The association between cigarette smoking attitudes and social capital among Iranian health and medical students: a cross-sectional study

Cigarette smoking is one of the most significant public health concerns worldwide, accounting for more than 5 million deaths annually, with the figure expecting to grow [1]. According to a World Health Organization projection, more than 8 million deaths per year will occur due to tobacco smoking by 2030 [2]. More than 80% of these deaths are anticipated to occur in low- to middle-income countries [3]. Smoking incareses the risk developing cancer, heart disease, stroke, and chronic lung disease [2]. Somkers are also more likely to pyschological problems, such as anxiety and depression [4].

The prevalence of cigarette smoking is high among university students globally, including students who study in health-related fields [5‐8]. A recent study in Lithuania showed that 41.1 and 55.7% of local and international dental male students were smoking, respectively [6]. An international study which compared smoking rates in among medical students reported higher smoking rates among medical students in Spain and Turkey, but lower rates among Australia and the United States students [9]. In Iran, cigarette smoking rates among medical students vary between 15.2–23.8% [10, 11]. As the future role models, the high rates of smoking among health and medical students are concerning [1], particularly that health professionals are expected to play a crucial role in anti-smoking campaigns [12].

Many factors affect health-related behaviors [13‐16], including social contexts which reinforce desirable behaviors [13‐16]. Social capital is defined as the characteristics of social structures, such as levels of interpersonal trust, reciprocal norms, and mutual assistance, that create resources for individuals and facilitate collective actions [1]. Social capital is considered a significant psychosocial determinant of health [17], influencing various health behaviors and outcomes [18], such as violence and physical and psychological health [19]. Social capital affects health through several mechanisms: norms and attitudes that influence health behaviors, psychosocial networks that increase access to health care, and psychosocial mechanisms that increase self-esteem and influence health behaviors through interpersonal relationships [20]. Positive social capital is linked with lower social harms, substance use, smoking, alcohol consumption [21, 22], and improved determinants of health, such as education [17].

However, it should be noted that social capital itself is not a protective factor against risk behaviors, such as smoking. While healthy social capital can positively affect health attitudes and behaviors by reinforcing positive health messages, unhealthy social capital can impose negative effects. For example, Albert-Lőrincz et al. (2020) found that participation in neighborhood communities and social programs increased the risk of smoking among the youth in Romania [13]. Similarly, a study including participants from Flemish Belgium, Canada, Romania, and England, reported that social capital related to friends increased the likelihood of smoking among adolescents [16]. Due to peer pressure, unhealthy social capital can increase the chance of smoking [14], while healthy social capital strengthens cooperation and relations of mutual support in the communities and nations. Therefore, it can be a valuable tool in combating unhealthy behaviors, such as crimes and substance use [21, 22].

Several studies have examined the link between social capital and smoking behaviors, and the results of these studies have consistently supported the important role of social capital in influencing smoking behaviors [1, 13, 22, 23]. However, little is known about the impact of social capital on shaping attitudes towards smoking among health and medical students in Iran and internationally. This study aimed to examine the role of social capital in shaping attitudes toward smoking among Iranian health and medical students. This is an important topci to explore, considering the high rates of smoking amongst Iranian university students and some other nations and given that health and medical students are the critical members of future health care systems.

Out of 538 participants, 301 (59.9%) participants were female and 56 (10.4%) married. Most participants (68.7%) lived with their families, and 131 (24.3%) students reported smoking cigarettes either in the past or currently. The distribution of the CSA scores according to the demographic characteristics of participants is shown in Table 1. The results of Chi-Square analyses showed that there was a statistically significant association between the CSA scores and sex (p < 0.001), year of study (p = 0.021), and smoking cigarettes either in the past or currently (p < 0.001).

The total scores of the CSA, the SCQ, and their dimensions are presented in Table 2. The mean total scores of the CSA and the SCQ were 48.6 ± 11.2 and 105.1 ± 19.7, respectively.

The distribution of different levels of the CSA and the SCQ is shown in Table 3. About 30% of the participants had either positive or indifferent attitudes towards smoking. The majority of participants (76.6%) had a moderate level of social capital.

Pearson’s correlation coefficients revealed a statistically significant negative correlation between the SCQ and CSA scores (r = − 0.24, p < 0.001). The results of the multiple linear regression analysis are shown in Table 4. The model indicated that social capital scores were negatively associated with cigarette smoking attitude scores (B = − 0.09, 95% CI: − 0.13 to − 0.04) after adjusting for potential confounding variables. The CSA scores were statistically significantly associated with gender, with male students showing more positive attitudes towards smoking than female students (B = 0.12, 95% CI: 0.06 to 0.17). The year of study was also statistically significantly associated with the CSA scores; in that year one students showed more negative attitudes towards smoking than students in year four and above (B = − 0.14, 95% CI: − 0.24 to − 0.04). Also, students who had smoking experience (current or past) presented more positive attitudes towards smoking than those without such experience (B = 0.35, 95% CI: 0.28 to 0.41).

This study aimed to examine the role of social capital in shaping health and medical students’ attitudes towards smoking. Although most students (70.4%) held negative attitudes towards smoking, the attitudes of 29.6% of the health and medical students were either positive or indifferent. The association between social capital and cigarette smoking attitudes was negative, meaning that students with more robust social capital held less positive attitudes towards cigarette smoking. About one in four students (24.3%) reported smoking either in the past or currently. This result is in line with previous studies reporting the smoking rate among Iranian medical students between 15.2 and 23.8% [10, 11]. These findings warrant closer attention. Health professionals are expected to take the primary role in educating society about the health risk of smoking. Even a small number of smoking physicians, who are seen as role models in society, can negatively impact on smoking control programs. Consequently, smoking prevention must be an essential part of curriculum requirements for all health-related disciplines [6] to help future health professionals gain a comprehensive understanding of the health risks of smoking and prepare them to take an active role in anti-smoking campaigns.

The available evidence suggests that university students generally held positive attitudes towards prevention and cessation of smoking [29]. For example, the majority of Indian medical students in a study believed that smoking should be banned in the society [12]. Similarly, a study among Beirut University students in Lebanon showed that students overall held favorable attitudes towards smoking bans and non-smoking policies in the public arenas [30]. Nevertheless, the high rate of positive or indifferent attitudes towards smoking among the health and medical students in our study is of concern. Similarly, Penhai et al. (2016) reported that the knowledge and attitdues of Irainain health and medical students about smoking was at a moderate level [31]. Further, Heydari et al. (2013) found that 23.1% of male university students, lecturers, and clergymen in Tehran had favorable attitudes towards smoking [32].

In the current study, a low level of social capital, male sex, being a senior student, and having smoking experience were associated with more positive attitudes towards smoking. The association between social capital and cigarette smoking attitudes was negative. This finding is in line with other similar studies conducted in Iran and internationally [1, 13, 22, 23, 33]. The results of a study on teenagers in Iran showed that social capital had a protective role against harmful health-related behaviors, such as smoking [33]. Similar results have been reported from studies conducted on different populations. For example, social capital was inversely associated with smoking behaviors among Chinese male employees [1]. Two studies conducted in the United States found that neighborhood cohesion, which is a dimension of social capital, was related to lower smoking behaviors among Asian American men [23] and Mexican Americans [22].

Further, Giordano and Lindstrom (2011) reported that trust and social participation, another dimension of social capital, was positively associated with smoking cessation. The study also found that the onset of smoking was higher in those who less actively participated in social activities [34]. In addition, a low social capital has been linked to increased risk of substance use, such as opium, cannabis, water pipe, alcohol, and oral tobacco in adolescents [35]. Yet, several studies have reported conflicting results. For example, the results of a study in Romania showed that the level of community engagement was not a protective factor against smoking [13]. Other studies found that the risk of smoking increased with larger networks of friends [36], and a higher level of social capital [16, 37]. These results suggest that the concept of social capital is not always positive [38].

Overall, the students in our study showed a moderate level of social capital. This finding is consistent with a previous similar study conducted in Tehran, Iran, reporting the health and medical sciences students’ social capital at a low-moderate level [27]. Nevertheless, studies that have assessed social capital among adolescents in general, both in Iran and outside, reported a strong social capital among adolescents [21, 39]. Compared to adolescents in general, the relatively lower level of social capital among health and medical students may indicate that university students have limited opportunities to develop social capital likely due to their university commitments. Further, most students in the current study were still living with their families, which can affect development of certain aspects of social capital. This is supported by the finding that the highest level of social capital among the participants was in the dimension of the family and friends connections and lowest in the dimension of participation in the local community. Similar findings were found by Moghaddam et al. (2016), who examined social capital among students at Jahrom University of Medical Sciences, Iran [40]. These results suggest that families and authorities should provide a sound basis for the growth of social capital, among adolescents and youth, particularly in the dimention of commuinity engagmnet, by creating opportunities for social interactions and participation.

Female sex was associated with more negative attitudes towards smoking, which is an expected finding. Generally, smoking rates are higher among men than women [41], and men hold less negative attitudes towards smoking than their female counterparts [42‐44]. Gender differences in smoking are, to a great extend, related to socio-cultural differences [7]. Generally, smoking is more accepted culturally for men than women. It is also known that family relationships have a significant impact on smoking behaviours, and women are more likely than men to be affected by family factors [14]. A study found that American adolescent girls are more likely than boys to smoke during family conflicts [45]. In Iran, smoking is more accepted for men socially and culturally, while it is viewed as an abnormal behaviour for women. This can explain the lower rate of smoking and more negative attitudes towards this behaviour among the female students in our country.

First-year students held more negative attitudes towards smoking than those in year four and higher. This finding is in line with the past research, suggesting that the pervasiveness of smoking increases significantly according to years of study [46, 47]. The rate of smoking is generally higher in senior university students than in freshman stduents [48], and it is well known that people who smoke hold more positive attitudes towards smoking than those who do not smoke [44, 49, 50]. Our study further confirmed this by revealing a significant association between smoking experience (either current or past) and attitudes towards smoking, in that students who were either current or past smokers were more likely to possess positive attitudes towards smoking.

This study found that nearly one in four health and medical students were current or past smokers, and about 30% of the students held either positive or indifferent attitudes towards smoking. As future healthcare providers who are expected to play a crucial role in anti-smoking programs, these findings are concerning, and suggest that universities should implement innoviative evdienced based effective methods in traninign of medical and health stduents about the health risk of smoking. Social capital among the study participant was at a moderate level, and it was negativly associated with the students’ attitudes towards smoking. As a factor that can improve negative attitudes towards smoking, families and university authorities should promote social capital amongst youth through providing social interactions and participation opportunities to help reduce smoking rates in the society.