Courage with Clarity: Emotional Intelligence as a Mediator between Moral Courage and E-Cigarette Dependence among Nursing Students

Courage with Clarity: Emotional Intelligence as a Mediator between Moral Courage and E-Cigarette Dependence among Nursing Students | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Courage with Clarity: Emotional Intelligence as a Mediator between Moral Courage and E-Cigarette Dependence among Nursing Students Amal Hashem Mohamed, Mohammed Ibrahim Touni, Ingrid Jacinto Caspillo, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8946464/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The rising use of electronic cigarettes (e-cigarettes) among university students, including those in health professions, poses significant public health risks. Moral courage enables individuals to act according to professional values despite social pressures, while emotional intelligence (EI) supports emotion regulation and informed decision-making. Objective This study aimed to examine the mediating role of emotional intelligence in the relationship between moral courage and e-cigarette dependence among nursing students. Methods A descriptive cross-sectional correlational design was employed. A proportionate stratified random sample of 480 undergraduate nursing students completed an online survey. Instruments included the Brief Emotional Intelligence Scale (BEIS-10), the Nurses’ Moral Courage Scale (NMCS-21), and the E-Cigarette Dependence Scale (EDS-4). Data were analyzed using Pearson correlations, multiple regression, and mediation analysis. Results Participants reported moderate e-cigarette dependence, moderate emotional intelligence, and high moral courage. Moral courage was negatively associated with e-cigarette dependence (r = -0.238, p < 0.001) and positively associated with emotional intelligence (r = 0.193, p < 0.001). Emotional intelligence was also negatively correlated with e-cigarette dependence (r = -0.159, p < 0.001). Multiple regression analysis indicated that both moral courage (β = -0.212, p < 0.001) and emotional intelligence (β = -0.134, p = 0.004) independently predicted lower e-cigarette dependence. Mediation analysis revealed that emotional intelligence partially mediated the relationship between moral courage and e-cigarette dependence (Sobel z = -2.66, p = 0.005). Conclusion Moral courage and emotional intelligence are protective factors against e-cigarette dependence among nursing students. Emotional intelligence partially mediates the relationship between moral courage and e-cigarette dependence, highlighting its role in translating ethical values into health-protective behaviors. Integrating moral courage and emotional intelligence training into nursing curricula may enhance students’ ethical resilience and promote healthier lifestyle choices. Clinical Trial Registration Not applicable. This study is not a clinical trial. Emotional Intelligence Moral Courage Mediation E-Cigarette Dependence Nursing Students Figures Figure 1 Introduction Ensuring health lives and promotes well‑being for population is one of most important sustainable development goals to reduce burden of non‑communicable diseases and strengthening the implementation of the essential strategies on tobacco control. Use of electronic cigarettes (e‑cigarettes, ‘vapes’) has increased worldwide among university populations and carries risks including nicotine addiction and respiratory and cardiovascular harms. Nursing students are expected to model health‑promoting behaviors; therefore, understanding psychological determinants of resistance to vaping is of both personal and professional importance ( 1 – 3 ). Moral courage is a critical ethical attribute in nursing, defined as the capacity to act in accordance with ethical principles despite internal or external pressures ( 4 ). Within academic and clinical environments, nursing students frequently encounter social influences, peer norms, and stressors that may challenge their ethical decision-making, including decisions related to substance use ( 5 ). Emotional intelligence (EI) encompasses the appraisal, regulation, and effective use of emotions. Higher EI has been associated with stress management, adaptive coping, ethical sensitivity, and healthier lifestyle choices in student populations. Conceptually, EI may serve as a self‑regulatory mechanism that helps convert moral intent into consistent behavior ( 6 – 9 ). Based on this rationale, the study tested whether EI mediates the association between moral courage and e‑cigarette dependence among nursing students. The study hypothesized that: (H1) moral courage would be inversely associated with e cigarette dependence; (H2) EI would be inversely associated with e cigarette dependence; (H3) moral courage would be positively associated with EI; and (H4) EI would partially mediate the relationship between moral courage and e cigarette dependence. Methods Design This study employed a descriptive cross‑sectional design and adhered to the STROBE reporting guideline for observational studies. The study was conducted via an online questionnaire hosted on a secure platform. Participants and Sampling A proportionate stratified random sampling technique was employed to ensure adequate representation across academic levels and gender. The total population of enrolled undergraduate nursing students during the 2025 academic year (N = 900) was obtained from official university registration records. Students were stratified according to: Academic level (1st, 2nd, 3rd, and 4th year) Gender (male and female) The required sample size was calculated using G*Power 3.1 for multiple linear regression analysis (two predictors, small effect size f² = 0.02, α = 0.05, power = 0.95). The minimum required sample was 395 participants. To account for potential non-response and incomplete surveys, the target sample was increased to 480 students. The number of participants selected from each stratum was determined proportionally according to its representation in the total population. A computer-generated random number list was used to randomly select students from each stratum. Selected students were contacted via their official institutional email addresses and student portal accounts. Inclusion Criteria Enrolled undergraduate nursing students (1st–4th year) Aged 17 years or older Provided informed consent Exclusion Criteria Internship-year students Incomplete questionnaire responses (> 10% missing data) A total of 530 students were invited to participate. Of these, 480 completed the survey, yielding a response rate of 90.6%. All participants completed the E-Cigarette Dependence Scale (EDS-4). Students who reported no lifetime e-cigarette use were assigned a score of zero in accordance with the instrument scoring procedure. Data collection was conducted online via a secure survey platform. To prevent duplicate responses, each participant was permitted to submit the questionnaire only once using a unique institutional login. Data collection tools A structured questionnaire consisted of three tools were used. The first instrument gathered information about demographic characteristics of the studied students and consisted of age, gender, current program level and the Brief Emotional Intelligence Scale (BEIS-10) that consisted of 10-item self-report measure designed to assess emotional intelligence. The BEIS-10 was developed by Davies et al. (2010) as a shortened version of the 33-item Emotional Intelligence Scale ( 9 , 10 ). It is based on Salovey and Mayer’s (1990) theoretical framework which posits that emotionally intelligent individuals can accurately perceive emotions (both in themselves and others) ( 11 ), it has five subscale which include; appraisal of own emotions; assessing an individual’s ability to recognize and identify their own emotional states, appraisal of others’ emotions; measuring the capacity to interpret and understand emotions in others through verbal and nonverbal cues and regulation of own emotions; evaluating an individual’s perceived ability to control and manage their emotional responses, regulation of others’ emotions; assessing perceived ability to influence and manage the emotional states of others, utilization of emotions; measuring how effectively individuals can use emotional states to facilitate problem-solving and creativity. BEIS-10 scores range from 10 to 50 with higher scores indicating greater self-perceived emotional intelligence capabilities. Internal consistency reliability for the BEIS-10 has been demonstrated across multiple studies, with Cronbach’s alpha coefficients ranging from .74 to .91 for the total scale ( 10 , 12 ). At the subscale level, reliability coefficients are .60 – .84 for Appraisal of Own Emotions, .67 – .89 for Appraisal of Others’ Emotions, .48 – .84 for Regulation of Own Emotions, .57 – .88 for Regulation of Others’ Emotions, and .67 – .86 for Utilization of Emotions. The second instrument is nurses' moral courage scale (NMCS) ( 4 ). 21-item NMCS was utilized to assess nurses’ moral courage. This scale has four moral courage dimensions: compassion and true presence (5 items), moral responsibility (4 items), moral integrity (7 items), and commitment to providing good care (5 items). A 5-point Likert scale was used to rate each item (1 = does not in any way describe me to 5 = excellently characterizes me). The possible score range was 21–105. A higher score denotes stronger self-assessed moral courage. The scale’s overall Cronbach’s alpha was 0.93 ( 13 ). In this study, the alpha score was 0.94. The third instrument is E-cigarette Dependence Scale (EDS); It is a brief, validated tool designed to assess dependence on nicotine-containing e-cigarettes. It evaluates behavioral and psychological indicators of e-cigarette addiction, helping to identify students who may benefit from intervention or cessation support. It is intended for students who use e-cigarettes and can help healthcare providers understand the extent of dependence to provide appropriate interventions. It consisted of 4-item of the EDS asks about cravings, use frequency, and feelings of control over vaping behavior, on five Likert scale from 0–4, never -always. Cronbach’s α = 0.84 Data Collection Procedure Participants were invited via email and student portals. The online questionnaire was administered through a secure survey platform, ensuring anonymity and confidentiality. Before participation, students provided digital informed consent. Data was collected from September 10, to the end November, 2025. Ethical Considerations Ethical approval was obtained from the Scientific Research Ethics Committee, Faculty of Nursing, Damanhour University, Egypt (Approval No. 11-m; September 10, 2025). Informed consent was obtained electronically from all participants prior to enrollment. The study was conducted in accordance with the Declaration of Helsinki. Data Analysis The data analysis was conducted using IBM SPSS Statistics 27, employing a comprehensive analytical approach to examine the hypothesized relationships. Descriptive statistics were first computed to assess the distributional properties and reliability of all study measures. Internal consistency was evaluated using Cronbach's alpha coefficients for each scale and subscale. Bivariate relationships among variables were examined using Pearson correlation Results Table 1. Demographic characteristics of Study Participants (n= 480) variable N % Age -17-20 -21-23 - ≥24 196 212 72 40.8 44.2 15.0 Gender Male - Female 276 204 57.5 42.5 -Current Program Level -1 st -2 nd -3 rd -4 th 144 120 120 96 30.0 25.0 25.0 20.0 Table 1. participants were proportionally distributed across academic levels, with 30.0% in first year, 25.0% in second year, 25.0% in third year, and 20.0% in fourth year. Slightly more than half of participants were male (57.5%). The majority of students (44.2%) were aged 21–23 years. Table 2: Descriptive statistics of E-cigarette dependence, emotional intelligence and moral courage among study participants (n = 480). variable Mean SD Skewness Kurtosis E-cigarette 6.4500 4.46438 .578 -.359 Emotional intelligence - Appraisal of own emotions - Appraisal of others’ emotions - Regulation of own emotions - Regulation of others’ emotions - Utilization of emotions 33.0583 6.9125 7.2583 6.9854 6.9542 4.9479 7.62760 1.90939 2.35208 2.32213 2.31226 1.89257 -.592 -.230 -.621 -.527 -.404 .036 .297 -.630 -.383 -.412 -.555 -.235 Moral courage - Compassion and true presence - Moral responsibility - Moral integrity - Commitment to good care 68.4719 17.2896 12.1833 22.3042 16.6342 20.11481 6.50433 4.73909 7.99473 4.23168 -.577 -.662 -.264 -.508 -.276 .733 -.111 .113 .387 -.290 M= mean, Sd standard deviation, Skewness and Kurtosis are distribution of variables. Table 2 shows that, E‑cigarette dependence showed a moderate mean level (M = 6.45, SD = 4.46) with positive skewness. The emotional intelligence shows moderate overall levels (M = 33.06, SD = 7.63). Moral courage exhibited comparatively higher mean scores (M = 68.47, SD = 20.11). Table 3: Pearson Correlations analysis of Correlations among study scales(n=480). Scale - 1 2 3 E-smoking 1 - Emotional intelligence -.159** 1 - Moral Courage -.238** .193** 1 **p <0.01 Table 3 shows that E cigarette dependence was negatively correlated with emotional intelligence and moral courage (r=-0.159, p<0.001; r=-0.238, p<0.001, respectively). Additionally, there was a favorable correlation found between moral courage and emotional intelligence (r=0. 193, p<0.001). These reflecting that higher moral courage or EI → lower e-cigarette dependence. Table 4. Multiple Regression Analysis Results on Predicting E-cigarette Dependence among nursing students (n = 480) B B Std. Error Beta t P 95.0% Confidence Interval for B Lower Bound Upper Bound Constant 11.57 0.96 12.05 <0.001 9.69 13.54 Emotional intelligence -0.079 0.027 -.134 -2.93 .004 .-0.132 -0.026 Moral courage -.057 0.012 -.212 -4.63 .000 -0.081 -.033 Model fit; F (2, 477); R² = 0.074; Adj. R² = 0.070; p<0.001. Table 4 reveales that emotional intelligence (B = -0.079, β = -0.134, p = 0.004) and moral courage (B = -0.057, β = -0.212, p < 0.001) significantly predicted lower E-cigarette dependence, indicating that higher levels of them are associated with decrease E cigarette dependence. Table 5: The Mediating Role of Emotional Intelligence between Morl Courage and E-cigarette Dependence among nursing Students (n=480). Structural Path B SE β t p 95% CI for B (LB–UB) R² Step 1 Moral courage → E‑cigarette dependence –0.53 0.10 –0.238 –5.256 <0.001 –0.73 to –0.33 0.075 Step 2 Moral courage → Emotional intelligence 0.73 0.17 0.193 4.228 <0.001 0.41 to 1.08 0.075 Emotional intelligence → E‑cigarette dependence –0.19 0.056 -0.159 –3.522 <0.001 –0.25 to –0.010 Step 3 (Direct effects) Moral courage → Emotional intelligence → E‑cigarette dependence –0.47 0.10 –0.212 –4.633 <0.001 –0.67 to –0.27 0.074 Indirect Effect (Sobel Test) – – – z = -2.66 p = 0.005 – Table 5 shows that moral courage significantly predicted lower e-cigarette dependence both directly (B = -0.47, β = -0.212, p < 0.001) and indirectly through emotional intelligence (B = -0.19, β = -0.159, p < 0.001). Additionally, moral courage positively predicted emotional intelligence (B = 0.73, β = 0.193, p < 0.001), indicating that students with higher moral courage tend to have higher emotional intelligence, which in turn is associated with lower e-cigarette dependence. These findings highlight both the direct and mediated protective effects of moral courage against e-cigarette dependence. The Sobel test confirmed the mediation effect (z = -2.66, p = 0.005). Discussion Use of electronic cigarettes (e‑cigarettes, ‘vapes’) has increased worldwide among university populations and carries risks including nicotine addiction and respiratory and cardiovascular harms. Nursing students are expected to model health‑promoting behaviors; therefore, understanding psychological determinants of resistance to vaping is of both personal and professional importance ( 14 , 15 ). The current study was to examine the mediating role of emotional intelligence in the relationship between moral courage and e- cigarette dependence among nursing students. The results showed that higher moral courage was associated with lower e-cigarette dependence, this come in accordance with Huang M et al., (2025) who reported that that moral courage is an important ethical attribute among nursing students and is related to professional values ( 16 ). These results indicated that students with elevated moral courage may resist behaviors that conflict with their ethical or professional values, including risky health behaviors such as e-cigarette use.. The present study shows a significant indirect association mediated by emotional intelligence. Students with higher moral courage tended to report higher emotional intelligence, which was associated with lower e-cigarette dependence. These results agree with Mehralian G et al., (2024) who reported that emotional and moral competencies are contribute to better professional adjustment among nurses ( 17 ). Abdollahi A et al., (2015) reported that emotional intelligence partially mediates smoking-related attitudes among youth ( 18 ). The model accounted for 7.4% of the variance in e-cigarette dependence, a proportion consistent with the multifactorial nature of nicotine-use behaviours. Similar has been documented by Simpson KA et al., (2021), which illustrate how e-cigarette dependence emerges from a multidimensional interaction of psychological, social, and behavioural factors rather than a single predictor ( 19 ). The present study showed positive associations between emotional intelligence and moral courage as well as negative associations between both variables and e-cigaratte dependence. These findings come in same line with Mehralian G et al., (2024) who reported that emotional and moral competencies are interrelated and enhance nurses’ ability to respond adaptively in ethically or emotionally demanding situations ( 17 ). Regarding the predictive role of moral courage and emotional intelligence the present study revealed that emotional intelligence and moral courage each independently predicted lower e-cigaratte dependence. This finding is consistent with Mehralian G et al., (2024) who reported that emotional intelligence predicts favourable professional outcomes and reduces vulnerability to stress-related maladaptive behaviours ( 17 ). Also this results confirmed by Gebresilase, B. M et al., (2025); Pangestu et al., (2021) who reported that emotional intelligence may serve as a protective factor by supporting healthier coping and reducing susceptibility to peer influence ( 20 , 21 ). Concerning the mediating role of emotional intelligence, the present study showed that emotional intelligence mediated the association between moral courage and e-cigaratte dependence. This come in agree with Ma H et al., (2025) who mentioned that emotional and moral competencies affect the nursing students’ performance and professional attitudes in clinical environments ( 22 ). Conclusion and recommendation: This study showed that moral courage and emotional intelligence are associated with lower e-cigarette dependence among nursing students. Emotional intelligence partially mediated the relationship between moral courage and e-smoking, suggesting that emotional skills help translate ethical values into health-protective behaviors. These findings highlight the importance of integrating moral courage and emotional intelligence development into undergraduate curricula through ethics education. Faculty development programs are recommended to equip educators with strategies to foster these competencies. Future studies should employ longitudinal and intervention-based designs to evaluate the effectiveness of educational programs aimed at reducing e-cigarette use and strengthening ethical resilience among nursing students. Limitation: This study has several limitations. First, Data were collected using self-report measures, which may be influenced by recall and social desirability bias. Second: Although a stratified random sampling technique was used, the study was conducted within a limited number of nursing colleges, which may restrict generalizability. Declarations Ethics approval and consent to participate Ethical approval was obtained from the Scientific Research Ethics Committee, Faculty of Nursing, Damanhour University, Egypt (Approval No. 11-m; September 10, 2025) . Informed consent was obtained electronically from all participants prior to enrollment. The study was conducted in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this work. Author Contribution AHM and MIT conceptualized and designed the study. MGNM conducted data curation and statistical analysis. IJC and EEEE contributed to methodological validation and clinical review. AH drafted the manuscript. MFHM supervised data collection and critically revised the manuscript. All authors reviewed, approved the final version, and agreed to be accountable for the work. Acknowledgement The authors would like to thank all the participants in the study for their time, cooperation, and valuable contributions. Data Availability The datasets generated and analyzed during the current study are available from the corresponding author, ِAssistant Professor Amal Hashem Mohamed , upon reasonable request. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8946464","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":601821968,"identity":"966994af-4dd0-4fc3-826d-916a729ac74f","order_by":0,"name":"Amal Hashem Mohamed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYHACxsNgir0BwmsgRg9EC88BkrVIJBCphX/a4QeHC2rq5HRnvj344AeDjeyGA+wPP+DTInE7zeDwjGOHjc1u5yUb9jCkGW84wGMsgdea2wkGh3nYDiRuu51jJg10ZCJQCwNeLfK30z8c5vlXV7/t5hnz3wwM/4Fa2B//wKfF4HaOwWHeNuYEsxs8ZswMDAeAWhjM8NpieDun4DBv32HDbWdyjCV7DJKNZx7mMbPAp0XudvrGxzzf6uTNjp8x/PCjwk6273j74xv4tKC7E4iZSVA/CkbBKBgFowA7AADpLk+5zn+FnwAAAABJRU5ErkJggg==","orcid":"","institution":"Minia University","correspondingAuthor":true,"prefix":"","firstName":"Amal","middleName":"Hashem","lastName":"Mohamed","suffix":""},{"id":601821969,"identity":"97140f8f-9cfe-495b-9ddc-8d13821d7c68","order_by":1,"name":"Mohammed Ibrahim Touni","email":"","orcid":"","institution":"Jouf University","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"Ibrahim","lastName":"Touni","suffix":""},{"id":601821970,"identity":"6e0c349d-c24d-4bed-94be-7037e8111dbf","order_by":2,"name":"Ingrid Jacinto Caspillo","email":"","orcid":"","institution":"Northern Border University","correspondingAuthor":false,"prefix":"","firstName":"Ingrid","middleName":"Jacinto","lastName":"Caspillo","suffix":""},{"id":601821971,"identity":"4a48808e-0569-429f-a418-a2da22f535ab","order_by":3,"name":"Mohamed Gamal Noaman Malek","email":"","orcid":"","institution":"Minia University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Gamal Noaman","lastName":"Malek","suffix":""},{"id":601821972,"identity":"d207e8b8-3e04-4efa-a940-50c9bb1c15a5","order_by":4,"name":"Essam Eltantawy Elsayed Eltantawy","email":"","orcid":"","institution":"Hafr Al-Batin University","correspondingAuthor":false,"prefix":"","firstName":"Essam","middleName":"Eltantawy Elsayed","lastName":"Eltantawy","suffix":""},{"id":601821973,"identity":"7fc23d22-2be8-4a5b-aec3-f0cd7c149518","order_by":5,"name":"Abdelaziz Hendy","email":"","orcid":"","institution":"Qassim University","correspondingAuthor":false,"prefix":"","firstName":"Abdelaziz","middleName":"","lastName":"Hendy","suffix":""},{"id":601821974,"identity":"46eff627-7e26-425b-9909-1724ac175c4c","order_by":6,"name":"Marwa Fouad Hanafy Mahmoud","email":"","orcid":"","institution":"Damanhour University","correspondingAuthor":false,"prefix":"","firstName":"Marwa","middleName":"Fouad Hanafy","lastName":"Mahmoud","suffix":""}],"badges":[],"createdAt":"2026-02-23 11:23:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8946464/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8946464/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104311465,"identity":"83d137a7-c5ce-4057-a13e-3e78800dd412","added_by":"auto","created_at":"2026-03-10 10:59:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":101676,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8946464/v1/2669e794d7bde7e4ac97ee30.png"},{"id":106285727,"identity":"4be108a1-0af4-4706-8208-a7493bba3cb5","added_by":"auto","created_at":"2026-04-07 06:58:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1232237,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8946464/v1/2f650e20-e740-4a52-a421-57847fcea747.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Courage with Clarity: Emotional Intelligence as a Mediator between Moral Courage and E-Cigarette Dependence among Nursing Students","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEnsuring health lives and promotes well‑being for population is one of most important sustainable development goals to reduce burden of non‑communicable diseases and strengthening the implementation of the essential strategies on tobacco control. Use of electronic cigarettes (e‑cigarettes, \u0026lsquo;vapes\u0026rsquo;) has increased worldwide among university populations and carries risks including nicotine addiction and respiratory and cardiovascular harms. Nursing students are expected to model health‑promoting behaviors; therefore, understanding psychological determinants of resistance to vaping is of both personal and professional importance (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoral courage is a critical ethical attribute in nursing, defined as the capacity to act in accordance with ethical principles despite internal or external pressures (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Within academic and clinical environments, nursing students frequently encounter social influences, peer norms, and stressors that may challenge their ethical decision-making, including decisions related to substance use (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Emotional intelligence (EI) encompasses the appraisal, regulation, and effective use of emotions. Higher EI has been associated with stress management, adaptive coping, ethical sensitivity, and healthier lifestyle choices in student populations. Conceptually, EI may serve as a self‑regulatory mechanism that helps convert moral intent into consistent behavior (\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Based on this rationale, the study tested whether EI mediates the association between moral courage and e‑cigarette dependence among nursing students. The study hypothesized that: (H1) moral courage would be inversely associated with e cigarette dependence; (H2) EI would be inversely associated with e cigarette dependence; (H3) moral courage would be positively associated with EI; and (H4) EI would partially mediate the relationship between moral courage and e cigarette dependence.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003e This study employed a descriptive cross‑sectional design and adhered to the STROBE reporting guideline for observational studies. The study was conducted via an online questionnaire hosted on a secure platform.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and Sampling\u003c/h3\u003e\n\u003cp\u003eA proportionate stratified random sampling technique was employed to ensure adequate representation across academic levels and gender. The total population of enrolled undergraduate nursing students during the 2025 academic year (N\u0026thinsp;=\u0026thinsp;900) was obtained from official university registration records. Students were stratified according to:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAcademic level (1st, 2nd, 3rd, and 4th year)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGender (male and female)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe required sample size was calculated using G*Power 3.1 for multiple linear regression analysis (two predictors, small effect size f\u0026sup2; = 0.02, α\u0026thinsp;=\u0026thinsp;0.05, power\u0026thinsp;=\u0026thinsp;0.95). The minimum required sample was 395 participants. To account for potential non-response and incomplete surveys, the target sample was increased to 480 students.\u003c/p\u003e \u003cp\u003eThe number of participants selected from each stratum was determined proportionally according to its representation in the total population. A computer-generated random number list was used to randomly select students from each stratum. Selected students were contacted via their official institutional email addresses and student portal accounts.\u003c/p\u003e\n\u003ch3\u003eInclusion Criteria\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eEnrolled undergraduate nursing students (1st\u0026ndash;4th year)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAged 17 years or older\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eProvided informed consent\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eExclusion Criteria\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eInternship-year students\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIncomplete questionnaire responses (\u0026gt;\u0026thinsp;10% missing data)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eA total of 530 students were invited to participate. Of these, 480 completed the survey, yielding a response rate of 90.6%.\u003c/p\u003e \u003cp\u003eAll participants completed the E-Cigarette Dependence Scale (EDS-4). Students who reported no lifetime e-cigarette use were assigned a score of zero in accordance with the instrument scoring procedure. Data collection was conducted online via a secure survey platform. To prevent duplicate responses, each participant was permitted to submit the questionnaire only once using a unique institutional login.\u003c/p\u003e\n\u003ch3\u003eData collection tools\u003c/h3\u003e\n\u003cp\u003eA structured questionnaire consisted of three tools were used. The first instrument gathered information about demographic characteristics of the studied students and consisted of age, gender, current program level and the Brief Emotional Intelligence Scale (BEIS-10) that consisted of 10-item self-report measure designed to assess emotional intelligence. The BEIS-10 was developed by Davies et al. (2010) as a shortened version of the 33-item Emotional Intelligence Scale (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). It is based on Salovey and Mayer\u0026rsquo;s (1990) theoretical framework which posits that emotionally intelligent individuals can accurately perceive emotions (both in themselves and others) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), it has five subscale which include; appraisal of own emotions; assessing an individual\u0026rsquo;s ability to recognize and identify their own emotional states, appraisal of others\u0026rsquo; emotions; measuring the capacity to interpret and understand emotions in others through verbal and nonverbal cues and regulation of own emotions; evaluating an individual\u0026rsquo;s perceived ability to control and manage their emotional responses, regulation of others\u0026rsquo; emotions; assessing perceived ability to influence and manage the emotional states of others, utilization of emotions; measuring how effectively individuals can use emotional states to facilitate problem-solving and creativity.\u003c/p\u003e \u003cp\u003eBEIS-10 scores range from 10 to 50 with higher scores indicating greater self-perceived emotional intelligence capabilities. Internal consistency reliability for the BEIS-10 has been demonstrated across multiple studies, with Cronbach\u0026rsquo;s alpha coefficients ranging from .74 to .91 for the total scale (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). At the subscale level, reliability coefficients are .60 \u0026ndash; .84 for Appraisal of Own Emotions, .67 \u0026ndash; .89 for Appraisal of Others\u0026rsquo; Emotions, .48 \u0026ndash; .84 for Regulation of Own Emotions, .57 \u0026ndash; .88 for Regulation of Others\u0026rsquo; Emotions, and .67 \u0026ndash; .86 for Utilization of Emotions.\u003c/p\u003e \u003cp\u003eThe second instrument is nurses' moral courage scale (NMCS) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). 21-item NMCS was utilized to assess nurses\u0026rsquo; moral courage. This scale has four moral courage dimensions: compassion and true presence (5 items), moral responsibility (4 items), moral integrity (7 items), and commitment to providing good care (5 items). A 5-point Likert scale was used to rate each item (1\u0026thinsp;=\u0026thinsp;does not in any way describe me to 5\u0026thinsp;=\u0026thinsp;excellently characterizes me). The possible score range was 21\u0026ndash;105. A higher score denotes stronger self-assessed moral courage. The scale\u0026rsquo;s overall Cronbach\u0026rsquo;s alpha was 0.93 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In this study, the alpha score was 0.94. The third instrument is E-cigarette Dependence Scale (EDS); It is a brief, validated tool designed to assess dependence on nicotine-containing e-cigarettes. It evaluates behavioral and psychological indicators of e-cigarette addiction, helping to identify students who may benefit from intervention or cessation support. It is intended for students who use e-cigarettes and can help healthcare providers understand the extent of dependence to provide appropriate interventions. It consisted of 4-item of the EDS asks about cravings, use frequency, and feelings of control over vaping behavior, on five Likert scale from 0\u0026ndash;4, never -always. Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.84\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Procedure\u003c/h2\u003e \u003cp\u003eParticipants were invited via email and student portals. The online questionnaire was administered through a secure survey platform, ensuring anonymity and confidentiality. Before participation, students provided digital informed consent. Data was collected from September 10, to the end November, 2025.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e was obtained from the Scientific Research Ethics Committee, Faculty of Nursing, Damanhour University, Egypt (Approval No. 11-m; September 10, 2025). Informed consent was obtained electronically from all participants prior to enrollment. The study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe data analysis was conducted using IBM SPSS Statistics 27, employing a comprehensive analytical approach to examine the hypothesized relationships. Descriptive statistics were first computed to assess the distributional properties and reliability of all study measures. Internal consistency was evaluated using Cronbach's alpha coefficients for each scale and subscale. Bivariate relationships among variables were examined using Pearson correlation\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable 1. Demographic characteristics of Study Participants (n= 480)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003evariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e-17-20\u003c/p\u003e\n \u003cp\u003e-21-23\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u0026ge;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e196\u003c/p\u003e\n \u003cp\u003e212\u003c/p\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40.8\u003c/p\u003e\n \u003cp\u003e44.2\u003c/p\u003e\n \u003cp\u003e15.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e276\u003c/p\u003e\n \u003cp\u003e204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e57.5\u003c/p\u003e\n \u003cp\u003e42.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 444px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-Current Program Level\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e-1\u003csup\u003est\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e-2\u003csup\u003end\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e-3 rd\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e-4\u003csup\u003eth\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e144\u003c/p\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1. participants were proportionally distributed across academic levels, with 30.0% in first year, 25.0% in second year, 25.0% in third year, and 20.0% in fourth year. Slightly more than half of participants were male (57.5%). The majority of students (44.2%) were aged 21\u0026ndash;23 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Descriptive statistics of E-cigarette dependence, emotional intelligence and moral courage among study participants\u003c/strong\u003e (n = 480).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003e\u003cstrong\u003evariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSkewness\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKurtosis\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eE-cigarette\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e6.4500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e4.46438\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e.578\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e-.359\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmotional intelligence\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- Appraisal of own emotions\u003c/p\u003e\n \u003cp\u003e- Appraisal of others\u0026rsquo; emotions\u003c/p\u003e\n \u003cp\u003e- Regulation of own emotions\u003c/p\u003e\n \u003cp\u003e- Regulation of others\u0026rsquo; emotions\u003c/p\u003e\n \u003cp\u003e- Utilization of emotions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e33.0583\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6.9125\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.2583\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6.9854\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6.9542\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.9479\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e7.62760\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.90939\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.35208\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.32213\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.31226\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.89257\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e-.592\u003c/p\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e-.230\u003c/p\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e-.621\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-.527\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-.404\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.036\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e.297\u003c/p\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e-.630\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-.383\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-.412\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-.555\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-.235\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMoral courage\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- Compassion and true presence\u003c/p\u003e\n \u003cp\u003e- Moral responsibility\u003c/p\u003e\n \u003cp\u003e- Moral integrity\u003c/p\u003e\n \u003cp\u003e- Commitment to good care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e68.4719\u003c/p\u003e\n \u003cp\u003e17.2896\u003c/p\u003e\n \u003cp\u003e12.1833\u003c/p\u003e\n \u003cp\u003e22.3042\u003c/p\u003e\n \u003cp\u003e16.6342\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e20.11481\u003c/p\u003e\n \u003cp\u003e6.50433\u003c/p\u003e\n \u003cp\u003e4.73909\u003c/p\u003e\n \u003cp\u003e7.99473\u003c/p\u003e\n \u003cp\u003e4.23168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e-.577\u003c/p\u003e\n \u003cp\u003e-.662\u003c/p\u003e\n \u003cp\u003e-.264\u003c/p\u003e\n \u003cp\u003e-.508\u003c/p\u003e\n \u003cp\u003e-.276\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e.733\u003c/p\u003e\n \u003cp\u003e-.111\u003c/p\u003e\n \u003cp\u003e.113\u003c/p\u003e\n \u003cp\u003e.387\u003c/p\u003e\n \u003cp\u003e-.290\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eM= mean, Sd standard deviation,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSkewness and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eKurtosis are distribution of variables.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 shows that, E‑cigarette dependence showed a moderate mean level (M = 6.45, SD = 4.46) with positive skewness. The emotional intelligence shows moderate overall levels (M = 33.06, SD = 7.63). Moral courage exhibited comparatively higher mean scores (M = 68.47, SD = 20.11).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Pearson Correlations analysis of Correlations among study scales(n=480).\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"366\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScale\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eE-smoking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e- Emotional intelligence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e-.159**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003e- Moral Courage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e-.238**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e.193**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; **p \u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 shows that E cigarette dependence was negatively correlated with emotional intelligence and moral courage (r=-0.159, p\u0026lt;0.001; r=-0.238, p\u0026lt;0.001, respectively). Additionally, there was a favorable correlation found between moral courage and emotional intelligence (r=0. 193, p\u0026lt;0.001). These reflecting that higher moral courage or EI \u0026rarr; lower e-cigarette dependence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Multiple Regression Analysis Results on Predicting E-cigarette Dependence among nursing students (n = 480)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB Std. Error\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBeta\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95.0% Confidence Interval for B\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003eLower Bound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003eUpper Bound\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e11.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e12.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e9.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e13.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eEmotional intelligence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e-.134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e-2.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e.-0.132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-0.026\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eMoral courage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e-.057\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e-.212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e-4.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 71px;\"\u003e\n \u003cp\u003e-0.081\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eModel fit; F (2, 477); R\u0026sup2; = 0.074; Adj. R\u0026sup2; = 0.070; p\u0026lt;0.001.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4 reveales that emotional\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eintelligence (B = -0.079, \u0026beta; = -0.134, p = 0.004) and moral\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ecourage (B = -0.057, \u0026beta; = -0.212, p \u0026lt; 0.001) significantly predicted lower E-cigarette dependence, indicating that higher levels of them are associated with decrease E cigarette dependence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: The Mediating Role of Emotional Intelligence between Morl Courage and E-cigarette Dependence among nursing Students (n=480).\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"726\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStructural Path\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI for B (LB\u0026ndash;UB)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eR\u0026sup2;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStep 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMoral courage \u0026rarr; E‑cigarette dependence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.238\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;5.256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.73 to \u0026ndash;0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.075\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStep 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMoral courage \u0026rarr; Emotional intelligence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.228\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.41 to 1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.075\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEmotional intelligence \u0026rarr; E‑cigarette dependence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0.159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;3.522\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.25 to \u0026ndash;0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStep 3 (Direct effects)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMoral courage \u0026rarr; Emotional intelligence \u0026rarr; E‑cigarette dependence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;4.633\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.67 to \u0026ndash;0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0.074\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eIndirect Effect (Sobel Test)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ez = -2.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep = 0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 5 shows that moral courage significantly predicted lower \u003cstrong\u003ee-cigarette dependence\u003c/strong\u003e both \u003cstrong\u003edirectly\u003c/strong\u003e (B = -0.47, \u0026beta; = -0.212, p \u0026lt; 0.001) and \u003cstrong\u003eindirectly\u003c/strong\u003e through emotional intelligence (B = -0.19, \u0026beta; = -0.159, p \u0026lt; 0.001). Additionally, moral courage positively predicted emotional intelligence (B = 0.73, \u0026beta; = 0.193, p \u0026lt; 0.001), indicating that students with higher moral courage tend to have higher emotional intelligence, which in turn is associated with lower e-cigarette dependence. These findings highlight both the \u003cstrong\u003edirect and mediated protective effects\u003c/strong\u003e of moral courage against e-cigarette dependence. The Sobel test confirmed the mediation effect (z = -2.66, p = 0.005).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eUse of electronic cigarettes (e‑cigarettes, \u0026lsquo;vapes\u0026rsquo;) has increased worldwide among university populations and carries risks including nicotine addiction and respiratory and cardiovascular harms. Nursing students are expected to model health‑promoting behaviors; therefore, understanding psychological determinants of resistance to vaping is of both personal and professional importance (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The current study was to examine the mediating role of emotional intelligence in the relationship between moral courage and e- cigarette dependence among nursing students.\u003c/p\u003e \u003cp\u003eThe results showed that higher moral courage was associated with lower e-cigarette dependence, this come in accordance with Huang M et al., (2025) who reported that that moral courage is an important ethical attribute among nursing students and is related to professional values (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). These results indicated that students with elevated moral courage may resist behaviors that conflict with their ethical or professional values, including risky health behaviors such as e-cigarette use..\u003c/p\u003e \u003cp\u003eThe present study shows a significant indirect association mediated by emotional intelligence. Students with higher moral courage tended to report higher emotional intelligence, which was associated with lower e-cigarette dependence. These results agree with Mehralian G et al., (2024) who reported that emotional and moral competencies are contribute to better professional adjustment among nurses (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Abdollahi \u003cb\u003eA\u003c/b\u003e et al., (2015) reported that emotional intelligence partially mediates smoking-related attitudes among youth (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe model accounted for 7.4% of the variance in e-cigarette dependence, a proportion consistent with the multifactorial nature of nicotine-use behaviours. Similar has been documented by Simpson KA et al., (2021), which illustrate how e-cigarette dependence emerges from a multidimensional interaction of psychological, social, and behavioural factors rather than a single predictor (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe present study showed positive associations between emotional intelligence and moral courage as well as negative associations between both variables and e-cigaratte dependence. These findings come in same line with Mehralian G et al., (2024) who reported that emotional and moral competencies are interrelated and enhance nurses\u0026rsquo; ability to respond adaptively in ethically or emotionally demanding situations (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding the predictive role of moral courage and emotional intelligence the present study revealed that emotional intelligence and moral courage each independently predicted lower e-cigaratte dependence. This finding is consistent with Mehralian G et al., (2024) who reported that emotional intelligence predicts favourable professional outcomes and reduces vulnerability to stress-related maladaptive behaviours (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Also this results confirmed by Gebresilase, B. M et al., (2025); Pangestu et al., (2021) who reported that emotional intelligence may serve as a protective factor by supporting healthier coping and reducing susceptibility to peer influence (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Concerning the mediating role of emotional intelligence, the present study showed that emotional intelligence mediated the association between moral courage and e-cigaratte dependence. This come in agree with Ma H et al., (2025) who mentioned that emotional and moral competencies affect the nursing students\u0026rsquo; performance and professional attitudes in clinical environments (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eConclusion and recommendation:\u003c/h2\u003e \u003cp\u003eThis study showed that moral courage and emotional intelligence are associated with lower e-cigarette dependence among nursing students. Emotional intelligence partially mediated the relationship between moral courage and e-smoking, suggesting that emotional skills help translate ethical values into health-protective behaviors. These findings highlight the importance of integrating moral courage and emotional intelligence development into undergraduate curricula through ethics education. Faculty development programs are recommended to equip educators with strategies to foster these competencies. Future studies should employ longitudinal and intervention-based designs to evaluate the effectiveness of educational programs aimed at reducing e-cigarette use and strengthening ethical resilience among nursing students.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitation:\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, Data were collected using self-report measures, which may be influenced by recall and social desirability bias. Second: Although a stratified random sampling technique was used, the study was conducted within a limited number of nursing colleges, which may restrict generalizability.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003eEthical approval was obtained from the \u003cb\u003eScientific Research Ethics Committee, Faculty of Nursing, Damanhour University, Egypt\u003c/b\u003e (Approval \u003cb\u003eNo. 11-m; September 10, 2025)\u003c/b\u003e. Informed consent was obtained electronically from all participants prior to enrollment. The study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAHM and MIT conceptualized and designed the study. MGNM conducted data curation and statistical analysis. IJC and EEEE contributed to methodological validation and clinical review. AH drafted the manuscript. MFHM supervised data collection and critically revised the manuscript. All authors reviewed, approved the final version, and agreed to be accountable for the work.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank all the participants in the study for their time, cooperation, and valuable contributions.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author, ِAssistant Professor Amal Hashem Mohamed , upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eThakur JS, Nangia R, Singh S. Progress and challenges in achieving noncommunicable diseases targets for the sustainable development goals. 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Emotional intelligence and perceptions of patient safety competence among nursing students in clinical practice: The moderating role of moral courage. J Psychol Afr. 2025;35(1):21\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/14330237.2024.2345678\u003c/span\u003e\u003cspan address=\"10.1080/14330237.2024.2345678\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Emotional Intelligence, Moral Courage, Mediation, E-Cigarette Dependence, Nursing Students","lastPublishedDoi":"10.21203/rs.3.rs-8946464/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8946464/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe rising use of electronic cigarettes (e-cigarettes) among university students, including those in health professions, poses significant public health risks. Moral courage enables individuals to act according to professional values despite social pressures, while emotional intelligence (EI) supports emotion regulation and informed decision-making.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aimed to examine the mediating role of emotional intelligence in the relationship between moral courage and e-cigarette dependence among nursing students.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA descriptive cross-sectional correlational design was employed. A proportionate stratified random sample of 480 undergraduate nursing students completed an online survey. Instruments included the Brief Emotional Intelligence Scale (BEIS-10), the Nurses\u0026rsquo; Moral Courage Scale (NMCS-21), and the E-Cigarette Dependence Scale (EDS-4). Data were analyzed using Pearson correlations, multiple regression, and mediation analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eParticipants reported moderate e-cigarette dependence, moderate emotional intelligence, and high moral courage. Moral courage was negatively associated with e-cigarette dependence (r = -0.238, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and positively associated with emotional intelligence (r\u0026thinsp;=\u0026thinsp;0.193, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Emotional intelligence was also negatively correlated with e-cigarette dependence (r = -0.159, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Multiple regression analysis indicated that both moral courage (β = -0.212, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and emotional intelligence (β = -0.134, p\u0026thinsp;=\u0026thinsp;0.004) independently predicted lower e-cigarette dependence. Mediation analysis revealed that emotional intelligence partially mediated the relationship between moral courage and e-cigarette dependence (Sobel z = -2.66, p\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMoral courage and emotional intelligence are protective factors against e-cigarette dependence among nursing students. Emotional intelligence partially mediates the relationship between moral courage and e-cigarette dependence, highlighting its role in translating ethical values into health-protective behaviors. Integrating moral courage and emotional intelligence training into nursing curricula may enhance students\u0026rsquo; ethical resilience and promote healthier lifestyle choices.\u003c/p\u003e\u003ch2\u003eClinical Trial Registration\u003c/h2\u003e \u003cp\u003eNot applicable. This study is not a clinical trial.\u003c/p\u003e","manuscriptTitle":"Courage with Clarity: Emotional Intelligence as a Mediator between Moral Courage and E-Cigarette Dependence among Nursing Students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-10 10:59:09","doi":"10.21203/rs.3.rs-8946464/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0c0d195a-64b0-4bee-9144-cb67c2437e32","owner":[],"postedDate":"March 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T06:57:29+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-10 10:59:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8946464","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8946464","identity":"rs-8946464","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}