Knowledge, attitude, practice and policy support of college students toward electronic cigarette use: a nationwide multicentric study in Iran

Abstract

Background The use of electronic cigarettes (e-cigarettes) among young people is rising globally, including in the Middle East. This increase is largely due to widespread misconceptions that e-cigarettes are harmless alternatives to traditional smoking, despite the known health risks associated with their use. However, there is limited data on e-cigarette consumption among young adults in Iran. To address this gap, we conducted a nationwide survey to assess the prevalence of e-cigarette use, as well as the knowledge, attitudes, and factors influencing the use of these products among young adults. Methods Study of Measurement of Knowledge and Examination of Support for tobacco control policies (SMOKES) is a nationwide multi-center cross-sectional survey, which was conducted from 2024 to 2025. A total of 2,246 university students aged 18-40 years from 15 provinces, encompassing a wide range of disciplines and ethnicities, participated in an online survey that collected data on sociodemographics, tobacco use, knowledge of e-cigarettes, attitudes toward them, and support for related policies. Descriptive statistics were utilized to summarize patterns of e-cigarette use and related misconceptions. Candidate explanatory variables were selected through a comprehensive literature review, including sociodemographic (age, sex, parental education), behavioral (concurrent tobacco use), and social (peer influence) factors. All variables showing association at p < .20 in bivariate analysis were entered into the multivariable logistic regression model examining current e-cigarette use as the dependent variable, with final models retaining significant predictors (p < .05). Results Ever-use of e-cigarettes was reported by 28.2 of participants, while past-month use prevalence was 5.6. Knowledge of e-cigarette health risks was poor and misconceptions were common (34.4 believing the vapor is "just water"; 24.7 considering that e-cigarettes are less harmful than cigarettes;<40 recognizing cardiovascular or reproductive risks); on the other hand, the attitudes towards vaping was widely seen as socially acceptable (36.2 expressed e-cigarettes are more socially acceptable; 34.6 perceived that vaping is enjoyable). The ever-use of e-cigarette was significantly associated with several factors, including male sex (OR = 1.36), having divorced parents (OR = 2.37), part-time employment (OR = 1.42), concurrent use of cigarettes (OR = 6.76) or hookah (OR = 4.95), and the presence of peers or siblings who use tobacco products (OR = 1.93) (p < .05 for all). Students also reported weak enforcement of campus anti-e-cigarette policies and low access to cessation resources. Conclusion The high prevalence of e-cigarette use among Iranian university students is compounded by significant knowledge gaps and permissive attitudes. This underscores an urgent need for multi-level interventions, including targeted educational campaigns, comprehensive smoke-free campus policies, and national regulations to curb access and marketing, to effectively counter this public health threat.