Background
Tobacco smoking is an important risk factor accountable for non-communicable diseases (NCDs) such as cancer, cardiovascular diseases, diabetics, and chronic respiratory diseases [
1]. In Nepal, NCDs are accountable for 50.2 % of total deaths of which 50.7 % were female [
2]. WHO STEP Survey 2013 revealed the prevalence of current daily smoking was 18.5 % and their mean age of smoking initiation was 18.2 years (men = 18.5 years; women = 17.6 years) [
3]. Next, the mean age of smoking initiation was 16 years among 15–29 years old population [
3]. Recent global health professional school survey reported that 18 % of Nepalese medical students were smokers, of them 28 % were male [
4]. Another study from Nepal revealed that 16.8 % of public health students were smokers [
5]. Similarly, a study from Pokhara, Nepal showed nearly 55 % of medical students were current smokers [
6]. These findings revealed that college students or young adults (18–24 years) were vulnerable to cigarette smoking, for young adults, in this phase of life, were exposed to several psycho-social risk factors including the perceived risks and benefits of cigarette smoking which play a key role for smoking initiation and becoming established smokers [
7].
A prime aim of the Tobacco Control Act is to raise awareness on the health risks of tobacco use in the communities [
8]. The awareness programmes on the health risks of smoking among young adults would help to reduce the risk of dying from a smoking-related illness and at the same time discourage smokers to quit smoking [
9]. Understanding young adults’ perceptions on the health risks and the benefits of cigarette smoking is very essential. Here, perceived risk and benefits would mean subjective judgments that include the probability of occurrence of certain risks/negative outcomes and how an individual would concern with the consequences [
10]. The meaning of risks varies from individual to individual and is influenced by social and culture structure of a community [
10]. Hence, conducting a research on risk perception of smoking is crucial for it would even help to develop effective anti-smoking messages [
11].
The perceived risks and benefits of cigarette smoking is one of the factors associated with smoking initiation among adolescents and young adults [
12‐
14]. A community based survey from Nepal, for an example, showed that the adolescents who perceived benefits of smoking and did not think of health risks were at the risk of smoking initiation [
12]. Next, the young adults who did not think smoking harmful to their health were more likely to be smokers than those who perceived health risks of smoking [
5,
14]. The study also revealed that the young adult smokers did not believe in addictive nature of smoking [
5]. Thus, understanding the relationship between risk perception and benefits of smoking is crucial for developing effective tobacco control programmes. It is also considered to be the first step towards behavioural change from risk-taking to safer behaviour. Perceptions of smoking-related health risks and benefits regarding young adults’ smoking behaviour have not been adequately studied in low-income countries like Nepal. Therefore, the current study has aimed to examine perceived health risks and benefits of cigarette smoking between young adults who smoke vs. don’t smoke.
Discussion
This study has illustrated the smoking is common among Nepalese college students and how young adults have had the perceived health risks and the benefits of smoking. Even this study has tried to explore risk associated with smoking behaviour among male and female along with their faculties. Further, the study has shown the association of the risks of being a current smoking according to their perceptions on health risks and the benefits of smoking among young adults.
The study has also revealed that the current smoking prevalence and the proportion of intension to smoke among medical students was significantly lower than the non-medical students (management student) and comparable with similar studies [
6,
20‐
22]. Further, this study showed that the management students were at greater risk of becoming smokers than the medical students. Several studies including in Nepal demonstrated that the smoking prevalence was higher among non-medical college students than the medical students [
6,
21,
23]. A similar study in India also showed that exposure rate of tobacco was significantly higher among non-medical groups than medical groups (31 % vs. 10 %) [
23]. A study from Ukraine revealed that the young adults who were rarely exposed to tobacco were at lower risk of smoking initiation [
24]. Though this study did not measure the respondents’ exposure rate of tobacco, it might be one of the possible reasons for high prevalence of smoking as well as for higher risk of becoming smokers [
25].
Besides exposure to tobacco, young adults/college students are one of the target groups of tobacco companies because of the following reasons: they can easily progress from “experimenter” to “established smokers” by an important increase in consumption; they face multiple life transitions that provide opportunities for adaptation and solidification of smoking as a regular part of new activities; and stresses of these life transitions invite them to initiate to smoke cigarettes for the drug effects of nicotine [
26].
The analysis further revealed that overall and sex-wise prevalence of current smoking and intention to smoke was significantly low among the medical and the public health students than non-medical students which is consistent with the previous studies [
5,
20,
22]. International review of literatures revealed that there was variation in smoking prevalence rate among medical students across the countries [
22]. The prevalence rate was lower among female medical students than their male counterparts in the same medical college [
22]. Next, this study demonstrated that the male young adults were five times more likely to have risk of being a current smoking than their female counterparts. Similarly, Ukrainian young adult male were more likely to initiate smoking when they reported low knowledge of tobacco related diseases (HR > 1) [
24]. Two cross-sectional studies conducted in Nepal also explored that the male were more likely to be established smokers [
6,
27]. Thus, gender differences is one of the most important risk factor predictors of smoking behaviours among Asian population [
28].
Saudi-Arabian college students who smoked cigarettes had significantly different knowledge about the harmful effects of smoking [
29]. A study by Aryal et al. demonstrated the young adult smokers were less aware of risks and health consequences of smoking [
5]. An American study explained the same that young adult smokers did not have understanding about the risks associated with smoking [
30]. A Ukrainian study demonstrated that male young adults who had lower knowledge about harmful effects of smoking were at risk of smoking initiation [
24]. Likewise, the same Ukrainian study revealed that there was inverse relationship between tobacco related knowledge and current established smoking among male and female [
24]. Recent community based study from Nepal revealed that the perceived social benefits and an addiction risk of smoking and smoking susceptibility was positively associated among adolescents [
12]. Further, the perceived short-term physical risks of smoking are inversely related with smoking susceptibility [
12]. However, such a research has not been conducted yet among college students, but this study has provided similar findings after controlling age, sex, and faculty.
The findings of this study show that the majority of the young adults had their first cigarettes during adolescence. Age of smoking initiation was lower among male than female which is consistent with previous study [
31]. There are several socio-demographic and family factors as well as childhood environment factors including risk perception of smoking, which influence them to initiate smoking [
12,
32]. Next reason is the lack of knowledge on smoking consequences, and having smoking related positive beliefs which lead them to initiate smoking [
33]. According to GYTS 2011, only 51.3 % adolescents informed that their teachers discussed about the reasons for smoking and 67.8 % students had been taught in the class about the effects of smoking [
34]. These figures indicate a large number of adolescents are still unaware of harmful effects of smoking. It is an urgent need to identify the reasons why larger percentage of adolescents was still unexposed to discussion on tobacco in classrooms as well as teaching about health effects of tobacco. Such adolescents might be at a greater risk of being future smokers due to the lack of adequate knowledge on harmful effects of tobacco use. Therefore, it is necessary to conduct researches on tobacco on the aforementioned issues by applying rigorous methodology to obtain reliable and valid information for effective intervention [
35].
Finally, though the findings of this study mainly focused on the perceived risk and the benefits of cigarette smoking but this study also determined that the sex and the academic faculty were also important factors for current smoking behaviour of young adults. Thus, multi-component interventions are essential for effective tobacco control program.
Limitations of the study
Despite the findings of this study provide important information on young adults’ smoking behaviours, the study is not free from its limitations. First, this study adopted non-random sampling, thus the findings cannot be generalized to all young adults college students of other part of the country. It is recommended to take large and representative sample of college students by applying nested or cluster sampling techniques. Second, a sample size (number of smokers) is not large enough to perform faculty-wise Cox-regression analysis. It can also be recommended that the sample size need to be calculated based on power analysis in future study. Third, the data were gathered from self-reported questionnaire and collected only once. Thus, causal relationship between perceived items and smoking could not be established. Thus, the longitudinal study is essential to establish cause-effect relationship. Finally, this study did not include the questions on smoking related variables like socio-demographic factors except age and sex; environmental factors; and behavioural factors. Therefore, the future study should incorporate above mentioned factors to understand its affects on perceived risks and benefits.
Competing interest
The authors declare that they have no competing interest. This study was not supported by any types of funding.
Authors’ contributions
URA designed the structure, conducted analysis, interpretation and wrote the draft of the manuscript. DNB critically revised the manuscript. All authors read and approved the final manuscript.