This study analyzed a de-identified secondary dataset from the 2022 Global Youth Tobacco Survey (GYTS) in Saudi Arabia, provided by the Ministry of Health in collaboration with the World Health Organization (WHO). The GYTS is a nationally representative, school-based survey of intermediate school students that uses the standardized WHO/CDC GYTS protocol [18]. The survey was implemented jointly by the Ministry of Health and the Ministry of Education. All intermediate students were eligible and completed an anonymous, self-administered, scannable questionnaire covering tobacco use, secondhand smoke, cessation, access, marketing exposure, and related knowledge and perceptions. Using a two-stage cluster sampling design, with schools selected proportional to enrollment size, the survey achieved an overall response rate of about 92%, yielding a final sample of 5,610 students aged 13–15 years. Scientific and ethical approvals were obtained from King Abdullah International Medical Research Center (KAIMRC) and the Ministry of Health.

Our primary outcome was perceiving smoking as attractive among youth who have ever used e-cigarettes. First, we captured self-reported e-cigarette use, defined as a “yes” response to the question, “Have you ever used electronic cigarettes?” Among those reporting e-cigarette use, we then restricted the analysis to this subsample and categorized respondents into two groups based on whether they perceived smoking as attractive, using the item, “Do you think that young people who smoke are more attractive?” (yes/no). Finally, we examined a range of covariates associated with perceiving smoking as attractive, including demographics (age, gender, and grade level), pleasure-related factors (comfort and enjoyment), media and other exposures, tobacco marketing and branding, and exposure to anti-tobacco messages in the media. Further details on these variables are provided in Tables 1–3.

We summarized the distribution of the outcome variable (perceiving smoking as attractive vs. unattractive) and all candidate covariates using descriptive statistics. Covariates included demographic characteristics (age, gender, grade level), measures of pleasure (comfort, enjoyment), media and other exposure variables, tobacco marketing and branding, and exposure to anti-tobacco messages in the media. We first assessed crude associations between perceiving smoking as attractive and each covariate using chi-square tests for categorical variables. We then fitted a multivariate logistic regression model to identify contextual factors independently associated with perceiving smoking as attractive and to estimate adjusted odds ratios and predicted probabilities. Statistical significance was set at α = 0.05, and analyses were conducted using SPSS version 20 and cross-checked with STATA version 12.

Of the 5,455 students aged 13–15 years who participated in the 2022 GYTS, 14.3% (n = 779) reported ever using e-cigarettes. As shown in Figure 1, about one quarter of these e-cigarette users (26%, n = 202) perceived smoking as generally attractive.

Table 1 through Table 3 present the results of a Chi-Square Test regarding the association between the perception of smoking as attractive and various covariates, including demographics, comfort and enjoyment, media and other exposures, tobacco marketing and branding, and anti-tobacco messages in the media.

The association showed a clear gender gap in how youth e-cigarette users viewed smoking. Boys were almost twice as likely to see smoking as attractive (65.3%, n = 124) compared with girls (34.7%, n = 66), suggesting that, other factors being held constant, girls were much less inclined to view smoking positively than their male counterparts.

The results indicated a significant association between the perceived pleasure of smoking and its attractiveness. Among the youth who found smoking attractive, 75.3% (n = 58) held the belief that they would enjoy the experience. Conversely, among youth who viewed smoking unattractive, 75.3% (n = 195) did not believe they would enjoy the behavior. Thus, this result highlights a relationship in which expectation and perception mirror each other (Table 1).

Seeing smoking on TV showed a negative association with attractiveness. Only 35.3% (n = 67) of the youth who saw smoking on TV found it attractive, compared to 64.7% (n = 123) of the youth who viewed smoking as attractive and reported no such TV exposure. Nearly half (48.6%, n = 280) of those who saw smoking on TV viewed it as unattractive (Table 2).

Exposure to secondhand smoke in schools appeared to be associated with smoking perceptions. More than half (56.2%, n = 104) of those who saw people smoking in or around school buildings reported smoking as attractive, while over two-thirds (68.3%, n = 388) of those who did not see smoking at school said smoking was not attractive. Surprisingly, seeing people smoke in outdoor public places was associated with lower smoking appeal. Nearly a third (34.7%, n = 66) of the exposed youth viewed smoking as attractive, while 50.4% (n = 292) in this group found it unattractive. Yet 65.3% (n = 124) of youth who reported no outdoor exposure still believed smoking was attractive (Table 2).

Table 3 highlights how marketing, branding, and anti-smoking messages relate to how youth viewed smoking. The chi-square results pointed to a strong association between tobacco marketing/branding and finding smoking attractive. Young people who thought smoking was attractive were more likely to wear branded tobacco gear, more likely to own an item with a tobacco logo, and more likely to have been offered free tobacco. For example, 41.6% (n = 77) of those offered free tobacco found smoking attractive, compared with only 11% (n = 62) of those who were not. Similarly, 47% (n = 85) of those who owned a branded item saw smoking as attractive, while 85.1% (n = 457) of those without such items viewed smoking as unattractive. The pattern was strongest among youth wearing or owning branded products, where 60% (n = 33) of those who viewed smoking as attractive reported having such gear, versus 35.3% (n = 83) of those who considered smoking unattractive.

Table 3 illustrates a clear association between youth e-cigarette users’ perceptions of smoking and media messaging. Nearly two-thirds (62.6%, n = 114) of youth who viewed smoking as appealing reported having seen anti-tobacco messaging, indicating that these campaigns were reaching even youth who had favorable opinions on smoking. In contrast, perceptions among youth who considered smoking unattractive were more mixed, with just over half (54.1%, n = 302) reporting they had not seen recent anti-tobacco messages.

The multivariate analysis shown in Table 4 adjusted for such factors as gender, pleasure, media and other exposures, marketing and branding, and anti-tobacco messages. The results suggested that male e-cigarette users had 63% lower odds of perceiving smoking in general as attractive compared to females (OR = 0.37, CI: 0.20–0.69, p = 0.002). In addition, youth exposed to smoking in enclosed public places had 60% lower odds of seeing smoking as attractive compared to those who were not exposed (OR = 0.40, CI: 0.17–0.92, p = 0.031). Moreover, youth exposed to tobacco marketing at points of sale had 55% lower odds of perceiving smoking in general as attractive compared to those not exposed to such marketing (OR = 0.45, CI: 0.22–0.91, p = 0.026). Furthermore, youth with direct exposure to anti-tobacco cues and counter-branding had markedly lower odds of perceiving smoking as attractive. The results revealed that youth who reported owning or wearing items displaying a tobacco brand logo or company name had 67% lower odds of viewing smoking as attractive (OR = 0.33, CI: 0.12–0.92, p = 0.034). Similarly, youth who had seen or heard anti-smoking messages in the media had 69% lower odds of perceiving smoking as attractive (OR = 0.31, CI: 0.15–0.66, p = 0.002). On the other hand, the results revealed that young e-cigarette users who described smoking as comfortable were twice as likely to have a positive perception about smoking (OR = 2.38, CI: 1.00–5.63, p = 0.049). Similarly, young e-cigarette users who were offered a free tobacco product by a company representative had higher odds of perceiving smoking as attractive (OR = 7.88, CI: 2.01–30.91, p = 0.003). Finally, young e-cigarette users who owned an item displaying a tobacco product brand logo had higher odds of perceiving smoking as attractive (OR = 4.08, CI: 1.09–15.23, p = 0.037).

Together, these results showed that feeling comfortable with smoking and experiencing high exposure to tobacco marketing were associated with positive views on smoking. However, the multivariate analysis revealed that enjoyability and exposure to secondhand smoke in school buildings or at home were not associated with smoking perceptions.

Our study examined covariates of smoking perceptions among youth e-cigarette users, focusing on demographic, perceived enjoyment, media influence, marketing, and exposure to public places. Several limitations may affect the generalizability of these findings to other demographic groups and/or settings. First, youth may lack the cognitive maturity to accurately report their behaviors and perceptions, and self-reported data on sensitive behaviors are vulnerable to recall and social desirability bias, potentially leading to underreporting. Second, cultural and contextual factors specific to this setting may limit applicability to other countries and communities. Third, restricting the sample to intermediate-school students means the data may not capture the smoking patterns, perceptions, and experiences of youth in high schools, vocational programs, or out-of-school settings, further constraining external validity.

Other limitations are related to both the study design and the statistical modelling. The GYTS is a robust tool for monitoring youth tobacco use. However, while its cross-sectional design can identify association and generate hypotheses, it cannot provide causal understanding, let alone prove causality. This snapshot approach inherently restricts causal inference and limits the extent of which findings can inform the direction of effects, policy or intervention design. The statistical models may not fully adjust for all relevant confounders and unmeasured factors could influence both the perceived appeal of smoking and the characteristics of the youth included in the sample, potentially biasing the observed associations.

In conclusion, our findings suggest that among youth e-cigarette users, the attractiveness of smoking is shaped more by social comfort and direct promotional activities than by broader environmental or general media exposure. Although more male youth e-cigarette users rated smoking favorably, they had lower adjusted odds of viewing it as attractive than females, emphasizing the need for gender-responsive prevention strategies. Youth who perceived smoking as socially comfortable, those offered free tobacco products, or owned branded items were more likely to regard smoking as attractive, while exposure at school or home showed no independent association. Public health prevention efforts may therefore benefit from targeting comfort-based norms and industry promotional strategies. Future research should investigate these factors longitudinally and across settings to delineate causal pathways and inform tailored policy and communication approaches.