Articles

Background: Electronic cigarette (e-cigarette) use among adolescents is a growing public health concern, particularly in low-income and Black communities. However, little is known about how social determinants of health shape e-cigarette perceptions in this population. Aims: This study examined social determinants associated with perceptions of e-cigarette safety among Baltimore high school students. Methods: A cross-sectional survey (CEASE Youth: School Survey) was conducted with 604 Baltimore high school students aged 14–20. Participants completed a questionnaire assessing perceptions of e-cigarette safety, as well as parental education, race/ethnicity, parental employment, household composition, and community tobacco use. Results: Higher parental education was associated with lower perceived e-cigarette safety among students. Students in higher grades also reported lower perceived e-cigarette safety. In contrast, male students—particularly those in upper grades—were more likely to perceive e-cigarettes as safe. Race/ethnicity, household composition, parental employment, and community tobacco exposure were not associated with perceived e-cigarette safety. Conclusion: Higher parental education, female gender, and being in higher grades were associated with perceiving e-cigarettes as unsafe. These findings highlight the need for targeted interventions to address vaping perceptions among youth in urban settings.

Background: Electronic cigarette (e-cigarette) use is increasingly prevalent among youth and young adults, particularly college and university students. This is a population for whom e-cigarette use is not recommended due to potential health risks, including nicotine addiction and long-term respiratory effects. Social networks play a crucial role in shaping attitudes toward e-cigarettes and influencing use behaviors. However, the relative influence of different social ties—parents, siblings, and friends—on e-cigarette attitudes and use remains unclear. Objective: This study utilizes data from the SMOKES study to compare the influence of e-cigarette use within different social network sections—parents, friends, and siblings—on personal e-cigarette attitudes and use among college and university students. Methods: Using a cross-sectional survey of college and university students, we examined the associations between e-cigarette use within different social networks and individual e-cigarette attitudes and use. Multivariate regression models assessed the strength of these associations, adjusting for key demographic and behavioral covariates. Results: Findings indicate that among college and university students, the strongest influence on both e-cigarette attitudes and use comes from friends who use e-cigarettes. In contrast, parental and sibling e-cigarette use showed weak or non-significant effects. These results suggest that peer influence, rather than family influence, plays a dominant role in shaping e-cigarette-related behaviors and perceptions in young adults. Conclusion: This study underscores the importance of peer influence in e-cigarette uptake and attitudes among college and university students. Public health interventions aimed at reducing e-cigarette use in this population should consider targeting peer networks rather than focusing solely on family-based influences.

Background: Electronic cigarette (e-cigarette) use and vaping tobacco have increased rapidly worldwide, raising concerns about their health effects, social acceptability, and regulatory challenges. In many countries, e-cigarettes are more commonly used by individuals from higher socioeconomic status (SES) backgrounds, who, in theory, should have greater knowledge about e-cigarettes and their associated risks. However, it remains unclear why a group with more knowledge about e-cigarette risks would also hold more positive attitudes toward vaping and exhibit higher usage rates — a phenomenon that may represent a knowledge-behavior paradox. Understanding this paradox, along with the complex relationships between e-cigarette knowledge, attitudes, and behaviors, is critical for informing effective public health interventions, campaigns, social media messaging, and regulatory policies. Objectives: This study aimed to evaluate the complex relationship between SES, e-cigarette knowledge, pro-vaping attitudes, and e-cigarette use. Methods: The SMOKES Study (Study of Measurement of Knowledge and Examination of Support for Tobacco Control Policies) used a multi-center, cross-sectional design, collecting data from 2,403 college and university students across 15 provinces in Iran (covering nearly half of the country's provinces). The survey measured family income, age, sex, ethnicity, e-cigarette use, knowledge, and attitudes. Structural Equation Modeling (SEM) was employed to examine the interrelations between SES, knowledge, attitudes, and behavior, while adjusting for age, sex, and ethnic minority status. Results: SEM analysis confirmed the hypothesized paradox. Although greater knowledge about e-cigarettes was linked to less favorable attitudes toward vaping and lower use, pro-vaping attitudes emerged as the strongest predictor of vaping behavior, while knowledge played a weaker protective role. Notably, individuals with higher SES simultaneously showed higher knowledge and, paradoxically, more pro-e-cigarette attitudes and greater usage. Female students and ethnic minority students reported higher correct knowledge and lower pro-vaping attitudes and use. Although age and higher family income were associated with more favorable attitudes, they did not directly predict vaping behavior. These results suggest that for higher SES individuals, poor knowledge is not the main driver of e-cigarette use; rather, their pro-e-cigarette attitudes, which seem to outweigh the influence of knowledge, play a key role. Conclusions: Although individuals from higher SES backgrounds report greater correct knowledge about e-cigarettes, this knowledge does not necessarily translate into reduced positive attitudes or lower usage. This study highlights the complexity of these paradoxical effects and suggests that public health strategies need to go beyond simple education and knowledge-based interventions. Targeted approaches should address industry messaging, challenge misconceptions, and strengthen regulatory efforts to reduce e-cigarette use among young adults, including those from higher SES backgrounds.

Background: Tobacco control policies are implemented globally to reduce tobacco-related morbidity and mortality. Emerging evidence suggests that individual tobacco use may influence the level of support for these policies. However, the extent to which personal use affects policy endorsement remains underexplored, particularly among young adults in academic settings. Aims: This study aimed to examine whether college students who use tobacco exhibit lower support for tobacco control policies compared to their non-user counterparts. Methods: We conducted a multi-center, cross-sectional study involving 2403 college students from various provinces in Iran. Tobacco use was ascertained based on self-reported consumption of cigarettes, electronic cigarettes, and hookah. Attitudes toward tobacco control policies were evaluated using a structured survey instrument, and comparative analyses were performed to assess differences in policy support between tobacco users and non-users. Results: The analysis revealed that tobacco users demonstrated significantly lower support for tobacco control policies compared to non-users. This association was consistently observed across users of cigarettes, electronic cigarettes, and hookah, suggesting a systematic pattern irrespective of the type of tobacco product used. Conclusion: These findings indicated a clear association between tobacco use and reduced endorsement of tobacco control policies among Iranian college students. These results have potential implications for public health policy, emphasizing the importance of addressing individual tobacco use behaviors in the development and implementation of tobacco control strategies. Further research is needed to elucidate the underlying mechanisms of this relationship.

Background: Tobacco use remains a major global health concern, and understanding the factors that influence tobacco-related knowledge and support for tobacco control policies is critical for effective development of tobacco control policies that are accepted by the public. Objectives: This study introduces the rationale, design, methodology, and participants of the SMOKES Study (Study of Measurement of Knowledge and Examination of Support for tobacco control policies), which is conducted to evaluate tobacco use, tobacco-related knowledge and attitude, as well as support for tobacco control policies among college and university students. Methods: The SMOKES Study was designed to address significant gaps in literature by focusing on college and university students in a non-Western context. A multi-center, cross-sectional design was employed to collect data from a diverse sample of college and university students across different geographical provinces in Iran. The survey instrument incorporated a range of measures covering socio-demographic characteristics, university-related variables, family tobacco use status, personal tobacco consumption behaviors (including detailed assessments of cigarette, hookah, and electronic cigarette use), and attitudinal as well as knowledge-based assessments related to vaping. Support for tobacco control policies is also measured. Data were collected using an online survey that included self-administered questionnaires, enabling access to a large diverse sample. This study may be used to determine the prevalence of ever and current use of cigarettes, electronic cigarettes, and hookah, as well as examining the correlates of single, dual, and poly-tobacco use. The study also aims to assess the role of social determinants, attitudes, and ethnic/geographic differences in shaping these outcomes. Results: The study sample consisted of 2403 college and university students, including undergraduates enrolled in different academic programs from all faculties and disciplines. Participants were drawn from universities across 15 provinces, and 11 ethnic groups, ensuring a heterogeneous sample with respect to socio-demographic background, ethnicity, and institutional affiliation. This diversity enhances the generalizability of the findings and allows for the exploration of subgroup differences in tobacco use patterns and policy support. Conclusions: The SMOKES Study offers a framework for examining tobacco-related knowledge and the acceptability of tobacco control policies among a key part of the population, being college and university students. By providing detailed insights into the prevalence and correlates of tobacco knowledge, attitude, use, as well as the tobacco control policy support, the study lays the groundwork for tailored public health interventions and more effective tobacco regulation strategies particularly for college campuses in a non-Western setting.

Background: Early initiation of tobacco use among adolescents is a significant public health concern. While there is extensive research on overall tobacco use, much of it focuses on initiation in late adolescence, uses cross-sectional designs, and lacks specific exploration of electronic versus conventional cigarette use. This study aims to investigate social determinants influencing the early initiation of electronic and conventional cigarette use among U.S. adolescents. Methods: We utilized data from the Adolescent Brain Cognitive Development (ABCD) study, which follows a cohort of tobacco-naïve children from age nine through age 16. The social determinants examined included household income, parental education, financial difficulties, racial/ethnic minority status, family structure, neighborhood income, and gender minority status. Structural equation models were employed to assess associations between these determinants and early initiation of electronic and conventional cigarette use. Results: Male gender was associated with a higher likelihood of conventional cigarette use, while the risk of early initiation of electronic cigarette use was similar across genders. White adolescents were at a higher risk of conventional cigarette use; however, the risk for electronic cigarette use was comparable across White and non-White groups. Financial difficulties were linked to an increased likelihood of early initiation of conventional cigarette use but not electronic cigarette use. Higher household income was associated with a reduced risk of initiating conventional cigarettes but did not significantly impact electronic cigarette use. Adolescents from married families were less likely to initiate electronic cigarette use. No significant effects were found for parental education or neighborhood income on the initiation of either type of cigarette use. Age did not significantly affect the initiation of either cigarette type, and gender minority status was marginally associated with early initiation of conventional cigarette use. Conclusions: The social patterning of electronic cigarette use differs from that of conventional cigarette use, suggesting that distinct tobacco products do not pose a uniform risk across all adolescents. This study underscores the importance of tailored prevention efforts that address the unique challenges associated with early initiation of electronic and conventional cigarette use among adolescents. The differential risk factors identified suggest targeted prevention strategies for conventional cigarette use, focusing on financial difficulties, household income, and gender-specific interventions. In contrast, prevention efforts for electronic cigarette use may require broader, more inclusive approaches that address all adolescents, regardless of their background. Comprehensive universal screening for electronic cigarette use and targeted screening for conventional cigarette use among adolescents are recommended.