Knowledge, attitude, practice and policy support of college students toward electronic cigarette use: a nationwide multicentric study in Iran

Abstract

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-25557-0.

Introduction

Tobacco use is a major risk factor associated with preventable diseases [1]. The growing popularity of e-cigarettes among never-users of conventional cigarettes and former users, raises concerns that these devices could act as a gateway to tobacco smoking [2]. Electronic cigarettes (e-cigarettes), commonly referred to as vaping products, are devices powered by batteries, designed to deliver nicotine through the inhalation of an aerosolized liquid containing nicotine, flavoring agents, and other chemicals [3]. E-cigarettes were initially promoted as a smoking cessation tool and gained popularity [4]. E-cigarettes are often viewed as a safer option compared to regular cigarettes particularly for adults who wish to quit smoking [5], but they still carry significant risks for youth and young adults and are not entirely without harm, primarily when used regularly [6].

Emerging evidence indicates that e-cigarette use is linked to an elevated risk of respiratory health issues, including exacerbations of asthma, pneumonia, bronchitis, and acute respiratory distress, as well as cardiovascular disorders, cognitive impairments, and neurodevelopmental problems [7–10]. Additionally, for youth and young adults, the one-time experience of vaping may elevate the future risk of subsequent substance use, which encompasses the initiation of cigarette and cannabis consumption, aligning with the gateway hypothesis [11, 12]. Despite this concern, the ever-use of e-cigarettes has risen notably in recent years, especially among adolescents and young adults [13, 14]. Numerous studies have indicated that e-cigarette prevalence among young adults can reach up to 40% [15, 16]. The rapid increase in e-cigarette use among youth and young adults underscores the urgent need for public health measures to address its potential epidemic and the necessity to understand the social factors associated with e-cigarette use.

Research indicates that individuals’ intentions to engage in risky behaviors are primarily influenced by their knowledge, attitudes, and social norms [17]. Additionally, it has been proposed that misunderstandings and negative attitudes could contribute to the increased prevalence of e-cigarette use among college students [18, 19]. Regarding university students’ understanding and perspectives about e-cigarettes, the current circumstances are far from favorable [20]. A significant proportion of e-cigarette users, including both youth and adults, believe that these products are safer than conventional cigarettes and often utilize them as an alternative to traditional smoking [21–23]. Studies also highlight widespread misconceptions and inconsistencies in knowledge and attitudes toward e-cigarette use across different populations, such as the beliefs that e-cigarette aerosol is merely water vapor, that e-cigarettes are not tobacco products, and that they do not contain nicotine [20, 24]. Thus, there is an urgent need for targeted educational interventions to address these gaps and promote informed decision-making regarding e-cigarette consumption.

The increasing rate of vaping, coupled with the evolving perceptions surrounding their safety, underscores the necessity of further research in this domain. Additionally, the tobacco industry has actively marketed e-cigarettes to vulnerable populations, particularly young adults, by positioning them as a viable alternative to conventional smoking, despite the uncertainties surrounding their long-term health effects [25]. Although awareness of the risks associated with cigarette smoking has been positively correlated with smoking cessation efforts, studies suggest that young adults have limited knowledge regarding the composition and regulation of e-cigarettes, despite being the main consumer demographic for these products [26].

Iran’s tobacco control framework builds on its 2005 WHO Framework Convention on Tobacco Control (FCTC) ratification and 2006 national law, implementing smoke-free policies, advertising bans, and graphic health warnings [27]. However, enforcement remains weak, with poor Monitor Tobacco Use and Prevention Policies (MPOWER) despite strong health warnings. Challenges include resistance from the state tobacco monopoly, poor interagency coordination, and smuggling (20% of market) [28]. However, current provisions of Iran’s national tobacco control law do not specifically regulate e-cigarettes. As a result, these products remain available through informal markets and online platforms, creating a regulatory vacuum that undermines youth protection [29].

To date, no epidemiological study has ever investigated the prevalence of electronic cigarette use or knowledge and attitudes towards emerging vaping devices among Iranian population. Therefore, this nationwide multi-centric study aimed to assess the practice of e-cigarettes as well as knowledge and attitudes towards vaping devices among Iranian college and university students. University students represent a critical subset of young adults who are at a developmental stage characterized by increased autonomy, experimentation, and exposure to peer influence. This group is particularly relevant for intervention because university campuses provide accessible and structured environments for public health education and policy implementation.

The results may contribute to public health interventions and promote evidence-based policies regarding e-cigarette regulation, as well as public awareness of e-cigarette use and its associated risks.

Methods

Study design and participants

This nationwide multi-center, cross-sectional study was conducted among university students between 2024 and 2025 as part of the Study of Measurement of Knowledge and Examination of Support for tobacco control policies (SMOKES) [30]. In summary, the SMOKES study was conducted to evaluate patterns of tobacco use among Iranian college students and assess their support of tobacco control policies. This study also investigated the college students’ knowledge, attitudes, and motivations toward e-cigarette use. The study population, methodology, and design of the SMOKES have been described in detail previously [30].

To achieve a diverse and inclusive sample that accurately represents a range of academic disciplines, geographic locations, institutional types, and various fields of study, we selected 15 provinces throughout Iran, ensuring that no fewer than two colleges or universities were included from each province. Institutions were chosen to represent a diverse range of majors, academic environments, and student populations, thereby capturing a broad spectrum of Iranian university student demographics. Although the sample captures the demographic characters of Iranian college and university students, it should not be regarded as representative of the entire nation.

Participants in the study had to be actively enrolled in any academic program at universities in the specified provinces during the survey. Individuals aged 18 to 40 who completed the entire questionnaire without omissions were included. Those who had graduated, non-Iranian students, and respondents providing invalid answers, such as inconsistent or unrealistic responses, were excluded. Individuals with incomplete or missing questionnaires were also excluded from the study.

Survey measure

Data were gathered using a self-administered online structured questionnaire aimed at evaluating sociodemographic and lifestyle factors, university-related variables, tobacco usage behaviors, knowledge, attitudes, and support for policies concerning e-cigarette use among college students. The questionnaire also assessed parental tobacco use and exposure to secondhand smoke, which were later analyzed as potential correlates of e-cigarette use.

The survey was based on Porsline (https://porsline.ir), a widely used Iranian online survey platform, and invitation links were distributed through university-affiliated student groups in social media (Telegram).

The survey items were thoughtfully adapted from previously validated questionnaires [31–33] to ensure reliability and relevance. Additionally, new questions were developed based on the insights of experts in public health, pulmonology, and health policy, enriching the survey’s content. All inquiries were presented in Farsi to enhance accessibility and cultural relevance for the target population.

The reliability of the survey was evaluated in two pilot tests to ensure the internal consistency of individual scales. In the first pilot involving 50 students, the clarity and comprehensibility of the questionnaire items were examined. The survey was meticulously designed to ensure clarity and accuracy of responses. Initially developed in English, the questionnaire was translated into Persian and subsequently back-translated by a skilled bilingual expert to maintain linguistic fidelity. To enhance content validity, three experts in the field reviewed the questionnaire. In a follow-up pilot test involving 20 university students, the reliability of key components was reaffirmed, achieving Cronbach’s alpha coefficients of 0.78 for knowledge, 0.75 for attitudes, and 0.74 for policy support. These findings demonstrate acceptable and consistent reliability across the main sections of the SMOKES survey. The complete set of original survey items assessing knowledge, attitudes, and policy support has been published in our prior methodological work [34]. The English-language version of the questionnaire items analyzed in this study is available as a supplementary file. The items examined in different parts of the questionnaire were as follows:

‌Sociodemographic, lifestyle and University-related information

In the first part of the questionnaire, participants provided detailed sociodemographic information, including their sex, age, personal and family income, marital status (personal and parental), employment status, and the type and location of their residence (urban or rural). They also declared their university-related details, including college province, academic major, degree level, institution type (government-funded or tuition-based), and year of study. Lifestyle factors, including regular exercise habits, were also assessed.

Tobacco use behaviors

The survey also assessed tobacco use behaviors of students and their family members and friends. Specifically, participants were asked whether they had ever used cigarettes, hookah, or electronic cigarettes (vapes), and whether they were current users. Within this study, ‘ever-use’ of e-cigarettes was defined as any lifetime use, indicating whether a participant had tried the product at least once in their life. Current use of e-cigarettes was operationalized as any self-reported use within the past 30 days (past-month use), assessed through the question: “Have you used an e-cigarette or vaping device at least once in the past 30 days?”. The primary analytical outcome was ever-use (binary yes/no), while past-month use served as a secondary descriptive measure. Information about tobacco use by mothers, fathers, siblings, and close friends was included to evaluate the potential influence of family and peer environments on students’ smoking behaviors.

Knowledge toward E-Cigarette use

This part of the questionnaire was designed to assess the students’ comprehension by presenting 12 questions (with responses options of yes, no, or I don’t know) related to e-cigarettes, including their addictive properties and the health risks associated with them, such as their impact on lung infections, heart problems, and strokes.

Additionally, the survey examined widespread misconceptions, including beliefs such as “E-cigarettes contain only water vapor and flavoring” and “E-cigarettes do not contain carcinogenic ingredients”. These items provided insights into the extent of misinformation among university students and their awareness of the potential dangers of vaping.

Attitudes toward E-Cigarette use

This section evaluated students’ perceptions of e-cigarettes through 8 statements that addressed aspects such as social acceptability, regulatory viewpoints, and the relative harm of e-cigarettes compared to traditional cigarettes. Responses to these items were quantified using Likert scales, where a score of 5 was assigned to ‘strongly agree’ and a score of 1 to ‘strongly disagree,’ enabling a nuanced analysis of participants’ levels of agreement or disagreement with the various statements.

Support restricted policies for E-Cigarette use

The final section assessed participants’ support for tobacco control policies through 9 structured questions on various regulatory measures. One of the key items asked, “To what extent do you support banning the advertisement and sale of e-cigarettes on online websites and social media platforms such as Instagram?” Participants responded using a 5-point Likert scale, ranging from “Strongly Disagree” (1) to “Strongly Agree” (5). A composite policy support score was then calculated for each participant, with higher scores reflecting stronger endorsement of tobacco control regulations. This ordinal measure allowed for a quantitative comparison of policy support levels across the study sample, providing valuable insights into university students’ attitudes toward vaping restrictions and public health policies.

Ethical considerations

This study followed the guidelines outlined in the Declaration of Helsinki and was approved by the Ethics Committee at Shahid Sadoughi University of Medical Sciences in Yazd, Iran (ethics code: IR.SSU.MEDICINE.REC.1403.159). Participation was voluntary, and informed consent was obtained before starting the questionnaire. On the first page, participants were given information about the study’s purpose and had to confirm their consent to continue.

Statistical analysis

All statistical analyses were carried out using SPSS version 26. Descriptive statistics were used to summarize the study variables, with categorical variables shown as frequencies and percentages, while continuous variables were reported as means and standard deviations.

Knowledge and attitude scores were dichotomized into binary variables (high = 1, low = 0) based on predefined thresholds. For knowledge, ‘high’ reflected correct responses to ≥ 75% of items (e.g., recognizing nicotine content, health risks); for attitudes, ‘high’ indicated agreement with ≥ 75% of pro-e-cigarette statements (e.g., social acceptability, harm perception). To investigate the relationships between e-cigarette use and sociodemographic and university level characteristics, first bivariate analyses were conducted using the Chi-square test. Variables that had a p-value of less than 0.10 in the bivariate analysis were considered for the multivariable logistic regression model. In the final analysis, a p-value of less than 0.05 was considered statistically significant.

Missing data

From the initial sample of 2403 survey participants, we excluded 157 cases (6.53%) with incomplete data across key study variables, retaining 2246 complete cases for analysis. This complete-case approach was implemented due to the epidemiological nature of our research questions and the need for consistent measurement across all included predictors (sociodemographic, behavioral, and social factors). While this exclusion may introduce potential selection bias, we conducted sensitivity analyses comparing included versus excluded participants on available demographic variables (age, sex, province), which revealed no significant differences (p >.05). All reported results should therefore be interpreted as representing complete-case estimates, with the caveat that missingness may affect generalizability to the broader population of interest.

Results

Participants’ characteristics

This study included 2,246 university students from 15 provinces, covering 10 ethnic groups and 11 academic disciplines (Fig. 1). The average age of the participants was 22.16, with a standard deviation of 2.99, and their ages ranged from 18 to 40. Table 1 provides a detailed breakdown of the socio-demographic characteristics.

Fig. 1.

Distribution of Participants included in the study

Table 1.

Socio-demographic of participants

Variable	N	%
Sex
Male	1127	50.2%
Female	1119	49.8%
University Province
Yazd	333	14.8%
Mazandaran	245	10.9%
Tehran	236	10.5%
Isfahan	206	9.2%
Razavi Khorasan	191	8.5%
Kermanshah	161	7.2%
Fars	129	5.7%
East Azerbaijan	128	5.7%
Gilan	128	5.7%
Kerman	113	5.0%
Khouzestan	111	4.9%
Sistan and Balouchestan	105	4.7%
Semnan	69	3.1%
Alborz	49	2.2%
Hamedan	42	1.9%
Ethnicity
Fars	1294	57.6%
Turk	255	11.4%
Kurd	149	6.6%
Lur	131	5.8%
Mazani	130	5.8%
Gilak	110	4.9%
Balouch	46	2.0%
Bakhtiari	41	1.8%
Arab	27	1.2%
Other	63	2.8%
University Major
Medicine	990	44.1%
Engineering and Technology	304	13.5%
Humanities and Social Sciences	209	9.3%
Dentistry	200	8.9%
Allied Health	174	7.7%
Nursing	108	4.8%
Basic Sciences	87	3.9%
Architecture and Arts	81	3.6%
Pharmacy	63	2.8%
Veterinary Medicine	20	0.9%
Agriculture and Natural Resources	10	0.4%
University Type
Governmental	1722	76.7%
Non-Governmental/Private	524	23.3%
University Level
Associate’s Degree	55	2.4%
Bachelor’s Degree	850	37.8%
Master’s Degree	150	6.7%
Doctorate or Higher	1191	53.0%
University Year
1	486	21.6%
2	403	17.9%
3	332	14.8%
4	417	18.6%
5	294	13.1%
6	167	7.4%
7	70	3.1%
8 or higher	77	3.4%
Residence
Living with Family	1101	49.0%
Dormitory	928	41.3%
Private Housing (Without Family)	212	9.4%
Other	5	0.2%
Place of Residence
City	2125	94.6%
Village	121	5.4%
Marital Status of Parents
Married	2098	93.4%
Widowed	82	3.7%
Divorced	66	2.9%
Marital Status of Students
Single	2104	93.7%
Married	137	6.1%
Widowed	2	0.1%
Divorced	3	0.1%
Family Income
Less than 100 million	2100	93.5%
More than 100 million	146	6.5%
Student Income
Less than 10 million	1984	88.3%
Between 10 and 50 million	239	10.6%
More than 50 million	23	1.0%
Work
Yes, full-time	118	5.3%
Yes, part-time	583	26.0%
No	1545	68.8%
Regular Exercise (> 2 h/week)
No	1302	58.0%
Yes	994	42.0%

Tobacco use behaviors

From all participants, 20.2% reported lifetime cigarette use exceeding 100 cigarettes, while 16.2% were identified as current smokers. Hookah use was prevalent among 17.3% of students, with 11.1% reporting current use, primarily monthly (73.0%). The lifetime prevalence of e-cigarette use (ever-use) among participants was 28.2%. Of these ever-users, 23.0% (representing 5.6% of the total cohort) reported use within the past month (past-month use). Parental tobacco use was relatively low, with 0.8% of mothers and 16.0% of fathers reporting usage, yet a considerable proportion (41.9%) of students had friends who used tobacco. Additionally, secondhand smoke exposure was common, with 56.2% of students reporting occasional to frequent exposure within university environments. A detailed overview of these findings is provided in Table 2.

Table 2.

Tobacco use behaviors of participants

	N	%
Cigarette Use (> 100 in lifetime)
Yes	454	20.2%
No	1792	79.8%
Cigarette Current Use
Yes	364	16.2%
No	1882	83.8%
Hookah Ever Use
Yes	388	17.3%
No	1858	82.7%
Hookah Current Use
Yes	250	11.1%
No	1996	88.9%
Hookah Use Frequency
Monthly	181	73.0%
Weekly	60	24.2%
Daily	7	2.8%
Ever Use of E-cigarette
Yes	634	28.2%
No	1612	71.8%
Past-Month Use of E-cigarette
Yes	141	23.0%
No	471	77.0%
Mother Tobacco Use
Yes	17	0.8%
No	2229	99.2%
Father Tobacco Use
Yes	359	16.0%
No	1887	84.0%
Tobacco Use in Siblings
Yes	165	7.3%
No	2081	92.7%
Tobacco Use in Friends
Yes	942	41.9%
No	1304	58.1%
No Tobacco Use in Family
Yes	1325	59.0%
No	921	41.0%

Awareness and misconceptions regarding E-Cigarettes

While 74.1% correctly identified e-cigarettes as addictive, a significant proportion (52.1%) were unaware of their heavy metal content, and 59.9% and 59.3% correctly recognized their risks for lung infections and heart problems, respectively. Still, 42.3% successfully refuted the belief that e-cigarettes pose less risk than regular cigarettes, and 47.8% acknowledged that they have comparable levels of addiction. Notably, 57.3% were aware of nicotine content, yet 34.4% still believed that e-cigarettes contain only water vapor and flavoring. For a detailed summary, see Table 3.

Table 3.

Distribution of knowledge regarding E-Cigarette use among university students in the study sample

Question	True	False	I don’t know	Correct answer
Unlike traditional cigarettes, electronic cigarettes do not contain heavy metals such as lead and mercury.	459 (20.4%)	617 (27.5%)	1170 (52.1%)	617 (27.5%)
Electronic cigarettes can cause bladder cancer.	683 (30.4%)	128 (5.7%)	1435 (63.9%)	683 (30.4%)
Electronic cigarettes can cause infertility.	778 (34.6%)	136 (6.1%)	1332 (59.3%)	778 (34.6%)
Electronic cigarettes can cause stroke.	871 (38.8%)	105 (4.7%)	1270 (56.5%)	871 (38.8%)
Electronic cigarettes prevent the use of traditional cigarettes.	541 (24.1%)	934 (41.6%)	771 (34.3%)	934 (41.6%)*
Electronic cigarettes cause less harm to health compared to traditional cigarettes.	567 (25.2%)	949 (42.3%)	730 (32.5%)	949 (42.3%)*
Electronic cigarettes are less addictive than traditional cigarettes.	413 (18.4%)	1074 (47.8%)	759 (33.8%)	1074 (47.8%)
Electronic cigarettes contain nicotine.	1287 (57.3%)	147 (6.5%)	812 (36.2%)	1287 (57.3%)
Electronic cigarettes only contain water vapor and flavoring.	166 (7.4%)	1308 (58.2%)	772 (34.4%)	1308 (58.2%)
Electronic cigarettes can cause heart problems.	1331 (59.3%)	57 (2.5%)	858 (38.2%)	1331 (59.3%)
Electronic cigarettes can cause lung infections.	1346 (59.9%)	67 (3.0%)	833 (37.1%)	1346 (59.9%)
Electronic cigarettes are addictive.	1665 (74.1%)	116 (5.2%)	465 (20.7%)	1665 (74.1%)

*These two items are specifically relevant to young adults and may not apply to older adults

Students’ perceptions and attitudes toward E-Cigarettes

A majority of participants (64.8%) supported policies that prohibit vaping in workplaces and public spaces, while 57.1% agreed with governmental regulation and oversight. The influence of flavored e-cigarettes on their popularity was widely recognized, with 69.7% agreeing or strongly agreeing with this notion. However, opinions on social acceptability were divided, with 36.2% perceiving e-cigarettes as more socially acceptable than traditional cigarettes, whereas 35.6% disagreed. Additionally, 63.3% rejected the idea that e-cigarette use is attractive, and 52.9% did not consider e-cigarettes as an effective smoking cessation aid. A detailed breakdown of these attitudes is presented in Table 4.

Table 4.

Distribution of attitudes regarding E-Cigarette use in the study sample

Question	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
The variety of flavors in electronic cigarettes plays a significant role in their popularity.	65 (2.9%)	58 (2.6%)	559 (24.9%)	1118 (49.8%)	446 (19.9%)
Using electronic cigarettes is enjoyable.	296 (13.2%)	156 (6.9%)	1017 (45.3%)	537 (23.9%)	240 (10.7%)
Using electronic cigarettes is more socially acceptable than traditional cigarettes.	304 (13.5%)	497 (22.1%)	632 (28.1%)	687 (30.6%)	126 (5.6%)
Using electronic cigarettes makes a person look modern and attractive.	844 (37.6%)	578 (25.7%)	456 (20.3%)	284 (12.6%)	84 (3.7%)
People who use electronic cigarettes are not considered smokers.	465 (20.7%)	723 (32.2%)	421 (18.7%)	564 (25.1%)	73 (3.3%)
Electronic cigarettes can be an effective method to help people quit smoking.	384 (17.1%)	551 (24.5%)	769 (34.2%)	471 (21.0%)	71 (3.2%)
Electronic cigarettes are less harmful than traditional cigarettes.	361 (16.1%)	563 (25.1%)	767 (34.1%)	489 (21.8%)	66 (2.9%)
Electronic cigarettes are less expensive than traditional cigarettes.	245 (10.9%)	535 (23.8%)	1103 (49.1%)	297 (13.2%)	66 (2.9%)

Support for tobacco control policies

Almost half of the participants (46.6%) lacked awareness of the current regulations regarding nicotine use, while only 14.6% correctly identified that smoking is prohibited in all locations, both inside and outside university premises. Institutional interventions appeared to be limited, as 83.6% of participants stated that their university does not offer screening programs for smoking and drug addiction, and 81.7% reported the absence of any dedicated counseling or support centers for students wishing to quit smoking. Furthermore, the availability of educational content on the health effects of e-cigarettes was minimal, with only 13.0% of students indicating that their university had provided such materials. For a detailed breakdown of these responses, refer to Table 5.

Table 5.

Support for public policies and regulatory measures on E-Cigarette use

Question	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Support banning the advertisement and sale of electronic cigarettes for individuals under 18 years old	56 (2.5%)	41 (1.8%)	247 (11.0%)	516 (23.0%)	1386 (61.7%)
Support implementing educational and preventive programs on the harms of electronic cigarettes in the media.	51 (2.3%)	43 (1.9%)	428 (19.1%)	739 (32.9%)	985 (43.9%)
Support banning the advertisement and sale of electronic cigarettes in supermarkets?	81 (3.6%)	152 (6.8%)	494 (22.0%)	550 (24.5%)	969 (43.1%)
Support banning the advertisement and sale of electronic cigarettes on online websites and social media platforms such as Instagram	107 (4.8%)	165 (7.3%)	543 (24.2%)	525 (23.4%)	906 (40.3%)
Electronic cigarette use should be banned in workplaces and public places.	99 (4.4%)	221 (9.8%)	472 (21.0%)	734 (32.7%)	720 (32.1%)
The university is responsible for adopting policies to ensure people have smoke-free and nicotine-free air.	80 (3.6%)	93 (4.1%)	424 (18.9%)	883 (39.3%)	766 (34.1%)
The university has a responsibility to adopt policies that reduce the use of all nicotine products and lower the risk of nicotine addiction.	120 (5.3%)	147 (6.5%)	568 (25.3%)	800 (35.6%)	611 (27.2%)
The government should regulate and oversee electronic cigarette use.	115 (5.1%)	195 (8.7%)	654 (29.1%)	779 (34.7%)	503 (22.4%)
Students and faculty members follow the no-smoking policy in Iran universities.	280 (12.5%)	627 (27.9%)	697 (31.0%)	419 (18.7%)	223 (9.9%)

A large proportion of participants (84.7%) agreed with a need for restricting the marketing and sale of e-cigarettes to individuals younger than 18, while 76.8% felt a need for implementing educational and preventive programs through media channels. Additionally, 67.6% agreed or strongly agreed with restricting e-cigarette advertisements and sales in supermarkets, and 63.7% supported similar restrictions on online platforms. University policies were also seen as crucial, with 73.4% advocating for a smoke-free and nicotine-free environment and 62.8% agreeing that universities should implement policies to reduce nicotine product use. However, compliance with no-smoking policies in universities remained questionable, as only 28.6% believed that students and faculty adhered to these regulations. A summary of these responses is presented in Table 5.

Bivariate χ² tests assessed that ever use of e-cigarettes was widely associated with students’ sociodemographic, behavioral, and social characteristics: every variable in Table 6 reached statistical significance (p <.05) except university level, parental marital status, and knowledge score. Conversely, past‑month use assessed a more focused pattern. Significant differences were observed by university school, university type, year of study, sex, residence, employment status, family income, personal income, and parental marital status (p ≤.05). Behaviorally, past-month vaping was much more common among students who had smoked ≥ 100 cigarettes, used hookah (ever or in the past month), or used conventional cigarettes in the previous 30 days (p <.001). Having friends who smoke remained a strong correlate (p <.001), whereas parental or sibling tobacco use, and regular exercise were no longer significant (p >.05). Psychosocially, a clear gradient emerged: lower knowledge scores and stronger pro-vaping attitudes were each linked to higher past-month use (both p <.001). Together, these findings suggest that trying an e-cigarette is influenced by a wide range of student attributes, whereas current (past‑month) use is influenced by a smaller range of academic, economic, peer, and tobacco-related factors—highlighting priority targets for campus-level intervention.

Table 6.

Bivariate associations between Sociodemographic, Behavioral, and social factors with ever and past month E-Cigarette use among university students

	Variable
		Ever Use			Past Month Use
		No	Yes	P-Value	No	Yes	P-Value
University School	Humanities and Social Sciences	159	50	0.000	194	15	0.001
	Basic Sciences	67	20		83	4
	Engineering and Technology	188	116		262	42
	Medicine	741	249		917	73
	Dentistry	146	54		180	20
	Pharmacy	40	23		52	11
	Nursing	79	29		99	9
	Allied Health	138	36		169	5
	Agriculture and Natural Resources	8	2		9	1
	Architecture and Arts	35	46		64	17
	Veterinary Medicine	11	9		19	1
University Level	Associate’s Degree	40	15	0.075	49	6	0.720
	Bachelor’s Degree	591	259		769	81
	Master’s Degree	100	50		138	12
	Doctorate or Higher	881	310		1092	99
Type of university	governmental Tutation	1263	459	0.003	1587	135	0.003
	Non-governmental Tutation	349	175		461	63
Years of study	Year 1	390	96	0.000	457	29	0.004
	Year 2	315	88		372	31
	Year 3	216	116		296	36
	Year 4	278	139		374	43
	Year 5	212	82		274	20
	Year 6	110	57		152	15
	Year 7	45	25		60	10
	Year 8	46	31		63	14
Sex	Female	894	225	0.000	1066	53	0.000
	Male	718	409		982	145
Parent Marital Status	Single	1512	592	0.384	0	0	0.024
	Married	97	40		1919	179
	Widowed	2	0		75	7
	Divorced	1	2		54	12
Residence	Living with Family	807	294	0.000	997	104	0.002
	Dormitory	685	243		865	63
	Private Housing (Without Family)	117	95		181	31
	Other Housing	3	2		5	0
Job	No Job	1179	366	0.000	1446	99	0.001
	Yes, Part-time	375	208		513	70
	Yes, Full-time	58	60		89	29
Family Income	Less than 100 million	1526	574	0.000	1925	175	0.002
	More than 100 million	86	60		123	23
Personal Income	Less than 10 million	1481	503	0.000	1844	140	0.000
	Between 10 and 50 million	119	120		188	51
	More than 50 Million	12	11		16	7
Exercise	No	957	345	0.032	1200	102	0.054
	Yes	655	289		848	96
Father Smoker	No	1384	503	0.000	1728	159	0.135
	Yes	228	131		320	39
Mother Smoker	No	1604	625	0.023	2034	195	0.197
	Yes	8	9		14	3
Siblings Smoker	No	1526	555	0.000	1902	179	0.204
	Yes	86	79		146	19
Friends Smoker	No	1127	177	0.000	1262	42	0.000
	Yes	485	457		786	156
Family Smoker	No	544	377	0.000	291	80	0.282
	Yes	1068	257		180	61
Smoked ≥ 100 Cigarettes (Lifetime)	No	1526	555	0.000	1755	37	0.000
	Yes	86	79		293	161
Hookah use ever (Lifetime)	No	1127	177	0.000	1758	100	0.000
	Yes	485	457		290	98
Used Conventional Cigarettes Past 30 Days	No	545	135	0.000	1825	57	0.000
	Yes	1067	499		223	141
Hookah Past Month	No	1563	319	0.000	1863	133	0.000
	Yes	49	315		185	65
Knowledge Score (high = 1, low = 0)	Low	924	365	0.914	1148	141	0.000
	High	688	269		900	57
Attitude Score (high = 1, low = 0)	Low	1591	557	0.000	1998	150	0.000
	High	21	77		50	48

The results of Table 7 show demographic and academic variables that were significantly associated with e-cigarette use. Specifically, Table 7 presents the multivariable logistic regression model for ever-use of e-cigarettes (defined as any lifetime use). A similar model was also run for past-month use, showing comparable directions of association (not shown). Regarding university school, students in the Faculty of Architecture and Arts (OR = 3.12, 95% CI: 1.38–7.06, p =.006) and Veterinary Medicine (OR = 4.59, 95% CI: 1.28–16.51, p =.020) had significantly higher odds compared to those in Humanities and Social Sciences. University level assessed a protective association (OR = 0.76, 95% CI: 0.59–0.98, p =.035). The findings indicated that the students’ year of study was significantly associated with the outcome (e.g., higher odds observed in years 3, 4, and 7 with ORs ranging from 1.78 to 2.40). Being male (OR = 1.36, 95% CI: 1.01–1.84, p =.044), having divorced parents (OR = 2.37, 95% CI: 1.14–4.93, p =.020), and working part-time (OR = 1.42, 95% CI: 1.04–1.95, p =.027) were also associated with increased odds.

Table 7.

Multivariate logistic regression results for factors associated with E-Cigarette use among university students

	Adjusted OR			OR
	Variable	P-Value	OR (95% CI)	P-Value	OR (95% CI)
University School	Humanities and Social Sciences	0.007		0.000
	Basic Sciences	0.009	0.17 (0.04–0.645)	0.045	0.38 (0.15–0.98)
	Engineering and Technology	0.013	0.16 (0.41–0.68)	0.051	0.36 (0.13–1.00.13.00)
	Medicine	0.019	0.21 (0.06–0.779)	0.544	0.75 (0.30–1.87)
	Dentistry	0.020	0.25 (0.08–0.809)	0.051	0.41 (0.16–1.00.16.00)
	Pharmacy	0.025	0.24 (0.07–0.83)	0.096	0.45 (0.17–1.15)
	Nursing	0.343	0.52 (0.13–1.99)	0.498	0.70 (0.25–1.94)
	Allied Health	0.060	0.26 (0.06–1.05)	0.108	0.44 (0.16–1.19)
	Agriculture and Natural Resources	0.013	0.18 (0.05–0.7)	0.019	0.31 (0.12–0.82)
	Architecture and Arts	0.803	0.77 (0.09–6.01)	0.192	0.30 (0.05–1.81)
	Veterinary Medicine	0.508	0.62 (0.15–2.48)	0.345	1.60 (0.60–4.30)
University Level	Associate’s Degree	0.260		0.076
	Bachelor’s Degree	0.341	1.55 (0.62–3.87)	0.837	1.06 (0.58–1.95)
	Master’s Degree	0.050	2.02 (1.00–4.09.00.09)	0.027	1.24 (1.02–1.51)
	Doctorate or Higher	0.225	1.58 (0.75–3.36)	0.058	1.42 (0.98–2.04)
Type of university	Non-govermental Tutation	0.924	0.98 (0.71–1.36)	0.003	1.38 (1.11–1.70)
Years Of study	Year 1	0.398		0.000
	Year 2	0.926	1.04 (0.45–2.38)	0.000	0.36 (0.22–0.60)
	Year 3	0.585	1.24 (0.56–2.77)	0.001	0.41 (0.24–0.69)
	Year 4	0.132	1.79 (0.83–3.82)	0.381	0.79 (0.47–1.32)
	Year 5	0.177	1.66 (0.79–3.48)	0.241	0.74 (0.45–1.22)
	Year 6	0.251	1.58 (0.72–3.46)	0.037	0.57 (0.34–0.96)
	Year 7	0.125	1.90 (0.83–4.34)	0.355	0.76 (0.44–1.34)
	Year 8	0.085	2.29 (0.89–5.91)	0.571	0.82 (0.42–1.60)
	Sex	0.032	1.374 (1.02–1.83)	0.000	2.26 (1.87–2.73)
Parent Marital Status	Married	0.398		0.000
	Widowed	0.011	0.39 (0.19–0.80)	0.000	0.39 (0.24–0.65)
	Divorced	0.083	0.42 (0.15–1.11)	0.192	0.64 (0.33–1.24)
Residence	Living with Family	0.398		0.000
	Dormitory	0.210	0.25 (0.03–2.15)	0.509	0.54 (0.09–3.28)
	Private Housing (Without Family)	0.170	0.22 (0.02–1.88)	0.491	0.53 (0.08–3.20)
	Other Housing	0.259	0.29 (0.03–2.49)	0.831	1.218 (0.19–7.443)
Job	No Job	0.084		0.000
	Yes, Part-time	0.361	0.74 (0.40–1.39)	0.000	0.30 (0.20–0.43)
	Yes, Full-time	0.866	1.05 (0.56–1.95)	0.002	0.53 (0.36–0.79)
Family Income		0.151	1.46 (0.87–2.46)	0.000	1.85 (1.31–2.61)
Personal Income	Less than 10 million	0.251		0.000
	Between 10 and 50 million	0.423	2.33 (0.29–18.49)	0.038	0.28 (0.08–0.93)
	More than 50 million	0.241	3.46 (0.20–42.61.20.61)	0.779	0.84 (0.25 − 0.2.82)
Exercise		0.247	1.17 (0.89–1.54)	0.033	0.81 (0.67–0.98)
Father Smoker		0.586	0.89 (0.60–1.32)	0.000	1.58 (1.24–2.00.24.00)
Mother Smoker		0.428	1.74 (0.44–6.88)	0.03	2.88 (1.10–7.51)
Siblings Smoker		0.007	1.93 (1.20–3.10)	0.000	2.52 (1.83–3.48)
Friends Smoker		0.000	2.02 (1.51–2.70)	0.000	6.00 (4.89–7.35)
Family Smoker		0.003	1.64 (1.18–2.29)	0.000	2.88 (2.38–3.48)
	Smoked ≥ 100 Cigarettes (Lifetime)	0.000	6.76 (3.92–11.65)	0.000	0.03 (0.02–0.04)
	Hookah use ever (Lifetime)	0.000	4.95 (2.98–8.21)	0.000	12.16 (9.43–15.69)
	Conventional cigarette use Past 30 Days	0.003	2.54 (1.36–4.72)	0.000	31.49 (22.77–43.55)
	Hookah use Past Month	0.115	1.62 (0.88–2.98)	0.000	11.93 (8.72–16.34)
	Knowledge Score (high = 1, low = 0)	0.959	1.00 (0.76–1.32)	0.914	0.99 (0.82–1.19)
	Attitude Score (high = 1, low = 0)	0.000	7.29 (3.75–14.15)	0.000	10.47 (6.40–17.13.40.13)
	Constant	0.279	0.137	-	-

The findings derived from the multivariable logistic regression analysis suggest that both academic discipline and gender significantly influence e-cigarette usage among university students. Compared to students in the Humanities and Social Sciences, those in Basic Sciences (AOR = 0.17, 95% CI: 0.04–0.65, p =.009), Engineering and Technology (AOR = 0.16, 95% CI: 0.41–0.68, p =.013), Medicine (AOR = 0.21, 95% CI: 0.06–0.78, p =.019), Dentistry (AOR = 0.25, 95% CI: 0.08–0.81, p =.020), and Pharmacy (AOR = 0.24, 95% CI: 0.07–0.83, p =.025) had significantly lower odds of using e-cigarettes, suggesting a protective academic environment in health-related fields. Male students were more likely to use e-cigarettes than females (AOR = 1.37, 95% CI: 1.02–1.83, p =.032), and students with a Master’s degree had higher odds compared to those with an Associate’s degree (AOR = 2.02, 95% CI: 1.00–4.09, p =.050). Type of university and year of study were not significant in the adjusted model, although some year levels assessed protective trends in unadjusted analyses.

Behavioral and social influences showed the most significant links to e-cigarette usage. Among students, those who had smoked 100 or more cigarettes in their lifetime were considerably more inclined to use e-cigarette (AOR = 6.76, 95% CI: 3.92–11.65, p <.001), as were those who had ever used hookah (AOR = 4.95, 95% CI: 2.98–8.21, p <.001) or used conventional cigarettes in the past 30 days (OR = 31.49, 95% CI: 22.77–43.55, p <.001). Having siblings (AOR = 1.93, 95% CI: 1.20–3.10, p =.007), friends (AOR = 2.02, 95% CI: 1.51–2.70, p <.001), or family members (AOR = 1.64, 95% CI: 1.18–2.29, p =.003) who use tobacco products was also significantly associated with increased odds. Notably, students with a high-risk attitude toward e-cigarette use had substantially greater odds of usage (AOR = 7.29, 95% CI: 3.75–14.15, p <.001), emphasizing the influence of personal beliefs. Variables such as exercise, father’s smoking status, income, and knowledge scores were not significantly associated after adjustment.

Discussion

To our knowledge, this is the first nationwide epidemiological study with a substantial sample size aimed at evaluating the understanding, attitudes, and support for e-cigarette policies in Iran. As such, the results may inform policies and regulations to tackle the growing use of e-cigarettes in colleges and University students in Iran.

This nationwide, multicentric study offers new insights into the habits, understanding, attitudes, and policy support related to e-cigarette use among young adults in Iran. Although the Comprehensive Tobacco Control Law prohibits smoking in educational institutions, no explicit provisions address e-cigarettes on campuses. Enforcement is inconsistent, and most universities lack cessation services or awareness programs on vaping.

The lifetime prevalence of e-cigarette use (28.2%) identified in our sample reflects a concerning trend, particularly when compared with lower rates reported in Qatar (14%) [31] and Palestine (18.1%) [35], but remains somewhat lower than the 40.5% prevalence observed in New Zealand [15]. In the United States, national data indicate that while e-cigarette use has declined among youth, adult prevalence increased from 4.5% in 2019 to 6.5% in 2023, with the highest use (approximately 1 in 6) observed among young adults aged 21–24 [36]. Additionally, findings from other Eastern Mediterranean countries highlight similar trends. In Jordan, e-cigarette ever-use was 11% among university students, with widespread misconceptions about safety [32]. In Saudi Arabia, prevalence among health sciences students reached 27%, with most believing e-cigarettes were less harmful than cigarettes [37]. These results mirror our findings in Iran, underscoring that misconceptions, peer influence, and weak regulation are common drivers of vaping across the region.

These discrepancies may be explained by differences in regulatory environments, cultural norms, and marketing intensity across countries [38]. The high prevalence underscores a critical need for targeted public health strategies to address e-cigarette use among Iranian youth.

​More and more teens are trying e-cigarettes, many of them without ever having smoked before [39]. This is a concern because they are facing health risks that could easily be avoided, making it an important issue for public health [40].

Several factors may potentially contribute to such variations in usage. In regions with strict regulations on traditional cigarette smoking, such as indoor smoking bans, individuals might perceive e-cigarettes as a more acceptable alternative, potentially leading to higher usage rates [38]. Additionally, cultural norms and social acceptance of smoking behaviors can significantly influence e-cigarette use among university students [41]. For instance, in societies where smoking is less stigmatized, there may be higher prevalence rates. Furthermore, the availability and marketing of e-cigarettes, including the appeal of various flavors, can impact usage rates across different regions [42].

The findings of this study highlight considerable gaps in students’ knowledge regarding the health risks associated with e-cigarette use. Although 74.1% of participants correctly recognized the addictive potential of vaping products, over half were unaware of the presence of toxic metals such as lead and mercury in e-cigarette aerosols, consistent with previous studies reporting widespread misconceptions about their constituents [21, 43]. E-cigarette aerosols have been shown to contain harmful metals, including lead, nickel, and chromium [44], which are associated with adverse health effects such as oxidative stress, inflammation, and increased risk of neurological and cardiovascular conditions [45]. Inadequate knowledge about these risks may reduce harm perception, potentially contributing to increased uptake among non-smokers and reduced cessation motivation among current users [46]. While educational interventions have demonstrated effectiveness in improving awareness of e-cigarette-related harms, altering attitudes and behaviors remains more complex due to the influence of social norms, personal beliefs, and environmental factors [47]. Despite Iran’s progress in implementing FCTC measures, major gaps remain in tobacco and nicotine regulation. The absence of explicit laws covering e-cigarettes, weak taxation, and limited enforcement of campus bans have allowed online marketing, flavored products, and social normalization of vaping to proliferate [27].

Furthermore, our findings revealed that only 34.9% of students correctly identified that e-cigarettes can cause infertility. This lack of awareness is concerning, as it may contribute to increased e-cigarette use among students who are unaware of the potential reproductive health risks. Comparable studies have reported that while students are aware of some health risks associated with e-cigarettes, such as respiratory and cardiovascular issues, they are less informed about other risks, including seizures and depression [48].

Attitudes toward e-cigarettes were found to be highly divided. A large number still thought that vaping was more socially acceptable than smoking traditional cigarettes. These findings align with international literature demonstrating that the social normalization of vaping, coupled with the appeal of flavored products, is a major driver of e-cigarette uptake among young adults [42, 49]. Therefore, changing the perception of vaping as a socially desirable behavior should be a critical component of future intervention programs.

A study conducted in Qatar found that 67.9% of e-cigarette users view these devices as less harmful than traditional cigarettes, whereas only 37.6% of non-users share this perception. Additionally, 78.6% of users believed that e-cigarettes could reduce the likelihood of individuals starting to smoke conventional cigarettes, whereas only 40.4% of non-users shared this belief [31]. Similarly, a study of university students in Thailand found that 19.2% believe e-cigarettes are safer than traditional smoking, while 17.4% regard their use as a marker of sophistication. Furthermore, 34.4% feel that e-cigarette users should not be classified as smokers, and 37.9% consider e-cigarettes to be more cost-effective than conventional cigarettes [50]. A study across three universities in Mexico identified specific attitudes and perceptions among undergraduate students who vape. The research highlighted that the increase in popularity of e-cigarettes has been associated with adverse health outcomes, underscoring the need for targeted interventions [51]. These differing perceptions can influence the prevalence of e-cigarette use and highlight the need for clear communication about the risks associated with e-cigarette use. Addressing misunderstandings and providing accurate information is crucial in shaping informed attitudes and behaviors among university students.

In our study, multivariable analysis revealed factors associated with e-cigarette use, such as male gender, parental divorce, part-time employment, previous tobacco or hookah usage, and the presence of friends or siblings who use tobacco products. These findings are consistent with prior studies emphasizing the influential role of social networks and peer behaviors on smoking and vaping practices [52, 53]. Students who had more positive views about e-cigarettes were much more likely to report using them in the past or currently. This highlights the need to address both attitudes and social beliefs, in addition to improving knowledge, when designing prevention programs.

A multifaceted interaction of behavioral, social, and cognitive aspects shapes the differences in e-cigarette usage between genders among university students. Research shows that male students demonstrate higher e-cigarette usage than females, a pattern linked to increased risk-taking tendencies, social norms favoring use, and greater exposure to tobacco-related contexts [54, 55]. Additionally, poly-tobacco use, characterized by the simultaneous use of multiple tobacco products, is common among young adults [56]. The transition patterns indicate that e-cigarette use may act as a bridge from non-current use to poly-tobacco use [57]. Therefore, comprehensive prevention strategies are essential to address the complex nature of tobacco use and the factors driving multi-product usage.

This study’s strengths include a large, geographically diverse sample and the use of a validated survey instrument. However, its cross-sectional design limits causal inferences, and self-reported data may introduce biases. Although efforts were made to recruit a varied sample, the findings may not be fully generalizable to all Iranian university students.

In conclusion, we offer a multifaceted set of strategies to address e-cigarette use in university students in Iran. Universities should develop and implement tobacco- and nicotine-free policies that prohibit the use, promotion, and sale of any type of cigarette, including both tobacco and e-cigarettes, and develop mechanisms for compliance (e.g., through regular inspections and enforcement mechanisms). National public health education campaigns that remove misconceptions about e-cigarettes- such as the misconception e-cigarettes are “only water vapor”- and activities that re-position e-cigarette vaping as socially unacceptable through national mass media channels (i.e., platforms that are popular among Iranian youth; Instagram, Telegram) would be beneficial. At the policy level, the Comprehensive Tobacco Control Law should be amended to include e-cigarettes, and the existing heaviest and most draconian restrictions against advertising, providing tobacco products to minors, and protecting from smoke should be strictly enforced for vaping and e-cigarette products include prohibitions against advertising, and online sales of flavored e-cigarettes. However, the most effective responses will need to occur within university campuses by developing programs that systematically address tobacco and nicotine use, such as implementing prevention and cessation programs with a well-structured process, providing information through peer-led education campaigns, using digital platforms for e-counseling, and developing education programs as part of a larger health promotion curriculum. Finally, effective regulation of e-cigarette use will require collaboration between sectors, specifically the Health, Education, and Information Technology, to allow for certain policies (i.e., restrictive advertising policies) to be more effectively implemented in relevant settings (i.e., educational settings, digital settings, and health systems).

Conclusions

In conclusion, the high prevalence of e-cigarette use among Iranian university students, occurring within a regulatory vacuum, underscores an urgent need for comprehensive public health intervention. Effective strategies must address not only the significant knowledge gaps and misconceptions but also the influential social norms that drive vaping acceptability. A multi-level approach is essential, combining national policy reforms to restrict marketing and flavors with proactive university-level initiatives. Culturally tailored educational campaigns and the strict enforcement of nicotine-free campus policies are critical to de-normalizing use and fostering a healthier future for young adults in Iran.

Abbreviations

e-cigarette

Electronic cigarette

SMOKES

Study of Measurement Of Knowledge and Examination of Support for tobacco control policies

Authors’ contributions

M.P., S.A., and F.S.A. conceptualized and designed the study. M.P. and N.G. wrote the original draft of the manuscript. S.A. contributed to reviewing and editing the manuscript. M.P. and F.S.A. supervised and administered the project. N.G. conducted the data analysis. R.N., A.N., M.H.R., S.K., A.P., M.M., D.R., M.S., A.A., S.Ash., A.Y., and M.B.J. contributed to data collection. All authors read and approved the final manuscript.

Funding

None.

Data availability

Due to the extensive size of the study population, the datasets generated and/or analyzed during the present study are not publicly accessible. However, the corresponding author may make the data available upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Shahid Sadoughi University of Medical Sciences (approval code: IR.SSU.MEDICINE.1403.157.059). Written informed consent was obtained from all participants. All methods were carried out in accordance with relevant guidelines and regulations.

Declaration of Generative AI and AI-Assisted Technologies in the Writing Process

The authors employed artificial intelligence tools to enhance linguistic clarity and readability during the preparation of this manuscript. The authors independently reviewed, revised, and approved all content and accept full responsibility for the final version of the work.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.