Elaf AL-Tomma¹, Ghyath Karbouj¹, Raghad Darkal¹, Ahmad Shoujaa^2*, Ghena Najati¹

¹Faculty of Medicine - Al-Sham Private University – Syria

²Faculty of Pharmacy - Al-Sham Private University - Syria

^*Corresponding Author: Ahmad Shoujaa, Department of Biochemistry and Microbiology, Faculty of Pharmacy, Al-Sham Private University, Damascus, Syria. Email: a.s.foph@aspu.edu.sy

Abstract
Background: Smoking is the main factor of many chronic diseases and is one of the world's most important and growing public health problems.

Aim: This study aims to determine the prevalence of tobacco use and the associated factors among students of Al-Sham Private University/ al tall/.

Methods: A cross-sectional study was conducted from July to October of the academic year 2022 on a sample of 354 students at Al-Sham Private University, where the systematic stratified sampling method was used, and the sample size was calculated using OpenEpi for a study power of 95 % and an error rate of 0.05 % and an expected rate of 50 % based on two studies, the first study was conducted in 2008 at the Faculty of Medicine, Damascus University, in which the prevalence of tobacco use was (34.4 %) [1], and the second study was conducted in 2020 at the Syrian Private University, where the majority of tobacco use was (51.4 %) [2].

The data was collected after distributing the questionnaire to students of all academic years in the following faculties: (medicine - pharmacy - informatics engineering - international relations, and diplomacy).

Results: out of the 354 participants, 171 students were smokers giving a prevalence rate of 48%. The prevalence of smokers was much higher in males than in females (34% and 14%, respectively). 25.15% of students started smoking at the age of 18 years; there were significant differences in tobacco use among the mentioned colleges, in which the faculty of International Relations and Diplomacy reported a high percentage.

Conclusions: This study directs the problem of tobacco use among university students as a significant contribution to personal and socio-demographic factors. The study recommends integrating health awareness programs about the dangers of tobacco use into the education curriculum.

Keywords: Smoking, Prevalence, university, students.

Introduction
Tobacco use can be defined as any regular use of the leaves and products of the tobacco plant; the predominant use of tobacco is the inhalation of smoke from cigarettes, pipes, and cigars, while smokeless tobacco refers to a variety of tobacco products that are smelled, sucked, or chewed [3], and positive smokers have been divided into three categories [4]:

Current smoker: An adult who had 100 cigarettes in their life and still smokes cigarettes currently, and as of 1991, this group was divided into smokers "daily" or "non-dairy."

Smoker daily: An adult who has smoked at least 100 cigarettes in his lifetime and now smokes every day.

Non-daily smoker: An adult who has smoked at least 100 cigarettes in his lifetime and now smokes but does not smoke every day.

Former smoker: An adult who has smoked at least 100 cigarettes in his lifetime but quit Smoking during the interview.

Non-smoker: An adult who has never smoked or has smoked less than 100 cigarettes in his lifetime.

People who do not smoke are also exposed to so-called passive smoke, even if exposure is for a short time, but it carries great risks in the long run, and passive smoke is tobacco smoke that is puffed out by smokers or released by burning tobacco, and it is inhaled by people nearby [5].

Smoking is one of the outstanding global public health problems, as it is a preventable cause of smoking-related diseases and overall mortality. There are more than a billion cigarette smokers worldwide, and the number of smokers in developing countries is increasing. Tobacco use leads to about 6 million avoidable deaths each year worldwide [6]; Smoking causes a lot of serious diseases such as cancer, heart disease, stroke, lung disease, diabetes, and chronic obstructive pulmonary disease (COPD); Smoking also increases the risk of tuberculosis, certain eye diseases and immune system problems including rheumatoid arthritis [7].

It was stated that Two-thirds of smokers want to quit, and half have tried to quit smoking on their own, but only a tiny percentage have succeeded in quitting Smoking [8].

Social learning theory describes how we learn behavior by example from others; our parents and other people strongly influence us we look forward to, such as peers, actors, and pop stars; this can lead us to mimic their behavior and try to smoke.

Most people will tell you that the first cigarette tasted unpleasant, and they may even feel sick or choked. However, at the same time, there is an almost immediate effect on their brains with those first cigarettes, which the brain craves the most, so they continue to smoke to get this reward. Later, we learn to associate all aspects of Smoking: (Carrying the pack, playing with a lighter, pulling the cigarette out of the box, taking this first impression of lighting a cigarette, hand-arm movement to smoke, and so on with other activities such as drinking coffee, talking on the phone and so on.

We can get so used to the routine that just thinking about activity reinforces the need to use one of a tobacco product, just like Pavlov's experiment with a conditional reflex in which a dog learned to drool at the sound of a bell without food, and these psychological associations remain when smokers try to quit.

Over the years, TV shows and movies have built effective links between Smoking, flame, sex, and risk-taking, and the number of smoking-related images in film continues to increase over time, even though the amount of Smoking in the real world is decreasing. In addition, we are still exposed to advertisements that deliberately promote tobacco products and firm positive connections with brands, and unfortunately, what these images often do not convey are the negativities of Smoking, starting from yellow spots on your fingers and the smell of your breath, and the long-term severe smoking consequences [9,10,11,12,13,14].

Importance of the study: The importance of conducting such a study on this age group. Although many investigations were conducted by studying the type of tobacco, its prevalence, and the associated factors among university students, conducting a study on students of the faculties mentioned in the private Syrian universities still needs to be discovered accurately. Hence, this study aimed to determine the prevalence of tobacco use among ASPU students "Al Tall " faculty.

Research Methods and Materials: This cross-sectional study was conducted between July and October of 2022 at ASPU Al Tall faculty.

354 male and female students from the following faculties participated in this study: (Medicine - Pharmacy - Informatics Engineering- International Relations, and Diplomacy)

The systematic stratified sample method was used to select the study sample.

The data was collected by distributing random questionnaires within the students' places (university canteen, University Library, University Garden), and these questionnaires were self-filled by all students from different academic years At ASPU. The sample included Syrian students aged 18 years or older who can Speak Arabic and are willing to participate in this study.

The data was collected through a questionnaire developed by researchers based on a former literature review after experts in the field checked it to increase reliability and validity. The questionnaire consists of four parts:

The first part: contains social and demographic characteristics: such as age, sex, college, marital status, economic status, nature of housing and work, as well as illustrative definitions of "current smoker - a former smoker - non-smoker" based on the description of: National Health Interview Survey (NHIS).

The purpose of these definitions is to help each survey participant know under which category they belong and answer the related questions.

The second part: of the questionnaire contains questions specified to the current smoker category (type of tobacco used, daily and non-daily quantity, age of starting Smoking, the reason for starting and continuing Smoking, monthly spending rate, attempts to quit if any),

The third part: contains questions for the former smoker (the type of tobacco that was used, the daily and non-daily quantity that was consumed, the age of starting Smoking, the age of Smoking quitting, the number of attempts to stop, the reason for leaving, the methods used to control)

The fourth part: contains questions for non-smokers (why not smoking, awareness about the dangers of Smoking, passive Smoking.)

It was allowed to have multiple answers to some questions due to the importance of this; in addition to that, the data were analyzed using the statistical program (SPSS) version [20].

Ethical Considerations:
The official approval for conducting the study was obtained from ASPU Administration, and Consent from the student before distributing the questionnaire, after explaining the objective of the study and that the data collection is for a scientific research purpose, and subject to strict confidentiality. This is the link to our questionnaire

https://docs.google.com/forms/d/e/1FAIpQLSfjyaLvFb5zm69Ykd3 yhahgtnGmxUGWhBcfudrMnh-0q1fXJg/viewform?usp=pp_url

Conclusions and Discussion:
1). Demographic characteristics of participants (number = 354).
Table (1) Demographic characteristics of participants.

Table (1) shows the sample distribution according to demographic characteristics. The results showed that 154 (43.5 %) were females and 200 (5.56 %) were males. The most significant number of participants were from the Faculty of Medicine (31.9 %), and the rest of the sample members were from the following faculties, respectively: pharmacy (29.1 %), informatics engineering (28.2 %), and international among relations and diplomacy (10.7). The study also showed that the majority of respondents had a social status of (single) (83.1 %) Some had a social status (correlated) by (10.5 %). We also see in the study that the most significant percentage of the respondents had a moderate economic situation (69.8 %) and the rest respectively: excellent (15.5 %) and Fair (12.7 %). The results also showed that the nature of housing for the majority of individuals is family housing (85 %), that (74 %) of the sample members do not work, and (15 %) of them work during weekends only.

 2) Demographic characteristics and tobacco use among university students (Number = 354)
Table (2) Relationship between demographics and tobacco use.

Table (2) shows the relationship between demographic characteristics and smoking among university students, where the results showed that the prevalence rate of smoking among university students reached (48%), and the prevalence rate of smoking was higher among males (34 %) than among females (14 %), in addition, there was a significant difference in the prevalence of smoking among students in different colleges, where the results show that students of the Faculty of Medicine and Pharmacy recorded the lowest percentage of tobacco use compared to the rest of the students in Other Faculties, The results also showed that there are statistically significant differences between the average scores of the research sample members in the social status according to the smoking variable, in favour of former smokers, which will be clarified later by the single variance analysis test, while the study also showed that there are no statistically significant differences between the average scores of the research sample members in the economic situation according to the smoking variable, which will be clarified later by the single variance analysis test.

Table 3: Single variance analysis test to indicate the differences between the averages of the performance of sample members in the social status according to the smoking variable.

 Table (3) shows that p < a = (0.05) (probable-value) for differences in marital status are attributed to the smoking variable (current smoker, former smoker, non-smoker), and this means that there are statistically significant differences between the average scores of the research sample members in the marital status attributed to the smoking variable (current smoker, former smoker, non-smoker), in favor of former smokers.

Table 4: Single variance analysis test to indicate the differences between the averages of the performance of sample members in the economic status according to the smoking variable.

Table (4) shows that p> a = (0.05) (probable-value) for the differences in economic status are attributed to the smoking variable (current smoker, former smoker, non-smoker), and this means that there are no statistically significant differences between the average scores of the research sample members in the economic situation attributed to the smoking variable (current smoker, former smoker, non-smoker).

3) Characteristics of current tobacco users among university students (n=171).
Table 5: Characteristics of current tobacco users Multiple answers allowed for some characteristic

Table (5) shows the characteristics of tobacco users among university students, the results showed that sharing with friends who smoke is the main reason for starting smoking among the study participants with a percentage rate of (32.03 %), and due to curiosity (16.18 %), followed by the smoking family (14.56 %) and the study stress (12.94 %), the study also showed that the most significant percentage of smokers (25.15 %) started smoking at the age of 18 years, followed by the age of (16) years with rate of (11.70 %) and then the age of (15) and (17) years, and the results showed that the most significant number of cigarette smokers reached the number of years of smoking (4 years) with percentage of (18.91 %) followed by (5 years) (51.13 %), The results of the study also showed that smoking as a factor of mood enhancing is the main reason for continuing smoking with percentage of (61.22 %) followed by smoking friends with rate of (20.7%) then the study stress (16.24 %), Our results also showed the majority of participants do not.

Smoke during illness percentage of (63.7 %), Also that the majority of participants agreed that not swallowing or inhaling smoke while smoking reduces its harm with a share of (59.6 %), and the results showed that the rate of smoking during holidays increases among the study participants.

And we can also see that the most significant percentage of participants in the study, 49.1 % (do not prefer to get engaged with a smoker.

Table 6: The Average of monthly spending on smoking (among smokers)

Table (6) shows that the average expenditure on smoking amounted to (140,713.5) with a minimum of (7,000 SYP) and a maximum of (600,000 SYP).

4) Qualitative characteristics of consumed tobacco:
Table 7: Type of consumed tobacco on a daily and non-daily basis by the current and former smoker (number = 184)

The percentage is calculated based on the total number of answers, knowing that the current or former smoker does not necessarily have to smoke on a daily basis only or on a non-daily basis only, we may see answers containing both types of tobacco consumption together.

Table (7) shows the qualitative characteristics of tobacco consumed on a daily and non-daily basis by current and former smokers, as our results showed that the most common type of tobacco consumed daily by the current smokers is cigarettes (75 %), followed by hookah (22.30 %), then electronic cigarette and electronic mods by (1.35 %) and the most common type of former smoker is hookah by (81.82 %), followed by electronic Cigarettes and electronic hookah (9.09 %) The results of the study also showed that the most common type of tobacco consumed on a non-daily basis for the current smoker, it is the hookah (63 %), then the electronic cigarette (15 %), the cigarette (11 %) and the electronic hookah (10 %) and the most common type of former smoker is hookah (69 %), then cigarettes and electronic hookah (8 %).

Table 8: Statistical differences between cigarette smokers and hookah Smokers

Table (8) shows the statistical differences between cigarette and hookah smokers, where the results showed that the prevalence rate among hookah smokers It is similar in gender but tends to favor females (51.52 %) while the prevalence rate among cigarette smokers is favored by males (90 %).

Table 9: Commercial Names of Cigarette Packet for Cigarette Smokers
128 smokers answered this question, so the percentage is calculated relative to the total number of answers.

Table (9) shows the commercial trademark of cigarette packs for cigarette smokers, where the study showed that (19.53 %) of Study participants used Gauloises and Kent, followed by Marlboro (14.84 %) and Elegance and Master (11.72 %).

5) Quantitative characteristics of consumed tobacco (number = 184):
Table 10: The amount of tobacco consumed on a daily basis in the current and former smoker.
Currently, 148 smokers answered this question, so the percentage is calculated based on the total number of answers.
9 former smokers answered this question, so the percentage is calculated based on the total number of answers. The percentage is calculated based on to the total number of responses, knowing that the current or former smoker does not necessarily have to smoke on a daily basis only or on a non-daily basis only, we may see answers containing both types of tobacco consumption together.

Table (10) shows the amount of tobacco consumed on a daily basis by the current and former smoker, where the results showed that the largest number of participants in the study consumes (1-20 cigarettes) by (44.59 %), followed by consumption of (21-40 cigarettes) (25 %) and then consumption of (hookah session) by (14.18 %), And results showed in the former smoker that the largest number of participants consumed (1-20 cigarettes) by (77.78 %) followed by consumption of (two hookah sessions) and (21-40 cigarettes) by (11.11 %).

Table 11: The amount of tobacco consumed non-daily in the current and former smokers.

Table (11) shows the amount of non-daily tobacco consumed by current and former smokers, as the results showed for the current smoker that the most significant number of participants in the study consumed (two hookahs) at a rate of (22.96 %), followed by consumption of (1-10 cigarettes) at a rate of (20 %) Then the consumption of (more than 4 cigars) at a rate of (11.11 %), while the results showed that among the former smoker, the most significant number of participants consumed (one hookah) at a rate of (23.07 %), followed by consumption according to the following: (11-20 cigarettes), (two hookahs). (3-4 hookah), (more than 4 hookahs) by (15.38 %).

6) The level of nicotine addiction among daily cigarette smokers according to the Bergstrom scale and its relationship with different colleges (n = 111):
Table 12:

Table (12) shows the level of addiction to nicotine among cigarette smokers daily according to the Bergstrom scale, and the results showed that the most significant number of participants in the study had a high level of addiction with a percentage of (32.34 %). The Faculty of Informatics Engineering was on the top with a rate of (14.41 %), followed by Medicine with a speed of (9 %).

4) Quit Smoking:
Table 13: Numbers and Percentages of Smokers welling to quit.

Table (13) shows number of current smokers who are willing to quit smoking, The results showed majority of smokers willing to quit smoking were males with the percentage of (29.74 %).

Table 14: Numbers and Percentages of attempt to quit smoking.

Table (14) shows the number of attempts to quit smoking, as the results showed that the largest number of smokers had tried to quit smoking (11 attempts) with a rate of (34.28 %), followed by (one attempt) and (3 attempts) with a rate of (18.09 %)

Table 15: Characteristics of current smokers who want to quit smoking.
105 participants has answered this question, so the percentage is calculated based on the total number of answers knowing that multiple answers are allowed for some characteristics.

 Table (15) shows the characteristics of current smokers wishing to quit smoking, where the results showed that the most extended period in which succeeded to temporarily quit smoking was a week to less than a month with the percentage of (35.23 %) followed by a month to less than 6 months with the rate of (28.57 %), and our results showed that the most followed way to try to quit smoking was by "food, sports" distractions (43.33 %), followed by (16.66 %) of the participants who did not observe any method, The results also showed that the urgent need to smoke due to the occurrence of annoying personal symptoms during its suspension, such as mood disorder, headache, etc. was one of the most essential things that prompted the smoker who quit to return to smoking by (25.41 %) followed by the study stress with the percentage of (20.44 %) and then smoking stimuli "smoked surroundings, coffee" by (14.91 %), and the results also showed that the most significant number of participants in the study do not believe that vaping is an alternative to quitting traditional smoking (66.66 %), and the results also showed that the most significant number of participants confirmed that attempts to quit smoking were more straightforward during university off days (51.42 %). 

Table 16: Characteristics of former smokers who successfully quit smoking.
13 participants answered this question, so the percentage is calculated according to the total number of answers knowing that multiple responses were allowed for some characteristics.

Table (16) shows the characteristics of former smokers who succeeded in quitting smoking, where the results showed that the most significant number of participants in the study utterly quit smoking at the age of (21 years) and (23 years) by (23.07 %). Our results showed that the most significant number of attempts to quit until success in it definitively was 3 attempts (30.76 %). They showed that the main reason for quitting smoking was fear of its risks (50 %), The results also showed that depending on distractions, "food, sports" was one of the most important ways to quit smoking (30 %), followed by avoiding stimuli " smokers, coffee" by (25 %), and the results of the study indicate that all participants in the survey do not want to go back to smoking, and avoiding getting into a relationship with a smoker with the percentage of (61.53 %).

8) Characteristics of non-smokers (passive smokers) among university students (number = 170):
Table 17: Characteristics of non-smokers

Table (17) shows the characteristics of non-smokers (passive smoker) among university students, where our results showed that the main reason for not smoking among the study participants is (personal conviction of smoking risk) with the percentage of (60.41 %), Our results also showed that (88.23 %) of non-smokers do not want to try smoking, and we also see in the effects that the most significant number of study participants do not avoid having relation with a smoker with the percentage of (41.59 %), and the results showed that the most crucial number of non-smokers advise smokers to quit smoking with the rate of (76.51 %) followed by neutral with the percentage of (47.36 %), and the results also show that (58.70 %) of the study participants have a smoker in their family or close surroundings 2.35 %, We also see in our results that the most significant number of non-smokers do not stop smokers from smoking in their residential (62.35 %), and the results also showed that the most important number of participants are the Time they are with people who smoke inside the university for few minutes (42.35 %), And the duration of Time spent with smokers outside the university also for few minutes with the percentage of (76.51 %).

The continued popularity of tobacco smoking seems to defy a rational explanation. Smokers often acknowledge the harm they do to themselves, and many say they don't enjoy it – yet they continue to smoke [15], the reason being that the nicotine present generates strong incentives to smoke that overwhelm worries about the negative consequences of smoking, and a determination not to smoke in thosetrying to quit [16].

The appearance of tobacco products on college campuses, even if used sporadically, sends a dangerous message about the social acceptability of tobacco use. Widespread use of tobacco among a significant portion of 18-24-year-olds could foreshadow, in general, a future increase in adult tobacco use [17].

The results of our current study showed that the prevalence rate of tobacco use among students of the following faculties: Medicine - Pharmacy - Informatics Engineering - International Relations and Diplomacy at Al-Sham Private University / Al-Tal Campus / reached (48 %), and this rate is higher than the reported prevalence rate Among male students in colleges in the Syrian Arab Republic (8.24 %) in2004[18], and male students in Turkey (22.1 %) [19].

Gender was one of the main factors that significantly impacted tobacco use behaviors among the participants, as the results showed that male students consumed more tobacco products than female students at a rate of (34 %). This may be related to cultural and social issues in Syria. This result coincides with many previous studies conducted in Arab countries where tobacco use behaviors are more prevalent among males than among females, as they consider female smoking an unacceptable social behavior [20,21,22].

The results of our study also revealed that smoking friends are the main reason for starting smoking with a rate of (03.32 %), followed by curiosity with a speed of (18.16 %), followed by the smoking family (14.56 %) and study stress (12.94 %), and we also found that smoking as a factor that modifies mood is the main reason To continue tobacco at a rate of (22.61 %), followed by friends who smoke at a rate of (20.70 %), then study stress at a rate of (16.24 %). These results can be explained by the fact that young people at the university level are greatly affected by their friends as a result of constant contact with them and spending a long time with them, with the presence of curiosity motives and a spirit of discovery among these university students to go through this experience, so that each of them reaches an advanced stage in which smoking becomes an essential factor in adjusting the mood The most critical deterrent is preventing them from quitting quickly.

As for the reasons for not smoking among the non-smokers, most were due to personal conviction of the harms of smoking at a rate of (60.41 %), followed by a religious deterrent reason at a rate of (15.41 ). A study conducted in 2008 found that most of the sample did not smoke because of the smoking side effects, in addition to religious reasons [23].

The prevalence rate of tobacco uses among the students of the various colleges mentioned in Al-Sham Private University was (48 %). The students were significantly affected by their smoking friends, their excessive curiosity, their smoking families, their study stress, and their Psychological and social problems, and our study confirms that the issue of using tobacco products among students of different colleges is related to significant personal and demographic factors such as gender, age, college, marital status, and economic status.

Governments can reduce the prevalence of smoking by increasing the cost of tobacco through taxation, organizing ongoing social awareness campaigns, and providing medication and behavior support for final quitting.

Findings and Recommendations:
Our recommendations after this study are a modest set of messages addressed to each person, whether they are a smoker himself or a non-smoker:
Our first message headed to the smoker:

The sooner you stop smoking tobacco products, the faster your body will recover.

Don't risk your life and the lives of others around you.

Our second message is to non-smoking family and friends:

Teach your beloved children or friends the health risks of using tobacco products and encourage them to quit with your moral and psychological support.

Our third message to the administrative and teaching staff in universities:

You can place a policy prohibiting any tobacco product inside the campus by anyone at any time and a section dedicated to providing psychological support to any smoker who needs medical and psychological help to quit. Implement actions that raise awareness of the tobacco products dangers among students as a first step towards behavior change.

Our fourth message to the concerned authorities is to prevent and stop the media promotion of tobacco, as the media, social communication, films, and dramas contain temptations for this dangerous phenomenon.

Your body and you have a right against you, so don't let smoking steal your breath and life's unforgettable moments.

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