The Knowledge-Attitude-Behavior Paradox in E-Cigarette Adoption Among University Students at Northern Border University, Saudi Arabia

Abstract

Background: The proliferation of e-cigarette use among university students presents a critical public health challenge, yet the mechanisms driving adoption in non-Western sociocultural contexts remain inadequately theorized. Purpose: Guided by the Social Cognitive Theory and the Theory of Planned Behavior, this study investigated the prevalence and predictors of e-cigarette use among university students at Northern Border University in Saudi Arabia. Material and Methods: A cross-sectional survey of 670 students assessed knowledge, attitudes, and usage behaviors, with predictors identified via multivariable logistic regression. Results: The prevalence of current use was 20.6% (138/670), with a significant gender disparity where female students had lower odds of use (adjusted OR = 0.334**; 95% CI: 0.203–0.550**). A striking knowledge-attitude-behavior paradox emerged: while 77.6% (520/670) acknowledged addiction potential, substantial gaps in knowledge about respiratory risks (only 45%, 301/670) and nicotine content (35%, 234/670) persisted. Critically, medical students, despite having superior knowledge (53.2%, 141/265 vs 28.4%, 115/405 among non-medical students), exhibited only moderately more protective attitudes (61.5% vs 78.5% disapproving). More favorable attitudes significantly predicted current use (adjusted OR = 1.040 per one-point increase**; 95% CI: 1.008–1.073**), confirming the mediating role of attitudes. Conclusion: These findings indicate that e-cigarette adoption is a socially embedded behavior shaped by gender norms and educational contexts, challenging information-deficit models. This underscores the necessity for theory-driven, multilevel interventions that address cognitive, affective, and normative determinants of behavior to inform culturally sensitive prevention strategies and campus policies.