Exploring the relationship between knowledge, attitudes, and ENDS use among youth in Pakistan: Implications for effective tobacco control strategies

Tobacco use remains a major public health issue, especially among youth, with the rising use of Electronic Nicotine Delivery Systems (ENDS) posing new challenges for tobacco control. This study explores the relationship between knowledge, attitudes, and ENDS use among youth in Pakistan, focusing on socio-demographic and behavioral factors influencing smoking behavior. An exploratory cross-sectional study was conducted using a Computer-Assisted Personal Interviewing (CAPI) survey across 13 major cities in Pakistan. Participants aged 15-24 years were selected through convenience sampling, yielding a final sample of 462 respondents. A structured, pilot-tested questionnaire (Cronbachs = 0.76) assessed demographics, ENDS knowledge, attitudes, and smoking behaviors. Data was analyzed using SPSS Version 26 with descriptive statistics, Chi-square tests, Spearmans correlation, and multivariate logistic regression. Among respondents, 83.5% were male, 30.7% aged 18-20 years, 59.7% resided in urban areas, and 71.2% were students. Significant knowledge gaps were found, with many youth incorrectly believing that ENDS are nicotine-free or less harmful than cigarettes. Parental monitoring and student status were protective factors. Urban residence (AOR = 1.44, p = 0.0125) and male gender (AOR = 5.22, p = 0.009) were significant predictors of ENDS use, while employment (AOR = 0.43, p = 0.0146) and physical activity (AOR = 0.66, p = 0.0004) were associated with less favorable attitudes toward ENDS. Knowledge alone does not deter ENDS use. Social influences and attitudes significantly shape behavior, highlighting the need for targeted interventions addressing peer influence, misinformation, and stronger regulatory measures.