Interlinked Relationship of Nicotine Dependence, Nicotine Content and Physical Activity in E-cigarette Use Among Malaysian University Students

INTRODUCTION E-cigarette (EC) use in Malaysia surged from 0.8% (2011) to 5.0% (2023), raising public health concerns among young adults. This study investigated the link between EC use, nicotine content and physical activity among Malaysian university students. METHODS A cross-sectional study involving six universities in Peninsular Malaysia using an online structured questionnaire. A total of 660 university student EC users were conveniently sampled to participate in this study. RESULTS Most EC users 75% daily, 68% nicotine, mostly < 20mg reported low-to-moderate dependence (69%) but also health symptoms (42% gastrointestinal, 26% respiratory). Primary use reasons were to reduce/stop conventional smoking (44%) and experimentation (27%). Significantly, physical activity was inversely associated with nicotine dependence (χ ²  = 73.482, p < 0.001), use frequency (χ ²  = 27.795, p < 0.001), and nicotine content (χ ²  = 100.383, p < 0.001). Specifically, highly dependent daily users were 68–84% less likely to be physically active, and active users were 71% less likely to use higher nicotine EC. Nonetheless, physically active EC users are minimally affected by barriers related to their personal, social, or physical environments − (χ ²  = 163.947, p < 0.001), (χ ²  = 98.425, p < 0.001), (χ ²  = 65.117, p < 0.001). The aOR analysis further emphasised that personal attributes such as having energy, motivation and self-esteem are key contributors to physical activity participation among EC users. DISCUSSION These findings suggest physical activity acts as a protective factor against a more intensive EC use and higher nicotine dependence among university students. The observed healthy symptoms highlight potential risks. The inverse relationship underscores a crucial behavioural link – greater physical activity correlates with reduced engagement in high-risk EC use patterns. This implies promoting physical activity could be a valuable strategy in mitigating EC related harms, offering a novel intervention avenue for public health initiatives targeting this population. CONCLUSIONS Higher nicotine dependence and daily EC use are linked to lower physical activity, while active users have lower dependence and fewer exercise barriers. Promoting physical activity alongside nicotine reduction strategies may support healthier lifestyles and EC cessation among university students through tailored, multi-level interventions.