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Insights into Smoking Behaviors among University Students in Jordan: A Narrative Review
*Corresponding author: Laila Al Afnan, Department of Epidemiology, Florida International University, Miami, Florida, United States. lailaalafnan@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Afnan L. Insights into smoking behaviors among university students in Jordan: A narrative review. Int J Transl Med Res Public Health. 2025;09:e015. doi: 10.25259/IJTMRPH_91_2024
Abstract
Background and Objective:
This review examines smoking behavior among Jordanian university students, focusing on their habits, attitudes, perceptions, knowledge, and the factors that influence them. It also offers public health recommendations that could help reduce the smoking rate within this population.
Methods:
A search of the published studies was conducted in Google Scholar and PubMed. The publication date, study design, and results on smokers’ attitudes, perceptions, habits, knowledge, and influencing factors were considered. The extraction process was followed by a quality assessment method.
Results:
The smoking habits among Jordanian university students varied from cigarettes, smoked as many as 40 a day by some students, to waterpipes with sessions that lasted from as little as 30 minutes to as long as 90 minutes. Knowledge or risks related to smoking were also rounded to vary among students, with academic measures and smoking status serving as the predictors. In general, students in the older age groups and also the medical majors were better aware of the associated risks of smoking. Students also differ in their attitudes about tobacco; some students accept the waterpipe as a socially acceptable method of tobacco use. Additional studies will be required to outline the temporal changes in the smoking pattern and assess any measures of intervention that may be instituted.
Conclusion and Implications for Translation:
Targeted public health interventions, such as gender-sensitive smoking cessation campaigns at university campuses, can decrease the prevalence of smoking among Jordanian students. This initiative will be further reinforced by the smoke-free campus policy, restrictions on tobacco advertising, and the incorporation of smoking control education into academic curricula. Future research should aim to examine how social norms influence smoking behavior.
Keywords
Smoking
Smoking Behaviors
Students
Jordan
Universities
INTRODUCTION
Background
Tobacco smoking is a major cause of multiple health issues, such as cardiovascular disease, respiratory and reproductive diseases.[1] No matter whether a country is developed or developing, smoking consumption remains a pressing public health issue worldwide.[2,3] Jordanian tobacco use among university students remains an alarming health problem that is critical to address.[4]
One essential thing to notice is that smoking is a preventable health issue that can be controlled by following proper measures,[5,6] thus, understanding the student’s behavior is key to addressing this issue effectively.
Objective
This review focuses on the smoking behavior of Jordanian university students, aiming to identify and understand their habits, attitudes, perceptions, knowledge, and the factors that influence it. Although exciting studies highlight the students’ habits and influencing factors, no study fully explains the comprehensive behavior of Jordanian university smokers or provides evidence-based strategies to address this issue among this group. This paper aims to fill this gap.
Scope
The review examined smoking habits among Jordanian university students. It included all studies published from 2018 to September 2024 at Jordanian universities.
Research Question
What are the habits, knowledge, influencing factors, attitudes, and perceptions among Jordanian university students, and how can the smoking rate among this group be reduced?
METHODS
Search Strategy
A search of the published literature, “Insights into Smoking Behaviors Among University Students,” indexed in Google Scholar and PubMed was conducted on August 4, 2024, using the following search terms: “Smoking among university students in Jordan” for Google Scholar and (smoking AND Jordan AND “University students”) in PubMed. The publication period from 2018 to 2024 was selected to include the most recent studies and capture any recent changes.
Inclusion criteria include observational and experimental studies published between 2018 and 2024, written in English, conducted in Jordan, aimed at university students, and articles relevant to smoking behavior.
Ineligible publication types included commentaries, editorials, letters to the editor, conference proceedings, research protocols, and reviews. Other exclusion criteria included articles not relevant to smoking behavior among university students, studies not conducted in Jordan, not published between 2018 and 2024, and not published in English.
Study Selection
The search resulted in 3,772 papers across the two databases, of which 32 were duplicates. The titles and abstracts of 3,740 papers were screened to proceed to the full-text review phase. Nine articles that met the inclusion criteria are included in this review [Figure 1].
- PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only
Data Extraction
The author conducted data extraction and subsequently checked it by one reviewer. The extracted data included the following items: Author/year, study design, variables studied, and quality assessment. The author and one reviewer independently performed quality assessment after data extraction. Most studies included in the review were cross-sectional; therefore, the modified Newcastle–Ottawa Scale was used to assess the quality of the studies [Table 1].
| Author, year | Study design | Variables studied | Modified NOS | ||
|---|---|---|---|---|---|
| The representativeness of the sample. | The response rate | The adequacy of measurement tools for assessing the variables of interest | |||
| Al-Sawalha, et al. (2021) | Cross sectional | Attitudes and knowledge of the harmful effects of waterpipe tobacco smoking | The study’s sample representative of university students in Jordan, as it includes students from both public and private universities across the North, Middle, and South regions of the country. | The response rate is not mentioned | Online self-reported questioner |
| Rababah JA, et al. (2023) | Cross sectional | Health literacy and smoking habits | The study used stratified sampling from Jordanian university | The response rate is 68.1% | Self-reported questioner |
| Al-Sawalha,et al. (2021) | Cross sectional | Perception of E-cigarette and related knowledge | Representative of undergraduate and graduate students across Jordan, as it includes participants from both private and public universities located in North, Middle, and South Jordan. | The response rate is not mentioned | Self-reported questioner |
| Abu-Rmeileh ME,et al. (2018) | Cross sectional | Perceptions of waterpipe tobacco | Jordan University of Science and Technology and University of Jordan | The response rate is not mentioned | Self-reported questioner |
| Alkhalidy H,et al. (2021) | Cross sectional | Health-risk behaviors | The study was conducted at a single institution: Jordan University of Science and Technology (JUST) in Irbid, the sample only includes undergraduate students at JUST and excludes graduate students, as well as pregnant students. | The response rate is not mentioned | Self-reported questioner |
| Alnawaiseh N,et al (2018) | Cross sectional | Knowledge and attitude | The study was conducted at Mutah University in Jordan. The study used a randomly selected, cluster sampling technique. | The response rate is not mentioned | Self-reported questioner |
| Al-Natour A, et al. (2021) | Qualitative study | Perceptions | Female university students who agreed to be interviewed privately | The response rate is not mentioned | Interview |
| Al-Sheyab NA,et al. (2020) | Cross sectional | Risk perception | Students from two major governmental universities in Jordan: Jordan University of Science and Technology (in the north) and The University of Jordan (in the capital, Amman). These universities are described as the largest in Jordan, with students from all over the country, a multi-stage sampling technique that is stratified by university, faculty, and year. | The response rate is not mentioned | Self-administered questioner |
| Alaraj M,et al. (2021) | Cross sectional | E-cigarette culture | Undergraduate and postgraduate students attending Middle East University (MEU) in Amman, Jordan. | The response rate is not mentioned | Self-reported questioner |
RESULTS
Synthesis of Evidence
Smoking habits
Smoking habits among university students in Jordan are diverse. The commonly used smoking options include waterpipe, cigarettes, and e-cigarettes.[7-11] About 32.4% of students’ first attempt at smoking involved school friends,[12] and more than half of the students started smoking at their parents’ house or someone else’s home;[10] in addition, they had a family member who smoked.[11] Surprisingly, smokers who have a history of more than 2 years of smoking began smoking before the age of 18, which is the age of the majority in Jordan.[8] The average cigarette consumption is approximately 10–40 cigarettes per day, and about 65% of waterpipe smokers spend 30–90 minutes per tobacco break.[13] As well as, 50% of university student smokers prefer smoking waterpipes within their homes; interestingly, 41% try waterpipe smoking out of curiosity.[7] Notably, e-cigarette smokers are daily users of their smoking device, with 63% spending at least 30 minutes on each session.[9] Overall, tobacco consumption patterns among Jordanian university attendees are multifarious.
Attitude and perception
Jordanian university students are divided in their views on smoking, especially in terms of waterpipe use. Some believe that shisha tobacco does not have the same negative effects or withdrawal symptoms as standard cigarettes. However, they are aware of the dangers of using a waterpipe, such as cardiovascular diseases and cancers.[7,14] Roughly 30% of the students smoke waterpipes at social events, where it is socially acceptable.[7,15] Some also claim that it acts as a mental stimulant.[7,12] Additionally, a small number believe that e-cigarettes could help with quitting smoking.[9] While a few student smokers would recommend e-cigarettes as a substitute for traditional cigarettes to friends and family, many do not support or remain neutral about this.[9] Among female students, the majority started smoking to relieve stress from coursework and exams.[10] Interestingly, 65.2% of students are frightened to quit smoking because of the withdrawal symptoms.[12] In general, the attitudes and perceptions of Jordanian university students in terms of tobacco differ and could have an adverse impact on their health.
Knowledge and influencing factors
University smokers in Jordan show different levels of knowledge about smoking, influenced by several factors. Medical students and seniors tend to have a better understanding of the health risks associated with smoking.[7,12] While many students have clear knowledge about heart, lung, and cancer hazards, they often lack knowledge about other important issues such as cognitive effects, diabetes, and male fertility vulnerabilities.[7,10,12,13] Even though the majority recognize the threats of waterpipe smoking during pregnancy, a few understand the impact on the fetus’s weight and survival rates.[7] In addition, there is a noticeable relationship between health literacy and smoking habits. Students who smoke less frequently and for shorter durations generally have higher levels of health knowledge.[8] Furthermore, knowledge about e-cigarettes varies among students. Many presume that e-cigarettes are intended for one-time use and contain natural ingredients. Some are unaware of the risks associated with second-hand nicotine exposure from e-cigarettes and may not know that these products contain cancer-causing substances. On the other hand, the majority understand the harmful effects on the heart and lungs.[8]
Factors, including field of study and smoking habits, correlate with students’ knowledge.[9] Medical students, for instance, demonstrate a greater understanding compared to other groups. One study found that medical students had more knowledge of e-cigarettes than their peers, as indicated by an odds ratio (OR) of 1.710, with a 95% confidence interval (CI) ranging from 1.326 to 2.204, and a significance level of p < 0.001. Similarly, conventional smokers possess a better understanding of e-cigarettes than others, with an OR of 1.496, a 95% CI of 1.018 to 2.197, and a significance level of p = 0.040.[9] Furthermore, male students with higher incomes tend to have a higher knowledge score.[16] Overall, Jordanian university students exhibit varying levels of knowledge, which may result from various determinants.
Gaps and Future Directions
Cross-sectional studies are the dominant approach among Jordanian researchers. Although they are important in studying the smoking behaviors among Jordanian university students, they offer a snapshot of the situation. On the contrary, cohort studies, for instance, are a type of longitudinal study that is essential in monitoring changes regarding smoking habits, attitudes, perceptions, and knowledge over time. Moreover, water pipe smoking is socially acceptable and hence prevalent among university academics; future researchers should consider studying its rationale, as it is a key to developing such initiatives. Other studies should also be conducted to examine factors that influence health literacy and smoking behavior, such as self-efficacy beliefs, perceived societal norms, and availability of smoking cessation facilitation. Comprehensively, researchers should consider using longitudinal designs and investigating the sensitive factors underlying widespread smoking among students.
DISCUSSION
Interpretation
The aim of this review is to present the smoking behavior, attitude, perception, and knowledge of university student smokers in Jordan, along with the factors that may influence the relationship between smoking and education. For instance, the study found that smoking habits among Jordanian University students are prevalent and take many forms, including waterpipes, traditional cigarettes, and e-cigarettes. This is a critical public health issue that needs immediate attention. Furthermore, the rate of smoking is higher among users of waterpipe and e-cigarette, denoting a significant trend that can negatively impact the health of these students. This includes potential cardiovascular side effects leading to endothelial dysfunction, increased oxidative stress, and a higher risk of cardiovascular morbidity and mortality.[1] The results also exposed different levels of perception in terms of smoking detriments. Some students underestimated the harms caused by smoking, highlighting the necessity of targeted interventions to enlighten this group about the health risks associated with smoking, including lung cancer, respiratory illness, low birth weight, periodontal disease, infertility, and many other side effects.[15]
Moreover, the possibility to reduce the smoking rate among Jordanian University students is reflected in the relationship between their field of study, year of study, and their level of knowledge about smoking. Specifically, medical students and older individuals tend to have higher levels of knowledge and smoke less frequently than others. Research has proven the inverse relationship between the level of health literacy and smoking behavior.[17] Such a significant finding is important for the public health practitioner to prioritize health awareness and promote smoking cessation within this population. Most importantly, waterpipe smoking among female students is considered an alarming trend that requires specific initiatives targeting the concept of being socially acceptable. In general, smoking among Jordanian students is a critical public health concern that needs urgent attention and careful monitoring.
Implications
This study has several applications in the public health sector. First, the priority measure for this particular population should be implemented by public health practitioners through socially and culturally sensitive interventions, such as free gender-sensitive smoking cessation campaigns on university campuses. The concept of gender sensitivity here refers to separate campaigns for male and female students to address their specific needs, which may increase attendance rate for such programs and, hence, could lead to a higher quitting rate. Such initiatives should address misconceptions, attitudes, and habits related to smoking in addition to developing proper knowledge among university students. One study claimed the effectiveness of this kind of campaign; the intervention arm had 1.87 times the odds of smoking cessation than control participants.[18]
Policymakers play a critical role in decision-making; therefore, they can develop precise policies targeting university scholars, including, but not limited to, smoke-free campuses, restrictions on tobacco promotions, and integration of smoking control education into the university curriculum to ensure academics receive the latest data on the health impacts of smoking. A study in China showed that the tobacco control advocacy curriculum has positively impacted students’ attitudes and motivations and reduced smoking rates among them.[19]
In addition, future researchers should explore the targeted interventions and initiatives to emphasize their impact on mitigating the smoking rate among this particular population. They should also examine the influence of social norms on smoking initiation and cessation. Substantially, diminishing tobacco consumption among Jordanian University students can be achieved through the united efforts of public health practitioners, policymakers, and researchers.
Challenges and Recommendations
Addressing and resolving the problems seen in the literature is essential for the subsequent research. This is a literature review, not a systematic review that aims to map and summarize the available data on the topic. The search was limited to a six-year timeframe and utilized only two databases. To improve the comprehensiveness of the review, it is recommended to broaden the search years and include additional databases. Furthermore, organizing and analyzing numerous studies is a time-consuming process. To save time and effort, it is advisable to create a detailed planning timeline and use software programs for assistance. Although this paper was authored by a single individual and underwent an assessment assurance process, collaborating with a coauthor can be beneficial.
CONCLUSION AND IMPLICATIONS FOR TRANSLATION
Summary
The literature indicates that Jordanian students manifest different smoking habits, with the majority using waterpipe, conventional cigarettes, and e-cigarettes. Their attitudes and perceptions towards smoking vary significantly, some of which are dangerous, like believing the waterpipe has no harm to health, while others would recommend e-cigarettes to a family or friend. Jordanian students also gained different knowledge about smoking, influenced by many variables, including field of study, academic year, smoking habits, and gender.
Call to Action
This review urges policymakers, practitioners, and researchers to focus on developing and promoting smoking prevention initiatives at Jordanian universities. An extremely important strategy is implementing gender-sensitive campaigns on campuses that provide students with essential information and support for quitting smoking. Additionally, it is important to integrate smoking control education into the university curriculum to ensure that students receive upto-date data about the health impacts of smoking.
Key Messages
1) The smoking behaviors of Jordanian university students vary significantly with regard to the type of smoking, frequency, and duration. 2) The knowledge about the risks associated with smoking differs among students: Former smokers and those studying medical fields demonstrated better awareness of the associated health hazards. 3) Attitudes concerning the use of tobacco vary among students; some perceive waterpipe smoking as a form of social acceptance. More studies are needed to explore changes in the pattern of smoking and propose effective interventions.
Acknowledgments:
The author thanks Dr. Thaer Abdul-Hadi for helping determine the eligibility of the articles for this study and providing feedback on the draft of this article.
COMPLIANCE WITH ETHICAL STANDARDS
Conflicts of Interest: The author declares no competing interests. Financial Disclosure: Nothing to declare. Funding/Support: There was no funding for this study. Ethics Approval: Not applicable. Declaration of Patient Consent: Patient’s consent is not required, as there are no patients in this study. Use of Artificial Intelligence (AI)-Assisted Technology for Manuscript Preparation: The author confirms that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI. Disclaimer: None.
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