Table 1. Demographic Profile of the Study Participants among Undergraduate University Students (18-25 years) in Khyber Pakhtunkhwa (KP), Pakistan (n=560)
Tobacco use is considered as one of the leading causes of lung cancer and Chronic Obstructive Pulmonary Disease (COPD). The use of tobacco is dependent upon many factors, such as age, sex, social class, education and income. Therefore, the trend of tobacco consumption is shifting from the developed to the developing countries. The purpose of this study was to identify the contributing factors which lead to tobacco use among undergraduate university students (18-25 years). A retrospective Case-Control study was carried out on 560 (280 Cases and 280 Controls) undergraduate students in three universities of Khyber Pukhtunkhwa (KP), Pakistan. Data was collected through a self-filled structured questionnaire, which was analyzed using descriptive and inferential Odd Ratio (OR) statistics, via SPSS Version 19. The data revealed that tobacco use is significantly associated with brothers (OR: 1.81), and other family members (father in law, grandfather, nephew, relatives) (OR: 3.62) who are addicted to tobacco use. Tobacco using friends (OR: 15.39), use of tobacco in university (OR: 4.37), hostel (OR: 3.79), and public places (OR: 1.49) are also significantly associated with tobacco use. Staying in social gatherings (OR: 2.23) where people use tobacco and offer it to others (OR: 7.43) is also linked with tobacco use. Getting impressed by media promotion advertisements (OR: 1.81), and beliefs about the beneficial effects of tobacco use (OR: 2.19) are also significantly related to tobacco use. Furthermore, having personal problems (OR: 1.78), physical / medical diseases (OR: 1.78), and financial problems (OR: 1.57) were also found significantly associated with tobacco use. The study concluded that there are many factors like tobacco using family members, peer pressure, social gatherings where tobacco is used and offered freely, and promotion of tobacco by media, etc., are positively associated with tobacco use among undergraduate university students (18-25 years) in KP, Pakistan.
Tobacco use is considered as one of the leading causes of lung cancer and Chronic Obstructive Pulmonary Disease (COPD) (WHO, 2013). The youth, aged between 18-25 years, play a key role in the development of any society. However, the population in this age group is considered as vulnerable since they are more prone to indulge in unhealthy habits such as tobacco use, alcohol consumption and unprotected sexual activities.
Correspondingly, findings also illustrate increased prevalence of tobacco smoking in the South Asian countries (Dhanani et al., 2011). The prevalence of smokeless tobacco is very high in Pakistan and its consumption is socially acceptable to every age, gender, strata, culture and group (Valliani et al., 2012). A cross sectional study was carried out in Karachi, Pakistan to find out the prevalence of smoking among university students. The data was collected from ten universities and the findings showed that 23 % of the students were smokers (Ahmed et al., 2008).
The use of tobacco is dependent upon many factors, such as age, sex, social class, education and income. Therefore, the trend of tobacco consumption is shifting from the developed to the developing countries. The reasons behind the high prevalence in these countries are lack of awareness, easy accessibility to tobacco products and absence of policies and regulations for its use in educational institutions and public places (Valliani et al., 2012).
A quantitative study was conducted in Saudi Arabia to find out the risk factors of tobacco use. This study revealed that factors which led to tobacco use were; tobacco using parents, sisters, friends, teachers, media involvement, low price and easy availability in the market. Furthermore, availability of tobacco products near schools, colleges and universities were also identified as potential contributing factors (Park et al., 2012). In Pakistan, the young generation uses tobacco in different forms and there are multiple factors which provoke the youth towards tobacco use; these factors include: media advertisements, peer pressure, low price of tobacco stuff, social status and easy availability (Ahmed et al., 2008).
Another study was carried out in three medical colleges of Pakistan and its findings revealed that 21.5 percent of the students had used tobacco in some form in their lifetime; among these students, 6.4% were users of smokeless tobacco (Imam et al., 2007). The use of tobacco is dependent upon many factors, such as age, sex, social class, education and income. In addition, tobacco use is more common in rural and lower socio-economic populations, because they have no awareness regarding its adverse consequences (Thankappan, & Thresia, 2007). Therefore, the trend of tobacco consumption is shifting from the developed to the developing countries. The reasons behind the high prevalence in these countries are lack of awareness, easy accessibility to tobacco products, and absence of policies and regulations for its use in educational institutions and public places (Valliani et al., 2012). The purpose of this study was to identify the contributing factors for tobacco use among university students.
A retrospective case-control study design was used. This study compared the tobacco user students (outcome of interest, cases) with non-tobacco user students (controls) and observed the association of tobacco use with the risk factors present in each group. This study was carried out in 2014.
In Pakistan, Khyber Pukhtunkhwa (KP) is the smallest province in terms of area which is 74,521 square kilometers. The population of KP is 17.744 million, which is 13.4% of the total population of Pakistan (Shah & Baporikar, 2013). In this small province (KP), 24 government and private universities are registered with the Higher Education Commission (HEC), most of which are situated in Peshawar city. The data for the current study was collected from the Institute of Management Sciences (IM Sciences), Iqra National University and Peshawar University. Cases and controls were selected from the same universities at the ratio of 1:1. Eighteen to twenty-five years old, male and female undergraduate students were selected from the Institute of Management Sciences, Iqra National University and Peshawar University. As this age group, i.e. 18 to 25 years is the average age of university students in Pakistan (Sajwani et al., 2009), it was a good representation of the young population.
The non-probability purposeful sampling approach was utilized for this study. The researcher purposely selected the three universities based on interest and accessibility. Study sample size was 560 (280 Cases and 280 Controls) undergraduate students in three universities of Khyber Pukhtunkhwa (KP), Pakistan. The sample size was calculated through the Epi info 7 software. Literature was reviewed to determine the probability of various factors associated with tobacco use among controls; it was found to be 09 % by advertisements, peer pressure 75% and social factors 86%. It was found that the probability of exposure among controls was between 09 percent to 86 percent (Zaman et al., 2002). So, to obtain the maximum sample size, different proportions mentioned in the literature were used. For data collection, a self-structured questionnaire was used after verifying its validity and reliability (Appendix A).
The following inclusion and exclusion criteria were used for recruitment in this study
Inclusion Criteria for Cases:
Male/female students studying in two private (IM Science Institute and Iqra National University) and one government (Peshawar) university of KPK, who are years of age ,can communicate in Urdu and English, are found using one or more form of tobacco on a daily basis for the last three months ,bearing a domicile of KP and willing to participate and sign the informed consent.
Exclusion Criteria:
Those who use alcohol, cocaine or cannabis, those who use tobacco occasionally and not on a daily basis and those who had quit tobacco use.
The content validity index (CVI) of the variables in the questionnaire was calculated after ERC approval. The CVI of the English questionnaire was calculated by a committee of experts (for details, see Appendix A), including two epidemiologists, two nursing instructors and one public health expert. The standard protocol for calculating the CVI was followed (Sajwani et al., 2009). First, the questionnaire was modified, using a four-point Likert scale, for relevance and clarity.
In the beginning, five copies of the questionnaire were distributed to the identified five experts. The CVI of the questionnaire was calculated based on the experts ranking on the likert scale. The first calculated score for the questionnaire's relevance and clarity was 0.80 and 0.85 respectively, based on which modification was done. The same steps were repeated for the second step of CVI and the calculated score for relevance and clarity was 0.90 and 0.91, respectively. Moreover, the experts also provided detailed feedback on the content, related to removal and addition of new variables, which was incorporated.
For reliability, Cronbachs alpha was calculated. For the study questionnaire, the calculated value of Cronbachs alpha was 0.70. The purpose of checking validity and reliability of a questionnaire by experts in the research was to ensure that the questionnaire effectively assessed what it was deemed to assess (Polit & Beck, 2010).
The data was analyzed using the SPSS Version 19. A descriptive analysis (frequencies and percentages) was done for nominal and ordinal data. Odds ratio (OR) was calculated for Cases and Controls to find the association between tobacco use and risk factors. In this study, logistic regression was used to identify the extent of relationship between tobacco use and the identified risk factors, at 95% confidence level. Univariate and multivariate analysis was carried out to study the association between independent variables and tobacco use among the university students. The multivariate analysis of risk factors was done through backward logistic regression for the significant variables, to control the confounders in the study.
A total of 560 students (280 cases and 280 controls) were enrolled as Cases and Controls from the three universities. The students were recruited on the basis of inclusion criteria at the ratio of 1:1 for Cases and Controls. The response rate of Cases and Controls was 100%.
Table 1 highlights the demographic profile of the study participants (Cases and Controls) from the abovementioned universities. In this study, the selected students' age was 18 to 25 years, which was categorized into three groups, based on data presentation. A distinct majority of the students among Cases 136 (48.6%), as well as Controls 135 (48.2%), were between the age of 21-23 years. Moreover, 79 (28.2%) Cases and 118 (42.1%) Controls were in the age range of 18-20 years: followed by 65 (23.2%) Cases and 27 (09.6%) Controls aged 24 years or more (Table 1). Among the study participants, most of the cases, 278 (99.3%), and controls, 227 (81.1%), were male. Furthermore, it is evident from Table 1 that most of the students were single among Cases, 249 (88.9%), and Controls, 265 (94.6%). As far as the study year in the university is concerned, the percentages were roughly similar for Cases, 21.8%, 25.4%, 30%, 22.9%, and Controls, 29.6%, 29.0%, 23.2%, 17.5%, in the 1st, 2nd, 3rd, and 4th years, respectively. A majority of the Cases (76.4%) and Controls (75%) were living in hostels and 23.6% cases and 25.0% controls were living in their homes. All the cases and controls belonged to ten different divisions of KP. Most of the cases (56.1%) and controls (54.2%) belonged to the Peshawar and Malakand division, whereas, 43.9% cases and 45.8% control were from Abbotabad, Bannu, DI Khan, FATA, Hazara, Karak, Kohat, and Mardan division. A greater proportion of the cases (45.0%) and controls (43.2%) families had an average monthly income ranging from 25,000-50,000 Pakistani rupees, whereas, 28.2% cases, 26.8% controls were earning 51,000-100,000 rupees. In addition, 13.6% cases and 17.1% controls families' average monthly income was greater than 100,000 PKR, and13.2 %cases and 12.9% controls' income was less than 25,000 PKR (Table 1).
Table 1. Demographic Profile of the Study Participants among Undergraduate University Students (18-25 years) in Khyber Pakhtunkhwa (KP), Pakistan (n=560)
Table 2 explains the different products of tobacco used by cases in the mentioned universities. Most of the cases (80%) were using cigarette; almost 35% of the cases were engaged in snuffing; whereas a small proportion of cases (11.1%) were using shisha. Also, a small proportion of tobacco users (3.9%) were involved in cigar smoking. These cases had been obsessed with tobacco products (cigarettes, snuffs, shishas and cigars) for 07 months to 12 years.
Table 2. Different Products of Tobacco used by Cases (18-25 years) in the three Universities of Khyber Pakhtunkhwa (KP), Pakistan (n=280)
Table 3 illustrates the association between demographics and tobacco use. Students' age was significantly related with tobacco use (p=0.03). The students whose age was 24 years or more were more likely to be tobacco users as compared to those who were 18-20 years of age (OR=3.59; 95% CI:2.11 - 6.11). On the other hand, the students aged 21-23 years had a lower risk of indulging in tobacco use as compared to those who were 24 years or more (OR=1.50; 95% CI: 1.04 - 2.18). The result also revealed that being married was also significantly associated with tobacco use (OR=2.20; 95% CI: 1.16 – 4.17).
Table 3. Logistic Regression for Demographic Risk Factors of Tobacco Use among Undergraduate University Students (18-25 years) in Khyber Pakhtunkhwa (KP), Pakistan (n=560)
Moreover, an association was also observed between the year of the study in the university and tobacco use. While taking 1st year as reference, the students who were in 3rd or 4th year were found more engaged in tobacco use as compared to the 1st year and 2nd year students [2nd year (OR=1.6; 95% CI: 0.736- 2.18), 3rd year (OR=1.76; 95% CI: 1.11 – 2.79), 4th year (OR=1.78; 95% CI: 1.08 – 2.92)].
Family members' use of tobacco was also statistically linked with tobacco use among the university students. Students who had tobacco using brothers were more likely to be tobacco users themselves (OR=1.81; 95% CI: 1.25 –2.62). Similarly, students who had other family members using tobacco (father in law, grandfather, nephew, relatives) were also involved in tobacco use (OR=3.62; 95% CI: 1.18–11.17) (Table 4).
Table 4. Logistic Regression for Risk Factors of Tobacco Use among Undergraduate University Students (18-25 years) in Khyber Pakhtunkhwa (KP), Pakistan (n=560)
Peer pressure was significantly related to tobacco use among undergraduate university students. Having tobacco using friends in the university was linked with tobacco use among students (OR=15.39; 95% CI: 4.70 –50.38). In fact, having close friends who used tobacco (OR=5.13; 95% CI: 3.44 –7.66) and having friends who compelled tobacco use (OR=1.82; 95% CI: 1.27 –2.61), both were highly related to tobacco use. Furthermore, having a friend circle addicted to tobacco, who used it at the university (OR=4.37; 95% CI: 2.88 –6.64) and at the hostel (OR=3.79; 95% CI: 2.38 – 6.05), was significantly associated with tobacco use. Having friends who were using tobacco in public places was also positively linked with tobacco use (OR=1.49; 95% CI: 1.02 –2.17) (see Table 4).
The univariate analysis showed that the social factor and media were also associated with tobacco use (see Table 4). Staying at social gatherings where people used tobacco (OR=2.23; 95% CI: 1.58 –3.16) and offered it to others (OR=7.49; 95% CI: 4.59 –12.03) was significantly related with tobacco use. Similarly, advertisements through media were also related with tobacco use (OR=1.81; 95% CI: 1.15–2.84).Furthermore, students who assumed that tobacco had beneficial effects on the body (OR=2.19; 95% CI: 1.49 –3.20) were more likely to use tobacco.
As shown in Table 4, having personal problems was significantly (P=0.00) related to tobacco use among undergraduate university students. University students having personal problems (anxiety, career, lack of focus/ concentration, depression, anxiety about the future, issues with girlfriend, loneliness, issues with marriage, study problems) (OR=2.83; 95% CI: 1.93 –4.14) were more likely to use tobacco. The results of this study also revealed that having physical/medical problems (OR=1.78; 95% CI: 1.04 –3.04) was statistically linked with tobacco use. In addition, having a financial crisis was (OR=1.57; 95% CI: 1.12 –2.21) also observed as a factor leading to the habit of using tobacco.
In addition to the above mentioned variables the following variables were also significant, at level p=0.1. Having tobacco using cousins was also significantly related with tobacco use (OR=1.39; 95% CI: 0.98 –1.97).
On the other hand, in this study, families' average monthly income (P=0.961), and tobacco using family members, (P=0.199) father (0.783), mother (P=1.00), sisters (P=0.215), and uncles (P=.272), remained insignificant in relation to tobacco use. Furthermore, watching/reading tobacco promotion advertisements (0.447), problems related to study (0.96), level of satisfaction from academics (0.634), family related stresses (1.00), and political crises (p=0.252) were not found significantly contributing factors towards tobacco use among university students (Table 4).
A multivariable logistic regression analysis has been presented in Table 5. Having a tobacco using brother in the family was found to be an important factor for tobacco use among the young generation. The odds of having a tobacco using brother among cases (tobacco users) were 1.64 times higher as compared to controls (non-tobacco users) (OR=1.64; 95% CI: 1.04 –2.60). Likewise, having close friends using tobacco was found to be a highly significant factor for cases. The odds of having tobacco using close friends among cases were 2.78 times higher as compared to controls (OR=2.78; 95% CI: 1.73– 4.48). Furthermore, the odds of having friends using tobacco in the university among cases were 2.28 times greater than controls (OR=2.28; 95% CI: 1.36 – 3.81). In addition, having tobacco using friends in hostels was found to be considerably associated with cases among the university students. The odds of friends using tobacco in hostels among cases were 1.93 times higher as compared to controls (OR=1.93; 95% CI: 1.07 – 3.48) (Table 5).
Table 5. Multivariate (Logistic Regression Model) for Risk Factor of Tobacco Use among Undergraduate University Students (18-25 years) in Khyber Pakhtunkhwa (KP), Pakistan (n=560)
In this study, being offered tobacco products in social gatherings was found to be significantly associated with tobacco use among the university students. The odds of being offered tobacco products among cases were 6.25 times greater as compared to controls (OR=6.25; 95% CI: 3.65 – 10.69). Likewise, portrayal of the beneficial effects of tobacco through media was also highly associated with tobacco use. The odds of beneficial effects of tobacco use among cases were 2.13 times higher than controls (OR=2.13; 95% CI: 1.33 – 3.41).
Having personal problems (anxiety, career, inability to focus, depression, apprehension about future, disputes with girlfriend, loneliness, issues in marriage, study problems) was also found related with tobacco use among university students. The odds of personal problems among cases were 3.30 times higher than in controls (OR=3.30; 95% CI: 2.07 - 5.26).
Having physical/medical problems was also found related with tobacco use. The odds of having physical /medical problems in life among cases were 2.36 times the odds among controls (OR=2.36; 95% CI: 1.97 – 4.67). Similarly, financial crises/problems in life were found significantly related with tobacco use. The odds of having financial problems in life among cases were 1.85 times the odds among controls (OR=1.85; 95% CI: 1.19 –2.86).
In this study, students (cases and controls) aged between 18-25 years were selected. In the previous studies, the university students' mean age was found to be 21 ± 4 years (Centers for Disease Control and Prevention, 2010). In Pakistan, university students are usually aged between18 to 25 years (Sajwani et al., 2009). In this study, students' year of study in the university was found to be associated with tobacco use, i.e., more cases were enrolled in 3rd and 4th year. College and university students frequently move from non-tobacco use to tobacco use as their study tenure progresses (Al-Naggar et al., 2011).
The present study revealed that being married was also associated with tobacco use (OR=2.20). It has been observed that married students may have more responsibilities as compared to the unmarried ones. Therefore, they may face stress in their lives, which leads to increased tobacco use among them. Moreover, students living in hostels are away from their homes and may be using it as a stress reliever. Contrary to our finding, the CDC report shows that tobacco use was high among unmarried people (30.3%) (Centers for Disease Control and Prevention, 2010).
In the present study, the results revealed that tobacco using family members have a direct impact on others in the family with regard to tobacco use. Those students who had tobacco using brothers (35.4%) and cousins (68.2%) were more likely to be tobacco users as compared to non-using family members (23.3%, 60.7%), respectively. These findings are congruent with the available literature. A study in India reported that students who start tobacco at an early age are more likely to have been influenced by their fathers (54%), brothers (10%), cousins, and other relatives (Kelkar et al., 2013).
A study reported that 36% of the tobacco users' family members used tobacco (father 54%, mother 36%, and 10% siblings) (Kelkar et al., 2013). A study carried out in KP illustrated that tobacco using parents and siblings are responsible for (14.45%) adolescent tobacco initiation (Jamil et al., 2012). In the rural areas of Pakistan, most of the family members often send their children for tobacco purchase, which also increases the risk of tobacco use in them.
In this study, there were more tobacco user friends among cases (98.7%) as compared to controls (85.7%). Close friends who used tobacco and who compelled/ pressurized their friends for tobacco use were highly associated with tobacco use (cases 84.6%, 38.2%, control 51.8%, 25.4%). Furthermore, friend circles who used tobacco in the university and hostel were significantly more among cases (86.5%, 90.0%) than controls (59.3%, 70.4%). In KP, according to a study, 53.3% of the students started tobacco after admission in a college (Maula et al., 2012).
According to the social cognitive theory, students observe and join the actions of peer groups, in order to feel accepted in the group (Bandura, 2011). In another study conducted in Pune, India, 16% students mentioned peer pressure as a reason for tobacco initiation, whereas, 14% mentioned being forced by friends for tobacco use (Kelkar et al., 2013). A study in KP reported that 22.48% of the respondents had friends and peers who had a major role in their tobacco initiation (Jamil et al., 2012).
The present study revealed that the social factor is significantly associated with tobacco use. Staying in tobacco using social gatherings was found more in cases (70.0%) than controls (51.1%). Similarly, being offered tobacco by people in these social gatherings was recognized mostly in cases (115) than in controls (08.6%). Students sitting in social gatherings where people usually use tobacco, like cafeterias, playgrounds, and other recreational areas in villages and cities, as well as in the university, have an increased chance of indulging in tobacco use. Young adults in social gatherings often offer tobacco to each other. These findings are comparable with other studies and findings. In Ethiopia, most of the students get their first exposure to tobacco use through a friend which indicates that tobacco use relates to social factors (Reda et al., 2012).
Smokeless tobacco, shisha, etc., is culturally more acceptable than smoking, which increases the prevalence of tobacco use (Gupta & Ray, 2003). In Kerala, India, tobacco consumption is considered as a social norm, where tobacco is offered during celebrations (Thankappan & Thresia, 2007). Furthermore, in a survey, it has been identified in China, Fiji, Jordan, Sri Lanka, Ukraine, Venezuela and Zimbabwe that 40% of the students are exposed to tobacco use by other people (Warren et al., 2000). In KP, Pakistan, 14% of the students have been reported to have initiated tobacco use in social gatherings.
In this study, Cases (21.1%) were more impressed by media promoted advertisements (movies, commercial boards, and pamphlets, etc.) than Controls (12.9%). A survey in China, Fiji, Jordan, SriLanka, Ukraine, Venezuela and Zimbabwe reported that over two thirds of the university students were impressed by tobacco promotion advertisements on billboards (60.3%), in newspapers and magazines (69.9%), and cigarette brand names and logo items (t-shirts, pens, bags, etc.) (78.3%) (Warren et al., 2000).
Media played an evident role in portraying the beneficial effects of tobacco use, which led the people towards tobacco use. In this study, more cases (35.4%) believed that tobacco had beneficial effects on the body (activates/sharpens brain, decreases tension, relaxes the mind, decreases depression, enhances enjoyment and pleasure, relieves cough, helps overcome forgetting problem, promotes happiness, relieves headache, diverts mind, helps weight loss promotes risk taking, promotes life style, prevents tooth decay), as compared to controls (20.0%). These findings were also identified by previous studies. In Saudi Arabia, 20% students reported that tobacco use had beneficial effects on the body, and these benefits were stress alleviation, increased concentration, social interaction and prevention of viral diseases (cough) (Al-Naggar et al., 2011). In Turkey, students who had positive beliefs about tobacco were at higher risk (2.4 times) of tobacco use than those who did not (Kelkar et al., 2013).
Media portrays tobacco use as fashionable and an act of courage. Therefore, tobacco users were more likely to estimate the positive effects than of non-users (Al-Naggar et al., 2011). Also, tobacco marketers portray tobacco as a solution for insecurities, and associate its use with good looks (heroes), fame and maturity (Dhanani et al., 2011; Al- Naggar et al., 2011; Warren et al., 2000). In Pakistan, about 37% of the students mentioned that advertisement played a major role in making them see tobacco use as an enjoyable act (Ertas, 2007). Furthermore, 40% of the users in Pakistan held the media responsible for promoting tobacco use (Rozi & Akhtar, 2007). In KP, eight % have started using tobacco owing to advertisements (Jamil et al., 2012).
In the present study, more Cases (23.6%) were facing problems related to their study as compared to Controls (17.9%). The cases and controls both reported that the subjects they were studying were complex and tough. Furthermore, students reported stressors such as low marks, low Grade Point Average (GPA), failed exams, and inability to focus on studies. These findings are congruent with previous literature. According to a WHO report, poor academic performance is associated with increased risk of tobacco use, while good academic performance decreases the risk of tobacco use (Kakde et al., 2012). A study carried out on American Indian students, reported that those students who were more academic oriented (competent, having good grades) were less engaged with tobacco items (Blas & Kurup, 2010; Khader & Alsadi, 2008). In a study carried out in KP, Pakistan, 75.9% of the students declared study tension as a reason for engaging in tobacco use (LeMaster et al., 2002).
It was found in the present study that Cases (40.4%) had more personal problems as compared to Controls (19.3%), among the undergraduate university students. These problems were anxiety, career, inability to focus, depression, apprehension about future, girlfriend, loneliness, love, marriage and study problems. Similarly, students mainly used tobacco to cope with frustration, anger, depression and loneliness (Kelkar et al., 2013). In Pune, India, 11% students consumed tobacco to release tension. Moreover, another study reports that students use tobacco to pass their time (11%), cope with loneliness (16%), solve problems (6%), feel good (9%), and to resolve personal issues (11%) (Kelkar et al., 2013). Moreover, a study in Malaysia identified stress (20%) as a reason for tobacco use (Al-Naggar et al., 2012). In addition, 41.1% students used tobacco to relieve tension (Kazmi & Hashim, 2014), whereas, another study reported that 50% ended up using tobacco due to stress (Ahmed et al., 2008).
In KP, Pakistan, 33.3% of the students start tobacco use owing to stressful events in life (Maula, 2012); whereas, another study in KP identified that 8.9% did so for the same reason (Kazmi & Hashim, 2014). Similarly, in other studies in KP, around 10% students identified stress and anxiety as a reason for tobacco initiation; students believed that it helped them cope with problematic situations (Jamil et al., 2012; Zaman et al., 2002).
The findings of this study revealed that physical/medical problems(asthma, fracture, cough, hearing problem, headache, kidney stone, pain, skin problems, tiredness, visual problem) have an association with tobacco use among undergraduate university students; however, this was reported more by Controls than Cases (14.3% control, 08.6% cases). Students who do not have physical/medical problems are more prone to tobacco use. The available literature conflicts with our finding, as it reports that exposure to trauma increases the risk of tobacco use among the university students, who identify it as a remedy against diseases (Gupta & Ray, 2003; Pradhan et al., 2013; Al-Haqwi et al., 2010; Parslow & Jorm, 2006). Furthermore, in Karachi, Pakistan, 11.7% students used tobacco to seek relief from medical problems (headache, cough, etc.) (Dhanani et al., 2011).
The study findings also suggested that having no financial crises/problems also had an association with tobacco use among undergraduate university students (44.6% controls, 33.9% cases). Students who were financially stable and received more money from their family during their study were more associated with tobacco use. A study carried out in Nepal stated that students who received more pocket money were more prone to tobacco use as compared to those who received less money (Pradhan et al., 2013). Similarly, in India, possession of extra money increased the risk of tobacco use among the students (Sinha et al., 2012). Furthermore, the prevalence of tobacco use has been found to be positively associated with the high financial status of a family (Khader & Alsadi, 2008). This is quite logical, as those who have more money can afford to purchase tobacco products.
Though this study was undertaken quite rigorously, certain limitations can be assumed, which are as follows:
Case-control study has a great potential for re-call bias. For overcoming this, the current study was carried out on university students (18-25 years), who were young, educated and sharp enough to recall the information. Since, in this study, self-reported information was collected, there is a possibility of under and over reporting. To the best of the researchers' knowledge, no validated tool was available for this study. Therefore, a tool was designed, taking help from different WHO project questionnaires and published articles on tobacco use. For minimizing the effect of this limitation, the validity and reliability of the questionnaire was verified by experts. The study participants were enrolled from three universities (one government and two private) in Peshawar KP, Pakistan. Therefore, generalizability can be an issue, as to what extent the sample is representative of the KP population.
Based on the results of the study, the following recommendations can be considered to overcome tobacco use among young adults.
Health professionals need to be trained in handling tobacco cessation and prevention in hospitals and in the community, to fulfill their roles. These health professionals can then plan interventions to change the behavior of people towards tobacco use. Parents should be educated for parental monitoring and effective communication with their children to control tobacco use among them. School, college and university based educational programs should be arranged by health professionals to promote awareness regarding the contributing factors of tobacco use and its health consequences.
The Ministry of Education and Higher Education Commission (HEC) should introduce the subject of effects of tobacco use in the curriculum. The Ministry of Health needs to make new policies with the help of health professionals for the prevention and cessation of tobacco use, because in Pakistan there is no policy for smokeless tobacco use. The government needs to increase taxes on tobacco products; this will help in tobacco cessation and prevention. Institutional polices are also needed for restricting tobacco use on the campus as well as in hostels.
There is dearth of awareness among people about tobacco and its consequences (morbidity and mortality). Therefore, media can play a significant role in portraying the harmful effects of tobacco use instead of depicting false benefits.
Studies need to be carried out on tobacco use policies and their implementation. Further research can be conducted over the academic year in a university to track the stresses of the students and their association with tobacco use. A study can be carried out on the prevalence of substance abuse (marijuana, alcohol, hashish, drugs, etc.) among the university students, in KPK. A quantitative study needs to be carried out to explore students' attitudes towards tobacco use, in depth.
The study design and procedures were approved by the Ethical Review Committee of Aga Khan University, Karachi Pakistan.
Tobacco use is a serious public health concern, and the trend of tobacco use has shifted from the developed countries to the developing countries. Furthermore, tobacco use commonly leads to chronic diseases. The effect of tobacco depends upon the amount of tobacco and the number of years it has been used by a person.
In this study, it was found that tobacco use is associated significantly with the male gender, age, year of study in the university, family members' involvement in tobacco use, peer pressure, friends using tobacco in the university, hostel, and public places, social gatherings where people use and offer tobacco products, media advertisement, belief about the benefits of tobacco use on the human body, personal stressors / problems in life, and financial stability. Nonetheless, most of the identified factors are modifiable for tobacco prevention and cessation, which opens the front for health professionals, policy makers and family members to intervene.
