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.
Keywords: Attitude; Electronic cigarette; Iran; Knowledge; Policy; Smoking; Tobacco; Vaping.
© 2025. The Author(s).