International Journal of Nursing Studies 39 (2002) 793–802

Smoking habits and attitudes towards smoking among

university students in Jordan
Linda G. Haddad*, Malakeh Z. Malak1
Faculty of Nursing, Jordan University of Science and Technology, P.O. Box 3030, Irbid 11220, Jordan
Received 4 June 2001; received in revised form 1 January 2002; accepted 1 March 2002

Abstract

The aim of this study was to estimate the prevalence of smoking and to describe the habits, attitudes, and practices
related to smoking among students of Jordan University of Science and Technology (JUST), Irbid, Jordan.
Students ðn ¼ 650Þ were recruited in randomly selected, cluster samples drawn from the medical and engineering
colleges of JUST. They were made familiar with a modified Arabic version of the World Health Organisation Smoking
Questionnaire and the Attitudes towards Smoking Questionnaire to study their habits, attitudes, and beliefs in relation
to smoking.
The study revealed that the prevalence of smoking was 28.6% (50.2% among males and 6.5% among females).
Friends, not family, were the main source of the first smoking, and this most often occurred after 15 years of age
(82.3%). Males preferred smoking in the cafeteria, females in the bathroom. The main advantage of smoking for males
was calming down, while for females it was independence. Non-smokers chose not to smoke because of health and
hatred of the habit. The non-smokers had more positive attitudes against smoking and were more aware of the adverse
effects of smoking. The reasons smokers gave for starting smoking were pleasure, followed by stress and curiosity. Two-
thirds of smokers intended to quit smoking in the future. Some smokers disagreed with some criticisms against
smoking, and reasons why they did not want to quit included social attitudes, addiction, and not knowing how to quit.
Results of this study may provide baseline data to develop an anti-smoking program in the university and encourage
policy makers to limit smoking in the university by strengthening the policies against smoking.
r 2002 Elsevier Science Ltd. All rights reserved.

Keywords: Smoking prevalence; Attitudes; Habits; University students

1. Introduction of Jordanians who will die or be disabled as a result of

Smoking and tobacco consumption is on the increase
in countries of the Eastern Mediterranean Region
(WHO, 1997). The same trend is expected to be
occurring in Jordan, which suggests that the number
*Corresponding author.
E-mail address: linda@just.edu.jo (L.G. Haddad).
1
This research was part of a thesis submitted in partial
fulfillment of Malakeh Z. Malak degree of Master’s in
Community Health Nursing at Jordan University of Science
and Technology.
tobacco-related diseases will increase.
Although smoking is a major health problem in
Jordan its actual extent is not known. The last national
survey in Jordan in 1996 found that smoking prevalence
among people aged 25 years and over was 23.7% (48%
among males and 12% among females) (Abbas and
Kharabsha, 1996). A study (Ajlouni et al., 1998) on the
prevalence of obesity in semi-urban communities in
Jordan reported smoking prevalence among adults 25
years of age and older was 31.7% for males and 6% for
females. A more recent study in 1999 found that 21% of
school students were smokers (WHO, UNICEF, &
Smoking Surveillance Committee, 1999). Except for

0020-7489/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 2 0 - 7 4 8 9 ( 0 2 ) 0 0 0 1 6 - 0
794 L.G. Haddad, M.Z. Malak / International Journal of Nursing Studies 39 (2002) 793–802
these studies research on smoking among the different
age groups is lacking. Baseline information is needed to
quantify the size of the ‘smoking epidemic’ in Jordan in
terms of its effect on various segments of the population.
This information would enable targeting of anti-smok-
ing programs to specific groups with messages appro-
priate to their habits and beliefs.
Prevalence of smoking in developing countries such as
Jordan is noted to be increasing, especially among
students, whereas surveys of students in developed
countries are showing decline in smoking prevalence
(Nelson et al., 1995; WHO, UNICEF, & Smoking
Surveillance Committee, 1999). The increase of tobacco
use in Jordan could be the result of several factors:
growing population, rising income, increasing interest in
smoking on the part of girls and women, relentless
tobacco campaigns, and the lack of awareness of the
dangers and hazards of smoking.
The purpose of this study was to focus upon the
habits, attitudes, and practices related to smoking
behaviours of students at a university in northern
Jordan. The topic is new to Jordan, but has been
investigated by other researchers in other Arab countries
(Hashim, 2000; Abolfotouh et al., 1998; Felimban and
Jarallah, 1994; Felimban, 1993).
1.1. Review of the literature
Great majority of smokers starts the habit before 20
years of age (Young et al., 1989). There are many
reasons for smoking, such as alleviation of stress, life
problems, peer pressure, social acceptance issues, family
history (parental modelling of smoking behaviour),
lower educational attainment, and lower economic
status. Young smokers desire to appear mature, self-
confident and independent and to attain a high
personality profile (Kegler et al., 1999). On the other
hand, religion, sensory issues such as bad taste or smell,
negative health consequences, impaired physical perfor-
mance, negative physiological response, and issues
related to family are considered as some of the reasons
for not smoking (Felimban & Jarallah, 1994; Kegler
et al., 1999).
Attitudes and beliefs towards smoking predict inten-
tions and starting of smoking (Brownson et al., 1992).
Attitudes towards smoking serve as a deterrent to
initiating smoking and as a stimulus to quitting (Chassin
et al., 1984; Hansen et al., 1985).
Great majority of pupils (smokers and non-smokers
alike) recognise that smoking is harmful to the health
(Smith, 1991). Contrarily, pupils who tried cigarettes
had more adverse attitudes and beliefs about the effects
of smoking compared to non-smokers (Greenlund et al.,
1997). Smokers are responsible for their own health, yet
most are still unaware of the grave dangers of smoking
or of ways they could avoid them (Royal College of
Physicians, 1983). Hill and Gray (1989) found most
smokers did not believe that smoking caused illness and
most of them thought that only those who smoke
heavily (by which they meant those who smoke more
cigarettes than they do themselves) are likely to get
serious illnesses caused by smoking. In fact about one-
third of all premature deaths caused by smoking occur
in smokers who smoke less than 20 cigarettes per day
(Royal College of Physicians, 1983).
Most smokers understood smoking as a strategy to
cope with the social anxieties rather than as deviant or
illegal behaviour (Leventhal et al., 1991). Use of
cognitive coping and problem solving methods has been
shown to be a deterrent to initiating smoking (Lotecka
and MacWhinney, 1983) and to be maintaining absti-
nence among adults (Supnick & Colletti, 1984; Wewers,
1988).
Many studies focused on attitudes and beliefs towards
smoking were conducted. Kegler et al. (1999) studied the
functional value of smoking and non-smoking from the
perspective of American Indian youth by using focus
groups. The results indicated for smokers, the functional
value of smoking was associated with peers, moods,
image, addiction, family and sensory pleasures. For non-
smokers, the functional value of non-smoking was
related to sensory aspects, health consequences, physical
performance, physiological response and family.
Felimban and Jarallah (1994) conducted a study in
Riyadh, Saudi Arabia, to examine the attitudes and
practice of secondary school boys towards smoking.
They surveyed 1312 randomly selected students using a
questionnaire and found a smoking prevalence of 21.8%
in the study sample. They also noted that prevalence
rates increased with increase in age with more than two-
thirds of the ever-smoked group starting the habit after
age 10 years. Of the participants as a whole more than
72% consumed less than 10 cigarettes per day and
67.3% never smoked at school. The most common cause
of smoking suggested by the students was boredom
(29.1%), followed by habit (23.5%) and imitation
(17.1%). Despite participants’ concern about smoking
hazards, 27.6% of the ever-smokers were still smoking
on regular basis.
Felimban (1993) studied the attitudes towards smok-
ing and smoking practices of female university students
in Riyadh, Saudi Arabia. Of the 663 females who
completed the questionnaire, 45.6% had a formal
medical educational background and 54.4% had other
scientific educational backgrounds. The smoking pre-
valence was 8.6% and 11.6% for medical and non-
medical groups, respectively, and 53.8% and 71.4% for
those who had ever-smoked were still smoking. Also,
46.2% of the former group and 28.6% of the latter
group had quit smoking. Nearly all of those studied
were aware of the hazards of smoking, and the media
was the major source of this information. Religion,
 L.G. Haddad, M.Z. Malak / International Journal of Nursing Studies 39 (2002) 793–802
health and social considerations were important barriers
which may inhibit an individual from smoking, as well
as provide a potential pressure to quit.
Bener et al. (1999) studied cigarette-smoking habits
among high school boys in the United Arab Emirates.
The survey of 1500 public secondary school boys found
that 18.9% were currently smoking and another 28.2%
had smoking experience. Most of the smokers had
begun smoking between the age of 10 and 15, and were
much likely to have family members who smoked.
Hashim (2000) established a baseline data on the
smoking habits of health science students in Saudia
Arabian University environment. In a random sample of
647 students 29% were current smokers. Among major
factors that influence the smoking prevalence were the
smoking habits of peers, siblings, and parents. The
major source of information on the health consequences
of smoking was the media.
In summary, researchers in East Mediterranean
countries have been working on building research-based
knowledge particular to their local areas. Many studies
have estimated the prevalence of smoking within general
and particular populations, notably school and uni-
versity students. The age of initiation of smoking has
been determined for some populations; as well as
reasons for smoking and related environmental factors
that influence children and young adults to take up
smoking are also determined. Also, student knowledge
about the hazards of smoking and attitudes toward
quitting has been investigated.
Smoking habits among university students have been
described and predictors of smoking, such as peer group
influences, explored. There are some studies about the
prevalence, practices, and attitudes towards smoking
university students. They assessed the knowledge about
health consequences of smoking and explored important
aspects of knowledge, attitudes and beliefs of smokers
and non-smokers.
Little research has been conducted in the East
Mediterranean area on the initiation of smoking and
factors that may determine smoking frequency, such as
type of school, academic achievement, social conse-
quences of smoking, socio-economic status and presence
of smokers at home. Research in this area has so far not
assessed the relative contribution of such factors as self-
image, peer pressure and dieting behaviour to frequency
of smoking among school or university students.
Few studies have been conducted among females.
Most East Mediterranean studies have concentrated and
focused on males, and reports of gender differences
should be viewed with a particular caution because these
differences may be due to varying degrees of expressive-
ness by gender rather than true gender differences in
factors and values of smoking.
Given the gaps found in the literature review, this
research study is needed to understand the habits,
795
attitudes, and practices in relation to smoking among
university students. In addition, the need to examine
gender differences in expressions and values of smoking
will be addressed. Locally derived, gender-specific
information gained through this study will be useful to
develop anti-smoking education programs that are
designed to meet the different needs of young men and
women in relation to their attitudes toward smoking.
2. Materials and methods
A descriptive, exploratory study design was used to
describe and identify smoking habits, beliefs, and
attitudes towards smoking. The population under study
was all students enrolled in Jordan University of Science
and Technology (JUST), one of the largest govern-
mental universities in Jordan. Given the total student
population of 9898, assuming a prevalence of smoking
of 50% and accepting a margin of error not exceeding
4% with a 95% confidence level, the needed sample size
was 625. The investigator enlarged the sample size to 650
to allow for loss of subjects.
Questionnaires (Attitudes towards smoking qestion-
naire, 1998) were distributed proportionately, according
to student enrolment in the medical and engineering
colleges of the university. This generated a sample of 400
students from the medical building and 250 from the
engineering building. Questionnaires were randomly
distributed to whole classes of students in either college
by randomly choosing one lecture room from each
corridor containing at least three lecture rooms. At the
same time, cafeterias for the two college buildings were
included in the distribution of questionnaires by
randomly choosing one table from every five tables.
All students in the study sample were given a
questionnaire composed of two parts. The first part is
a modified Arabic version of the smoking questionnaire
developed by the WHO in 1984 (WHO, 1984). From this
questionnaire, only the area about smoking behaviour
was used to measure habits and beliefs. This consisted of
questions about prevalence of smoking, type of smoker,
type of smoking, practice of smoking (number of
cigarettes and favourite smoking place) and initiation
of smoking (age, source and causes of first smoking).
The smoking behaviour of participants was categorised
as smoker/non-smoker. Smokers were classified as daily,
weekly or experimental; and as low, medium or high
users of cigarettes. Also included in the questionnaire
were beliefs about smoking (advantages of smoking,
reasons for not smoking and attempts to quit smoking),
which consisted of statements that students were to
check indicating those best reflecting their beliefs. The
second part was an attitude toward smoking question-
naire developed by a student in the Department of
Psychology, University of Plymouth, Devon, UK
796 L.G. Haddad, M.Z. Malak / International Journal of Nursing Studies 39 (2002) 793–802
(http://www.psy.plym.ac.uk/students/amills98/amanda2.
htm). The questionnaire consists of two sub-scales:
positive (good) attitude sub-scale against smoking,
which consists of 17 items, and negative (bad) attitude
sub-scale against smoking, which consists of 14 items.
Each item was rated on a five-point scale.
To determine the content validity and domain
representatives of the instrument being developed, three
experts, selected for their experience in public health and
nursing education in Jordan, evaluated it. Following
revision and refinement, the total content validity index
of the instrument was 1.00.
The Arabic version of the instrument was pilot tested
on a group of non-medical speciality students in Jordan
University ðN ¼ 20Þ: Questions were found to be clear,
and respondents took an average of 10–15 min to
complete it. Internal consistency was used in ascertain-
ing reliability of the instrument between individual items
in the scale. The Cronbach’s Alpha obtained from the
pilot data was 0.8349.
A letter describing the nature and significance of this
study was sent to the Dean of Students’ Affairs at JUST,
to request permission to access students for recruitment
to this study. After obtaining permission from faculty
members and students, arrangements were made for
questionnaires to be completed by the selected students
in lecture rooms and cafeterias. Closed areas, such as
lecture rooms and cafeterias, were chosen because it was
important to control the setting for administration of
the questionnaires. In this way participants would
consistently complete only one questionnaire. The
objectives and the content of the questionnaire were
first explained to the whole group of students, and then
this questionnaire was directly administered to them and
collected on completion. A code of confidentiality was
maintained throughout the study, and faculty members
were requested to not be present during the actual
completion of and submission of the questionnaire.
Each questionnaire contained a cover letter with
instructions stating how to respond to the instrument.
In addition to personal details, the students were asked
about their smoking habits and practices, beliefs about
smoking, and attitudes towards smoking. Administra-
tion and collection of the questionnaire from each site
required approximately 40–50 min. The Statistical Pack-
age of the Social Science (SPSS) was used to compute all
data in this study. The significance of association was
tested at an alpha level of p0.05.
3. Results
The results are based on the questionnaire responses
of 650 study participants. As seen in Table 1 half
(50.6%) of the sample was male. The population age
ranged from 17 to 28 years, with the majority between
20 and 24 years (58.5%). Overall, 28.6% of the students
were smokers, with significant differences in prevalence
rates by gender, 50.2% among males and 6.5% among
females (w2 ¼ 151:270; P ¼ 0:000). Also, prevalence of
smoking increased significantly according to year of
studies: first year, 9.6%; second year, 25.0%; third year,
28.9%; and fourth year, 56.7% (w2 ¼ 6:609; P ¼ 0:000).
Almost half (45.9%) of the students had parents and/or
siblings who were smokers, 12.8% had others such as
close relatives as smokers, 41.2% had no smokers in
their families; however, family smoking was not
statistically significant related to smoking status
(w2 ¼ 1:065; P ¼ 0:178). Significantly, most smokers
came from families with middle and high-income status
(w2 ¼ 11:444; P ¼ 0:022) (see Table 1).
3.1. Smoking habits among students
The majority of smokers were daily smokers (74.7%),
while 9.7% were weekly smokers, and 15.6% were
experimental smokers. Cigarettes were more prevalent
among smokers (68.4%) then water pipes (30%) and
cigars (1.6%). Nearly a third (32.9%) were classified as
high smokers (>20/day), 37.6% were classified as low
smokers (o10/day) and 29.5% were classified as
medium smokers (11–20/day). Health sciences students
were categorised significantly as the lowest smokers
among all students (chi-square=12.2; P ¼ 0:05) (data
available on request). There were no significant differ-
ences in favourite smoking place, the highest percentage
of smokers reported cafeteria (28%), home (26.3%),
college (22.0%), while 9.7% reported bathroom and
14.1% reported others. Significant gender differences
were found in preferences: male preferred cafeteria for
smoking (30.9%), and female preferred bathroom for
smoking (52.4%) (w2 ¼ 4:531; P ¼ 0:000).
The majority of smokers started smoking at or after
15 years (82.3%), 15.1% started between 10 and 15 years
and 2.7% started when they were less than 10 years.
Friends were considered as the major source of first
smoking (58.6%), this was followed by buying and
smoking (30.1%) and for 11.3% family members and /
or close relative. The cause or reason for first smoking
included pleasure (35.5%), stress (28.0%) and curiosity
(23.1%), and 13.5% reported other reasons. Previous
attempts to stop smoking were reported by 57.5% of
smokers, and 42.5% did not attempt to stop smoking.
About 69.4% of smokers reported that they intend to
stop smoking in the future; however, almost a third
(30.6%) did not intend to stop smoking. The results
indicate that there were no significant differences
between health science, engineering, and basic science
students in their intentions to stop smoking in the future
(w2 =6.316; p ¼ 0:09).
The reasons for not smoking were ranked as follows:
health and hatred (34.1%), religion (15.3%), saving
 L.G. Haddad, M.Z. Malak / International Journal of Nursing Studies 39 (2002) 793–802 797

Table 1 list, smokers and males had means of 3.62 (1.02SD) and
Demographic characteristics of the study population ðN ¼ 650Þ 3.88 (0.98SD), respectively, compared to non-smokers
Characteristic Frequency Per cent 4.18 (0.82SD) and females 4.12 (0.84SD). Using t-test
with a 0.05 significance level, there were significant
Gender differences among smokers and non-smokers
Male 329 50.6 (t ¼ 7:006; P ¼ 0:000) and males and females
Female 321 49.4 (t ¼ 12:161; P ¼ 0:000) (see Table 2).
Age
A second list of statements tended to minimise or
>20 263 40.5
20–24 380 58.5
deny known health hazards of smoking. Smokers and
>24 7 1.1 males were more likely to agree with these statements,
College i.e. ‘Smoking is not as harmful as taking drugs or
Agriculture 44 6.8 alcohol’, such that overall for the list they had means of
Engineering 127 19.5 2.68 (1.13SD) and 2.98 (1.14SD), respectively, compared
Science 224 34.5 to non-smokers 2.29 (0.99SD) and females 2.30
Health Science 255 39.2 (1.01SD). Using t-test with a 0.05 significance level,
Year there were significant differences among smokers and
1st year 245 37.7 non-smokers (t ¼ 8:279; P ¼ 0:000) and males and
2nd year 204 31.7
females (t ¼ 14:838; P ¼ 0:000) (see Table 3).
3rd year 97 14.9
4th year and above 104 16
Smoking
Yes 186 28.6 4. Discussion
No 464 71.4
Smokers in familya 4.1. Smoking habits among students
None 279 41.2
Parents and/or siblings 311 45.9 The great majority of smokers in this study started
Others 87 12.8 smoking after the age of 15 years. This is consistent with
Family income/month studies in other Arab countries finding that the most
o250 J.D 66 10.2
common age of starting smoking was between 15 and 19
250–500 J.D 127 38.0
500–750 J.D 224 28.9 among all ever-smokers (Bawazeer et al., 1999; Felim-
750–1000 J.D 255 8.5 ban and Jarallah, 1994). Young et al. (1989) set the age
X1000 J.D 94 14.5 of onset as 20 years for the great majority of smokers
a
and described adolescence as the most vulnerable period
Response more than one. for acquiring the smoking habit.
This study found the prevalence to be 28.6% among
university students. The prevalence of smoking in-
money (6.7%), social acceptability (6.5%), and other creased significantly according to year of studies from
reasons (3.2%). 9.6% in the first year to 56.7% in the fourth year.
No significant relationships were found between Smoking initiation during university years (19% of
variables: smoking status and family smoking, male sample) was found by a national survey of US college
and female smokers reporting pleasure as the major students (Everette, 1999). A finding of this study
cause of first smoking (35.8% vs. 33.3%), source of first suggested the pleasure was the main reason for smoking,
smoking and favourite place of smoking, and number of followed by stress and curiosity. This finding has been
cigarettes smoked daily and attempt to stop smoking. seen in several American studies (Kegler et al., 1999;
Emmon et al., 1998; Pomerleau et al., 1978; Ikard et al.,
3.2. Attitudes towards smoking among students 1973).

With respect to the attitude questionnaire, respon-
dents were given a list of statements asserting the
harmful effects of smoking, such as ‘Smoking seriously
damages health’. For every statement, smokers were
more likely to disagree with negative statements against
smoking than non-smokers. Males were also more likely
to disagree than females, except for two statements
‘Smoking shortens a person life’ and ‘one does not have
to smoke for a long period of time to be in danger of
developing tobacco related disorders’. Overall for the
4.2. Factors that influence smoking
The major factors associated with continued smoking
in this study were smoking in the cafeteria and the role
of friends; thus the university environment itself is
conducive to increase in prevalence. Other reasons may
include as lack of opportunity or motivation to spend
time in healthier, pleasure-giving activities, such as
sports. Being away from family, experiencing stress
from studies and new adulthood are also factors
798 L.G. Haddad, M.Z. Malak / International Journal of Nursing Studies 39 (2002) 793–802

Table 2
Positive attitudes against smoking by gender (male N ¼ 329; female N ¼ 321; total N ¼ 650Þ

Item Gender

Male Female Total

M SD M SD M SD

All forms of smoking are dangerous as 4.47 0.86 4.75 0.59 4.61 0.75
opposed to only heavy smoking
Smoking during pregnancy is harmful 4.73 0.61 4.88 0.43 4.81 0.53
to unborn baby
Smoking should be avoided 4.32 0.9 4.61 0.74 4.46 0.84
Smoking seriously damages health 4.31 0.78 4.57 0.65 4.44 0.73
Smoking shortens a person life 3.23 1.36 3.0 1.15 3.51 1.29
Smoking is a purposeless less activity 3.90 1.13 4.21 0.97 4.05 1.06
Smokers can totally reverse damage to 4.13 0.82 4.27 0.66 4.20 0.75
their health by deciding to give up
smoking
Smoking kills 3.91 1.03 4.21 0.84 4.06 0.95
Passive smoking is harmful to the 4.18 0.82 4.38 0.74 4.28 0.79
health of non-smokers
Smokers die younger than non-smokers 3.12 1.20 3.51 1.09 3.3 1.16
Smoking is revolting vice 3.73 1.18 4.19 0.98 3.96 1.11
No one should be allowed to smoke 3.38 1.19 3.91 1.10 3.64 1.18
The risk of developing lung cancer as a 3.94 0.91 4.23 0.79 4.08 0.86
direct result of smoking is very high
The damage done through the 3.15 1.08 3.54 1.05 3.34 1.08
inhalation of tobacco smoke is
irreversible
The lung cancer rate is significantly 3.93 0.85 4.16 0.77 4.04 0.82
higher for all smokers than among non-
smokers
One does not have to smoke for a long 3.49 1.02 3.36 1.10 3.42 1.06
period of time to be in danger of
developing tobacco related disorders
The smokers are more exposed to heart 4.16 0.88 4.40 0.70 4.28 0.81
and arteriosclerosis diseases than non-
smokers

Total sub-scale 3.88 0.98 4.12 0.84 4.02 0.92

associated with student smoking. Students may also be
influenced by role models, such as family members and
teachers (Stead et al., 1996).
Policy makers need to seek research-tested measures
to offset such pressures affecting young people. In
Jordan, preventive measures and tobacco control
programs must be employed in secondary schools and
universities in order to limit the smoking epidemic.
These measures would be strengthened by local research
to discover factors that are associated with starting of
smoking in adolescence and those that are specific to
eastern cultures and gender.
Most developing countries report high rates of male
smokers and low rates of female smokers. The WHO
(1999a) indicated that smoker rates in all developing
countries are approaching 48% among males and 7%
among females. The low percentage of prevalence of
smoking among females is true with Arab studies also as
they revealed the prevalence of smoking among uni-
versity female students approximately 9% (Felimban,
1993; Hashim, 2000). Low rates may be reported either
due to actual few female smokers due to social
unacceptability or inaccurate self-reporting due to
shame. Higher rates have been reported in Jordan,
16% female smoking rate during high school and 6%
during university (WHO, UNICEF, & Smoking Sur-
veillance Committee, 1999), but this higher rate may be
caused by short-term experimentation. With increased
education, smokers quit smoking and the prevalence of
smoking declines (Pierce, 1990). However, Li et al.
(1996) have identified that financially independent,
socially mobile women are at high risk for taking up
smoking. University students and graduates may imitate
successful women who are smokers.
 L.G. Haddad, M.Z. Malak / International Journal of Nursing Studies 39 (2002) 793–802 799

Table 3
Negative attitudes against smoking by gender (male N ¼ 329; female N ¼ 321; total N ¼ 650)

Item Gender

Male Female Total

M SD M SD M SD

Smoking is one of life’s basic pleasures 2.34 1.34 1.64 0.96 1.99 1.22
There is nothing like a good smoke 1.76 1.08 1.36 0.71 1.56 0.93
Only heavy smoking is dangerous 2.97 1.21 2.79 1.23 2.88 1.22
Smoking is not as harmful as taking 3.37 1.27 2.84 1.21 3.11 1.27
drugs or alcohol
Smoking is less of danger than other 3.10 1.19 2.64 1.13 2.87 1.18
risks, such as the risk of a car accident
Statistics which show a relationship 3.04 1.15 2.79 1.17 2.92 1.16
between smoking and health hazards
are generally misleading
Anti-smoking advertisements over 2.85 1.18 2.31 1.07 2.58 1.16
emphasise the dangers of smoking
Smoking is relatively harmless 2.20 0.94 1.94 0.88 2.07 0.92
Smoking low tar cigarettes reduces the 3.16 1.08 2.92 1.02 3.04 1.06
risk of developing serious diseases
The health of non-smokers is not 1.95 1.00 1.70 0.83 1.83 0.93
affected by breathing cigarette smoke
Life is too short to worry about the 2.97 1.20 2.61 1.25 2.79 1.23
harmful effects of smoking
One has to smoke for a long period of 2.52 1.17 2.13 0.98 2.33 1.09
time to be in danger of developing
serious diseases
There is no significant differences 2.74 0.99 2.27 0.85 2.51 0.95
regarding mortality rate between
smokers and non-smokers
Many old people that have smoked for 2.56 1.06 2.31 0.93 2.44 1.00
years and have not developed lung
cancer is clear evidence that lung cancer
is not caused by smoking

Total sub-scale 2.68 1.13 2.30 1.01 2.49 1.09

The WHO (1999b) approaches the ‘smoking epidemic’
with a model based on the experience of the developed
countries. In the first phase, young males with higher
income first take up smoking, followed years later by
females with higher income. Then those with lesser
income follow the example of the higher class, which
finally quits smoking when the negative health effects
begin to be apparent, leaving smoking more and more a
habit of the lower class. The number of smokers of older
age increase as those who began at a young age continue
to smoke for decades. The significance of this model for
developing countries is to encourage groups who have
not yet started smoking to stay away from smoking.
WHO has special concern for women who generally
have much lower prevalence than men in the developing
world, but could without adequate preventive efforts
follow the pattern of developing countries where half or
more of smokers are women. In the present study a low
percentage of females who smoke in a university in
Jordan is not necessarily a ‘good sign’. It may indicate
the beginning of rising trend that must be monitored and
countered by universities and community health efforts.
In the beginning of this paper, the author warned of the
impending disaster of large number of ageing smokers
imposing the cost of chronic illness on society. If females
take up smoking to the extent of males, the problem
caused by long-term smoking will reach even greater
magnitude than anticipated with current smoking
patterns.
4.3. Beliefs about smoking among students
Two-thirds of smokers expressed a desire to stop
smoking in the near future. A high percentage of
intention to stop smoking among smokers was reported
in other studies conducted in Arab countries (Hashim,
800 L.G. Haddad, M.Z. Malak / International Journal of Nursing Studies 39 (2002) 793–802
2000; Bener et al., 1999). Intention to quit smoking may
be related to the respondents’ fear of the harmful effects
of smoking upon their health. Another reason could be
attributed to wanting to reduce spending. That most
smokers in the sample intend to quit smoking is hopeful
as they may respond well to smoking cessation programs
if made available in the university.
4.4. Attitudes towards smoking among students
Non-smoking and female students reported higher
scores of positive attitudes against smoking than
smoking and male students. They were more aware of
the negative impact and harmful effects of smoking.
Male and smoking students reported higher scores of
negative attitudes against smoking than female and non-
smoking students. These findings might be explored in
future research.
First, a general principle affecting attitudes is that
people tend to justify their behaviour or avoidance of
behaviour with perceived benefits or harm. Therefore, a
non-smoker would focus on the harms of smoking. A
smoker would tend to deny or ignore those harms in the
remote future and focus on the pleasure and relaxation
gained from it. Also, as noted above, students preferred
to smoke in the cafeteria; therefore smoking has a social
function. Smokers knew about the negative impact of
smoking on their bodies and physical performance but
knowledge by itself is not enough. The smokers’
perception of the health hazards of smoking is not
enough to change their smoking behaviour or confirm
their intention to quit. Having a pre-intervention level of
motivation is important in terms of chances of success in
quitting.
Second, females were more aware of the health
hazards of smoking and took notice of the consequences
than males. This may be due to women having greater
concern for their own health due to periodic changes in
their bodies related to menstruation, childbirth and
lactation. Furthermore, they may have more concern for
the health of others because they tend to have a
nurturing role in families, thus leading to greater
concern for health than the male members of their
families.
Future research is needed to determine the relation-
ship between motives for stopping and its outcome.
Smokers are generally aware of the adverse health
effects of smoking and of beneficial health effects of
giving up, but often they have to struggle with the
physical and psychological problems associated with
giving up smoking without assistance or group support.
Also, social pressures and status are closely involved in
continued smoking (Felimban, 1993). Jordan lacks
smoking cessation programs, but they should be tried
and evaluated using scientific research methods.
The findings that related to positive and negative
attitudes correspond with the previous studies which
revealed that most students showed positive attitudes
towards public action against smoking. However,
smokers showed less positive attitudes than did non-
smokers (Abolfotouh et al., 1998). Also, smokers who
tried smoking had more adverse attitudes and beliefs
about the effects of smoking compared with non-
smokers (Greenlund et al., 1997). Additionally, several
studies have found that more positive attitudes toward
smoking have been associated with changes in smoking
behaviours (Kegler et al., 1999; Greenlund et al., 1997;
Felimban, 1993). More negative attitudes against smok-
ing have been found to be indicative of both increased
frequency of smoking and growth in uses and this needs
to be explained) (Greenlund et al., 1997).
4.5. Implications for health care professionals
The findings of this study could be used as a basis for
developing health education and tobacco control
programs. Intention to stop smoking was remarkably
high among students. Quitting is not an easy task;
however, the motivation to quit might be the first step
for an individual to stop smoking. Developing a pre-
intervention level of motivation is likely more important
in quitting.
Interventions are needed to enhance students’ efforts,
intentions, and strategies to quit smoking. Also, these
findings could recommend strategies and policies to
maintain a university culture of non-smoking zone. In
order to encourage a smoke-free society, the university,
through education and prevention measures, should
develop and implement an active anti-smoking program.
These efforts if successful could then be extended to a
national anti-smoking program to combat smoking
through reaching all students and the whole of
Jordanian society.
JUST, in cooperation with WHO and the Smoking
Surveillance Committee, has developed a program for
smoking surveillance. They planned and started to
implement an anti-smoking program, which has many
instructions and policies. These policies prohibit and
prevent smoking in public areas in the university, specify
certain areas for smoking and restrict cigarette sales.
Toward creating a smoke-free university environment,
the plan aims to develop greater awareness through
campaigns and lectures against smoking, conducting
scientific research about smoking, and punishing stu-
dents who smoke in public areas. Through the
combination of education, policies, and enforcement,
the university’s anti-smoking program has the following
goals: to promote non-smoking as the norm, to reduce
the risks to non-smokers of passive smoking and finally,
to reinforce smoking prevention efforts. This combina-
tion may help to reduce smoking levels. Non-smoking
 L.G. Haddad, M.Z. Malak / International Journal of Nursing Studies 39 (2002) 793–802
policies already exist in Jordanian universities but most
of them are not active yet because many of the students
do not know them. The role of health care professionals
is to encourage students to market and monitor the
program themselves. They need to develop strategies
based on this study and have to conduct studies related
to smoking prevention and cessation.
Furthermore, findings obtained in this study are
considered to be baseline data of students’ own beliefs
and values related to smoking and students’ behaviours
about smoking attitudes. These findings could help
health care professionals to develop a targeted anti-
smoking education program for this population. This
program should do more than give information about
the harmful health effects of tobacco smoking; it should
change student attitudes. It should include lessons
designed to meet the different needs of males and
females in relation to their attitudes towards smoking
and their smoking behaviour. Also, proper understand-
ing of the life situation of the smoking student, as well as
the phases through which student can proceed on the
road to a healthier way of life provides a firm basis for
more effective health education.
References
Abbas, A., Kharabsha, S., 1996. Morbidity and Mortality
Survey, Ministry of Health, Jordan, Unpublished Study.
Abolfotouh, M., Abdel-Aziz, M., Al-Akija, W., Al-Safy, A.,
Khattab, M., Mirdad, S., Al-Juhani, A., Al-Humaidi, M.,
1998. Smoking habits of King Saud University students in
Abha, Saudi Arabia. Annual Saudi Medicine 18 (3), 212–
216.
Ajlouni, K., Jaddou, H., Batieha, A., 1998. Obesity in Jordan.
International Journal of Obesity 22, 624–628.
Attitudes towards smoking qestionnaire, 1998 [online]. Avail-
able: ahttp://www.psy.plym.ac.uk/students/amills98/aman-
da2.html.
Bawazeer, A., Hattab, A., Morales, E., 1999. First cigarette
smoking experience among secondary-school students in
Aden, Republic of Yemen. Eastern Mediterranean Health
Journal 5 (3), 440–449.
Bener, A., Stewart, T., Al-Ketbi, L., 1999. Cigarettes smoking
habits among high school boys in the United Arab
Emirates. International Quarterly of Community Health
Education 18 (2), 209–222.
Brownson, R.C., Wilkerson, J.C., Davis, J.R., Owen, N.,
Fisher, E.B., 1992. Demographic and socio-economic
differences in beliefs about health effects of smoking.
American Journal of Public Health 82, 99–103.
Chassin, L., Presson, C.C., Shermann, S.J., 1984. Cognitive and
social influence factors in adolescent smoking cessation. In:
Gulick, E., Escobar-Florez, L. (Eds.), 1995. Reliability and
validity of the smoking and women questionnaire among
three ethnic groups. Public Health Nursing 12 (2), 117–126.
Emmon, K., Wechsler, H., Dowdall, G., Abraham, M., 1998.
Predictors of smoking among US college students. Amer-
ican Journal of Public Health 88 (1), 104–107.
801
Everette, S.A., 1999. Smoking initiation and smoking patterns
among US college students. Journal of American College
Health Journal of American College Health 48 (2), 55–61.
Felimban, F., 1993. The smoking practices and attitudes
towards smoking of female university students in Riyadh.
Saudi Medical Journal 14 (3), 220–224.
Felimban, F., Jarallah, J., 1994. Smoking habits of secondary
school boys in Riyadh, Saudi Arabia. Saudi Medical
Journal 15 (6), 438–442.
Greenlund, K., Johnson, C., Webber, L., Berenson, G., 1997.
Cigarette smoking attitudes and firs use among Third-
through sixth-Grade students: the Bogalusa Heart study.
American Journal of Public Health 87 (8), 1345–1348.
Hansen, W.B., Collins, L.M., Johson, C.A., Graham, J.W.,
1985. Self-initiated smoking cessation among high school
students. In: Gulick, E., Escobar-Florez, L. (Eds.), 1995.
Reliability and validity of the smoking and women
questionnaire among three ethnic groups. Public Health
Nursing 12 (2), 117–126.
Hashim, T., 2000. Smoking habits of students in college of
Applied Medical Science. Saudi Arabia, Saudi Medical
Journal 21 (1), 79–80.
Hill, D., Gray, N., 1989. Australian patterns of tobacco
smoking and related health beliefs in 1983. Community
Health Studies 8, 307–316.
Ikard, F.F., Tomkings, S., 1973. The experience of affect as a
determinant of smoking behavior: a series of validity
studies. In: Gulick, E., Escobar-Florez, L. (Eds.), 1995.
Reliability and validity of the smoking and women
questionnaire among three ethic groups. Public Health
Nursing 12 (2), 117–126.
Kegler, M., Kingsley, B., Malcoe, L., Cleaver, .V., Reid, J.,
Soloman, G., 1999. The functional value of smoking and
non-smoking from the perspective of American Indian
Youth. Family Community Health 22 (2), 31–42.
Leventhal, H., Keeshan, P., Baker, T., Wetter, D., 1991.
Smoking prevention: towards a process approach. In: Stead,
M., Hastings, G., Smith, C. (Eds.), 1996. Preventing
adolescent smoking: a review of options. Health Education
Journal 55, 31–54.
Li, C., Fielding, R., Hedley, A., 1996. Survey of knowledge,
perceptions and behaviour related to smoking in young
Asian women airline cabin crew. Health Education Journal
55, 92–100.
Lotecka, L., MacWhinney, M., 1983. Enhancing decision
behavior in high school smokers. In: Gulick, E., Escobar-
Florez, L. (Eds.), 1995. Reliability and validity of the
smoking and women questionnaire among three ethnic
groups. Public Health Nursing 12 (2), 117–126.
Nelson, D., Giovino, G., Shoplard, D., Mowery, P., Mills, S.,
Eriksen, M., 1995. Trends in cigarette smoking among US
adolescents, 1974 through 1991. American Journal of Public
Health 85 (1), 34–40.
Pierce, J.P., 1990. Time to ban cigarette advertising and
continue the quit, for life campaigns (Editorial). Medical
Journal of Australia 152, 113–114.
Pomerleau, O., Adkins, D., Pertschuch, M., 1978. Predictors of
outcome and recidivism in smoking cessation treatment. In:
Gulick, E., Escobar-Florez, L. (Eds.), 1995. Reliability and
validity of the smoking and women questionnaire among
three ethnic groups. Public Health Nursing 12 (2), 117–126.
802 L.G. Haddad, M.Z. Malak / International Journal of Nursing Studies 39 (2002) 793–802
Royal College of Physicians, 1983. Health or Smoking? Follow
up report of the Royal College of Physicians. Pitman,
London.
Smith, C., 1991. Smoking among young people: some recent
developments in Wales. Health Education Journal 50 (1),
8–11.
Stead, M., Hastings, G., Tudor-Smith, C., 1996. Preventing
adolescent smoking: a review of options. Health Education
Journal 55, 31–54.
Supnick, J.A, Colletti, G., 1984. Relapse coping and problem
solving training following treatment for smoking. In:
Gulick, E., Escobar-Florez, L. (Eds.), 1995. Reliability and
validity of the smoking and women questionnaire among
three ethnic groups. Public Health Nursing 12 (2), 117–126.
Wewers, M.E., 1988. The role of post-cessation factors in
tobacco abstinence: stressful events and coping responses.
In: Gulick, E., Escobar-Florez, L. (Eds.), 1995. Reliability
and validity of the smoking and women questionnaire
among three ethnic groups. Public Health Nursing 12 (2),
117–126.
WHO, UNICEF, & Smoking Surveillance Committee, 1999.
Studying the Problem of Smoking among Secondary-School
Students in Jordan, Smoking Surveillance Committee,
Jordan, Unpublished Study.
World Health Organization, 1984. Guidelines for the Conduct
of Tobacco Smoking among Health Professionals, WHO/
SMO84.
World Health Organization, 1997. Plan of action for tobacco
control in the Eastern Mediterranean region. Eastern
Mediterranean Health Journal 3 (1), 168–175.
World Health Organization, 1999a. Combating the Tobacco
Epidemic, WHO Report, 65–70.
World Health Organization, 1999b. WHO International Con-
ference on Tobacco and Health, Kobe, Japan, 14–18
November [on line]. Available: http://tobacco.who.int/en/
fctc/kobe/kobereport.html.
Young, D., Swan, A., Melia, J., 1989.. Cigarette advertising and
the youth market. Health Education Journal 48 (3).