Self-efficacy and Vaping Behavior among Female Health Students: An Assessment of Health Belief Components

1. INTRODUCTION

Electronic cigarettes pose a growing threat to public health, particularly among young adults. Their sleek designs, appealing flavors, and widespread promotion on social media contribute to a deceptive image that downplays their addictive properties and potential to cause lung damage and cardiovascular problems [1-4]. Electronic cigarettes contain nicotine, flavoring, and various chemicals, several of which can be addictive and harmful to the lungs of both users and bystanders [5, 6]. They are commonly referred to as e-cigs, vape pens, vapes, or tank systems. In 2018, the number of electronic cigarette users in the United States was reported to be 8.1 million, including 1.3 million teenagers [7, 8]. In Saudi Arabia, changing patterns of prevalence, knowledge, and beliefs regarding vaping have been reported over the years. A 2018 study in Saudi Arabia found that 68.9% of adults (aged 18–60 years) vaped, whereas 67% considered it dangerous [9]. One year later, a survey of 1,080 adults (aged 18–74 years) in eastern Saudi Arabia reported a vaping prevalence of 33.6%, whereas 53.8% considered it unsafe [10]. A survey of medical and health sciences college students in Saudi Arabia (aged 18–26 years) found that 27% used electronic cigarettes, nearly twice the prevalence of conventional cigarette smoking [11]. Similarly, a study at the University of Ha’il in Saudi Arabia reported that nearly a quarter of medical and health sciences college students (aged 18–27 years) vaped because of peer pressure [12]. However, higher-quality evidence is needed to better understand the health impacts of e-cigarette use and the role of peer pressure in influencing usage behaviors [13]. Electronic cigarettes are sometimes used alongside tobacco products, as reported among adults in China [14]. Therefore, understanding the reasons behind and patterns of electronic cigarette use is crucial [14]. Most electronic cigarettes contain nicotine and emit dangerous chemicals that can cause lung and cardiovascular diseases [15, 16]. Second-generation vape devices have significantly increased the demand for electronic and combustible cigarettes [4]. Additionally, electronic cigarette use has been associated with adverse effects, including impaired brain development in teenagers, coughing, breathing difficulties, chest pain, nausea, fatigue, fever, and weight loss [17].

Public health professionals play a key role in developing and sharing strategies for addressing electronic cigarette use, which requires an understanding of young users' attitudes and behaviors toward vaping [18-21]. The knowledge, beliefs, attitudes, and behavioral practices of health professional students regarding electronic cigarettes are crucial, as they are responsible for educating patients and staying informed on the latest knowledge. A study among medical students in Saudi Arabia highlighted significant concerns regarding electronic cigarette education, with only 35.1% feeling confident in counseling patients about electronic cigarettes [22], despite reported vaping rates of 12–22% in this population [23, 24]. Moreover, vaping is harmful to pregnant women and their infants. Nicotine in electronic cigarettes restricts the placental blood flow, resulting in low birth weight and premature birth. Additionally, chemicals in electronic cigarettes can cross the placental barrier and affect fetal brain development [25]. Thus, investigating the overlooked relationship between vaping behavior and psychological constructs, such as self-efficacy and behavioral health correlates, among female health sciences students is of significant importance. Bandura introduced self-efficacy as a construct that defines an individual’s beliefs, determining how effectively action plans are implemented in potential situations [26]. Beliefs about self-efficacy significantly contribute to the prediction of intention. Even after controlling for intention, self-efficacy directly influences behavior [27]. Self-efficacy has proven to be effective in motivational and health promotion programs [28]. Additionally, it has been found to correlate with or mediate various smoking cessation programs, primarily in randomized controlled trials where electronic cigarettes were used as an intervention [29, 30].

The Health Belief Model (HBM) is linked to smoking cessation success [31]. A key factor, perceived threat, increases the likelihood of taking action to quit [32, 33]. This perceived threat combines how serious a threat one believes smoking is (perceived severity) and how likely one believes they are to become sick from it (perceived susceptibility) [33]. Individuals who perceive smoking as a serious threat are more likely to attempt quitting smoking and less likely to initiate smoking [31, 36].

In Saudi Arabia, female medical students were found to vape less than male students due to cultural social norms [23]. Therefore, exploring the sociodemographic, psychological, and behavioral correlates of vaping behavior among female medical students is essential for developing prevention strategies based on self-efficacy, perceived susceptibility, and perceived severity for future female health professionals.

This study examined vaping behavior, self-efficacy, perceived susceptibility, and perceived severity among female health sciences students at a university in Riyadh. The selected sample helps address a research gap regarding the unique vaping patterns among female students in Saudi Arabia. While several studies have explored the sociodemographic correlates, prevalence [11, 24], knowledge, attitudes [22], and perceptions [23] of Saudi medical students toward vaping, the current study specifically investigated the theoretical implications of the HBM. In particular, it examines how self-efficacy, perceived susceptibility, and perceived severity are related to vaping behavior.

Based on the present findings, this study aimed to determine whether the assessment would further include the need to incorporate health promotion campaigns. It was hypothesized that self-efficacy, perceived susceptibility, and perceived severity would correlate with electronic cigarette use among participants.

2. MATERIALS AND METHODS

2.2. Sample and Study Population

The target population comprised female health sciences students enrolled at a university in Riyadh. The sample size was determined using the following formula:

where n represents the required sample size, Z is the standard normal deviation at a 95% confidence level (1.96), p is the estimated proportion of the characteristic under study (set at 0.5 to ensure maximum variability), q is calculated as 1−p1 - p1−p, d denotes the margin of error (0.05), and N refers to the total student population (6,500). Based on this formula, the estimated sample size was 363 participants. However, due to a higher-than-expected response rate, 425 students ultimately participated in the study.

Eligible participants were students actively enrolled in a health sciences program. To ensure a comprehensive assessment of vaping behavior, individuals who had used vapes, traditional cigarettes, cigars, or shisha were included. Students from non-health programs were excluded to maintain the focus of the study.

3. RESULTS

3.4. Relationship between Sociodemographic Variables and Vaping Behavior

Pearson’s correlation analysis between sociodemographic variables (age, college program, college level, mother’s education, father’s education, residence, and monthly stipend) and vaping behavior showed that college level (r = -0.121, p = .01), mother’s education (r = -0.129, p = .008), and father’s education (r = -0.129, p = .008) were significantly negatively correlated with vaping (Table 5). This implies that students with higher parental education levels and those in higher college levels were less likely to vape.

Table 5.

Variables	Age	College	College Level	Mother’s Education	Father’s Education	Residence
Vaping	-.075	-.001	-.121*	-.129*	-.129*	.028

Note: p ≤ .05.

4. DISCUSSION

Vaping is a rapidly growing global public health concern among young adults. Given the increasing use of electronic cigarettes in many countries, understanding them as a novel phenomenon is essential. However, few studies have specifically examined female health students, who are expected to recognize the health risks associated with electronic cigarette use. This study aimed to assess self-efficacy and its relationship with key HBM components, including perceived severity and susceptibility to electronic cigarettes, among health sciences students. The findings partially supported the hypothesis. Although self-efficacy, perceived severity, and perceived susceptibility were interrelated, they did not directly influence vaping behavior. Several factors may account for this inconsistency, including social, environmental, and situational influences, such as peer pressure, the normalization of vaping among youth, and the novelty and accessibility of electronic cigarettes, which may further create resistance toward behavioral change. Among environmental factors, the availability and marketing of electronic cigarettes, as well as the role of media or social media in promoting vaping, play a significant role. Certain sociodemographic factors, such as the number of friends who use electronic cigarettes, were found to be significantly associated with vaping behavior, reinforcing previous findings [12]. Simultaneously, certain protective factors within sociodemographic variables emerged as protective factors against vaping, aligning with existing literature on resistance to vaping behavior. One such factor is related to senior-level students who are less likely to engage in vaping. Previous studies support these findings, indicating that maturity and knowledge play a protective role against vaping, as well as novelty and sensation-seeking behaviors [3]. Another protective factor is parental education, which is negatively related to vaping behavior [34].

The negative correlation between higher college level and vaping behavior may be attributed to multiple factors. First, senior students typically have greater exposure to health-related coursework and professional training, particularly in health science programs, which enhances their awareness of the risks associated with vaping. Second, increased maturity and life stability at advanced college levels may contribute to more health-conscious decision-making and a reduced likelihood of engaging in risky behaviors, such as vaping. These findings align with previous research suggesting that as students progress through their academic careers, they become more inclined to prioritize long-term health over short-term social trends [46]. Additionally, senior students may experience less peer pressure, as their social circles often shift toward academic and professional networks, which discourages risky behaviors such as vaping.

The observed negative correlation between parental education and vaping behavior suggests that higher parental education levels may contribute to more health-conscious parenting styles and stronger communication regarding the risks of substance use. Educated parents are more likely to emphasize preventive health behaviors, provide accurate health information, and model healthy lifestyle choices, which may reduce the likelihood of their children engaging in vaping [34]. Furthermore, higher parental education is often associated with greater socioeconomic stability, which reduces stressors that may drive students toward risk-taking behaviors, including vaping. This aligns with the findings of Jaffar et al. [46] who reported that socioeconomic and educational backgrounds play critical roles in shaping youth perceptions of vaping risks.

Approximately 425 health science college students, with a mean age of 20 years, participated in this study. The prevalence of vaping behavior among female health sciences students was 18%. This may be attributed to companies that advertise and market electronic cigarettes and the fact that these devices are now more readily available. These factors may lead to a high rate of intentional behavior. This finding is in contrast with those of previous studies [11, 22]. In 2017, 27% of health sciences students in Jeddah reported using electronic cigarettes, which was higher than that reported in this study [11]. A study from Alfaisal University conducted in 2020 reported that females were less likely to use electronic cigarettes than men; however, the prevalence among females in that study (12.2%) was lower than that in the present study [23].

Moreover, the majority of participants who reported vaping were from the College of Health and Rehabilitation Sciences, which may be attributed to the college’s proportionately larger size than other health colleges (comprising 13 academic programs and more than 1500 students out of a total of 5000 students in health sciences colleges). Furthermore, in the current study, most participants who used vapes were in college levels 5–6. This suggests that the novelty that students experienced during the lower levels of college may increase the likelihood of experimenting with vaping, whereas the senior levels are more demanding, which discourages vaping. A long-term study conducted by the University of Michigan reported a decline in vaping rates among adolescents as they age. This trend can also be observed in medical schools. In this context, smoking/vaping cessation programs/clinical awareness programs, as well as workshops on life skills, can help young adults overcome undesirable behaviors [31, 39].

Approximately one-quarter of students who reported vaping had one or two friends who also vaped, suggesting that peer influence, conformity, and curiosity may have contributed to their behavior. Similar outcomes have been previously reported [12, 24, 39]. Regarding the sociodemographic correlates of vaping behavior, higher college and parental education levels were negatively correlated with vaping. Students at a higher college level are typically more mature, knowledgeable, and educated about healthy behaviors. Various course modules are available for health students, such as Health Behavior, Society and Health, Human Behavior, Introduction to Health Determinants, Mental Health, and Substance Abuse. Jones et al. [3] posited that knowledge of harmful behaviors could decrease vaping behaviors.

Furthermore, the role of parents in shaping behavioral development cannot be overlooked [3]. Higher parental education can positively affect children’s behaviors. Consistent with this, previous research has reported a negative correlation between maternal education and vaping behavior [40]. Self-efficacy plays a significant role in preventing vaping behaviors. More than half of the participants strongly agreed with the statement, “No one could persuade me to try vaping,” indicating a high level of self-efficacy among the students [3]. This finding can be linked to increased self-protective behavior against vaping. This is consistent with a previous study that found a low probability of trying electronic cigarettes among respondents who had never used them [41].

Furthermore, one-quarter of the participants expressed a neutral stance on the statement, “I will become an addict if I vape electronic cigarettes.” In contrast, a study conducted in Saudi Arabia reported that nearly half of the participants perceived vaping as less addictive than traditional cigarette smoking [9]. This difference in perceived addictiveness may stem from the belief that electronic cigarettes help users quit smoking. Moreover, over one-third of the participants strongly agreed with the statement, “I would get sick if I vape,” likely due to their awareness of vaping-related harmful effects, such as cancer. Similarly, in the aforementioned Saudi Arabian study, more than half of the participants believed that electronic cigarettes were unsafe; however, they were considered less dangerous than traditional cigarettes [9]. Over one-third of the participants strongly agreed with the statement, “If I vape, I may die earlier,” possibly reflecting their belief that electronic cigarettes contain harmful substances similar to those in tobacco cigarettes. In contrast to the current findings, 23% of university students perceived electronic cigarettes to be less harmful than tobacco cigarettes [42]. In this study, half of the respondents (56%) strongly agreed with the statement, “The earlier a person starts vaping, the greater the harm.” Higher levels of education and knowledge strengthen this belief. Therefore, respondents were familiar with the product and recognized the effects of vaping on their health. Consistent with this, a study in the Aljazan region of Saudi Arabia reported that the majority of undergraduate students perceived that exhaled vapor from electronic cigarettes could adversely affect their health [43]. Moreover, in an Austrian study, most surveyed students believed that electronic cigarettes damaged their health [44].

Finally, although the regression model yielded insignificant results, it predicted that age, self-efficacy, perceived severity, and perceived susceptibility were associated with a decreased likelihood of vaping, whereas a higher student stipend was linked to an increased likelihood. This indicates that self-efficacy and HBM-based programs can promote healthy behaviors among students. However, knowledge of risk alone is insufficient to prevent addictive behaviors [34]. Participants in this study were not enrolled in any treatment program. Other significant mediating factors, such as self-control and self-regulation, may influence the relationship between HBM components and vaping behavior [47] and should be examined in future research. Additionally, the Theory of Planned Behavior could serve as an alternative framework for a deeper exploration of psychological factors that contribute to behavioral change.

This study has some limitations that should be addressed in future research. Treatment-related factors and vaping cessation attempts, which are essential for understanding quitting behaviors and the challenges individuals face, were not explored. Additionally, further investigation into psychological and social motivators, such as pleasure, sensation-seeking, and curiosity, could provide deeper insights into vaping behavior. As the current study is correlational, future longitudinal or experimental research is required to explore potential causal relationships. Moreover, qualitative methods, such as focus groups, could help uncover the underlying attitudes, motivations, and social influences related to vaping behavior.

A key limitation of this study is its focus on a single university in Saudi Arabia, which may not fully represent broader national or international populations of university students. These findings specifically reflect the vaping behaviors and perceptions of female health sciences students, leaving uncertainty about whether similar trends apply to male students or those from other academic disciplines. Additionally, cultural and institutional differences across universities may shape vaping attitudes and behaviors. To enhance external validity, future research should include multiple universities, a wider range of academic disciplines, and male students to determine whether these patterns persist across different cultural settings.

CONCLUSION

This study found that 18% of female health science students reported vaping, with peer influence being a significant factor in their behavior. Although self-efficacy, perceived severity, and perceived susceptibility were positively correlated, they did not show a direct association with vaping behavior. However, higher college level and parental education were negatively correlated with vaping, suggesting that maturity and knowledge may serve as protective factors.

These findings emphasize the need for targeted health education interventions that strengthen self-efficacy and perceived threat to reduce vaping among students. Prevention strategies should address peer influence, social norms, and misconceptions regarding vaping-related health risks. Health education specialists and psychologists can play key roles in designing awareness campaigns, smoking cessation programs, and behavioral interventions tailored to young adults. Future research should explore additional psychological and environmental factors influencing vaping, including social media exposure, stress, and self-regulation strategies. Additionally, expanding the study population to include male students, students from different universities, and individuals from diverse cultural backgrounds is essential for understanding the broader applicability of these findings and strengthening their external validity.

REFERENCES