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

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. Plain Language Summary: Why was the study done? E-cigarettes, or vaping, have become very popular among young people worldwide, including university students in Saudi Arabia. As traditional smoking rates fall, vaping presents new public health challenges. We conducted this study to understand what drives students to vape, looking beyond simple numbers to explore their knowledge, attitudes, and social influences. What did the researchers do and find? We surveyed 670 university students across Saudi Arabia. We found that 1 in 5 students currently vape. A major gender difference emerged: male students were much more likely to vape than female students, likely reflecting cultural norms. A key discovery was a “knowledge-attitude gap”. Even medical students, who knew more about health risks, did not have much stronger negative opinions about vaping than their peers. Many students mistakenly believed the vapor was harmless water. What do these results mean? Our findings show that just giving students facts about the dangers of vaping is not enough to stop them. To be effective, health programs must also address the powerful influence of friends and challenge the idea that vaping is a safe or socially acceptable activity. Interventions need to be culturally sensitive, especially considering the different social pressures on male and female students, to help them make healthier choices. Keywords: E-cigarettes, university students, Saudi Arabia, knowledge, attitudes, practice, gender differences, prevalence, tobacco control, harm reduction