Knowledge, attitude and practice of cigarette smoking among university students in Muzaffarabad, Pakistan: a cross-sectional study

INTRODUCTION

Smoking is the leading cause of preventable deaths and is estimated to kill more than five million people each year worldwide. If current trends persist, smoking will kill more than eight million people worldwide each year by the year 2030, with 80% of these premature deaths in low and middle-income countries. By the end of this century, tobacco may kill a billion people or more unless urgent action is taken.¹

Smoking harms nearly every organ of the human body and diminishes the general health of the smokers. Smoking causes coronary heart diseases, blood vessel constriction, and the nicotine stimulates adrenal epinephrine secretion, which increases blood pressure and heart rate. In addition, smoking is a leading cause of respiratory diseases such as emphysema, bronchitis, pneumonia and chronic airway obstruction by damaging the airways and alveoli of the lungs. Tobacco users are at risk for several other types of cancers such as carcinoma of the upper respiratory tract, cervix, throat, larynx, mouth, pancreas, kidney, bladder and acute myeloid leukemia.²

Trends of smoking are now changing in developed and developing countries. Although smoking is static or declining in most of the developed countries such as Western Europe, UK, US, Canada, New Zealand and Australia due to intense public health measures, while it is increasing in the developing countries such as Asia, South America and Africa due to massive promotional activities of cigarette companies.³

There are about 1.1 thousand million people (47% of males and 12% of females) are currently smoking in the world of which nearly 80% of the world’s total smokers live in the developing regions.⁴ One such developing country, which has the highest prevalence of cigarette smoking in the South East Asian Region is Pakistan. It is estimated that about 32.4% of the males and 5.7% of the females are currently smoking in Pakistan.⁵ Among young adults especially university students in Pakistan, the prevalence of cigarette smoking is 15%.⁶

Information on cigarette smoking is essential to improve the focus of prevention and control measures and thereby succeed in the struggle against tobacco use. Since, there is scarcity of data regarding knowledge, attitude and practice of cigarette smoking in this particular region from Pakistan. Therefore, this study was conducted with the objective of determining the current status of the knowledge, attitude and practices of cigarette smoking among students at University of Azad Jammu and Kashmir in Muzaffarabad, Pakistan.

METHODS

Study design and duration

A university-based descriptive cross-sectional study was conducted among male students at University of Azad Jammu and Kashmir in Muzaffarabad, Pakistan from July to December, 2015.

Study setting and population

This study was conducted among students at University of Azad Jammu and Kashmir, Muzaffarabad that is the leading university of the state of Azad Jammu and Kashmir established more than 30 years ago in the capital Muzaffarabad. It is mainly consisted of three faculties: sciences and engineering, arts and design and health and medical sciences. A list of all the students was procured from the office of academic affairs at University of Azad Jammu and Kashmir, which served as a sampling frame for this study. There was total 3002 number of students in the academic year 2015.

Sampling procedure

By using a stratified sampling technique, a random sample of 542 students was selected from all the three faculties of University of Azad Jammu and Kashmir and appropriate representation from each faculty was ensured.

Data collection

The data were collected using a self-administrated, pretested validated questionnaire in English that was developed based on previous literature review. The questionnaire included information about socio-demographic characteristics, practice and patterns of cigarette smoking, knowledge regarding harmful effects of smoking and attitude towards smoking prevention and control measures.

Inclusion and exclusion criteria

Students who were present at the time of data collection were included and students who were not present at the time of data collection or those students who refused to participate were replaced by the next student in the sampling frame.

Ethical considerations

The study was approved by the ethical and research committee of the University of Azad Jammu and Kashmir. The students were informed about the aims and objectives of the study and both written and verbal consent was taken from the students before administering the questionnaire. Confidentiality of the information was assured.

Pilot study

A pilot study was conducted among 20 male students who met the eligibility criteria to find out the feasibility, easy readability and comprehensibility of the questionnaire a month prior to the data collection. The pilot study was conducted one month prior to the data collection.

Data analysis

The data was entered, cleaned and analysed by using Statistical Programme of Social Sciences (SPSS) version 21. Chi-Square test was used to evaluate the difference regarding knowledge about harmful effects of smoking at the significance level of p=0.05.

RESULTS

Characteristics of the students

This study included 542 students, about 321 students were from faculty of sciences and engineering, 165 were from faculty of arts and design and 56 students were from faculty of health and medical sciences. The age of the students ranged from 17 to 45 years. The mean age of the students was 22 years and standard deviation was 5.06. The majority of the students (53.9%) were distributed among group of 21-25 years. Most of the students (58.1%) were from urban regions and about 41.7% had family income of 31,000-60,000 rupees per month (Table 1).

Prevalence and patterns of cigarette smoking

The prevalence of current cigarette smoking among students at University of Azad Jammu and Kashmir in Muzaffarabad was found to be 49.5%. Of the students, 11.6% were former smokers and 38.9% were never smokers. The mean age for starting cigarette smoking was 19.2±2.73 years. The majority of the students (68.0%) started smoking at the age of 16-20 years. Most of the students (32.6%) smoked 6-10 cigarettes per day. Cigarettes (61.3%) were found to be the most common form of tobacco use followed by shisha (18.4%). The favourite places for cigarette smoking were home (59.8%) and university (23.6%). About 79.5% of the smokers want to quit smoking in the near future times. The main motives for cigarette smoking were peer pressure (35.0%), family influencing (24.5%), stress alleviation (19.0%), style and fun (10.0%) and curiosity (7.3%) (Table 2).

Knowledge regarding harmful effects of smoking

The majority of the students were knowledgeable about harmful effects of smoking. Non-smoker students had higher knowledge than smoker students with a statistically significant difference (p<0.05) regarding knowledge of smoking as a harmful effect on their health, risk factor of cancer, heart diseases, respiratory illness, infertility, mental conditions, addiction, poor quality of life and increased mortality (Table 3).

Attitudes towards cigarette smoking

Regarding the attitude of the students towards smoking prevention and control measures, smoking ban at university campus (94.7%), increased taxes on cigarettes (96.3%), ban on smoking at public places (91.5%), family restriction on tobacco use (91.0%), prevention of smoking advertisement (87.5%), health warning message on cigarette packages (86.3%) and health education regrading harmful effects of smoking (82.8%) were suggested for prevention and control of cigarette smoking from the students point of view (Table 4).

Factors associated with cigarette smoking

There was no significant difference (p=0.484) in prevalence of cigarette smoking among students of different faculties. However, the prevalence of cigarette smoking was reported highest (52.4%) among students from faculty of arts and design compared to students from other faculties. The prevalence of cigarette smoking significantly decreased (p=0.003) as the age of students increased. Students who were in the age group of 16-20 years (48.7%) had higher prevalence of cigarette smoking than students who were in age group of >35 years (20%). The difference between other characteristics of smokers and non-smokers are shown in Table 5.

DISCUSSION

The main objectives of this study was to determine the prevalence of cigarette smoking among students at University of Azad Jammu and Kashmir in Muzaffarabad as well as their knowledge and attitude about cigarette smoking. The study was carried out with the expectation that the information from this study can be used to conduct smoking prevention and control measures among students at University of Azad Jammu and Kashmir in Muzaffarabad, Pakistan.

The prevalence of current cigarette smoking among students in this study was found 49.5%, while in general population, the national health survey of Pakistan reported a prevalence of male tobacco smoking of about 54%.⁷ It was found that the prevalence of smoking among male medical students in Rawalpindi, Pakistan was 57.7%⁸. Another study reported that the prevalence of cigarette smoking among male medical students at King Edward Medical University, Lahore, Pakistan was 60.55%.⁹

In India, the prevalence of smoking among male college students was 26.7%.¹⁰ A study conducted among university students in Iran revealed that the prevalence of smoking was 31.1%.¹¹ The percentage of current smokers among university students in Bangladesh was 60.2%.¹² In China, the prevalence of current smoking among male undergraduate’s students was 91.8%.¹³

The prevalence of current smoking among college students in USA was 42%.¹⁴ Similarly, a study from Europe reported that the prevalence of current smoking among university students was 42.7%.¹⁵ In Saudi Arabia (Najran University), the prevalence of smoking among male college students was found 30.1%.¹⁶

The difference in prevalence of smoking in this study and other studies may be due to different age groups studied, different research methodologies adopted and the use of different criteria for defining cigarette smoking

There was no significant difference (p=0.484) between prevalence of cigarette smoking among students of different faculties in this study. This finding was consistent with a study conducted in Malasyia.¹⁷ On the other hand, prevalence of cigarette smoking significantly decreased (p=0.003) as the age of students increased. This finding was in an agreement with a study conducted in Turkey.¹⁸ This could be better explained by the fact that old age students are more receptive to medical advice and public health messages and they are more likely to quit cigarette smoking as compared to young age students.

The mean age for starting cigarette smoking in this study was 19.2±2.73 years. The majority of the students (67.47%) started cigarette smoking before the age of 20 years. This finding was consistent with a study conducted in Iran reporting that the average age for initiating cigarette was 19 years.¹⁹ This implies early identification of the smokers so that tobacco control measures could be implemented in this age group.

The main motives for cigarette smoking in this study were peer pressure (35.0%) followed by family influencing (24.5%). Similarly, in a study conducted in Pakistan obtained same associated factors like curiosity (27.27%), family influencing (16.66%) and peer pressure (18.18%) as associated with increased prevalence of cigarette smoking.²⁰ These personal and environmental characteristics are major contributors of cigarette smoking which need an important attention to regulate smoking free environment, and to reduce the prevalence of cigarette smoking among students.

About 79.5% of the smoker students had a desire to quit cigarette smoking in this study. Similarly, studies from Saudi Arabia and India also reported higher percentage of the students (74.6% and 74.4% respectively) who want to cease cigarette smoking.^21,22 This indicates that the majority of the smokers may respond well to the cigarette smoking prevention and control programmes if these are established in university.

In this study, the majority of the students, irrespective of their cigarette smoking behaviour, had high knowledge about harmful effects of smoking such as cancer, respiratory illness, heart diseases, addiction, mental conditions, infertility, diminished health status and increased mortality. Although, smoker students had lower knowledge than non-smoker students. Similar findings were also reported among university students from Iran and Jordan.^23,24 The majority of the students (94.1%) in this study, knew that smoking is harmful for their health and 89.1% of them knew that it causes cardiovascular diseases. This finding is an agreement with a study conducted in Palestine which found that 88.7% of the students knew that smoking is harmful for health.²⁴

CONCLUSION

In conclusion, this study found a considerable high prevalence (49.5%) of cigarette smoking among male students at University of Azad Jammu and Kashmir, Muzaffarabad, Pakistan. One of the major and significant findings of this study was the positive attitudes of the students towards smoking control and prevention measures. About 79.5% of the students had intension to quit cigarette smoking. This indicates that the majority of the smoker students may respond well to the cigarette smoking prevention and control programmes if these are established in the university. It would be very helpful to organize smoking campaign in the different faculties at the university to increase the knowledge about the harmful affects of smoking.

ACKNOWLEDGEMENTS

We wish to express our sincere gratitude to all the students who took part in this study as well as the staff of the University of Azad Jammu and Kashmir, Muzaffarabad, Pakistan.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee at University of Azad Jammu and Kashmir, Muzaffarabad, Pakistan

REFERENCES

1. 1. Bhatti MUD, Choksi HM, Bashir NS. Tobacco Knowledge, Attitudes and Trends amongst Staff and Students of University College of Dentistry Lahore, Pakistan. Pakistan Oral Dental J. 2010;30(2):468-72.
2. 2. Askarian M, Kouchak F, Youssef M, Romito LM. Comparing Tobacco Use Knowledge, Attitudes and Practices between Engineering Students at a Public and Islamic Azad University in Shiraz, Iran 2011. Int J Prev Med. 2013;4(10):1154-61.
3. 3. Abou-Faddan HH, Ahmed SM. Knowledge, Attitude and Practice Study on Smoking among Male Students in Al-Jabal Al-Gharbi University, Gharian–Libya. J Am Sci. 2012;8(11):485-91.
4. 4. Bushra R, Aslam N, Khan U, Bano N, Jamal A, Sial AA, et al. Prevalence of Smoking in Teenagers Male Undergraduate Students a Study of Karachi, Pakistan. J Pakistan Med Assoc. 2013;3(2):49-54.
5. 5. Khan J. Tobacco Epidemic in Pakistan. J Postgrad Med Inst. 2012;26(3):233-6.
6. 6. Ahmed R, Rashid RU, McDonald PW, Ahmed SW. Prevalence of cigarette smoking among young adults in Pakistan. J Pakistan Med Assoc. 2008;58(11):597-601.
7. 7. Awan S, Sathiakumar N, Delzell E. Prevalence and Socio-Demographic Factors Associated with Tobacco Smoking among Adult Males in Rural Sindh, Pakistan. Southeast Asian Trop J Med Public Health. 2006;37(5):1054-60.
8. 8. Ali IS, Yaqoob N, Fatima G, Iftekhar H, Abbas M. Pattern of Smoking in Medical Students. J Rawalpindi Med Coll. 2013;17(1):140-3.
9. 9. Karamat A, Arif N, Malik AK, Chaudhry A, Cheema MA, Rauf A. Cigarette smoking and medical students at King Edward Medical University, Lahore (Pakistan). J Pak Med Assoc. 2012;61(5):509-12.
10. 10. Mathew DP, Indiradevi ER, Srijith R, Mathew T, Varghese V, Vijavan V. Prevalence and Risk Factors for Tobacco Smoking, Among College Students of South India. Int J Healthcare Sci. 2015;2(2):354-7.
11. 11. Gholamreza HMY, Fard, Hosseini M, Khani AR, Masjedi MR. Cigarette Smoking, Knowledge, Attitude and Prediction of Smoking Between Male Students, Teachers and Clergymen in Tehran, Iran, 2009. Int J Prevent Med. 2013;4(5):557-64.
12. 12. Hossain S, Hossain S, Ahmed F, Islam R, Sikder T, Rahman A. Prevalence of Tobacco Smoking and Factors Associated with the Initiation of Smoking among University Students in Dhaka, Bangladesh. Central Asian J Global Health. 2017;6(1):244.
13. 13. Xu X, Leung DYP, Li B, Wang P, Zhao Y. Smoking-Related Knowledge, Attitude, Social Pressure, and Environmental Constraints among New Undergraduates in Chongqing, China. Environ Res Public Health. 2015;12:895-909.
14. 14. Ah DV, Ebert S, Ngamvitroj A, Park N, Kang D. Factors Related to Cigarette Smoking Initiation and Use among College Students. Tobacco Induced Diseases. 2005;3(1):27-40.
15. 15. Steptoe A, Wardle J. Health behaviour, risk awareness and emotional well-being in students from Eastern Europe and Western Europe. Social Sci Med. 2001;53:1621-30.
16. 16. Al-Qahtani JM. Knowledge, Attitude and Practice of Tobacco Smoking among Health Colleges’ Students at Najran University, Saudi Arabia: A Cross‑sectional Descriptive Study. J Health Specialties. 2017;5(1):35-41.
17. 17. Al-Naggar RA, Al-Dubai SAR, Al-Naggar TH, Chen R, Al-Jashamy K. Prevalence and Associated Factors of Smoking among Malaysian University Students. Asian Pacific J Cancer Prevent. 2012;12:619-24.
18. 18. Tumer UE, Yurtseven E, Donuk B. Prevalence of Smoking and Related Risk Factors among Physical Education and Sports School Students at Istanbul University. Int J Environ Res Public Health. 2012;9:674-84.
19. 19. Ehsan TA, Ghorbani A, Salehi M, Sadeghnia HR. Cigarette Smoking Behavior and the Related Factors among the Students of Mashhad University of Medical Sciences in Iran. Iran Red Crescent Med J. 2014;17(1):1-6.
20. 20. Hussain A, Khan MW, Zaidi N, Hussain S, Waqas. Attitudes And Beliefs of Non-Medical Students towards Tobacco Use and Smoking. Pak J Heart. 2014;47(1):23-7.
21. 21. Murad A, Haleem A. Knowledge, Attitude and Behaviour of Medical and Dental Students towards Smoking Habit in Saudi Arabian Universities: A Comparative Study. Int Dental J Student’s Res. 2012;1(1):16.
22. 22. Devi MB, Sreegiri S, Gopi S, Koyyana S. Perceptions of Young Male Smokers in Visakhapatnam about Tobacco Use and Control Measures. Int J Res Development Health. 2013;1(3):129-35.
23. 23. Sharif L, Qandil A, Alkafajei A. Knowledge, attitude and practice of university students towards smoking in Irbid, Jordan. J Public Health Epidemiol. 2013;5(1):29-36.
24. 24. Heydari G, Youseffard M, Hosseini M, Ramezankhani A, Masjedi, MR. Cigarette Smoking, Knowledge, Attitude and Prediction of Smoking Between Male Students, Teachers and Clergymen in Tehran, Iran, 2009. Int J Prev Med. 2013;4(5):557-64.
25. 25. Shomar RTA, Lubbad IK, Ansari WE, Al-Khatib IA, Alharazin HJ. Smoking, Awareness of Smoking-Associated Health Risks, and Knowledge of National Tobacco Legislation in Gaza, Palestine. Cent Eur J Public Health. 2014;22(2):80-9.