9% of Turkish students
(male) reported that they used e-cigarettes. In
the same study, 2.9% of Turkish male students
and 13.2% of Turkish female students stated
that they only used cigarettes.16 The reason for
dierent frequency percentages found in e-cig-
arette smoking in studies may be the legal bar-
riers to accessing e-cigarettes and information
about the dangers of e-cigarettes.
One of the findings we obtained was that the
frequency of both tobacco use and e-cigarette
experience increased with age (Table 2). Similar
to our findings, Vogel et al22 reported that at the
16-month follow-up, more than 40% of e-cig-
arette users (at least once in life) had started
smoking. East et al.23 in their study conducted
Table 2. Correlation Between Age and Tobacco Use and e-Cigarette Experience
Tobacco Use Experience of e-Cigarette
Age Correlation coecient 0.136 0.226
Sig .022 .000
19.2
16.4 15.7
14
10.5
9.1
5.2 4.9
curiosty tasty smell good everywhere
use
help quit
smoked
impressed by
friends
glitzy easy to hide
0
5
10
15
20
25
Figure1. Reasons for participants’ e-cigarette experience.

130 • Kurtuluş and Can. Tobacco Use and e-Cigarette Experiences of the Youth Eurasian J Med 2022; 54(2): 127-132
in 2018, reported that those in the 16-18 age
group found e-cigarettes less harmful than
cigarettes compared to individuals in the
lower age groups. These results prove that
e-cigarettes cause addiction just as other
tobacco products do.
It is known that individuals’ lack of information
and awareness about a subject causes a feeling of
curiosity.25 Even if youth do not express that they
use tobacco, their interest in these products and
the curiosity they may have might be an impor-
tant public health indicator in terms of future
addiction.26 Another common reason for using
electronic cigarettes reported by both teens and
young adults is flavor or taste.27 Villantietal.28 with
data from the Population Assessment of the
Tobacco and Health Survey and the National
Tobacco Youth Survey, found that 63-70% of
youth tobacco product users choose flavored
products.28 Although the reasons for trying
e-cigarettes vary among youth, they are funda-
mentally similar. In our study, it was found that
youth tried e-cigarettes because of curiosity
(19.2%) and the good flavor (16.4%). In addi-
tion, it was determined that the smell of e-cig-
arettes was better than cigarettes (15.7%) and
could be used everywhere (although this is false
information) (14%) are among the reasons for
trying. This finding, which is similar to the litera-
ture, shows that youth’s perspective on tobacco
products is similar regardless of where they are
in the world. Similar to our study findings, in their
study conducted with high school and university
students who are smokers, Konget al29 found
that participants reported that e-cigarettes are
a better alternative to cigarettes due to better
smell, being able to use e-cigarettes in indoor
areas where smoking is prohibited (e.g., movie
theatres and schools), and they can hide from
parents/teachers because they are odorless. In
another study, the most important 3 reasons for
using e-cigarettes were curiosity, the influence of
friends or family, and quitting smoking.30
In our study, it was determined that there
was a significant dierence between partici-
pants’ smoking/e-smoking status and know-
ing that e-cigarettes are harmful to health.
Of the 251 (87.8%) students who stated that
e-cigarettes are harmful to health in all study
groups, 74 (29.5%) were youth who smoke or
use e-cigarettes. Although low according to our
study findings, East et al reported that 63.4%
of respondents perceived e-cigarettes as less
harmful than cigarettes, 22.9% perceived them
as equally harmful, and 2.6% as more harmful.
While 0.7% in our study stated that they do
not know whether e-cigarettes are harmful, this
frequency was reported as 11.2% in the study
of Eastet al (2018).23 In a study conducted in
Egypt, 31.9% of respondents who knew about
e-cigarettes believed that e-cigarettes were less
harmful than traditional cigarettes.31
E-cigarettes contain dierent amounts of nico-
tine in their cartridges.27 Of the study group,
239 reported that the information that e-ciga-
rettes contain nicotine is correct, and of those,
76 (31.8%) were cigarette/e-smokers. However,
there was no dierence between knowledge of
e-cigarettes containing nicotine and cigarette/e-
cigarette use. This result may be related to per-
ception management used in advertising and
promoting e-cigarettes. Similarly, in the study
of Eastetal.23 no relation was found between
the correct perceptions of nicotine harm and
e-cigarette use.23 Contrary to our study findings,
Gorukanti et al32 reported that groups dier
from each other in terms of addiction among
e-cigarettes/cigarettes, both with and without
users (e-cigarette/cigarette).32
One situation we examined was the risk percep-
tion of e-cigarettes. In our study, 252 (88.1%) of
the youth reported that e-cigarettes had a risk
of explosion, and 250 (87.4%) reported that
Table 3. Opinions According to Tobacco/e-Cigarette Use
Tobacco/e-Cigarette Use
Yes, n (%) No, n (%) Total, n (%) Test Value/P
e-Cigarettes are harmful
True 74 (29.5) 177 (70.5) 251 (87.8) 6.782/.034
False 17 (5.5) 16 (48.5) 33 (11.5)
I don’t know 1 (50.0) 1 (50.0) 2 (0.7)
e-Cigarettes contain nicotine
True 76 (31.8) 163 (68.2) 239 (83.6) 0.073/.787
False 15 (34.1) 29 (65.9) 44 (15.4)
I don’t know 1 (33.3) 2 (66.7) 3 (1.0)
e-Cigarette has risk of explosion
True 78 (31.0) 174 (69.0) 252 (88.1) 1.309/.253
False 13 (41.9) 18 (58.1) 3 (10.8)
I don’t know 1 (33.3) 2 (66.7) 3 (1.0)
Swallowing or inhaling the liquid in the e-cigarette cartridge caused poisoning
True 77 (30.8) 173 (69.2) 250 (87.4) 2.752/.097
False 13 (46.4) 15 (53.6) 28 (9.8)
I don’t know 2 (25.0) 6 (75.0) 8 (2.8)
Smoke from e-cigarettes is harmful
True 67 (28.3) 170 (71.7) 237 (82.9) 8.550/.003
False 23 (53.5) 20 (46.5) 43 (15.0)
I don’t know 2 (33.3) 4 (66.7) 6 (2.1)
E-cigarette is forbidden to sell and advertise in our country
True 39 (26.7) 107 (73.3) 146 (51.0) 4.089/.043
False 50 (38.8) 79 (61.2) 129 (45.1)
I don’t know 3 (27.3) 8 (72.7) 11 (3.8)
Use of e-cigarette is prohibited in our country
True 61 (29.8) 144 (70.2) 205 (71.7) 2.275/.312
False 27 (39.7) 41 (60.3) 68 (23.8)
I don’t know 4 (30.8) 9 (69.2) 13 (4.5)
E-cigarette is produced by cigarette companies
True 72 (56.8) 157 (68.6) 229 (80.1) 3.492/.174
False 16 (43.2) 21 (56.8) 37 (12.9)
I don’t know 4 (20.0) 16 (80.0) 20 (7.0)

Eurasian J Med 2022; 54(2): 127-132 Kurtuluş and Can. Tobacco Use and e-Cigarette Experiences of the Youth • 131
swallowing or inhaling the liquid in the e-cigarette
cartridge caused poisoning. However, there was
no dierence between the risk of explosion of
e-cigarettes and the ingestion or inhalation of
liquid in the e-cigarette cartridge causing poison-
ing and being or not being a cigarette/e-cigarette
user. These results can be explained by the insuf-
ficient knowledge of e-cigarettes and the lack of
addressing this issue among youth. Indeed, stud-
ies reporting that youth are e-smokers for social
reasons such as curiosity, better smell, ease of use,
and being cool rather than mechanical and con-
textual reasons support our findings.20 Despite
the studies showing the eects of e-cigarettes on
health, studies report that adolescents who pre-
viously used cigarettes or e-cigarettes, compared
to non-users, stated that e-cigarettes produce
only water, do not contain tar, are not addictive,
are not tobacco products, produce smoke, feel
cleaner, and safer than smoking.32
The smoke produced by e-cigarettes is harm-
ful, like other tobacco products. E-cigarettes,
like other tobacco products, contain many car-
cinogenic substances and nicotine and spread
from the cartridge to the environment through
heating.33 In our study, 237 of the participants
(82.9%) reported that the smoke from e-ciga-
rettes is harmful. It has been determined that
there is a significant dierence between the
harmful state of the smoke coming out of the
e-cigarette and the cigarette/e-cigarette use.
This finding is in line with the state of knowing
whether smoking/e-cigarettes is harmful or not
and use of cigarettes/e-cigarettes, while know-
ing that swallowing or breathing the fluid in the
cartridge of an e-cigarette causes poisoning is in
contradiction with the use. However, the results
we obtained are promising for youth despite
their limited knowledge about e-cigarettes.
Of our participants, 146 (51%)—almost 1 in
2 people, whether they are cigarette/e-ciga-
rette users or not—knew that smoking and
advertising e-cigarettes is prohibited in our
country. There was a significant dierence
between smoking cigarettes/e-cigarettes and
the sale and advertisement of e-cigarettes
being banned in our country. The number of
people who knew that use of e-cigarettes is
forbidden in our country was 205 (71.7%).
However, there was no significant dierence
between being a cigarette/e-cigarette user
or not and the ban on using e-cigarettes in
our country. Although the sale and use of
e-cigarettes in Turkey is not legal, they can
be obtained easily through online e-sales
and without any questions. This may indicate
that nicotine addiction may continue to gain
momentum, especially among youth.
In conclusion, the use of e-cigarettes in the
Turkish youth community is seen in only 1 in 100
people, the insuciency of control mechanisms
and legal practices in online systems may increase
the prevalence of use. To protect youth, all ENDS
should be considered as tobacco products, and
the addictive power and negative eects of
nicotine in their content should not be ignored.
These restrictions should be applied by increas-
ing the restrictions on the sale and advertisement
of e-cigarettes. Larger sampling and longitudinal
studies are needed to understand the prevalence
and risks of using e-cigarettes in Turkish society.
Limitations
This study had several limitations. The surveys used
were self-managed in the school environment.
All participants consist of youth in high school.
Thus, no generalization can be made for youth in
other cities. Secondly, this study is cross-sectional.
Therefore, causality cannot be determined. Future
research through longitudinal studies should
examine how perceptions of harm and benefit are
associated with the introduction of e-cigarettes.
Ethics Committee Approval: The study was approved
by Harran University Ethical Committee (December
30, 2019; session: 08; decision no: 15).
Informed Consent: Written informed consent was
obtained from all parents of individual participants.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept – R.C., Ş.K.; Design
– R.C., Ş.K.; Supervision – R.C., Ş.K.; Funding – R.C.,
Ş.K.;Materials – RC, ŞK; Data Collection and/or
Processing – RC, ŞK; Analysis and/or Interpretation –
R.C., Ş.K.; Literature Review – R.C., Ş.K.; Writing
Manuscript – R.C., Ş.K.; Critical Review – R.C., Ş.K..
Declaration of Interests: The authors have no con-
flicts of interest to declare.
Funding: The authors declared that this study has
received no financial support.
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