Nicotine dependence and self-esteem among respiratorytherapy students in Saudi Arabia: A cross-sectional study

INTRODUCTION: Nicotine dependence among university students remains a public health concern, and psychological factors such as self-esteem may influence dependence severity. Evidence among respiratory therapy students in Saudi Arabia is limited. Hence, this study aimed to assess the relationship between nicotine dependence and self-esteem among respiratory therapy students in Saudi Arabia. METHODS: This cross-sectional study was conducted between 13 March and 16 September 2025, and included 1041 respiratory therapy students. Inclusion criteria were enrollment from the second academic year through the internship year; first-year students were excluded. Data were collected via an anonymous online survey assessing smoking history, nicotine dependence using the Fagerström test for nicotine dependence (FTND), and self-esteem using the Rosenberg Self-Esteem Scale (RSES). Negative binomial regression was used to identify factors associated with nicotine dependence. RESULTS: The median FTND score was 5 (IQR: 3-6). Smoking duration was significantly associated with higher nicotine dependence in a dose-response pattern. Compared with students who smoked for less than one year, those with 1-5 years (adjusted incidence rate ratio, IRR=1.10; 95% CI: 1.03-1.19; p=0.008), 6-10 years (IRR=1.15; 95% CI: 1.04-1.27; p=0.006), and >10 years of smoking (IRR = 1.31; 95% CI: 1.07-1.60; p=0.009) had higher dependence scores. Higher self-esteem was independently associated with lower nicotine dependence, with each one-point increase in RSES score linked to a 3% reduction in FTND score (IRR=0.97; 95% CI: 0.95-0.99; p=0.011). No demographic or academic variables were significantly associated with nicotine dependence. CONCLUSIONS: Nicotine dependence among respiratory therapy students is strongly related to smoking duration and self-esteem. Further longitudinal and interventional studies are needed to clarify the temporal relationship between selfe-steem and nicotine dependence and to determine whether psychosocial support could complement tobacco control efforts in university settings.