thesis in smoking

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• Published: 21 January 2021

The effects of tobacco control policies on global smoking prevalence

• Luisa S. Flor   ORCID: orcid.org/0000-0002-6888-512X 1 ,
• Marissa B. Reitsma 1 ,
• Vinay Gupta 1 ,
• Marie Ng   ORCID: orcid.org/0000-0001-8243-4096 2 &
• Emmanuela Gakidou   ORCID: orcid.org/0000-0002-8992-591X 1  

Nature Medicine volume  27 ,  pages 239–243 ( 2021 ) Cite this article

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Substantial global effort has been devoted to curtailing the tobacco epidemic over the past two decades, especially after the adoption of the Framework Convention on Tobacco Control 1 by the World Health Organization in 2003. In 2015, in recognition of the burden resulting from tobacco use, strengthened tobacco control was included as a global development target in the 2030 Agenda for Sustainable Development 2 . Here we show that comprehensive tobacco control policies—including smoking bans, health warnings, advertising bans and tobacco taxes—are effective in reducing smoking prevalence; amplified positive effects are seen when these policies are implemented simultaneously within a given country. We find that if all 155 countries included in our counterfactual analysis had adopted smoking bans, health warnings and advertising bans at the strictest level and raised cigarette prices to at least 7.73 international dollars in 2009, there would have been about 100 million fewer smokers in the world in 2017. These findings highlight the urgent need for countries to move toward an accelerated implementation of a set of strong tobacco control practices, thus curbing the burden of smoking-attributable diseases and deaths.

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Decades after its ill effects on human health were first documented, tobacco smoking remains one of the major global drivers of premature death and disability. In 2017, smoking was responsible for 7.1 (95% uncertainty interval (UI), 6.8–7.4) million deaths worldwide and 7.3% (95% UI, 6.8%–7.8%) of total disability-adjusted life years 3 . In addition to the health impacts, economic harms resulting from lost productivity and increased healthcare expenditures are also well-documented negative effects of tobacco use 4 , 5 . These consequences highlight the importance of strengthening tobacco control, a critical and timely step as countries work toward the 2030 Sustainable Development Goals 2 .

In 2003, the World Health Organization (WHO) led the development of the Framework Convention on Tobacco Control (FCTC), the first global health treaty intended to bolster tobacco use curtailment efforts among signatory member states 1 . Later, in 2008, to assist the implementation of tobacco control policies by countries, the WHO introduced the MPOWER package, an acronym representing six evidence-based control measures (Table 1 ) (ref. 6 ). While accelerated adoption of some of these demand reduction policies was observed among FCTC parties in the past decade 7 , many challenges remain to further decrease population-level tobacco use. Given the differing stages of the tobacco epidemic and tobacco control across countries, consolidating the evidence base on the effectiveness of policies in reducing smoking is necessary as countries plan on how to do better. In this study, we evaluated the association between varying levels of tobacco control measures and age- and sex-specific smoking prevalence using data from 175 countries and highlighted missed opportunities to decrease smoking rates by predicting the global smoking prevalence under alternative unrealized policy scenarios.

Despite the enhanced global commitment to control tobacco use, the pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, sex and age 8 ; in 2017, there were still 1.1 billion smokers across the 195 countries and territories assessed by the Global Burden of Diseases, Injuries, and Risk Factors Study. Global smoking prevalence in 2017 among men and women aged 15 and older, 15–29 years, 30–49 years and 50 years and older are shown in Extended Data Figs. 1 , 2 , 3 and 4 , respectively. We found that, between 2009 and 2017, current smoking prevalence declined by 7.7% for men (36.3% (95% UI, 35.9–36.6%) to 33.5% (95% UI, 32.9–34.1%)) and by 15.2% for women globally (7.9% (95% UI, 7.8–8.1%) to 6.7% (95% UI, 6.5–6.9%)). The highest relative decreases were observed among men and women aged 15–29 years, at 10% and 20%, respectively. Conversely, prevalence decreased less intensively for those aged over 50, at 2% for men and 9.5% for women. While some countries have shown an important reduction in smoking prevalence between 2009 and 2017, such as Brazil, suggesting sustained progress in tobacco control, a handful of countries and territories have shown considerable increases in smoking rates among men (for example, Albania) and women (for example, Portugal) over this time period.

In an effort to counteract the harmful lifelong consequences of smoking, countries have, overall, implemented stronger demand reduction measures after the FCTC ratification. To assess national-level legislation quality, the WHO attributes a score to each of the MPOWER measures that ranges from 1 to 4 for the monitoring component (M) and 1–5 for the other components. A score of 1 represents no known data, while scores 2–5 characterize the overall strength of each measure, from the lowest level of achievement (weakest policy) to the highest level of achievement (strongest policy) 6 . Between 2008 and 2016, although very little progress was made in treatment provision (O) 7 , 9 , the share of the total population covered by best practice (score = 5) P, W and E measures increased (Fig. 1 ). Notably, however, a massive portion of the global population is still not covered by comprehensive laws. As an example, less than 15% of the global population is protected by strongly regulated tobacco advertising (E) and the number of people (2.1 billion) living in countries where none or very limited smoke-free policies (P) are in place (score = 2) is still nearly twice as high as the population (1.1 billion) living in locations with national bans on smoking in all public places (score = 5).

To assess national-level legislation quality, the WHO attributes a score to each MPOWER component that ranges from 1 to 5 for smoke-free (P), health warning (W) and advertising (E) policies. A score of 1 represents no known data or no recent data, while scores 2–5 characterize the overall strength of each policy, from 2 representing the lowest level of achievement (weakest policy), to 5 representing the highest level of achievement (strongest policy).

Source data

In terms of fiscal policies (R), the population-weighted average price, adjusted for inflation, of a pack of cigarettes across 175 countries with available data increased from I$3.10 (where I$ represents international dollars) in 2008 to I$5.38 in 2016. However, from an economic perspective, for prices to affect purchasing decisions, they need to be evaluated relative to income. The relative income price (RIP) of cigarettes is a measure of affordability that reflects, in this study, what proportion of the country-specific per capita gross domestic product (GDP) is needed to purchase half a pack of cigarettes a day for a year. Over time, cigarettes have become less affordable (RIP 2016 > RIP 2008) in about 75% of the analyzed countries, with relatively more affordable cigarettes concentrated across high-income countries.

Our adjusted analysis indicates that greater levels of achievement on key measures across the P, W and E policy categories and higher RIP values were significantly associated with reduced smoking prevalence from 2009 to 2017 (Table 2 ). Among men aged 15 and older, each 1-unit increment in achievement scores for smoking bans (P) was independently associated with a 1.1% (95% UI, −1.7 to −0.5, P  < 0.0001) decrease in smoking prevalence. Similarly, an increase of 1 point in W and E scores was associated with a decrease in prevalence of 2.1% (95% UI, −2.7 to −1.6, P  < 0.0001) and 1.9% (95% UI, −2.6 to −1.1, P  < 0.0001), respectively. Furthermore, a 10 percentage point increase in RIP was associated with a 9% (95% UI, −12.6 to −5.0, P  < 0.0001) decrease in overall smoking prevalence. Results were similar for men from other age ranges.

Among women, the magnitude of effect of different policy indicators varied across age groups. For those aged over 15, each 1-point increment in W and E scores was independently associated with an average reduction in prevalence of 3.6% (95% UI, −4.5 to −2.9, P  < 0.0001) and 1.9% (95% UI, −2.9 to −1.8, P  = 0.002), respectively, and these findings were similar across age groups. Smoking ban (P) scores were not associated with reduced prevalence among women aged 15–29 years or over 50 years. However, a 1-unit increase in P scores was associated with a 1.3% (95% UI, −2.3 to −0.2, P  = 0.016) decline in prevalence among women aged 30–49 years. Lastly, while a 10 percentage point increase in RIP lowered women smoking prevalence by 6% overall (95% UI, −10.0 to −2.0, P = 0.014), this finding was not statistically significant when examining reductions in prevalence among those aged 50 and older (Table 2 ).

If tobacco control had remained at the level it was in 2008 for all 155 countries (with non-missing policy indicators for both 2008 and 2016; Methods ) included in the counterfactual analysis, we estimate that smoking prevalence would have been even higher than the observed 2017 rates, with 23 million more male smokers and 8 million more female smokers (age ≥ 15) worldwide (Table 3 ). Out of the counterfactual scenarios explored, the greatest progress in reducing smoking prevalence would have been observed if a combination of higher prices—resulting in reduced affordability levels—and strictest P, W and E laws had been implemented by all countries, leading to lower smoking rates among men and women from all age groups and approximately 100 million fewer smokers across all countries (Table 3 ). Under this policy scenario, the greatest relative decrease in prevalence would have been seen among those aged 15–29 for both sexes, resulting in 26.6 and 6.5 million fewer young male and female smokers worldwide in 2017, respectively.

Our findings reaffirm that a wide spectrum of tobacco demand reduction policies has been effective in reducing smoking prevalence globally; however, it also indicates that even though much progress has been achieved, there is considerable room for improvement and efforts need to be strengthened and accelerated to achieve additional gains in global health. A growing body of research points to the effectiveness of tobacco control measures 10 , 11 , 12 ; however, this study covers the largest number of countries and years so far and reveals that the observed impact has varied by type of control policy and across sexes and age groups. In high-income countries, stronger tobacco control efforts are also associated with higher cessation ratios (that is, the ratio of former smokers divided by the number of ever-smokers (current and former smokers)) and decreases in cigarette consumption 13 , 14 .

Specifically, our results suggest that men are, in general, more responsive to tobacco control interventions compared to women. Notably, with prevalence rates for women being considerably low in many locations, variations over time are more difficult to detect; thus, attributing causes to changes in outcome can be challenging. Yet, there is already evidence that certain elements of tobacco control policies that play a role in reducing overall smoking can have limited impact among girls and women, particularly those of low socioeconomic status 15 . Possible explanations include the different value judgments attached to smoking among women with respect to maintaining social relationships, improving body image and hastening weight control 16 .

Tax and price increases are recognized as the most impactful tobacco control policy among the suite of options under the MPOWER framework 10 , 14 , 17 , particularly among adolescents and young adults 18 . Previous work has also demonstrated that women are less sensitive than men to cigarette tax increases in the USA 19 . Irrespective of these demographic differences, effective tax policy is underutilized and only six countries—Argentina, Chile, Cuba, Egypt, Palau and San Marino—had adopted cigarette taxes that corresponded to the WHO-prescribed level of 70% of the price of a full pack by 2017 (ref. 20 ). Cigarettes also remain highly affordable in many countries, particularly among high-income nations, an indication that affordability-based prescriptions to countries, instead of isolated taxes and prices reforms, are possibly more useful as a tobacco control target. In addition, banning sales of single cigarettes, restricting legal cross-border shopping and fighting illicit trade are required so that countries can fully experience the positive effect of strengthened fiscal policies.

Smoke-free policies, which restrict the opportunities to smoke and decrease the social acceptability of smoking 17 , also affect population groups differently. In general, women are less likely to smoke in public places, whereas men might be more frequently influenced by smoking bans in bars, restaurants, clubs and workplaces across the globe due to higher workforce participation rates 16 . In addition to leading to reduced overall smoking rates, as indicated in this study, implementing complete smoking bans (that is, all public places completely smoke-free) at a faster pace can also play an important role in minimizing the burden of smoking-attributable diseases and deaths among nonsmokers. In 2017 alone, 2.18% (95% UI, 1.8–2.7%) of all deaths were attributable to secondhand smoke globally, with the majority of the burden concentrated among women and children 21 .

Warning individuals about the harms of tobacco use increases knowledge about the health risks of smoking and promotes changes in smoking-related behaviors, while full advertising and promotion bans—implemented by less than 20% of countries in 2017 (ref. 20 )—are associated with decreased tobacco consumption and smoking initiation rates, particularly among youth 17 , 22 , 23 . Large and rotating pictorial graphic warnings are the most effective in attracting smokers’ attention but are lacking in countries with high numbers of smokers, such as China and the USA 20 . Adding best practice health warnings to unbranded packages seems to be an effective way of informing about the negative effects of smoking while also eliminating the tobacco industry’s marketing efforts of using cigarette packages to make these products more appealing, especially for women and young people who are now the prime targets of tobacco companies 24 , 25 .

While it is clear that strong implementation and enforcement are crucial to accelerating progress in reducing smoking and its burden globally, our heterogeneous results by type of policy and demographics highlight the challenges of a one-size-fits-all approach in terms of tobacco control. The differences identified illustrate the need to consider the stages 26 of the smoking epidemics among men and women and the state of tobacco control in each country to identify the most pressing needs and evaluate the way ahead. Smoking patterns are also influenced by economic, cultural and political determinants; thus, future efforts in assessing the effectiveness of tobacco control policies under these different circumstances are of value. As tobacco control measures have been more widely implemented, tobacco industry forces have expanded and threaten to delay or reverse global progress 27 . Therefore, closing loopholes through accelerated universal adoption of the comprehensive set of interventions included in MPOWER, guaranteeing that no one is left unprotected, is an urgent requirement as efforts toward achieving the Sustainable Development Goals by 2030 are intensified.

This was an ecological time series analysis that aimed to estimate the effect of four key demand reduction measures on smoking rates across 175 countries. Country-year-specific achievement scores for P, W and E measures and an affordability metric measured by RIP—to capture the impact of fiscal policy (R)—were included as predictors in the model. Although the WHO also calls for monitoring (M) and tobacco cessation (O) interventions, these were not evaluated. Monitoring tobacco use is not considered a demand reduction measure, while very little progress has been made in treatment provision over the last decade 7 , 9 . Further information on research design is available in the Life Sciences Reporting Summary linked to this paper.

Smoking outcome data

The dependent variable is represented by country-specific, age-standardized estimates of current tobacco smoking prevalence, defined as individuals who currently use any smoked tobacco product on a daily or occasional basis. Complete time series estimates of smoking prevalence from 2009 to 2017 for men and women aged 15–29, 30–49, 50 years and older and 15 years and older, were taken from the Global Burden of Disease (GBD) 2017 study.

The GBD is a scientific effort to quantify the comparative magnitude of health loss due to diseases, injuries and risk factors by age, sex and geography for specific points in time. While full details on the estimation process for smoking prevalence have been published elsewhere, we briefly describe the main analytical steps in this article 3 . First, 2,870 nationally representative surveys meeting the inclusion criteria were systematically identified and extracted. Since case definitions vary between surveys, for example, some surveys only ask about daily smoking as opposed to current smoking that includes both daily and occasional smokers, the extracted data were adjusted to the reference case definition using a linear regression fit on surveys reporting multiple case definitions. Next, for surveys with only tabulated data available, nonstandard age groups and data reported as both sexes combined were split using observed age and sex patterns. These preprocessing steps ensured that all data used in the modeling were comparable. Finally, spatiotemporal Gaussian process regression, a three-step modeling process used extensively in the GBD to estimate risk factor exposure, was used to estimate a complete time series for every country, age and sex. In the first step, estimates of tobacco consumption from supply-side data are incorporated to guide general levels and trends in prevalence estimates. In the second step, patterns observed in locations, age groups and years with smoking prevalence data are synthesized to improve the first-step estimates. This step is particularly important for countries and time periods with limited or no available prevalence data. The third step incorporates and quantifies uncertainty from sampling error, non-sampling error and the preprocessing data adjustments. For this analysis, the final age-specific estimates were age-standardized using the standard population based on GBD population estimates. Age standardization, while less important for the narrower age groups, ensured that the estimated effects of policies were not due to differences in population structure, either within or between countries.

Using GBD-modeled data is a strength of the study since nearly 3,000 surveys inform estimates and countries are not required to have complete survey coverage between 2009 and 2017 to be included in the analysis. Yet, it is important to note that these estimates have limitations. For example, in countries where a prevalence survey was not conducted after the enactment of a policy, modeled estimates may not reflect changes in prevalence resulting from that policy. Nonetheless, the prevalence estimates from the GBD used in this study are similar to those presented in the latest WHO report 28 , indicating the validity and consistency of said estimates.

MPOWER data

Summary indicators of country-specific achievements for each MPOWER measure are released by the WHO every two years and date back to 2007. Data from different iterations of the WHO Report on the Global Tobacco Epidemic (2008 6 , 2009 29 , 2011 30 , 2013 31 , 2015 32 and 2017 20 ) were downloaded from the WHO Tobacco Free Initiative website ( https://www.who.int/tobacco/about/en/ ). To assess the quality of national-level legislation, the WHO attributes a score to each MPOWER component that ranges from 1 to 4 for the monitoring (M) dimension and 1–5 for the other dimensions. A score of 1 represents no known data or no recent data, while scores 2–5 characterize the overall strength of each policy, from the lowest level of achievement (weakest policy) to the highest (strongest policy).

Specifically, smoke-free legislation (P) is assessed to determine whether smoke-free laws provide for a complete indoor smoke-free environment at all times in each of the respective places: healthcare facilities; educational facilities other than universities; universities; government facilities; indoor offices and workplaces not considered in any other category; restaurants or facilities that serve mostly food; cafes, pubs and bars or facilities that serve mostly beverages; and public transport. Achievement scores are then based on the number of places where indoor smoking is completely prohibited. Regarding health warning policies (W), the size of the warnings on both the front and back of the cigarette pack are averaged to calculate the percentage of the total pack surface area covered by the warning. This information is combined with seven best practice warning characteristics to construct policy scores for the W dimension. Finally, countries achievements in banning tobacco advertising, promotion and sponsorship (E) are assessed based on whether bans cover the following types of direct and indirect advertising: (1) direct: national television and radio; local magazines and newspapers; billboards and outdoor advertising; and point of sale (indoors); (2) indirect: free distribution of tobacco products in the mail or through other means; promotional discounts; nontobacco products identified with tobacco brand names; brand names of nontobacco products used or tobacco products; appearance of tobacco brands or products in television and/or films; and sponsorship.

P, W and E achievement scores, ranging from 2 to 5, were included as predictors into the model. The goal was to not only capture the effect of adopting policies at its highest levels but also assess the reduction in prevalence that could be achieved if countries moved into the expected direction in terms of implementing stronger measures over time. Additionally, having P, W and E scores separately, and not combined into a composite score, enabled us to capture the independent effect of different types of policies.

Although compliance is a critical factor in understanding policy effectiveness, the achievement scores incorporated in our main analysis reflect the adoption of legislation rather than degree of enforcement, representing a limitation of these indicators.

Prices in I$ for a 20-cigarette pack of the most sold brand in each of the 175 countries were also sourced from the WHO Tobacco Free Initiative website for all available years (2008, 2010, 2012, 2014 and 2016). I$ standardize prices across countries and also adjust for inflation across time. This information was used to construct an affordability metric that captures the impact of cigarette prices on smoking prevalence, considering the income level of each country.

More specifically, the RIP, calculated as the percentage of per capita GDP required to purchase one half pack of cigarettes a day over the course of a year, was computed for each available country and year. Per capita GDP estimates were drawn from the Institute for Health Metrics and Evaluation; the estimation process is detailed elsewhere 33 .

Given that the price data used in the analysis refer to the most sold brand of cigarettes only, it does not reflect the full range of prices of different types of tobacco products available in each location. This might particularly affect our power in detecting a strong effect in countries where other forms of tobacco are more popular.

Statistical analysis

Sex- and age-specific logit-transformed prevalence estimates from 2009 to 2017 were matched to one-year lagged achievement scores and RIP values using country and year identifiers 34 . The final sample consisted of 175 countries and was constrained to locations and years with non-missing indicators. A multiple linear mixed effects model fitted by restricted maximum likelihood was used to assess the independent effect of P, W and E scores and RIP values on the rates of current smoking. Specifically, a country random intercept and a country random slope on RIP were included to account for geographical heterogeneity and within-country correlation. The regression model takes the following general form:

where y c,t is the prevalence of current smoking in each country ( c ) and year ( t ), β 0 is the intercept for the model and β p , β w , β e and β r are the fixed effects for each of the policy predictors. \(\mathrm{P}_{c,\,t - 1},\,\mathrm{W}_{c,\,t - 1},\,\mathrm{E}_{c,\,t - 1}\) are the P, W and E scores and R c , t −1 is the RIP value for country c in year t  − 1. Finally, α c is the random intercept for country ( c ), while δ c represent the random slope for the country ( c ) to which the RIP value (R t − 1 ) belongs. Variance inflation factor values were calculated for all the predictor parameters to check for multicollinearity; the values found were low (<2) 35 . Bivariate models were also run and are shown in Extended Data Fig. 5 . The one-year lag introduced into the model may have led to an underestimation of effect sizes, particularly as many MPOWER policies require a greater period of time to be implemented effectively. However, due to the limited time range of our data (spanning eight years in total), introducing a longer lag period would have resulted in the loss of additional data points, thus further limiting our statistical power in detecting relevant associations between policies and smoking prevalence.

In addition to a joint model for smokers from both sexes, separate regressions were fitted for men and women and the four age groups (15–29, 30–49, ≥50 and ≥15 years old). To assess the validity of the mixed effects analyses, likelihood ratio tests comparing the models with random effects to the null models with only fixed effects were performed. Linear mixed models were fitted by maximum likelihood and t -tests used Satterthwaite approximations to degrees of freedom. P values were considered statistically significant if <0.05. All analyses were executed with RStudio v.1.1.383 using the lmer function in the R package lme4 v.1.1-21 (ref. 36 ).

A series of additional models to examine the impact of tobacco control policies were developed as part of this study. In each model, cigarette affordability (RIP) and a different set of policy metrics was used to capture the implementation, quality and compliance of tobacco control legislation. In models 1 and 2, we replaced the achievements scores by the proportion of P, W and E measures adopted by each country out of all possible measures reported by the WHO. In model 3, we used P and E (direct and indirect measures separately) compliance scores provided by the WHO to represent actual legislation implementation. Finally, an interaction term for compliance and achievement to capture the combined effect of legislation quality and performance was added to model 4. Results for men and women by age group for each of the additional models are presented in the Supplemental Information (Supplementary Tables 1–4 ).

The main model described in this study was chosen because it includes a larger number of country-year observations ( n  = 823) when compared to models including compliance scores and because it is more directly interpretable.

Counterfactual analysis

To further explore and quantify the impact of tobacco control policies on current smoking prevalence, we simulated what smoking prevalence across all countries would have been achieved in 2017 under 4 alternative policy scenarios: (1) if achievement scores and RIP remained at the level they were at in 2008; (2) if all countries had implemented each of P, W and E component at the highest level (score = 5); (3) if the price of a cigarette pack was I$7.73 or higher, a price that represents the 90th percentile of observed prices across all countries and years; and (4) if countries had implemented the P, W and E components at the highest level and higher cigarette prices. To keep our results consistent across scenarios, we restricted our analysis to 155 countries with non-missing policy-related indicators for both 2008 and 2016.

Random effects were used in model fitting but not in this prediction. Simulated prevalence rates were calculated by multiplying the estimated marginal effect of each policy by the alternative values proposed in each of the counterfactual scenarios for each country-year. The global population-weighted average was computed for status quo and counterfactual scenarios using population data sourced from the Institute for Health Metrics and Evaluation. Using the predicted prevalence rates and population data, the additional reduction in the number of current smokers in 2017 was also computed. Since models were ran using age-standardized prevalence, the number of smokers was proportionally redistributed across age groups using the sex-specific numbers from the age group 15 and older as an envelope.

The UIs for predicted estimates were based on a computation of the results of each of the 1,000 draws (unbiased random samples) taken from the uncertainty distribution of each of the estimated coefficients; the lower bound of the 95% UI for the final quantity of interest is the 2.5 percentile of the distribution and the upper bound is the 97.5 percentile of the distribution.

Reporting Summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data availability

The dataset generated and analyzed during the current study is publicly available at http://ghdx.healthdata.org/record/ihme-data/global-tobacco-control-and-smoking-prevalence-scenarios-2017 ( https://doi.org/10.6069/QAZ7-6505 ). The dataset contains all data necessary to interpret, replicate and build on the methods or findings reported in the article. Tobacco control policy data that support the findings of this study are released every two years as part of the WHO’s Global Report on Tobacco Control; these data are also directly accessible at https://www.who.int/tobacco/global_report/en/ . Source data are provided with this paper.

Code availability

All code used for these analyses is available at http://ghdx.healthdata.org/record/ihme-data/global-tobacco-control-and-smoking-prevalence-scenarios-2017 and https://github.com/ihmeuw/team/tree/effects_tobacco_policies .

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Acknowledgements

The study was funded by Bloomberg Philanthropies (grant 47386, Initiative to Reduce Tobacco Use). We thank the support of the Tobacco Metrics Team Advisory Group, which provided valuable comments and suggestions over several iterations of this manuscript. We also thank the Tobacco Free Initiative team at the WHO and the Campaign for Tobacco-Free Kids for making the tobacco control legislation data available and providing clarifications when necessary. We thank A. Tapp, E. Mullany and J. Whisnant for assisting in the management and execution of this study. We thank the team who worked in a previous iteration of this project, especially A. Reynolds, C. Margono, E. Dansereau, K. Bolt, M. Subart and X. Dai. Lastly, we thank all GBD 2017 Tobacco collaborators for their valuable work in providing feedback to our smoking prevalence estimates throughout the GBD 2017 cycle.

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Luisa S. Flor, Marissa B. Reitsma, Vinay Gupta & Emmanuela Gakidou

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L.S.F., M.N. and E.G. conceptualized the study and designed the analytical framework. M.B.R. and V.G. provided input on data, results and interpretation. L.S.F. and E.G. wrote the first draft of the manuscript. All authors read and approved the final version of the manuscript.

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Extended data

Extended data fig. 1 prevalence of current smoking for men (a) and women (b) aged 15 years and older (age-standardized) in 2017..

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 15 years and older for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 2 Prevalence of current smoking for men (a) and women (b) aged 15 to 29 years old (age-standardized) in 2017.

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 15–29 years old for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 3 Prevalence of current smoking for men (a) and women (b) aged 30 to 49 years old (age-standardized) in 2017.

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 30–49 years old for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 4 Prevalence of current smoking for men (a) and women (b) aged 50 years and older (age-standardized) in 2017.

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 50 years and older for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 5 Percentage changes in current smoking prevalence based on fixed effect coefficients from bivariate mixed effect linear regression models, by policy component, sex and age group.

Bivariate models examined the unadjusted association between smoke-free (P), health warnings (W), and advertising (E) achievement scores, and cigarette’s affordability (RIP) and current smoking prevalence, from 2009 to 2017, across 175 countries (n = 823 country-years). Linear mixed models were fit by maximum likelihood and t-tests used Satterthwaite approximations to degrees of freedom. P values were considered statistically significant if lower than 0.05.

Supplementary information

Supplementary information.

Supplementary Tables 1–4: additional models results.

Source Data Fig. 1

Input data for Fig. 1 replication.

Source Data Extended Data Fig. 1

Input data for Extended Data 1 replication.

Source Data Extended Data Fig. 2

Input data for Extended Data 2 replication.

Source Data Extended Data Fig. 3

Input data for Extended Data 3 replication.

Source Data Extended Data Fig. 4

Input data for Extended Data 4 replication.

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Flor, L.S., Reitsma, M.B., Gupta, V. et al. The effects of tobacco control policies on global smoking prevalence. Nat Med 27 , 239–243 (2021). https://doi.org/10.1038/s41591-020-01210-8

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Article Contents

Introduction, supplementary material, declaration of interests.

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Smokers’ Understandings of Addiction to Nicotine and Tobacco: A Systematic Review and Interpretive Synthesis of Quantitative and Qualitative Research

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Daniel Pfeffer, Britta Wigginton, Coral Gartner, Kylie Morphett, Smokers’ Understandings of Addiction to Nicotine and Tobacco: A Systematic Review and Interpretive Synthesis of Quantitative and Qualitative Research, Nicotine & Tobacco Research , Volume 20, Issue 9, September 2018, Pages 1038–1046, https://doi.org/10.1093/ntr/ntx186

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Despite the centrality of addiction in academic accounts of smoking, there is little research on smokers’ beliefs about addiction to smoking, and the role of nicotine in tobacco dependence. Smokers’ perspectives on nicotine’s role in addiction are important given the increasing prevalence of nontobacco nicotine products such as e-cigarettes. We conducted a systematic review of studies investigating smokers’ understandings and lay beliefs about addiction to smoking and nicotine.

We searched PubMed, Embase, CINAHL, and PsycINFO for studies investigating lay beliefs about addiction to smoking. Twenty-two quantitative and 24 qualitative studies met inclusion criteria. Critical interpretive synthesis was used to analyze the results.

Very few studies asked about addiction to nicotine. Quantitative studies that asked about addiction to smoking showed that most smokers believe that cigarettes are an addictive product, and that they are addicted to smoking. Across qualitative studies, nicotine was not often mentioned by participants. Addiction to smoking was most often characterized as a feeling of “need” for cigarettes resulting from an interplay between physical, mental, and social processes. Overall, we found that understandings of smoking were more consistent with the biopsychosocial model of addiction than with more recent models that emphasize the biological aspects of addiction.

Researchers should not treat perceptions of addiction to smoking interchangeably with perceptions of addiction to nicotine. More research on lay beliefs about nicotine is required, particularly considering the increasing use of e-cigarettes and their potential for long-term nicotine maintenance for harm reduction.

Quantitative studies show that most smokers believe that smoking is addictive and that they are addicted. A feeling of “need” for cigarettes was central to qualitative accounts of addiction, but nicotine was not often discussed. Overall, smokers’ understandings of addiction reflect a biopsychosocial model rather than a neurobiological one. Given the growing market for e-cigarettes and therapeutic nicotine, more research is required on lay beliefs about nicotine and addiction.

Nicotine was declared addictive by the US Surgeon General in 1988, 1 and it is increasingly recommended that nicotine addiction be approached as a disorder requiring medical treatment. 2–4 Various measures of nicotine dependence have been developed, validated and are in regular use in both research and clinical applications. 5–8 The constellation of features included in such measures include continued smoking despite known harms, difficulty quitting, feelings of craving or compulsion, and how long after waking someone smokes their first cigarette. An example of a commonly used measure of dependence is the Fagerstrom Test for Nicotine Dependence (FTND). 6 In 2012, this test was renamed the Fagerstrom Test for Cigarette Dependence, in acknowledgement of the fact that dependence on cigarettes encompasses more than an addiction to nicotine. 9 In a similar vein, the DSM-IV labeled addictive smoking as “nicotine dependence,” 10 however, was labeled “tobacco use disorder” in the DSM 5. 5 The complexity of the relationship between tobacco dependence and nicotine dependence has largely focused on academic arguments about the role of nicotine replacement therapy (NRT), and the neurobiology of nicotine and cigarette smoking. 9 The distinction between nicotine and tobacco dependence has become very relevant to contemporary legal and public health arguments about the potential for dependence on nontobacco forms of nicotine such as e-cigarettes. 11 , 12

Unlike other psychoactive substances such as opiates and alcohol that have long been associated with addiction, nicotine has relatively recently joined the realms of substances defined as addictive. Historically, smoking has been more closely associated with a public health approach than an addiction medicine approach. 13 The increasing recommendation for health professionals to identify smokers and to provide them with pharmacological treatments such as NRT or prescription medications has medicalized smoking to some extent. 14 Also contributing to the medicalization of smoking is the increasing emphasis on the neurobiological aspects of smoking that create and maintain addiction. 15–17 Tobacco dependence is increasingly defined in terms of “nicotine addiction” and is beginning to be labeled a “chronic brain disorder” and a “chronic disease.” 3 , 18

However, whether smokers view themselves as addicted to nicotine, and the role they ascribe to nicotine in their smoking, is less clear. The answer to this question is important for two current public health debates: (1) the amount of emphasis that should be given to therapeutic nicotine (NRT) for quitting smoking, given the limited population impact of cessation medicines despite widespread availability and public subsidization in high income countries; and (2) what contribution nontherapeutic nicotine products (eg, e-cigarettes) will play in reducing the burden of tobacco-related disease. The marketing of NRT a medicinal smoking cessation product, and the recommendation to use it for only a limited period of time, meant that long-term dependence on NRT products has not been a big concern. E-cigarettes have been controversial in the tobacco control field because they are marketed as consumer products that are much safer alternatives to conventional cigarettes. Their potential to foster long-term nicotine dependence and their appeal as a recreational form of nicotine delivery has brought to the fore arguments about how nicotine should be conceptualized and regulated. 11 , 19 , 20

It is important to investigate whether smokers see themselves as addicted to smoking and what meanings they associate with this term. The role that smokers ascribe to nicotine in their understandings of smoking is likely to influence their views about cessation methods and also switching to alternative nicotine products such as NRT or e-cigarettes.

Only one previous systematic review has examined lay perceptions of addiction to smoking. 21 This review focused on youth perceptions of addiction and the health harms of smoking. The authors found that young people were optimistic about their ability to quit before their smoking became problematic, and many did not believe that they were addicted to smoking. However, this review excluded the views of older and more established smokers. Also, the search strategy may have excluded relevant studies because it only included publications that contained one of the following terms: “invincibility, in denial, denial, invulnerable, optimism.” Although a stated aim was to examine perceptions of addiction, no search terms about addiction were used.

Our systematic review aimed to examine smokers’ subjective assessment of tobacco addiction in both adolescent and adult smokers, with an emphasis on investigating beliefs about nicotine. We collated data on smokers’ perceptions, beliefs, and understandings of addiction to smoking in general, or to nicotine specifically where available. We applied critical interpretive synthesis (CIS) 22 to analyze smokers’ understandings of addiction, and the methods by which they have been studied. PRISMA guidelines, which were developed to encourage standardized reporting of systematic reviews, were used to report the method and findings wherever appropriate. 23

Search Strategy

We searched PubMed, Embase, CINAHL, and PsycINFO using broad search terms to capture all relevant studies. While search strategies were adjusted for each database’s features, the key search terms were (cigarette OR tobacco OR nicotine OR smoking) AND (addiction OR habit OR dependence OR “tobacco use disorder”) AND (attitude OR belief OR understanding OR perception OR awareness OR “health belief”). Supplementary File 1 includes the full search strategy for each database.

Searches were conducted in June 2015, restricting results to English language articles published in peer-reviewed journals in or after 1988, to coincide with the publication of the US Surgeon General’s report that declared that nicotine was addictive. 1 The reference lists of relevant studies were manually searched for additional publications that met the selection criteria.

Inclusion/Exclusion Criteria

Figure 1 illustrates the process for identifying studies. After excluding 1087 duplicates, 2424 articles were screened by title and abstract, retaining those that involved current or ex-smokers and investigated beliefs, attitudes, or self-assessment regarding addiction to tobacco or nicotine. Studies that did not report participants’ understandings of “addiction” or “dependence” were excluded. Qualitative studies were included if they explored the meanings that smokers associate with addiction. Quantitative studies were included if they provided smokers’ ratings of their own addiction, or their ratings on the general addictiveness of smoking. Two authors (KM and DP) screened the full texts of 97 publications. Five of these studies were identified from the manual searching of reference lists of relevant articles. Where KM and DP disagreed over inclusion, third author (BW) independently reviewed the article and inclusion was based on majority judgment. Forty-six articles were deemed to meet the selection criteria.

Process of study inclusion.

Data Extraction

Separate data extraction forms were used for qualitative and quantitative articles ( Supplementary File 2 ). One mixed-methods article 24 was included as qualitative because the quantitative component did not address perceptions of addiction. For each study, BW and DP extracted information on research aims, context and methodology, key findings, conclusions, and study quality. Where studies included data from both smokers and nonsmokers, only data from smokers and ex-smokers was extracted. For qualitative studies, all text relating to addiction were imported into NVivo10 25 to enable further analysis.

While formal quality appraisal is common in conventional systematic reviews, many quality appraisal criteria for clinical trials are not applicable to observational studies, and quality appraisal is a contentious exercise for qualitative research. 22 , 26 , 27 For this review, formal quality appraisal in the form of scoring or ranking studies was not appropriate because it predominantly included qualitative or cross-sectional survey studies. Instead, we integrated reporting criteria from the NICE guidelines (quantitative and qualitative) 28 , 29 and STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklists 30 into our extraction forms and quality concerns informed our interpretation of these studies. These reporting guidelines include many items which assist researchers in judging the quality of a study such as details about selection of participants, validity, and generalizability of the results, how the study was explained to participants, and the explicitness of data analysis methods. No articles were excluded based on judgments about quality.

Quantitative studies ( n = 22) varied in aims, methodology, and survey items; therefore meta-analysis was not possible. For qualitative studies ( n = 24), DP conducted a secondary analysis of extracted results (ie, participant quotes and authors’ interpretations) using Nvivo 10. KM independently coded eight randomly chosen studies and differences were discussed until a consensus was reached. Codes were organized into themes, and then further into overarching thematic domains.

We drew on the approach of CIS to interpret the identified literature. 22 CIS has been applied to a wide range of research areas and is particularly useful when reviewing a methodologically diverse body of literature. 22 , 26 , 31 A CIS approach goes beyond the aggregation of data and aims to interpret the findings. The process of CIS includes an evolving research question; a pragmatic approach to quality appraisal based strongly on relevance rather than specific criteria of methodological rigor; and a critical approach to key concepts and assumptions. 22

Quantitative Studies

Key characteristics and results of the 22 quantitative studies (20 research articles and 2 research letters) 32–53 are provided in Supplementary File 3 . These were published between 1990 and 2012 and were cross-sectional designs, with the exception of one prospective cohort study. 39 The study target populations varied, with some focused exclusively on smokers ( n = 12), while others also included nonsmokers for comparison ( n = 10). Most focused on adults ( n = 14), while a number recruited adolescents only ( n = 6), and a minority included both age groups ( n = 2). Some included subgroup analysis based on age ( n = 2), sex ( n = 2), smoking status ( n = 11), and/or ethnicity ( n = 3).

There were substantial differences between studies in the way perceptions of the addictiveness of smoking were measured. Some studies asked about perceptions of personal addiction, for example, “Are you [not at all, somewhat, or very] addicted to cigarettes?” 39 Others used more general questions about the addictiveness of smoking, particularly when comparing smoker and nonsmoker ratings. For example, one study asked participants “How much of a risk is it for someone to get addicted if they try smoking cigarettes even once?” 37 Several studies asked participants to provide ratings of both their own addiction to cigarettes, and the general addictiveness of tobacco/cigarettes. 40 , 49 , 52 , 53

Other aspects of smoking included the ease/difficulty of quitting 38 , 41 , 43 , 44 , 46 ; the addictiveness of tobacco compared to other drugs 34 , 40 , 49 ; and the extent to which they believed addiction was a reason for their smoking. 42 , 45 In many cases, participants’ perceptions of addiction were not the major focus of the study, however, ratings of addiction were included as a relevant variable.

Another important difference between studies was whether participants were asked about addiction to “cigarettes”, “smoking”, “tobacco”, or “nicotine”. Most items asked about the addictiveness of “tobacco”, “cigarettes” or “smoking”. Only two articles contained items that specifically questioned participants about addiction to nicotine. 52 , 53 Weinstein et al. 52 asked “If a teenager starts smoking half a pack of cigarettes a day, how long do you think it takes them to show signs of nicotine addiction?” However, they switched to asking about addiction to cigarettes when questioning participants about their own addiction: “Do you consider yourself addicted to cigarettes?” The survey administered by Zinser et al. 53 included the item “People who smoke cigarettes regularly are addicted to nicotine.” No quantitative studies asked if participants personally felt they were addicted to nicotine.

The included studies consistently found that the majority of smokers agreed that smoking is addictive 32 , 34 , 36 , 37 or that “smokers” in general are addicted. 33 , 40 , 42 , 53 The single study that asked whether people who smoke are addicted to nicotine found that 89% Latino participants and 94% non-Latino Whites agreed with the statement. 53 When asked whether they personally were addicted, most adult daily smokers reported that they were. 39 , 52 , 53 Adolescent smokers were less likely than adults to agree that they personally were addicted, 32 , 52 but most agreed that smoking was addictive, 34 , 36 , 41 and that quitting would be difficult. 35 Other groups who were less likely to report being addicted to smoking were Hispanics in US studies 46 , 49 , 53 and lighter or “occasional” smokers. 39 , 40 , 48

While most studies did not ask about different aspects of addiction to smoking, there were exceptions. Four studies presented more than one explanation for smoking, for example, asking to what extent participants agreed that smoking was a habit and/or an addiction, or that addiction to smoking was physical and/or mental. 42–44 , 48 Where participants were given the option to rate their agreement with each item separately, both smoking as a habit and an addiction were endorsed in adults. 42 One study found that smokers reported psychological addiction to be more of a motive for smoking than physical addiction, but the difference was not large. 44 Three further studies suggested that smokers tend to agree that smoking tobacco is as addictive as other drugs (eg, cocaine or heroin). 34 , 40 , 49

Common methodological limitations included the absence of reporting on response rates; a lack of descriptive statistics on addiction-related variables; information about ethical clearance not being provided; and a lack of clarity about how participants were categorized in relation to smoking status.

Qualitative Studies

Twenty-three qualitative studies were included from 24 articles (one study was reported in two separate articles) published between 1997 and 2015. 24 , 54–76 Details of the studies are included in Supplementary File 4 . Data collection methods were primarily focus groups, individual interviews, or a combination of both. One study used Q-methodology. 61 Sampling strategies varied, with most articles including current smokers ( n = 12) or a combination of current smokers and ex-smokers ( n = 8). Three articles included data from never smokers in their sample. 64 , 69 , 73 Fourteen articles focused on adults and 10 on adolescents.

Similar to the quantitative studies, exploring smokers’ understandings of addiction was not the explicit aim for many studies. However, addiction often arose as a major theme as it was closely tied to discussions around starting and stopping smoking. Although some studies did not report their interview questions, and the results presented were not always linked to specific questions, discussions of addiction appeared to arise from a range of questions about quitting, reasons for smoking, and thoughts about smoking in general. This shows that addiction is a central concern of smokers.

Many studies did not provide sufficient information to allow judgments on study quality. There was often limited reporting on the role of the researcher in the analysis, including whether multiple team members coded the data, and how researcher beliefs and practices may have influenced the results (reflexivity); details about interview questions; recruitment methods or the study’s context; evidence to support claims (eg, few participant quotes); and the analytic approach. These issues are not uncommon in the reporting of qualitative research, particularly in journals with tight word count restrictions, where methodological detail is often sacrificed to allow more room for the reporting of results.

Qualitative findings across studies revealed smokers attach a range of meanings to their addiction. We first discuss common ways in which smokers described addiction to smoking. We then delineate the ways in which these “signs” of addiction were used by some participants to separate themselves from “addicted smokers” or to downplay their own addiction. Last, we explore instances where discussions around nicotine arose, and draw preliminary conclusions about the role of nicotine in smokers’ understandings of addiction.

What Does Addiction Look Like to Smokers?

The most commonly reported sign of addiction to smoking was a feeling of “need” for cigarettes that was seen to set apart addicted smokers from nonaddicted smokers. 55 , 56 , 59 , 63–69 , 73 The feeling of need was often associated with the sensation of craving, such as “sweating at the bit for a fag,” 55 “not satisfied until I have one,” 67 and “twitching ... aching for a cigarette.” 65 Smokers described having emotional withdrawal symptoms, such as “you get these mood swings and temper and everything,” 76 and “you feel more nervous.” 66 Frequent reference to physical withdrawal symptoms occurred across studies including headaches, 58 insomnia, 54 nausea, 59 concentration difficulties, 54 , 59 shakiness, 63 , 68 cold sweats, and dry mouth. 63 Smoking cigarettes relieved these symptoms, but was also associated with pleasure in the form of “a tingly feeling,” 69 a “buzz,” 70 a pleasurable smell and taste, 74 or an enjoyable feeling “going down my throat.” 65 Smoking was often portrayed as necessary to enable “normal” functioning. In some studies, participants described “tanking up” before periods of enforced abstinence 56 and exaggerated reactions to running out of cigarettes, such as willingness to walk for two hours to buy more. 63

Another key aspect of addiction according to smokers was diminished control over smoking, and an associated difficulty in quitting. Addiction was seen as, “trying and trying to give up”, 56 “want to quit, but can’t” 64 or “if it controls you.” 58 Control was tied to notions of choice and those who denied that they were addicted to smoking asserted their autonomy in statements such as “I feel like I’m not addicted because I can stop myself at any time. I choose to smoke that cigarette,” 58 and “Every time it is my own decision to smoke.” 54 The themes of need and control are closely linked, as demonstrated by one participant who stressed that her smoking was not a need, but a “want.” She reflected on times when she had said no to a cigarette as evidence that her addiction is “not too bad.”

I mean the amount of times I’ve said no when people have offered me and I say no and they say go on have one, but I go no it’s alright (laughs), yeah so I’d say you know I’m not too bad really ’cos some people just smoke for the sake of it, I try and just smoke when I want one. 62

A number of factors were offered to explain why only some people become addicted, with frequent references to “overdoing smoking.” 59 In particular, some smokers were viewed as being very controlled and constrained, while others were thought to smoke excessively. Views that, “a cigarette every so often doesn’t get you addicted” 65 ; “the more that somebody smokes for a while, the greater the chance of them getting addicted” 59 ; or “if I was addicted to smoking then I’d be smoking every day” 55 reveal how notions of excess and addiction are intertwined.

Some studies noted a highly physical conception of the process of addiction, employing ideas of tolerance in regards to the development of addiction. Tolerance was seen as a gradual progression toward addiction: “they just need a little bit and then they need more and then they need more” 59 ; “It’s a boring feeling after a while. It doesn’t feel the same anymore. You have to like smoke more to get that feeling—to get that like little high.” 69 Inherent in these descriptions was the identification of subtypes of smoking behavior, based on varying criteria. These included the “in control social smoker” versus the “habitual smoker” versus the “full-fledged addicted smoker” 55 ; light versus moderate versus heavy degrees of addiction 59 ; and “wanting/enjoying” versus “needing” cigarettes. 63 In each case, the process of becoming addicted was associated with progression and moving up a ladder of smoking typologies. This comparison between different smoker “types” was common across studies.

Ambivalence About Addiction to Smoking

Many participants expressed uncertainty about whether they were addicted to smoking, or as to the nature or strength of their addiction. This was particularly the case for adolescent smokers. 54 , 59 , 70 , 71 While an acknowledgement of addiction in some form was common, views on what this meant varied widely. Where addiction was challenged, alternative discourses of smoking were often employed, commonly that it was primarily a social activity. ‘Social smoking’ was presented as an alternative to addiction, for example, “I do have a craving like other people, but it’s more a social thing really” 55 or as a precursor to addiction from which smoking progresses to become “more than just sitting with friends.” 55 One participant stated that the social aspects were as addictive as nicotine: “it is a social aspect of their life that they have become dependent on, as much as the nicotine, you know. I think the social setting of it all is something that is somewhat addictive itself.” 63 Adolescents in particular frequently referenced the social aspects of smoking.

“Habit” was another frequently employed term across studies. While its meaning was not often elaborated on, several studies suggested that smokers associated it with regular and repeated smoking. Yet, how this relates to “addiction” was often unclear due to the varied use of the term both within and across studies. Phrases such as, “I think it’s a habit, it’s not really an addiction …”; “probably an addiction now, it used to be a habit, but now it’s not” 55 ; and “not a habit, it’s an addiction,” 56 seem to suggest a dichotomy, in which “habit” is conceived as a distinctly different phenomenon to “addiction.” 56 , 63 However, other examples reveal less simplistic conceptualizations of the addiction/habit divide.

(. . .) It’s like it’s a drug, it’s er addictive, er I do enjoy it sometimes um, I suppose really it’s become part of my life, it’s a habit really . . . I think if you haven’t had a fag for a long time the first fag you have is like a stimulant, it’s um goes straight into the bloodstream and goes to the brain . . . I think it relaxes people um and I think then it just becomes a habit, a habit-forming er er thing really (. . .). It’s just a habit it’s just a just a really nasty horrible bad habit and I just don’t think I can break out (. . .) 62

Taken together, smokers appear to use the term “habit” to refer to the routine nature to their smoking behavior. While it is sometimes framed as being in contrast to addiction, others refer to it being a sign of addiction.

Across studies there was recognition of the stigma associated with being an addicted smoker. Resisting addiction was seen as a matter of being “strong enough,” 66 revealing a negative perception that “they are weak if they are addicted because they don’t have the willpower to quit.” 59 This conceptualization of addiction more closely aligns with a moral rather than neurobiological framing of addiction.

There was a tendency across studies for participants to use depersonalized language to distance themselves from discussions of their own smoking or addiction. Bottorff et al. 59 explicitly observed this in their interviews with adolescent smokers, and we also found this depersonalization to be common across studies. One example is the limited use of personal pronouns in accounts of addiction, with references to smoking’s effect on “ the body,” “ the brain,” or “ the bloodstream.” 59 , 62 For example, “Your body says you need one at that time; you just can’t ignore what your body says.” 59 Similarly, when discussing addiction, many participants discussed smoking in general terms rather than reflecting on their own smoking. If they did refer to their own smoking, it was often in comparison to “other” smokers who they considered heavier smokers, and more addicted. For example, Farrimond et al. 61 , p.995 stated that some participants made “positive comparisons between themselves as ‘social smokers’ and addicted smokers, for example, by emphasizing their high self-control and external ‘social’ motivation.” Young people used this strategy of distancing themselves from addiction by comparing themselves to older and heavier smokers. 55 , 59

How Do Smokers Understand the Role of Nicotine in Addiction to Smoking?

As described above, feeling a need to smoke was seen as a sign of addiction to smoking. But what aspect of smoking was “needed” was often not clarified. While some participants specifically discussed the role of nicotine, it was uncommon for researchers to probe about nicotine, and many of the discussions about smoking and addiction did not mention it. The chemical composition of cigarettes in general was seen as playing a role in promoting addiction, but participants rarely elaborated on how nicotine contributed to their addiction to cigarettes, and some displayed misunderstandings. For example, one participant implicated the tobacco industry in adding an addictive ingredient to cigarettes, suggesting they were unaware that nicotine is naturally found in tobacco: “If the cigarette manufacturers are putting stuff in the cigarettes that make your body addicted to ‘em, then how are you going to quit?” 57

While nicotine was only occasionally discussed, the physical nature of addiction to smoking was often acknowledged. Cravings were described as when the body “needs the stuff” 62 ; and “is basically crying out for a fag.” 56 Others referred specifically to the brain in describing this physical process, claiming the “brain tricks you” 63 and “forces you to think you need a cigarette.” 59 One participant explained that the brain “is already addicted to it, and the thinking just can’t go away.” 57 These participants often used such physical descriptions to attribute responsibility and development of addiction to the “the body” or “the brain,” situating them as entities external to themselves over which they had little or no control.

Where discussions about the role of nicotine did arise, it was often in the context of comparing tobacco dependence to other drug addictions. For example, “it’s like it’s a drug,” 62 “we’re just junkies, we need nicotine,” 56 “it’s worse than heroin,” 57 or “smokers are preoccupied with where the next nicotine fix is, the nicotine monkey on their backs.” 61 Although, others denied this relationship, claiming they don’t view their relationship to smoking like that of “a heroin addict.” 55

Accounts of addiction that refer to nicotine in the “bloodstream,” 57 , 62 a “chemical dependency” 57 , 62 ; and “tolerance,” 59 reflect—with varying degrees of sophistication—a biomedical understanding of “nicotine dependence.” Participants across studies often presented addiction as a “physical need,” however, we found that physical descriptions of addiction were rarely discussed in isolation from other factors such as family and peer influence. These influences were seen to act at a young age either through access to cigarettes, 59 , 65 children “getting used” to the idea of smoking, 59 , 62 or direct pressure to smoke. 69 A further psychosocial influence that arose was one’s personality, with some mentioning an “addictive personality” 74 or “inner weakness.” 59 , 73 Such a personality was attributed to genetics, immaturity, 59 or one’s mental health status. 73 These discussions implicated a complex web of factors that are seen to mediate addiction, illustrating a common view that tobacco dependence is not caused solely by the brain’s exposure to nicotine.

DiFranza 77 , p.1 has written that “Those who claim to have the power to define nicotine addiction are burdened to provide that they can identify it more accurately than those who live with it every day of their lives.” In this research, we reviewed studies examining smokers’ perceptions and understandings of addiction to smoking. By prioritizing participants’ own views and interpretations, theoretical debates surrounding the nature of addiction to smoking can become grounded in the daily lives and realities of cigarette smokers. The quantitative findings summarized here suggest that most smokers agree that smoking is addictive and that they themselves are addicted to cigarettes. However, when smokers are asked open-ended questions about what addiction means to them, a complex and multidimensional picture emerges. Moreover, there remains a considerable number of smokers who express ambivalence about their own addiction or reject the “addicted” label entirely, even if they believe smoking is addictive for others.

Our qualitative analysis shows that addiction is perceived as a complex process involving relationships between physical processes and sensations, behavioral patterns and the social contexts in which these occur. A feeling of “need” and lack of control over smoking were identified by smokers as the most common signs of addiction, and these align with the “craving” and “loss of control” criteria of the DSM 5. 5 These symptoms that smokers recognize are also consistent with other self-reported data on nicotine addiction, where a developmental sequence of “wanting, craving, needing” was identified during quit attempts. 78 However, smokers often distanced themselves from these symptoms of addiction by referring to addiction in a general way, and using depersonalized terms. Descriptions of smoking as a social practice or habit were sometimes invoked as an alternative to addiction. While the difficulty of quitting was often acknowledged, it was also common for smokers to maintain some sense of autonomy over their smoking. Overall, we found that subjective understandings of smoking were more consistent with the biopsychosocial model of addiction than with more recent models that emphasize the neurobiological or genetic aspects of addiction. 79–81

Largely absent from this literature was a thorough investigation of smokers’ understandings of “nicotine addiction”—as most studies neglected to ask participants specifically about nicotine. It was more common to ask about addiction to smoking, tobacco or cigarettes. Before the emergence of e-cigarettes, nicotine and tobacco were by and large interchangeable since the vast majority of long-term nicotine consumption was in the form of smoking cigarettes. Previous studies may not have specifically explored nicotine separately from other aspects of addiction because addiction to nicotine separated from smoking tobacco was less common. It is important to ask about smoking and cigarettes, as addiction to smoking cannot be reduced to nicotine dependence. However, understanding how smokers conceptualize the role of nicotine in their smoking is more and more important in light of increasing recommendation for smokers to use NRT, and because of the growing market for e-cigarettes, which offer nicotine in a form that could induce and sustain addiction, but without smoking tobacco. Smokers’ attitudes to, and ideas about, nicotine addiction, may influence the uptake and use of nontobacco nicotine products as substitutes for tobacco cigarettes. More specifically, if people do not believe that nicotine plays a central role in their smoking, they may be less likely to use NRT to assist quitting and be less interested in switching to e-cigarettes.

The qualitative studies we reviewed show that smoking is rarely understood primarily through the lens of nicotine addiction. This suggests that a biomedical understanding of addiction to smoking, where nicotine induces neurochemical changes to the brain, which make it very difficult to stop, does not dominate lay beliefs about addiction to cigarettes. These findings are consistent with previous research on how addicted individuals understand the biological basis of their addiction. 15 , 82–84 While the physical aspects of addiction are often acknowledged, smokers’ explanations of addiction are much broader, referring to the role of peers, routine, emotions, habits, inner strength or weakness, and contextual cues. These aforementioned aspects of smoking are not often linked with the mechanisms of nicotine dependence. The role of nicotine in addiction, where it was discussed, was often glossed over, rather than considered in detail. These findings suggest that promises of effective nicotine delivery may not provide sufficient motivation for many smokers to switch from combustible cigarettes to reduced harm alternatives such as NRT or e-cigarettes. Other factors, such as the extent to which e-cigarette use satisfies the social factors that smokers believe contribute to their addiction (eg, the smoking “routine” and sociability) 85 could influence its acceptability as a substitute for smoking. Therefore, the use of e-cigarettes (vaping) as a social practice may be just as important as it’s more functional role of relieving nicotine withdrawal symptoms.

These findings may partly explain the limited uptake of medicinal cessation aids, despite evidence of efficacy from clinical trials, wide availability, promotional advertising and public subsidization to make them more affordable. Cessation medicines may be viewed as addressing only one aspect of addiction (nicotine dependence), which smokers may not consider to be the most important factor driving their addiction. Furthermore, many have written of the increasing stigmatization of smokers that has occurred as tobacco use has become denormalized. 11 , 86–89 The extent to which medicinal cessation aids are associated with notions of substance (nicotine) addiction and the identity of a nicotine addict may make them unattractive to smokers given the techniques used by smokers to distance themselves from “addiction.” 90 This strong association between cigarettes and nicotine, and negative perceptions of being addicted, may also deter some smokers from experimenting with nicotine containing e-cigarettes. 91 Further research on how attitudes toward addiction influence smokers’ choices in relation to quitting smoking would be helpful.

These findings have a number of methodological implications. In limiting our review to literature on smokers’ understandings, the question arose—‘ who is a smoker ?’ How should we classify those who have recently taken up, or stopped smoking, or who smoke regularly but do not classify themselves as smokers? Our approach was to include any studies that claimed to include smokers or ex-smokers and to explicitly report the criteria used to identify and classify their participants. In doing so, we found there was significant diversity in the way that smoking status was classified across the reviewed studies. A number of studies provided either no information on how smokers were classified, or very vague descriptions of smoking status such as ‘known smokers’ 66 or ‘those with recent smoking experience.’ 65 Furthermore, very few studies discussed the rationale or implications of their chosen classifications.

This has a number of implications for interpretations of the above findings. First, adding these disparate classifications to the existing variation between study populations and context resulted in a sample of studies representing a very heterogeneous body of ‘smokers.’ Hence, the reported findings should be interpreted as providing an overall indication of the range of ways in which smokers conceptualize addiction. Further research in this area should ensure that methods for selecting and classifying smokers are reported. This is crucial both for reporting and analytical purposes.

A second methodological issue surrounds variation in the questions used to investigate addiction to smoking. It is likely that the framing of these questions significantly constrained the possible range of responses. For example, studies asking both “is tobacco physically addictive?” and “is tobacco mentally addictive?” presuppose that these are the ways in which addiction is experienced and preclude consideration of other explanations of addiction. While it is necessary to limit responses among large samples of smokers, qualitative literature can inform the most pertinent and useful questions to ask when there is limited scope. Finally, although investigations of addiction were not the primary aim of many studies, addiction consistently arose as a central theme. In the qualitative studies, detailed discussions of addiction sometimes arose from questions exploring smoking in general. This illustrates the significance of the concept of addiction both within smokers’ relationship with smoking as well as smoking research more broadly.

Based on these results, we recommend that researchers should not treat perceptions of addiction to smoking interchangeably with perceptions of addiction to nicotine. There is little research on perceptions of nicotine addiction, and more is needed, particularly considering the increasing use of nontobacco nicotine products and the potential for long-term nicotine maintenance. 19 Researchers should be deliberate in their choice of terms used in surveys and interviews to examine understandings of addiction to smoking and nicotine to improve the clarity of their research findings.

Supplementary data are available at Nicotine and Tobacco Research online.

DP received a UQ Winter Research Scholarship from the UQ School of Public Health to work on this project. KM was supported by an Australian Government Australian Postgraduate Award (APA) scholarship, as well as a top up scholarship from the University of Queensland. CG was supported by a National Health and Medical Research Council Career Development Fellowship (GNT1061978).

None declared.

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College anti-smoking policies and student smoking behavior: a review of the literature

• Brooke L. Bennett 1 ,
• Melodi Deiner 1 &
• Pallav Pokhrel 1  

Tobacco Induced Diseases volume  15 , Article number:  11 ( 2017 ) Cite this article

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Currently, most college campuses across the U.S. in some way address on-campus cigarette smoking, mainly through policies that restrict smoking on campus premises. However, it is not well understood whether college-level anti-smoking policies help reduce cigarette smoking among students. In addition, little is known about policies that may have an impact on student smoking behavior. This study attempted to address these issues through a literature review.

A systematic literature review was performed. To identify relevant studies, the following online databases were searched using specific keywords: Ovid MEDLINE, PsycINFO, PubMed, and Google Scholar. Studies that met the exclusion and inclusion criteria were selected for review. Studies were not excluded based on the type of anti-smoking policy studied.

Total 11 studies were included in the review. The majority of the studies (54.5%) were cross-sectional in design, 18% were longitudinal, and the rest involved counting cigarette butts or smokers. Most studies represented more women than men and more Whites than individuals of other ethnic/racial groups. The majority (54.5%) of the studies evaluated 100% smoke-free or tobacco-free campus policies. Other types of policies studied included the use of partial smoking restriction and integration of preventive education and/or smoking cessation programs into college-level policies. As far as the role of campus smoking policies on reducing student smoking behavior is concerned, the results of the cross-sectional studies were mixed. However, the results of the two longitudinal studies reviewed were promising in that policies were found to significantly reduce smoking behavior and pro-smoking attitudes over time.

More longitudinal studies are needed to better understand the role of college anti-smoking policies on student smoking behavior. Current data indicate that stricter, more comprehensive policies, and policies that incorporate prevention and cessation programming, produce better results in terms of reducing smoking behavior.

Tobacco use, especially cigarette smoking, continues to remain a leading preventable cause of mortality in the United States (U.S.). Across different age-groups, young adults (18–29 year olds) tend to show the highest prevalence of cigarette smoking [ 1 ]. For example, past-30-day prevalence of cigarette smoking among 18–24 year olds is 17%, whereas the prevalence is approximately 9% among high school students [ 2 ]. Although most smokers initiate cigarette smoking in adolescence, young adulthood is the period during which experimenters transition into regular use and develop nicotine dependence [ 1 ]. Young adulthood is also the period that facilitates continued intermittent or occasional smoking [ 3 ], neither of which is safe. In addition to the possibility that intermittent smokers may show escalation in nicotine dependence, intermittent smoking exposes individuals to carcinogens and induces adverse physiological consequences [ 4 ].

Research [ 5 ] shows that smokers who quit smoking before the age of 30 almost eliminate the risk of mortality due to smoking-induced causes. Thus smoking prevention and cessation efforts that target young adults are of importance. Traditionally, tobacco-related primary prevention efforts have mostly focused on adolescents [ 6 ] and have utilized mass media as well as school and community settings [ 7 , 8 ]. This is only natural given that most smoking initiation occurs in adolescence. However, primary and secondary prevention efforts focusing on young adults have been less common. This is particularly of concern because tobacco industry is known to market tobacco products strategically to promote tobacco use among young adults by integrating tobacco use into activities and places that are relevant to young adults [ 9 ].

As more and more young adults attend college [ 10 ], college campuses provide a great setting for primary and secondary smoking prevention as well as smoking cessation efforts targeting young adults. According to the American College Health Association [ 11 ], approximately 29% U.S. college students report lifetime cigarette smoking and 12% report past-30-day smoking. Currently, most college campuses across the U.S. in some way address on-campus cigarette smoking, mainly through policies that restrict smoking [ 12 , 13 ]. One of the main reasons why such policies are considered important is the concern about students’ exposure to secondhand tobacco smoke [ 14 ]. Therefore, at their most rudimentary forms, such policies tend to be extensions of local- or state-level policies restricting smoking in public places [ 15 ]. However, some colleges may take a more comprehensive approach, by integrating, for example, smoke-free policies with anti-smoking campaigns and college-sponsored cessation services [ 16 ]. Further, some colleges may implement plans to enhance enforcement of and compliance to the smoke-free policies [ 17 – 19 ].

At present, there are a number of questions related to college-level anti-smoking policies that need to be examined carefully in order to scientifically inform how colleges can be better utilized to promote smoking prevention and cessation among young adults. Besides the degree of variation in anti-smoking policies, there are questions about students’ compliance with such policies and whether such policies have influence on students’ attitudes and behavior related to cigarette smoking. Past reviews of the studies on the effects of tobacco control policies in general (e.g., not specific to college populations) [ 20 – 22 ] emphasize the need for a review such as the current study. Wilson et al. [ 20 ] found that interventions involving smoke-free public places, mostly restaurants/bars and workplaces, showed a moderate to low effect in terms of reducing smoking prevalence and promoting smoking cessation. The review included three longitudinal studies, none of which showed that the policies had an effect on smoking cessation. Fichtenberg & Glanz [ 21 ] focused on smoke-free workplaces and found that the effects of such policies seemed to depend on their strength. That is, 100% smoke-free policies were found to reduce cigarette consumption and smoking prevalence twice as much as partial smoke-free policies that allowed smoking in certain areas. In a recent exhaustive review, Frazer et al. [ 22 ] found that although national restrictions on smoking in public places may improve cardiovascular health outcomes and reduce smoking-related mortality, their effects on smoking behavior appear inconsistent. There are reasons why college anti-smoking policies may be more effective than policies focused on restaurant/bars or even workplaces. For example, students tend to spend the majority of their time on campus premises. In fact, in the case of 4-year colleges, a large number of students live on or around campus premises. Strong anti-smoking policies may deter students from smoking by making, for example, smoking very inconvenient. However, the current state of research on college anti-smoking policies and student smoking behavior is not well documented.

The purpose of the current study is to systematically review quantitative studies that have investigated the impact of college-level anti-smoking policies on students’ attitudes towards tobacco smoking and smoking behavior. In the process, we intend to highlight the types of research designs used across studies, the types of college and student participants represented across studies, and the studies’ major findings. A point to note is that this review’s focus is on anti-smoking policies and cigarette smoking. Although the review does assess tobacco-free policies in general, our assumption at the outset has been that most studies in the area have had a focus on smoke-free policies and smoking behavior because of the emphasis on secondhand smoke exposure. Smoke-free and tobacco-free policies are different in that smoke-free policies have traditionally targeted smoking only whereas tobacco-free policies that have targeted tobacco use of any kind, including smokeless tobacco [ 23 ]. Both types of policy could be easily extended to incorporate new tobacco products such as the electronic nicotine delivery devices, commonly known as e-cigarettes. Given that e-cigarettes are a relatively new phenomenon in the process of being regulated, we assumed that the studies eligible for the current review might not have addressed e-cigarette use, although if addressed by the studies reviewed, we were open to addressing e-cigarettes and e-cigarette use or vaping in the current review.

Study selection

We searched Ovid MEDLINE (1990 to June, 2016), PubMed (1990 to June, 2016), PsycINFO (1990 to 2013), and Google Scholar databases to identify U.S.-based peer-reviewed studies that examined the effects of college anti-smoking policies on young adults’ smoking behavior. Searches were conducted by crossing keywords “college” and “university” separately with “policy/policies” and “smoking”, “tobacco”, “school tobacco”, “smoke-free” “smoking ban,” and “tobacco free.” Article relevance was first determined by scanning the titles and abstracts of the articles generated from the initial search. Every quantitative study that dealt with college smoking policy was selected for the next round of appraisal, during which, the first and the last authors independently read the full texts of the articles to vet them for selection. Studies were selected for inclusion in the review if they met the following criteria: studies 1) were conducted in the U.S. college campuses, including 2- and 4-year colleges and universities; 2) were focused on young adults (18–25 year olds); 3) focused on implementation of college-level smoking policies; 4) were quantitative in methodology (e.g., case studies and studies based on focus groups and interviews were excluded); and 5) directly (e.g., self-report) or indirectly (e.g., counting cigarette butts on premises) assessed the cigarette smoking behavior. References and bibliographies of the articles that met the inclusion criteria were also carefully examined to locate additional, potentially eligible studies.

Selected studies were reviewed independently by the first and the last authors in terms of study objectives, study design (i.e., cross-sectional or longitudinal), data collection methods, participant characteristics, U.S. region where the study was conducted, college type (e.g., 2- year vs. 4-year), policies examined and the main study findings. The review results independently compiled by the two authors were compared and aggregated after differences were sorted out and a consensus was reached.

Study characteristics

Figure  1 depicts the path to the final set of articles selected for review. Initial searches across databases resulted in total 71 titles and abstracts related to college smoking policies. Of these, 49 were deemed ineligible at the first phase of evaluation. The remaining 22 articles were evaluated further, of which, 11 were excluded eventually. Two studies [ 24 , 25 ] were excluded because these studies did not assess students’ tobacco use behavior. One study [ 26 ] was excluded because it was not quantitative. Five studies [ 17 – 19 , 27 , 28 ] were excluded because the studies focused on compliance to existing smoking policies and did not assess the impact of policies on behavior. One study [ 15 ] was excluded because although it studied college students, the smoking policies examined were county-wide rather than college-level. Two studies [ 29 , 30 ] were excluded because their samples consisted of college personnel rather than students. Thus, a total of 11 studies were included in the current review.

Chart depicting selection of the final set of articles reviewed

Table  1 summarizes the selected studies in terms of research purpose, study design, subjects, type of college, region, policies and findings. The majority of the studies were conducted in the Midwestern ( n  = 3; 27.3%) or Southeastern United States ( n  = 3; 27.3%). Other regions represented across studies were Southern ( n  = 2; 18.1%), Northwestern ( n  = 2; 18.1%), and Western United States ( n  = 1; 9.1%). Six studies (54.5%) included predominantly White participants (i.e., greater than 70%), and 2 studies (18%) included predominantly female participants. Nationally, women and Whites comprise 56% and 59% of the U.S. college student demographics, respectively [ 10 ]. Two studies (18.1%) assessed smoking behavior indirectly by counting cigarette butts on college premises, counting the number of individuals smoking cigarettes in campus smoking “hotspots,” or counting the number of smokers who utilized smoking cessation services. Across studies, the sample size ranged between N  = 36 and N  = 13,041. The mean and median sample sizes across studies were 3102 (SD = 4138) and 1309, respectively. Participants tended to range between 18 and 30 years in age. The majority of the studies ( n  = 6; 54.4%) were cross-sectional in design. Only 2 (18%) of the studies were longitudinal. The majority of the studies were conducted at 4-year colleges ( n  = 10; 90.9%). Only 1 study was conducted at a 2-year college ( n  = 1; 9.1%).

Three studies (27%) focused on tobacco-free policies and 3 studies (27%) on smoke-free policies. Three studies ( n  = 3; 27.3%) compared the associations of differing policies on smoking behavior. One study [ 31 ] examined the relative impacts of policies utilizing preventive education, smoking cessation programs, and designated smoking areas or partial smoking restriction. Another study [ 32 ] implemented an intervention to increase adherence to a partial smoking policy (i.e., smoking ban within 25 ft of buildings). The intervention involved increasing anti-tobacco signage, moving receptacles, marking the ground, and distributing reinforcements and reminder cards.

Anti-smoking policies and students’ smoking behavior

Table  1 lists the types of anti-smoking policies examined across studies and the corresponding findings. Major findings are as follows:

Partial smoking restriction

Borders et al. [ 31 ] compared colleges that utilized partial smoking restriction by providing “designated smoking areas” to curb smoking with college-level policies that incorporated preventive education and with those that provided smoking cessation courses only. Results indicated that the presence of preventive education was associated with lower odds of past-30-day smoking whereas the presence of designated smoking areas only or smoking cessation programs only was associated with higher odds of past-30-day smoking. Fallin et al. [ 16 ] found that college campuses with designated smoking areas tended to show higher prevalence of smoking, compared with campuses that enforced smoke-free and tobacco-free policies. Braverman et al.’s [ 33 ] findings indicate that enforcing smoke-free policies tends to reduce secondhand exposure close to college buildings but may increase smoking behavior on the campus periphery.

Smoke- and tobacco-free campuses

Fallin et al. [ 16 ] found that compared with policies that relied on partial smoking restriction, tobacco-free policies were associated with reduced self-reported exposure to secondhand smoke as well as students’ lower self-reported intentions to smoke cigarettes in the future. Studies [ 34 , 35 ] consistently observed fewer cigarette butts or smokers in campuses under smoke-free policies compared with campuses without smoke-free policies. Prevalence of cigarette butts was likely to be inversely related to policy strength [ 35 ]. A study that monitored smokers’ behavioral compliance to smoke-free policies [ 32 ] indicated that interventions to promote compliance, such as use of signage, are likely to be effective in improving compliance and reducing student smoking in areas were the policy is enforced.

Lechner et al. [ 36 ] conducted assessments at a single college campus before and after a tobacco-free policy went into implementation. The policy, which also involved making smoking cessation services available campus-wide, was found to reduce proportions of high- and low-frequency smokers, pro-smoking attitudes (i.e., weight loss expectancy), and exposure to second-hand tobacco smoke [ 36 ]. The study did not find an effect on smoking prevalence. Seo et al. [ 37 ] followed a similar design where a policy intervention was evaluated based on pretest and posttest surveys. However, this study [ 37 ] included a “control” campus where similar assessments as in the “treatment” campus were conducted but no intervention was implemented. The study found that compared with the control campus, the campus that implemented smoke-free policies showed an overall decrease in smoking prevalence.

Other policies

Borders et al. [ 31 ] did not find policies governing the sales and distribution of cigarettes on campus to be associated with smoking behavior. Hahn et al. [ 38 ] found that college smoking policies that integrate smoking cessation services may increase the use of such services as well as promote smoking cessation. This study kept track of students who utilized the smoking cessation service offered by a college after the policy offering such a service was enacted. Sixteen months after the policy was first implemented, smokers who utilized the service were surveyed. Based the results it was estimated that approximately 9% of them had quit smoking.

To our knowledge, this is the first study to systematically review studies examining the effects of anti-smoking policies on smoking behaviors among U.S. college students. We found that such studies are severely limited. Only 11 studies met the inclusion criteria in the present review, although the review appeared to encompass all policies aimed at smoking behavior on college campuses. Thus, this review stresses the need for increased smoking policy and smoking behavior research on college campuses.

Rigorous evaluation of existing college anti-tobacco policies are needed to refine and improve the policies so that national-level efforts to reduce tobacco use among young adults are realized. Key initiatives at the national level have recognized the importance of mobilizing college campuses in the fight against tobacco use. For example, in September 2012 several national leaders involved in tobacco control efforts, in collaboration with the ACHA, came together to launch the Tobacco-Free College Campus Initiative (TFCCI) [ 39 ]. The TFCCI aims to promote and support the use of college-level anti-tobacco policies as a means to change pro-tobacco social norms on campuses, discourage tobacco use, protect non-smokers from second-hand exposure to tobacco smoke and promote smoking cessation. The ACHA’s position statement [ 11 ] regarding college tobacco control recommends a no tobacco use policy aimed towards achieving a 100% indoor and outdoor campus-wide tobacco-free environment.

We found that the majority of studies on smoking policies were cross-sectional in nature. Researchers relied upon students to report their smoking behavior or their observations of other students’ smoking behavior after a smoke-free or tobacco-free policy had been implemented. It is difficult to draw conclusions about an anti-smoking policy’s ability to change smoking behavior without knowing the smoking behavior prior to policy implementation. This domain of research would benefit from additional longitudinal studies. Ideally, research studies should collect data before the policy is implemented, immediately after, and at follow-up time points.

We found inconsistencies in the measurement of smoking behavior across studies. Two studies [ 34 , 35 ] counted cigarette butts, one study [ 38 ] counted people seeking tobacco dependence treatment, one study [ 32 ] counted smokers violating policy, and seven studies [ 16 , 31 , 36 , 37 , 40 , 41 ] relied upon self-report of smoking behavior. Another study [ 33 ] used survey methods to obtain participants’ response on other students’ smoking behavior. Counting cigarette butts has been validated as an effective measure of smoking behavior [ 19 ], especially when validating compliance to an anti-smoking policy, and self-report measures are commonly used in public health research [ 42 ]. Despite the validity and feasibility of these measures, the lack of a consistent measurement tool makes comparing effectiveness of anti-smoking policies on smoking behaviors across campuses difficult. Research in this domain would benefit from a consistently used measurement of smoking behaviors.

Although the reviewed studies represented diverse U.S. regions, the majority of the research was set in the Southeastern and Midwestern United States; Northeastern and Southwestern regions were not represented. Only one of the reviewed studies reported a sample that contained less than 50% White participants. Across studies, the minority group most represented was Asian American; but only one of the reviewed studies [ 16 ] included 20% or more Asian Americans. Relatively few studies included or reported Hispanic participants, although Hispanics are the largest minority group in the United States [ 43 ]. None of the reviewed studies included 20% or more Black participants. Only three studies [ 33 , 36 , 37 ] included American Indian/Alaska Natives and in only one of those studies [ 32 ] was the proportion greater than one percent. Only two studies [ 33 , 37 ] included Pacific Islanders, and in both the proportion was less than one percent. Clearly, more research is needed on minority populations, specifically Black, Hispanic, Native Hawaiian/Pacific Islander, American Indian/Alaska Native students and the subgroups commonly subsumed under these ethnic/racial categories. The U.S. college student demography is ethnically/racially diverse [ 10 ], comprising 59% Whites. The remaining 44% include various minority groups. Thus, for research on U.S. college students across the nation, studies with more ethnically/racially diverse student samples are needed.

The review findings were helpful in elucidating the types of tobacco policies being implemented on college campuses and their effects on the smoking behavior of U.S. college students. Mainly, three types of smoking policies were studied: smoke-free policies, tobacco-free policies and policies that enforced partial smoking restriction, including prohibition of smoking within 20–25 ft of all buildings and providing designated smoking areas. Indeed, campus-wide indoor and outdoor tobacco-free policy is considered a gold-standard for college campus tobacco control policy [ 11 ]. But only one study [ 16 ] compared tobacco-free and smoke-free policies. Other policies such as governing the sale and distribution of tobacco products, preventive education programs, and smoking cessations programs were also studied, but to a lesser extent. In general, interventions regarding the implementation of smoking policies on college campuses were difficult to find in the existing literature.

The combined results of the studies reviewed suggest that stricter smoking policies are more successful in reducing the smoking behavior of students. Tobacco-free and smoke-free policies were linked with reduced smoking frequency [ 16 , 36 , 37 ], reduced exposure to second-hand smoke [ 16 , 36 ], and a reduction in pro-smoking attitudes [ 36 ]. Implementation of a campus-wide tobacco-free or smoke-free policy combined with access to smoking cessation services was also associated with increased quit attempts [ 38 , 40 ] and treatment seeking behaviors [ 38 ]. It appears that 100% smoke-free policies are not only successful in reducing smoking rates, but also have strong support from students and staff members alike [ 33 ]. These results remained consistent when compared to less comprehensive tobacco control policies, which was evidenced by student report and the number of cigarette butts found on campus [ 34 , 35 ].

There was one important consistent exception to the general success of anti-smoking policies: designated smoking areas. All three studies which included designated smoking areas [ 16 , 31 , 41 ] found that designated smoking areas were associated with higher rates of smoking compared with smoke-free or tobacco-free policies. Designated smoking areas were also associated with the highest rates of recent smoking [ 16 ]. Lochbihler, Miller, and Etcheverry [ 41 ] proposed that students using the designated areas were more likely to experience positive effects of social interaction while smoking. They found that social interaction while smoking on campus significantly increased the perceived rewards associated with smoking and the frequency of visits to designated smoking areas [ 41 ].

None of the studies included in this review addressed new and emerging tobacco products such as e-cigarettes. This is understandable given that the surge in e-cigarette use is relatively new and in general there have only been a few studies examining the effects of anti-smoking policies on student smoking behavior, which has been the focus of this review. However, going forward, it will be crucial for studies to examine how campus policies are going to handle e-cigarette use, including the enforcement of on-campus anti-smoking policies given the new challenges posed by e-cigarette use [ 44 ]. For example, e-cigarette use is highly visible, the smell of the e-cigarette vapor does not linger in the air for long and e-cigarette consumption does not result in something similar to cigarette butts. These characteristics are likely to make the monitoring of policy compliance more difficult. Moreover, because of the general perception among e-cigarette users that e-cigarette use is safer than cigarette smoking, compared with cigarette smokers smoking cigarettes, e-cigarette users might be more likely to use e-cigarettes in public places. The fact that the TFCCI strongly recommends the inclusion of e-cigarettes in college tobacco-free policies [ 39 ] bodes well for the future of college health.

The current study has certain limitations. It is possible that this review might have missed a very small number of eligible studies. We believe that the literature searches we completed were thorough. However, new studies are regularly being published and the possibility that a new, eligible study may have been published after we completed our searches cannot be ignored. In addition, we may not have tapped eligible studies that were in press during our searches. If indeed a few eligible studies were not included in our review, the non-inclusion may have biased our results somewhat, although it is difficult for us to speculate the nature of such a bias. Hence, we recommend that similar studies need to be conducted in the future to periodically review the literature. Second, non-peer-reviewed articles or book chapters were excluded from this review. Despite the potential relevance of non-peer-reviewed materials, the choice was made to limit the inclusion in order to maintain scientific rigor of the review. However, it is possible that some data pertinent to the review might have been overlooked because of this, thus increasing the possibility of introducing a bias to the current findings. Third, this study focused on anti-smoking policies. Although we used “tobacco free” as search terms, “smoking” dominated our search strategies. Thus our results are more pertinent to cigarette smoking than other tobacco products and may not generalize to the latter. Lastly, in order to be as inclusive as possible, we reviewed three studies [ 32 , 35 , 38 ] that focused on more on compliance to anti-smoking policy than on the effect of policy on student smoking behavior. The findings of these studies may not be comprehensive in regard to student smoking behavior, even though they are indicative of the success of the policies under examination.

Conclusions

Despite limitations, this study is significant for increasing the understanding of smoking policies on U.S. college campuses and their effects on the smoking behavior of college students. We found that research on smoking policies on U.S. college campuses is very limited and is an area in need of additional research contribution. Within existing research, the majority used samples that were primarily White females. More diverse samples are needed. Future research should also report the full racial/ethnic characteristics of their samples in order to identify where representation may be lacking. Future research would benefit from longitudinal and interventional studies of the implementation of smoking policies. The majority of current research is cross-sectional, which does not provide the needed data in order to make causal statements about anti-smoking policies. Lastly, existing research was primarily conducted at 4-year colleges or universities. Future research would benefit from broadening the target campuses to include community colleges and trade schools. Community colleges provide a rich and unique opportunity to collect data on a population that is often older and more racial diverse than a typical 4-year college sample [ 45 ]. Also, there is at present a need to understand through research how evidence-based implementation and compliance strategies can be utilized to ensure policy success. A strong policy on paper does not often translate into a strong policy in action. Thus, comparing policies on the strength of written documents alone is not enough; policies need to be compared on the extent to which they are enforced as well as the impact they have on student behavior.

This review may be of particular interest to college or universities in the process of making their own anti-smoking policies. The combined results of the existing studies on the impact of anti-smoking policies on smoking behaviors among U.S. college students can help colleges and universities make informed decisions. The existing research suggests that stricter policies produce better results for smoking behavior reduction and with smoking continuing to remain a leading preventable cause of mortality in the U.S. across age-groups [ 1 ], college and university policy makers should take note. Young adults (18–25 year olds) show the highest prevalence of cigarette smoking [ 1 ], which places colleges and universities in the unique position to potentially intervene through restrictive anti-smoking policies on campus.

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Acknowledgements

Not applicable.

This research was supported by National Cancer Institute (NCI) grant 1R01CA202277-01.

Availability of data and materials

Data sharing not applicable to this article as no datasets were generated during the current study. All articles that contributed to the results and conclusions of the current study are included in the reference list.

Authors’ contributions

BB conducted the literature review, analyzed and interpreted results, and was a major contributor in writing the manuscript. MD assisted with the literature review. PP conceptualized the study, assisted with the literature review and manuscript preparation, and provided overall guidance. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

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Bennett, B.L., Deiner, M. & Pokhrel, P. College anti-smoking policies and student smoking behavior: a review of the literature. Tob. Induced Dis. 15 , 11 (2017). https://doi.org/10.1186/s12971-017-0117-z

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• Young adults
• Cigarette smoking

Tobacco Induced Diseases

ISSN: 1617-9625

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Psychological Health and Smoking in Young Adulthood: Smoking Trajectories and Responsiveness to State Cigarette Excise Taxes

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• March 19, 2019
• Affiliation: Gillings School of Global Public Health, Department of Health Behavior
• While smoking rates have significantly decreased among the general population in the past several decades, they have not significantly decreased among those with poorer psychological health. As posited by theories such as the Transactional Model of Stress and Coping, smoking may represent an important coping mechanism for individuals who experience stress or unpleasant feelings related to poorer psychological health. If poorer psychological health is experienced during young adulthood, a critical time for tobacco use experimentation and uptake, individuals may be particularly likely to become dependent on nicotine and develop longer term smoking habits. In addition, tobacco control policies that have reduced tobacco use in the general population, like raising the price of cigarettes, may be less effective among people with poorer psychological health. Using two indicators of psychological health, a continuum of psychological distress and ever diagnosis of a mental illness, this dissertation explored first, how psychological health accounts for variability within and between individuals in trajectories of smoking (status and amount) across the ages of 18 to 30, and second, whether psychological health moderates the effectiveness of cigarette excise taxes in preventing and reducing smoking. Using a longitudinal national sample across years 2007 to 2013, between-individual effects were found such that individuals with poorer psychological health were more likely to be smokers and to smoke greater numbers of cigarettes over young adulthood than those with better psychological health (Aim 1 and Aim 2). Additionally, the positive effect of having a diagnosed mental illness on smoking amount increased with age, suggesting older young adults may be important targets for intervention (Aim 1). While the effect of cigarette excise taxes encouragingly was not shown to differ by psychological health, cigarette excise taxes showed little effect on smoking at all, perhaps suggesting taxes need to be raised higher than they have been to meaningfully impact smoking (Aim 2). Interventions should aim to target high-risk young adults with poorer psychological health to treat unpleasant psychological symptoms simultaneously with smoking prevention and cessation programs. Overall, this work helps us understand the relationships between psychological health, smoking, and tobacco control policy, with implications for interventions.
• psychological distress
• mental health
• Health sciences
• Mental health
• tobacco control
• public health
• young adults
• https://doi.org/10.17615/ef4w-5738
• Dissertation
• In Copyright
• Ribisl, Kurt
• Ennett, Susan
• Gottfredson, Nisha
• Golden, Shelley
• Aiello, Allison
• Doctor of Philosophy
• University of North Carolina at Chapel Hill Graduate School

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235 Smoking Essay Topics & Examples

Looking for smoking essay topics? Being one of the most serious psychological and social issues, smoking is definitely worth writing about.

🏆 Best Smoking Essay Examples & Topic Ideas

🥇 good titles for smoking essay, 👍 best titles for research paper about smoking, ⭐ simple & easy health essay titles, 💡 interesting topics to write about health, ❓ essay questions about smoking.

In your essay about smoking, you might want to focus on its causes and effects or discuss why smoking is a dangerous habit. Other options are to talk about smoking prevention or to concentrate on the reasons why it is so difficult to stop smoking. Here we’ve gathered a range of catchy titles for research papers about smoking together with smoking essay examples. Get inspired with us!

Smoking is a well-known source of harm yet popular regardless, and so smoking essays should cover various aspects of the topic to identify the reasons behind the trend.

You will want to discuss the causes and effects of smoking and how they contributed to the persistent refusal of large parts of the population to abandon the habit, even if they are aware of the dangers of cigarettes. You should provide examples of how one may become addicted to tobacco and give the rationales for smokers.

You should also discuss the various consequences of cigarette use, such as lung cancer, and identify their relationship with the habit. By discussing both sides of the issue, you will be able to write an excellent essay.

Reasons why one may begin smoking, are among the most prominent smoking essay topics. It is not easy to begin to enjoy the habit, as the act of smoke inhalation can be difficult to control due to a lack of experience and unfamiliarity with the concept.

As such, people have to be convinced that the habit deserves consideration by various ideas or influences. The notion that “smoking is cool” among teenagers can contribute to the adoption of the trait, as can peer pressure.

If you can find polls and statistics on the primary factors that lead people to tweet, they will be helpful to your point. Factual data will identify the importance of each cause clearly, although you should be careful about bias.

The harmful effects of tobacco have been researched considerably more, with a large body of medical studies investigating the issue available to anyone.

Lung cancer is the foremost issue in the public mind because of the general worry associated with the condition and its often incurable nature, but smoking can lead to other severe illnesses.

Heart conditions remain a prominent consideration due to their lethal effects, and strokes or asthma deserve significant consideration, as well. Overall, smoking has few to no beneficial health effects but puts the user at risk of a variety of concerns.

As such, people should eventually quit once their health declines, but their refusal to do so deserves a separate investigation and can provide many interesting smoking essay titles.

One of the most prominent reasons why a person would continue smoking despite all the evidence of its dangers and the informational campaigns carried out to inform consumers is nicotine addiction.

The substance is capable of causing dependency, a trait that has led to numerous discussions of the lawfulness of the current state of cigarettes.

It is also among the most dangerous aspects of smoking, a fact you should mention.

Lastly, you can discuss the topics of alternatives to smoking in your smoking essay bodies, such as e-cigarettes, hookahs, and vapes, all of which still contain nicotine and can, therefore, lead to considerable harm. You may also want to discuss safe cigarette avoidance options and their issues.

Here are some additional tips for your essay:

• Dependency is not the sole factor in cigarette consumption, and many make the choice that you should respect consciously.
• Cite the latest medical research titles, as some past claims have been debunked and are no longer valid.
• Mortality is not the sole indicator of the issues associated with smoking, and you should take chronic conditions into consideration.

Find smoking essay samples and other useful paper samples on IvyPanda, where we have a collection of professionally written materials!

• How Smoking Is Harmful to Your Health The primary purpose of the present speech is to inform the audience about the detrimental effects of smoking. The first system of the human body that suffers from cigarettes is the cardiovascular system.
• Conclusion of Smoking Should Be Banned on College Campuses Essay However, it is hard to impose such a ban in some colleges because of the mixed reactions that are held by different stakeholders about the issue of smoking, and the existing campus policies which give […]
• Smoking: Problems and Solutions To solve the problem, I would impose laws that restrict adults from smoking in the presence of children. In recognition of the problems that tobacco causes in the country, The Canadian government has taken steps […]
• Should Smoking Be Banned in Public Places? Besides, smoking is an environmental hazard as much of the content in the cigarette contains chemicals and hydrocarbons that are considered to be dangerous to both life and environment.
• Advertisements on the Effect of Smoking Do not Smoke” the campaign was meant to discourage the act of smoking among the youngsters, and to encourage them to think beyond and see the repercussions of smoking.
• Should Cigarettes Be Banned? Essay Banning cigarette smoking would be of great benefit to the young people. Banning of cigarette smoking would therefore reduce stress levels in people.
• Quitting Smoking: Strategies and Consequences Thus, for the world to realize a common positive improvement in population health, people must know the consequences of smoking not only for the smoker but also the society. The first step towards quitting smoking […]
• Smoking Cigarette Should Be Banned Ban on tobacco smoking has resulted to a decline in the number of smokers as the world is sensitized on the consequences incurred on 31st May.
• On Why One Should Stop Smoking Thesis and preview: today I am privileged to have your audience and I intend to talk to you about the effects of smoking, and also I propose to give a talk on how to solve […]
• Smoking and Its Effects on Human Body The investigators explain the effects of smoking on the breath as follows: the rapid pulse rate of smokers decreases the stroke volume during rest since the venous return is not affected and the ventricles lose […]
• Causes and Effects of Smoking Some people continue smoking as a result of the psychological addiction that is associated with nicotine that is present in cigarettes.
• Smoking Cessation Programs Through the Wheel of Community Organizing The first step of the wheel is to listen to the community’s members and trying to understand their needs. After the organizer and the person receiving treatment make the connection, they need to understand how […]
• Hookah Smoking and Its Risks The third component of a hookah is the hose. This is located at the bottom of the hookah and acts as a base.
• Peer Pressure and Smoking Influence on Teenagers The study results indicate that teenagers understand the health and social implications of smoking, but peer pressure contributes to the activity’s uptake.
• Ban of Tobacco Smoking in Jamaica The first part of the paper will address effects of tobacco smoking on personal health and the economy. Cognizant of its international obligation and the aforementioned health effects of tobacco smoke, Jamaica enacted a law […]
• Teenage Smoking and Solution to This Problem Overall, the attempts made by anti-smoking campaigners hardly yield any results, because they mostly focus on harmfulness of tobacco smoking and the publics’ awareness of the problem, itself, but they do not eradicate the underlying […]
• Smoking Among Teenagers as Highlighted in Articles The use of tobacco through smoking is a trend among adolescents and teenagers with the number of young people who involve themselves in smoking is growing each day.
• Smoking Cessation and Patient Education in Nursing Pack-years are the concept that is used to determine the health risks of a smoking patient. The most important step in the management plan is to determine a date when the man should quit smoking.
• “Thank You For Smoking” by Jason Reitman Film Analysis Despite the fact that by the end of the film the character changes his job, his nature remains the same: he believes himself to be born to talk and convince people.
• Smoking and Its Negative Effects on Human Beings Therefore, people need to be made aware of dental and other health problems they are likely to experience as a result of smoking.
• Aspects of Anti-Smoking Advertising Thus, it is safe to say that the authors’ main and intended audience is the creators of anti-smoking public health advertisements.
• Health Care Costs for Smokers Higher Tobacco taxes Some of the smokers have the same viewpoint that the current level of taxes imposed on the tobacco is high, 68%, and most of them, 59%, are in agreement for the increase […]
• Smoking: Effects, Reasons and Solutions This presentation provides harmful health effects of smoking, reasons for smoking, and solutions to smoking. Combination therapy that engages the drug Zyban, the concurrent using of NRT and counseling of smokers under smoking cessation program […]
• Cigarette Smoking in Public Places Those who argue against the idea of banning the smoking are of the opinion that some of them opt to smoke due to the stress that they acquire at their work places.
• The Change of my Smoking Behavior With the above understanding of my social class and peer friends, I was able to create a plan to avoid them in the instances that they were smoking.
• Health Promotion for Smokers The purpose of this paper is to show the negative health complications that stem from tobacco use, more specifically coronary heart disease, and how the health belief model can help healthcare professionals emphasize the importance […]
• Gender-Based Assessment of Cigarette Smoking Harm Thus, the following hypothesis is tested: Women are more likely than men to believe that smoking is more harmful to health.
• Hazards of Smoking and Benefits of Cessation Prabhat Jha is the author of the article “The Hazards of Smoking and the Benefits of Cessation,” published in a not-for-profit scientific journal, eLife, in 2020.
• The Impact of Warning Labels on Cigarette Smoking The regulations requiring tobacco companies to include warning labels are founded on the need to reduce nicotine intake, limit cigarette dependence, and mitigate the adverse effects associated with addiction to smoking.
• Psilocybin as a Smoking Addiction Remedy Additionally, the biotech company hopes to seek approval from FDA for psilocybin-based therapy treatment as a cigarette smoking addiction long-term remedy.
• Investing Savings from Quitting Smoking: A Financial Analysis The progression of interest is approximately $50 per year, and if we assume n equal to 45 using the formula of the first n-terms of the arithmetic progression, then it comes out to about 105 […]
• Smoking as a Community Issue: The Influence of Smoking A review of the literature shows the use of tobacco declined between 1980 and 2012, but the number of people using tobacco in the world is increasing because of the rise in the global population.
• Smoking Public Education Campaign Assessment The major influence of the real cost campaign was to prevent the initiation of smoking among the youth and prevent the prevalence of lifelong smokers.
• Quitting Smoking and Related Health Benefits The regeneration of the lungs will begin: the process will touch the cells called acini, from which the mucous membrane is built. Therefore, quitting the habit of smoking a person can radically change his life […]
• Smoking and Stress Among Veterans The topic is significant to explore because of the misconception that smoking can alleviate the emotional burden of stress and anxiety when in reality, it has an exacerbating effect on emotional stress.
• Smoking as a Predictor of Underachievement By comparing two groups smoking and non-smoking adolescents through a parametric t-test, it is possible to examine this assumption and draw conclusions based on the resulting p-value.
• Smoking and the Pandemic in West Virginia In this case, the use of the income variable is an additional facet of the hypothesis described, allowing us to evaluate whether there is any divergence in trends between the rich and the poor.
• Anti-Smoking Policy in Australia and the US The anti-smoking policy is to discourage people from smoking through various means and promotion of a healthy lifestyle, as well as to prevent the spread of the desire to smoke.
• Smoking Prevalence in Bankstown, Australia The secondary objective of the project was to gather and analyze a sufficient amount of auxiliary scholarly sources on smoking cessation initiatives and smoking prevalence in Australia.
• Drug Addiction in Teenagers: Smoking and Other Lifestyles In the first part of this assignment, the health problem of drug addiction was considered among teens and the most vulnerable group was established.
• Anti-Smoking Communication Campaign’s Analysis Defining the target audience for an anti-smoking campaign is complicated by the different layers of adherence to the issue of the general audience of young adults.
• Smoking Cessation Project Implementation In addition, the review will include the strengths and weaknesses of the evidence presented in the literature while identifying gaps and limitations.
• Smoking Cessation and Health Promotion Plan Patients addicted to tobacco are one of the major concerns of up-to-date medicine as constant nicotine intake leads to various disorders and worsens the health state and life quality of the users.
• Maternal and Infant Health: Smoking Prevention Strategies It is known that many women know the dangers of smoking when pregnant and they always try to quit smoking to protect the lives of themselves and the child.
• A Peer Intervention Program to Reduce Smoking Rates Among LGBTQ Therefore, the presumed results of the project are its introduction into the health care system, which will promote a healthy lifestyle and diminish the level of smoking among LGBTQ people in the SESLHD.
• Smoking: Benefits or Harms? Hundreds of smokers every day are looking for a way to get rid of the noose, which is a yoke around the neck, a cigarette.
• The Culture of Smoking Changed in Poland In the 1980-90s, Poland faced the challenge of being a country with the highest rates of smoking, associated lung cancer, and premature mortality in the world.
• The Stop Smoking Movement Analysis The paper discusses the ideology, objective, characteristics, context, special techniques, organization culture, target audience, media strategies, audience reaction, counter-propaganda and the effectiveness of the “Stop Smoking” Movement.”The Stop Smoking” campaign is a prevalent example of […]
• Health Promotion Plan: Smokers in Mississippi The main strategies of the training session are to reduce the number of smokers in Mississippi, conduct a training program on the dangers of smoking and work with tobacco producers.
• Smoking Health Problem Assessment The effects of smoking correlate starkly with the symptoms and diseases in the nursing practice, working as evidence of the smoking’s impact on human health.
• Integration of Smoking Cessation Into Daily Nursing Practice Generally, smoking cessation refers to a process structured to help a person to discontinue inhaling smoked substances. It can also be referred to as quitting smoking.
• E-Cigarettes and Smoking Cessation Many people argue that e-cigarettes do not produce secondhand smoke. They believe that the e-fluids contained in such cigarettes produce vapor and not smoke.
• Introducing Smoking Cessation Program: 5 A’s Intervention Plan The second problem arises in an attempt to solve the issue of the lack of counseling in the unit by referring patients to the outpatient counseling center post-hospital discharge to continue the cessation program.
• Outdoor Smoking Ban in Public Areas of the Community These statistics have contributed to the widespread efforts to educate the public regarding the need to quit smoking. However, most of the chronic smokers ignore the ramifications of the habit despite the deterioration of their […]
• Nicotine Replacement Therapy for Adult Smokers With a Psychiatric Disorder The qualitative research methodology underlines the issue of the lack of relevant findings in the field of nicotine replacement therapy in people and the necessity of treatment, especially in the early stages of implementation.
• Smoking and Drinking: Age Factor in the US As smoking and drinking behavior were both strongly related to age, it could be the case that the observed relationship is due to the fact that older pupils were more likely to smoke and drink […]
• Smoking Cessation Clinic Analysis The main aim of this project is to establish a smoking cessation clinic that will guide smoker through the process of quitting smoking.
• Cigarette Smoking Among Teenagers in the Baltimore Community, Maryland The paper uses the Baltimore community in Maryland as the area to focus the event of creating awareness of cigarette smoking among the teens of this community.
• Advocating for Smoking Cessation: Health Professional Role Health professionals can contribute significantly to tobacco control in Australia and the health of the community by providing opportunities for smoking patients to quit smoking.
• Lifestyle Management While Quitting Smoking Realistically, not all of the set goals can be achieved; this is due to laxity in implementing them and the associated difficulty in letting go of the past lifestyle.
• Smoking in the Actuality The current use of aggressive marketing and advertising strategies has continued to support the smoking of e-cigarettes. The study has also indicated that “the use of such e-cigarettes may contribute to the normalization of smoking”.
• Analysis of the Family Smoking Prevention and Tobacco Control Act The law ensures that the FDA has the power to tackle issues of interest to the public such as the use of tobacco by minors.
• “50-Year Trends in Smoking-Related Mortality in the United States” by Thun et al. Thun is affiliated with the American Cancer Society, but his research interests cover several areas. Carter is affiliated with the American Cancer Society, Epidemiology Research Program.
• Pulmonology: Emphysema Caused by Smoking The further development of emphysema in CH can lead to such complications caused by described pathological processes as pneumothorax that is associated with the air surrounding the lungs.
• Smoking and Lung Cancer Among African Americans Primarily, the research paper provides insight on the significance of the issue to the African Americans and the community health nurses.
• Health Promotion and Smoking Cessation I will also complete a wide range of activities in an attempt to support the agency’s goals. As well, new studies will be conducted in order to support the proposed programs.
• Maternal Mental Health and Prenatal Smoking It was important to determine the variables that may lead to postpartum relapse or a relapse during the period of pregnancy. It is important to note that the findings are also consistent with the popular […]
• Nursing Interventions for Smoking Cessation For instance, the authors are able to recognize the need to classify the level of intensity in respect to the intervention that is employed by nurses towards smoking cessation.
• Smoking and Cancer in the United States In this research study, data on tobacco smoking and cancer prevalence in the United States was used to determine whether cancer in the United States is related to tobacco smoking tobacco.
• Marketing Plan: Creating a Smoking Cessation Program for Newton Healthcare Center The fourth objective is to integrate a smoking cessation program that covers the diagnosis of smoking, counseling of smokers, and patient care system to help the smokers quit their smoking habits. The comprehensive healthcare needs […]
• Risks of Smoking Cigarettes Among Preteens Despite the good news that the number of preteen smokers has been significantly reducing since the 1990s, there is still much to be done as the effects of smoking are increasingly building an unhealthy population […]
• Public Health Education: Anti-smoking Project The workshop initiative aimed to achieve the following objectives: To assess the issues related to smoking and tobacco use. To enhance the health advantages of clean air spaces.
• Healthy People Program: Smoking Issue in Wisconsin That is why to respond to the program’s effective realization, it is important to discuss the particular features of the target population in the definite community of Wisconsin; to focus on the community-based response to […]
• Health Campaign: Smoking in the USA and How to Reduce It That is why, the government is oriented to complete such objectives associated with the tobacco use within the nation as the reduction of tobacco use by adults and adolescents, reduction of initiation of tobacco use […]
• Smoking Differentials Across Social Classes The author inferred her affirmations from the participant’s words and therefore came to the right conclusion; that low income workers had the least justification for smoking and therefore took on a passive approach to their […]
• Cigarette Smoking Side Effects Nicotine is a highly venomous and addictive substance absorbed through the mucous membrane in the mouth as well as alveoli in the lungs.
• Long-Term Effects of Smoking The difference between passive smoking and active smoking lies in the fact that, the former involves the exposure of people to environmental tobacco smoke while the latter involves people who smoke directly.
• Smoking Cessation Program Evaluation in Dubai The most important program of this campaign is the Quit and Win campaign, which is a unique idea, launched by the DHCC and is in the form of an open contest.
• Preterm Birth and Maternal Smoking in Pregnancy The major finding of the discussed research is that both preterm birth and maternal smoking during pregnancy contribute, although independently, to the aortic narrowing of adolescents.
• Enforcement of Michigan’s Non-Smoking Law This paper is aimed at identifying a plan and strategy for the enforcement of the Michigan non-smoking law that has recently been signed by the governor of this state.
• Smoking Cessation for Patients With Cardio Disorders It highlights the key role of nurses in the success of such programs and the importance of their awareness and initiative in determining prognosis.
• Legalizing Electronic Vaping as the Means of Curbing the Rates of Smoking However, due to significantly less harmful effects that vaping produces on health and physical development, I can be considered a legitimate solution to reducing the levels of smoking, which is why it needs to be […]
• Inequality and Discrimination: Impact on LGBTQ+ High School Students Consequently, the inequality and discrimination against LGBTQ + students in high school harm their mental, emotional, and physical health due to the high level of stress and abuse of various substances that it causes.
• Self-Efficacy and Smoking Urges in Homeless Individuals Pinsker et al.point out that the levels of self-efficacy and the severity of smoking urges change significantly during the smoking cessation treatment.
• “Cigarette Smoking: An Overview” by Ellen Bailey and Nancy Sprague The authors of the article mentioned above have presented a fair argument about the effects of cigarette smoking and debate on banning the production and use of tobacco in America.
• “The Smoking Plant” Project: Artist Statement It is the case when the art is used to pass the important message to the observer. The live cigarette may symbolize the smokers while the plant is used to denote those who do not […]
• Dangers of Smoking While Pregnant In this respect, T-test results show that mean birthweight of baby of the non-smoking mother is 3647 grams, while the birthweight of smoking mother is 3373 grams. Results show that gestation value and smoking habit […]
• The Cultural Differences of the Tobacco Smoking The Middle East culture is connected to the hookah, the Native American cultures use pipes, and the Canadian culture is linked to cigarettes.
• Ban on Smoking in Enclosed Public Places in Scotland The theory of externality explains the benefit or cost incurred by a third party who was not a party to the reasoning behind the benefit or cost. This will also lead to offer of a […]
• How Smoking Cigarettes Effects Your Health Cigarette smoking largely aggravates the condition of the heart and the lung. In addition, the presence of nicotine makes the blood to be sticky and thick leading to damage to the lining of the blood […]
• Alcohol and Smoking Abuse: Negative Physical and Mental Effects The following is a range of effects of heavy alcohol intake as shown by Lacoste, they include: Neuropsychiatric or neurological impairment, cardiovascular, disease, liver disease, and neoplasm that is malevolent.
• Smoking Prohibition: Local Issues, Personal Views This is due to the weakening of blood vessels in the penis. For example, death rate due to smoking is higher in Kentucky than in other parts of the country.
• Ban Smoking in Cars Out of this need, several regulations have been put in place to ensure children’s safety in vehicles is guaranteed; thus, protection from second-hand smoke is an obvious measure that is directed towards the overall safety […]
• Smoking: Causes and Effects Considering the peculiarities of a habit and of a disease, smoking can be considered as a habit rather than a disease.
• Smoking and Its Effect on the Brain Since the output of the brain is behavior and thoughts, dysfunction of the brain may result in highly complex behavioral symptoms. The work of neurons is to transmit information and coordinate messengers in the brain […]
• Smoking Causes and Plausible Arguments In writing on the cause and effect of smoking we will examine the issue from the point of view of temporal precedence, covariation of the cause and effect and the explanations in regard to no […]
• Summary of “Smokers Get a Raw Deal” by Stanley Scott Lafayette explains that people who make laws and influence other people to exercise these laws are obviously at the top of the ladder and should be able to understand the difference between the harm sugar […]
• Smoking Qualitative Research: Critical Analysis Qualitative research allows researchers to explore a wide array of dimensions of the social world, including the texture and weave of everyday life, the understandings, experiences and imaginings of our research participants, the way that […]
• Motivational Interviewing as a Smoking Cessation Intervention for Patients With Cancer The dependent variable is the cessation of smoking in 3 months of the interventions. The study is based on the author’s belief that cessation of smoking influences cancer-treated patients by improving the efficacy of treatment.
• Factors Affecting the Success in Quitting Smoking of Smokers in West Perth, WA Australia Causing a wide array of diseases, health smoking is the second cause of death in the world. In Australia, the problem of smoking is extremely burning due to the high rates of diseases and deaths […]
• Media Effects on Teen Smoking But that is not how an adult human brain works, let alone the young and impressionable minds of teenagers, usually the ads targeted at the youth always play upon elements that are familiar and appealing […]
• Partnership in Working About Smoking and Tobacco Use The study related to smoking and tobacco use, which is one of the problematic areas in terms of the health of the population.
• Causes and Effects of Smoking in Public The research has further indicated that the carcinogens are in higher concentrations in the second hand smoke rather than in the mainstream smoke which makes it more harmful for people to smoke publicly.
• Quitting Smoking: Motivation and Brain As these are some of the observed motivations for smoking, quitting smoking is actually very easy in the sense that you just have to set your mind on quitting smoking.
• Health Effects of Tobacco Smoking in Hispanic Men The Health Effects of Tobacco Smoking can be attributed to active tobacco smoking rather than inhalation of tobacco smoke from environment and passive smoking.
• Smoking in Adolescents: A New Threat to the Society Of the newer concerns about the risks of smoking and the increase in its prevalence, the most disturbing is the increase in the incidences of smoking among the adolescents around the world.
• Smoking and Youth Culture in Germany The report also assailed the Federal Government for siding the interest of the cigarette industry instead of the health of the citizens.
• New Jersey Legislation on Smoking The advantages and disadvantages of the legislation were discussed in this case because of the complexity of the topic at hand as well as the potential effects of the solution on the sphere of public […]
• Environmental Health: Tabaco Smoking and an Increased Concentration of Carbon Monoxide The small size of the town, which is around 225000 people, is one of the reasons for high statistics in diseases of heart rate.
• Advanced Pharmacology: Birth Control for Smokers The rationale for IUD is the possibility to control birth without the partner’s participation and the necessity to visit a doctor just once for the device to be implanted.
• Legislation Reform of Public Smoking Therefore, the benefit of the bill is that the health hazard will be decreased using banning smoking in public parks and beaches.
• Smoking Bans: Protecting the Public and the Children of Smokers The purpose of the article is to show why smoking bans aim at protecting the public and the children of smokers.
• Clinical Effects of Cigarette Smoking Smoking is a practice that should be avoided or controlled rigorously since it is a risk factor for diseases such as cancer, affects the health outcomes of direct and passive cigarette users, children, and pregnant […]
• Public Health and Smoking Prevention Smoking among adults over 18 years old is a public health issue that requires intervention due to statistical evidence of its effects over the past decades.
• Smoking Should Be Banned Internationally The questions refer to the knowledge concerning the consequences of smoking and the opinions on smoking bans. 80 % of respondents agree that smoking is among the leading causes of death and 63, 3 % […]
• Microeconomics: Cigarette Taxes and Public Smoking Ban The problem of passive smoking will be minimized when the number of smokers decreases. It is agreeable that the meager incomes of such families will be used to purchase cigarettes.
• Tobacco Debates in “Thank You for Smoking” The advantage of Nick’s strategy is that it offers the consumer a role model to follow: if smoking is considered to be ‘cool’, more people, especially young ones, will try to become ‘cool’ using cigarettes.
• Alcohol and Smoking Impact on Cancer Risk The research question is to determine the quantity of the impact that different levels of alcohol ingestion combined with smoking behavioral patterns make on men and women in terms of the risks of cancer.
• Indoor Smoking Restriction Effects at the Workplace Regrettably, they have neglected research on the effect of the legislation on the employees and employers. In this research, the target population will be the employees and employers of various companies.
• Hypnotherapy Session for Smoking Cessation When I reached the age of sixty, I realized that I no longer wanted to be a smoker who was unable to take control of one’s lifestyle.
• Social Marketing: The Truth Anti-Smoking Campaign The agreement of November 1998 between 46 states, five territories of the United States, the District of Columbia, and representatives of the tobacco industry gave start to the introduction of the Truth campaign.
• Smoking Experience and Hidden Dangers When my best college friend Jane started smoking, my eyes opened on the complex nature of the problem and on the multiple negative effects of smoking both on the smoker and on the surrounding society.
• South Illinois University’s Smoking Ban Benefits The purpose of this letter is to assess the possible benefits of the plan and provide an analysis of the costs and consequences of the smoking ban introduction.
• Smoking Cessation in Patients With COPD The strategy of assessing these papers to determine their usefulness in EBP should include these characteristics, the overall quality of the findings, and their applicability in a particular situation. The following article is a study […]
• Smoking Bans: Preventive Measures There have been several public smoking bans that have proved to be promising since the issue of smoking prohibits smoking in all public places. This means it is a way of reducing the exposure to […]
• Ban Smoking Near the Child: Issues of Morality The decision to ban smoking near the child on father’s request is one of the demonstrative examples. The father’s appeal to the Supreme Court of California with the requirement to prohibit his ex-wife from smoking […]
• The Smoking Ban: Arguments Comparison The first argument against banning smoking employs the idea that smoking in specially designated areas cannot do harm to the health of non-smokers as the latter are supposed to avoid these areas.
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• v.17(1); 2015 Jan

Cigarette Smoking Behavior and the Related Factors Among the Students of Mashhad University of Medical Sciences in Iran

Ehsan taheri.

1 Neurocognitive Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran

Ahmad Ghorbani

2 Pharmacological Research Center of Medicinal Plants, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran

Maryam Salehi

3 Department of Community Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran

4 Research Center for Patient Safety, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran

Hamid Reza Sadeghnia

5 Department of Pharmacology, Department of New Sciences and Technology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran

Background:

Tobacco consumption is the second major cause of death and the fourth most common risk factor for diseases, worldwide. Epidemiologic studies have traced the use of alcohol, tobacco, and illicit substances among medical students and physicians.

Objectives:

The current study aimed to investigate the prevalence of cigarette smoking and the related factors among the students of medical sciences in Mashhad University of Medical Sciences, Mashhad, Iran.

Patients and Methods:

This cross-sectional study was conducted on 946 health professional students in Mashhad University of Medical Sciences (MUMS, Iran) in autumn 2008. A standard self-administered questionnaire consisting of socio-demographic data, participant smoking status, family and peer smoking, attitudes and beliefs about smoking, awareness of cigarette negative effects and reasons for smoking cessation was used in the current study.

Among the students, 18.3% reported having ever tried or experienced with cigarette smoking. The overall prevalence of cigarette smoking was 9.8% with significant differences in prevalence rates by gender, 17.6% among males and 4.2% among females. Starting and continuing smoking was significantly correlated with the family cigarette consumption habits. The most common reason to start smoking was friends (24.9%) and the most important reason to continue smoking was personal life distress (17.6%). The majority of participants (92.3%) reported that they were aware of the hazards of smoking. A significant difference regarding awareness of smoking hazards was observed between smokers and non-smokers. The most important preventive factor for cigarette smoking was religious beliefs (69.1%).

Conclusions:

Although the prevalence of regular smokers among health professions students of MUMS was lower than general populations, but this level is still alarming and points at the rapid growth of cigarette use, especially among female students. Medical schools should work harder to tackle this phenomenon and address it more efficiently in their curricula.

1. Background

According to the World Health Organization reports (WHO), 22% of the world's population aged over 15 years are smokers and approximately six million people die from tobacco use or exposure to tobacco smoke. Studies in Iran show that about 26% of the Iranian men and 3.6% of the women participating in the study are current smokers ( 1 ). Unfortunately, the prevalence of smoking between college students is higher than in the general population in Iran. With a cross-sectional population-based study, Fotouhi et al. reported that prevalence of smoking in residents of Tehran, capital of Iran, is 12% ( 2 ). On the other hand, Jafari et al. found that among the students of Tehran University, 35.4% of men and 12.6% of women are smokers ( 3 ). The high prevalence of smoking (42.5%) among university students was also reported by other investigators in the Middle-East countries ( 4 ).

Cigarette use among medical students is of particular concern because medically educated persons play a leading role in the development of overall public health policy and the prevention of tobacco use in the society. In some studies on medical students in the developed countries, the smoking rate was 16-21% ( 5 - 8 ). On the other hand, a multi-country survey in the developing countries revealed a smoking prevalence rate of 11%, 6.7%, 10.6%, 17.8% and 17.4% among medical students of Malaysia, India, Pakistan, Nepal and Bangladesh, respectively ( 9 ). Although many researches are conducted in different countries, there have been few researches on cigarette smoking in Iran. Nazary et al. studied the prevalence of smoking among male students in Semnan University of Medical Sciences, Iran, and found a smoking rate of 14.4% ( 10 ). In another study, Ahmadi et al. assessed the prevalence of cigarette smoking among students of Shiraz University of Medical Sciences. The authors reported that 16.79% of males and 0.69% of females were smokers. The internship students showed the highest prevalence of smoking (17%) among the medical students ( 11 ). The preliminary studies highlight the need for performing more investigations on the prevalence and determinants of tobacco use and developing effective cessation interventions for health professional students.

2. Objectives

The current study aimed to investigate the prevalence of active cigarette smoking, socio-demographic data, knowledge and attitudes about cigarette use, exposure to second-hand tobacco smoke, attitude of willingness to stop smoking, etc. among health professional students in MUMS, Mashhad, Iran.

3. Patients and Methods

The current cross-sectional study was conducted on the students of six faculties of MUMS (dentistry, medicine, midwifery and nursing, pharmacy, paramedical sciences and public health) in autumn (October and November) 2008. A standard self-administered questionnaire adopted from the Global Health Professional Survey (GHPS), designed for health professionals by the WHO and the Canadian Public Health Association was used in this study ( 12 ). The questionnaires were distributed to all 1100 students residing in dormitories of MUMS. The inclusion criteria for the analysis were (a) student status, (b) age between 18 and 28 years, (c) consent to participate in the survey, and (d) no missing data for the tobacco-related variables. A total of 936 students met these criteria and completed the information (about 85%). Informed consent was obtained from each participant included in the study and the study protocol conformed to the ethical guidelines of the 1975 Helsinki Declaration. Ethical approval was granted by MUMS Ethics Committee prior to the data collection (ethical approval code: 87685). The study proposal and instruments were approved by the MUMS research committee. Before distributing the questionnaires, the students were informed that the information collected would be kept anonymous and that participation was completely voluntary.

The questionnaire was designed in three parts; the first part consisted of socio-demographic data (age, sex, health professional discipline, marital status and ethnicity), smoking status of their father/mother/other family members, daily exposure to cigarette smoking and participant smoking status (current smokers including daily smokers and occasional smokers and former smokers). The second part of the questionnaire included the data on attitudes towards using or not using cigarettes, age of the smoking onset, reasons to start smoking, reasons to continue smoking, number of cigarettes smoked per day, duration of smoking, places most commonly smoked in, and the number of quit attempts. The third part included the questions regarding the cigarette advertisements and prohibitions, awareness of cigarette negative effects and reasons, smoking cessation, and the reaction of participant in places where there are people who smoke.

In accordance with the WHO guidelines, the students were categorized as daily smokers, occasional smokers, former smokers or nonsmokers. Daily smokers were defined as those who smoked at least one cigarette per day for at least one month before completing the questionnaire; occasional smokers were defined as those who did not smoke daily; former smokers (ex-smokers) were defined as those who previously had a daily smoking habit for a continuous period of six months but had given up smoking at least one month prior to completion of the questionnaire; and nonsmokers were defined as those who had never smoked or who had been smoking for less than one month. No missing values were reported by the investigators. Descriptive data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 17.0. The Chi-square test was used for statistical analysis. The significance level was set at P < 0.05. To assess the independent effect of individual factors, multiple logistic regression analysis was used and odds ratio (OR) with 95% CIs were computed.

Among all 936 students included in the study, 44.6% were male and 55.4% were female ( Table 1 ). The effects of various independent variables on the prevalence rate of cigarette smoking were investigated, and odds ratios were calculated. The overall prevalence of cigarette smoking was 9.8% with significant differences in prevalence by gender; 17.6% among males and 4.2% among females (χ 2 70.57; P < 0.001). Prevalence of smoking did not significantly change according to the year of study: first year, 7%; second year, 8%; third year,8.3%; fourth year, 17%; fifth year, 11%; sixth year, 20%; seventh and over, 6.7% (χ 2 3.49; P > 0.05). Also, the mean age of starting cigarette was 19.6 ± 2.5 and 18.9 ± 2.4 years for male and female students, respectively.

a Abbreviation: CI, confidence interval.

b Data are presented as No. (%).

Among all students, 18.3% (95% CI 8.2-15.4) reported never having tried or experienced cigarette smoking. The prevalence of daily, occasional and former smokers was 9.8%, 3% and 5%, respectively ( Table 2 ). Also, analysis of data showed that men were significantly more likely to become daily smokers than women (18.9% vs. 2.5%; P < 0.001; χ 2 70.57). The onset age of female students who smoked regularly was 18.9 ± 2.4 years, lower but not statistically significant compared to that of male students (19.6 ± 2.56 years). Most of the men (26.6%) and women (44.5%) were smokers for more than four years ( Table 3 ). Also, it was found that 50% of the students had smokers in their family, father, mother, brother or sister ( Table 4 ).

a Data are presented as No. (%).

Table 5 summarizes the reasons of students’ attitudes toward starting and continuing smoking. The most common reasons to start smoking were ranked as follows: friends (24.9%), distress and anxiety due to dormitory residency (23%) or pleasure and fun (22.8%). On the other hands, the most important reasons to continue smoking was personal life distress (17.6%). Most of the smokers (53%) reported that they achieved their goals set prior to the onset of smoking and 18.5% of smokers believed that cigarette smoking was not helpful to achieve their goals, while 28.4% had no knowledge about it. The number of cigarettes per day was 1-5, 6-10, 11-15, and 16-20 cigarettes in 25%, 32%, 17.7% and 25.5% of smokers, respectively. Favorite smoking places were as follows: parks and campus (37.8%), dormitory (18%), no particular places (9.4%), at parties (8%) and bath room (7.1%).

a Data are presented as %.

The majority of participants (92.3%) reported that they were aware of the hazards of smoking. A significant difference regarding awareness of smoking hazards was observed between smokers and non-smokers (χ 2 604.17; P < 0.001). Significant gender differences (χ 2 11.11, P < 0.001) were also found in smoking hazards beliefs. Females (97.9%) were more likely to agree with smoking hazard effects on health than males (85.5%). In the current study, 5% of the participants reported that they have a history of successfully quitting cigarette smoking. They believed that the nisus (50%) was the most important reason to quit smoking. Better knowledge about dangerous effects of cigarette smoking on health (27.8%) and caring for one’s own health (11%) were the most important reasons to quit smoking. Among the smokers, 90% intended to quit smoking, 45.4% had tried to quit smoking without any success, and 54.6% believed themselves able to quit smoking.

All of the nonsmokers stated that they avoided environments where people were smoking, because of complications like respiratory distress (60.6%), hatred toward smoking persons (55.8%), headache (42.5%) and other problems such as nausea and vomiting, coughing and tearing. The most important preventive factors upon cigarette smoking were as follows: religious beliefs (70%), parents (40.2%), knowledge about cigarette-induced health problems (33.4%), information from mass media about the hazards of smoking (19%), and close friends (18.7%).

5. Discussion

The collected data showed that cigarette smoking was common (10%) among medical students in Mashhad. Previous studies in other cities of Iran revealed that prevalence of smoking was 9%, 6%, 11% and 7.4% in Shiraz, Golestan, Kerman and Ardabil Universities of Medical Sciences, respectively ( 13 - 16 ). Therefore, it seems that the prevalence of smoking among Iranian health professional students is approximately in the range of 6% to 11%. Regarding the other countries in the Middle-East, approximately similar prevalence (11%) was found by Almerie et al. among the medical students of Syria ( 17 ). On the other hand, other researchers reported different incidence of smoking among medical students in the United State (20%), Germany (25%), Turkey (22%), Brazil (16.5%), Jordan (28.6) and Hong Kong (0.7%) ( 5 - 8 , 18 , 19 ). Therefore, the prevalence of tobacco smoking in the current sample is still lower than those of medical students in many other countries. Also, a cross-country, cross-sectional study among 12 medical schools in four countries in Europe (Germany, Italy, Poland and Spain) found that the overall prevalence of smoking among medical students (almost 30%) was higher than the general population ( 20 ). On the other hand, the rate of regular smokers in the MUMS is relatively smaller than that of general population in Mashhad city (12.7%) described by Boskabady et al. ( 21 ). According to the current study data, the prevalence of smokers in male students was more than females. Besides, the study found that in Mashhad city, the prevalence of female smokers in students of medical sciences was 17.6% which is markedly higher than that of general population (1.7%) reported by Boskabady et al. ( 21 ). Therefore, this point emphasized the necessity for a quit-smoking plan and a more active approach to prevent smoking among female medical students. Moreover, the average age of starting smoking in the current sample was almost 19 years, which is two years lower than that of general population in Mashhad and Shiraz cities, Iran ( 1 , 22 ). The smoking onset age indicates that most of the participants started smoking after attending the university.

In the current study, the most common reason to start smoking was friends. In agreement with the current study findings, previous studies on medical students in Japan and Albania also reported that friends were the most important factor associated with smoking behavior ( 22 , 23 ). Also in the current study student sample about 50% of the participants had smokers in their family, which again emphasizes on the important role of relatives and friends on starting cigarette smoking. More prevalence of smoking in some ethnicities, particularly Turk and Lor, emphasizes on identifying the ethnicity and cultural factors which influence the smoking behavior and probably manifests the lower knowledge of these groups regarding smoking complications. Sixth-year students had higher prevalence of smoking (20%) than the students in the other study years. Therefore, it seems that the students in the last years of education need a specific training regarding smoking cessation.

Understanding the prevalence and the factors associated with cigarette use among the health professional students is of particular concern because medically educated persons play a leading role in the development of overall public health policy and prevention of tobacco use in the society. Thus, this understanding will aid to design tobacco/substance abuse prevention and control activities in the populations. The present study had also some limitations. Regarding sampling, in order to include as many students as possible, the questionnaires were distributed to the students in dormitories. Living without parents (in dormitories) is accompanied with freedom of previous limitations which can be associated with some changes in individual’s life ( 3 ). Therefore, the prevalence of smoking among the students living in dormitories may not be exactly the same as the general population of MUMS students. Also, under-reporting of smoking was possible, because health professional students may be more sensitized than the other populations to reporting their smoking habits ( 18 , 24 ). In addition, the study used a cross-sectional design to collect data on smoking behavior and related factors and possible bias could have occurred. Smoking among medical students and health professionals is a serious concern because they should play important roles in smoking prevention and in assisting patients to quit smoking. This indicated the necessity of much more attention to educate the health professional students.

In conclusion, although the prevalence of regular smokers among health professions students of MUMS was lower than those of the general populations, this level was still alarming and pointed at the rapid growth towards cigarette use, especially among female students. Medical schools should work harder to tackle this phenomenon and address it more efficiently in their curricula.

Acknowledgments

Authors wish to thank Miss Maryam Masumi for her valuable contribution.

Authors’ Contributions: Hamid Reza Sadeghnia and Ehsan Taheri designed the study, collected data and wrote the first draft of the manuscript. Ahmad Ghorbani and Maryam Salehi performed the statistical analysis, managed the literature searches and reviewed the manuscript. All authors read and approved the final version of the manuscript.

Funding/Support: This work was supported by Mashhad University of Medical Sciences, Iran.