Keywords

1 Introduction

Cigarette smoking is one of the most important lifestyle risk factors for chronic and degenerative diseases including degenerative aortic valve disease, degeneration of the intervertebral disc, cardiovascular disease, diabetes, and inflammatory diseases which are responsible for a high number of deaths worldwide [1, 2]. Tobacco smoking has been classified by the International Agency for Research on Cancer (IARC) as causing a Group I carcinogenic effect in humans while at least 70 carcinogens have been identified in tobacco smoke [3]. World Health Organization (WHO) has estimated that tobacco use (active or secondhand smoking and smokeless products) is currently responsible for the death of about six million people across the world each year with many of these deaths occurring prematurely [4]. Smoking is usually initiated during puberty and young adulthood making tobacco use a global epidemic phenomenon [5]. Prevalence of any tobacco use is defined as the proportion of the population of interest who exclusively uses smoked tobacco products and/or exclusively uses smokeless tobacco products. Most policy programs by health authorities dedicated to the prevention of smoking in adolescents address smoking beliefs [6], because smoking belief is associated with smoking status [7]. The economic impact of smoking is another important factor for the public health authorities, and many studies showed parameters such as smoking-attributable health, care expenditures, and productivity losses associated with smoking-caused mortality or morbidity [8,9,10]. Just over 40% of deaths in Greece can be attributed to behavioral risk factors (which is above of the EU average of 39%), with smoking being the leading contributor. More than one in four adults smoke daily in Greece, thus ranking second highest among EU countries. In 2014, 32% of Greek men in the poorest income quintile smoked daily while EU average was 24%. In the same context, 25% of Greeks belonging to the highest incomes smoked while the average in EU was estimated at 16% [11].

2 Methods and Materials

This cross-sectional study was conducted in Larissa, Greece. A convenient sample of 30% from a total of 2500 students from undergraduate schools (including Medical Laboratories School, Logistics Department, Financial School/Business Administration Department, and Faculty of Nursing) were contacted in order to participate in this study. Anonymous self-report-adjusted questionnaire was distributed in 800 students of the Technological Educational Institute of Thessaly, and 600 questionnaires were completed and returned to researchers (response rate 75%). Sociodemographic characteristics including gender, age, type of educational school attended, as well as smoking habits (past and present), age of first smoking experience, and the knowledge about the smoking-ban laws in public places and finally the weekly cost for tobacco smoking were recorded. During administration of the questionnaire, researchers were available to explain the questions if needed. Data were entered into an Excel database and were tabulated. Absolute (N) and relative (%) frequencies were used for the description of qualitative variables. In addition, 95% Confidence Intervals were calculated for proportions by the use of OpenEpi. Data collection was self-completed, anonymously and voluntarily. The study period was from October 2018 to February 2019. The study was approved by the ethical committee of Medical Laboratories School of the Technological Institute of Thessaly (number 26/14-12-2017).

3 Results

The study population consisted of 220 male students and 308 were females. In the distribution of the schools, the Medical Laboratories School participated with 168 students, the Faculty of Nursing with 152 students, followed by Logistics Department with 142 students, and finally the Financial Department with 138 participants. The total prevalence of tobacco smoking was estimated at 35% with the majority of the smokers being females (65%) while 35% were males. When assessing the prevalence of smoking by School, the Financial Department showed the highest percentage of smoking (37.5%), followed by the Logistics Department with 37%, the Medical Laboratories with 34%, and finally the Faculty of Nursing with the lowest percentage (31.5%) (Table 1). In the question “when was the first time to smoke,” half of participants reported the age group of 11–17 years, 9% reported “10 years and less,” and finally 204 (34%) students reported that they had never tried to smoke in their life. The majority of the students (90%) reported that they knew about the ban law in indoor areas, and on behalf, 70% blamed the country culture for the failure to implement the law. Fifty-three of the participants reported that they were daily exposed to secondhand smoke inside their houses, 20% reported working at the study period, while 45% of them were exposed to smoke in their workplace in indoor areas during the last 30 days. Half of the students had tried to quit smoking at least once in the past 12 months, 61% had visited a physician for an unrelated reason, and 50.8% has received advices to quit smoking by the physicians during that visit. About the noticing warnings for health in cigarette packs, the vast majority (84%) reported awareness for the current health warnings. On behalf of anti-cigarette information, 53% of the participants reported they received warnings from newspapers or magazines and 58% from television. Finally, about the weekly cost for cigarettes, 68% from the smokers reported that they spend 3–10 € per week, 24.5% spend 10–20 € per week, and 7.5% spend up to 20 € per week (Table 2).

Table 1 Prevalence of smoking in undergraduate students
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Table 2 Knowledge attitudes and practices for tobacco smoking
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4 Discussion

According to the WHO report 2015, the prevalence of tobacco smoking among Greek persons aged 15 years and over was high (estimate prevalence 41.5%) in both genders [12]. In the current study, we recorded a total prevalence of 35% in both sexes with remarkable difference between female and male participants. From the report on the trends of daily tobacco smoking WHO estimate, the crude adjusted prevalence for Greek active smokers aged 15 years and over for both sexes will be active 36.2% [13]. The prevalence estimated from the present study displays similar results with other Greek researches studying undergraduate and postgraduate students. In a study that investigated smoking habits and alcohol consumption within first-year students, 32.4% of the sample were active smokers [14]. Diomidous et al. demonstrated that 36.8% of the students smoked systematically [15]. Saridi et al. reported 32% prevalence of active smokers in a sample with undergraduate and postgraduate students from Greece [16].

Furthermore, in 2000 the WHO was reported that one in six women (16.7%) aged 15 years and older were current users of some form of tobacco. By 2015, the proportion of women using tobacco had declined to under one in ten (9.5%), while in the present study smoking prevalence of female participants was estimated at 19.5%. Other studies from European countries report that smoking rates among girls surpass those among boys [17]. The exposure of undergraduate students to secondhand smoking in the present study indicated high levels for both home (53%) and enclosed workplaces (45%). Pacheco et al. reported that only 40% of college students were not exposed to secondhand smoke in the past 7 days, displaying similar results with our study [18].

For many years, one of the most important problems related to smoking in Greece was the failure to implement smoking-ban law, particularly in public places such as restaurants and cafeterias. The findings of the present study underlined this issue, and the majority of participants reported that they knew the smoking-ban law, while the country’s traditions were reported as an important reason for not implementing the law. In the same context, Satterlund et al. reported that in California bars, indoor smoking was significantly related to patron ethnicity. Specifically, the research staff consistently observed smoking in bars serving primarily Irish and Asian patrons [19].

In the present study, the majority of smokers started to smoke while younger than 17 years old, and this percentage reduces to the students 18 years of age and up. A study conducted by the University of Montreal School of Public Health suggests that for people between 18 and 24 years, the three strongest risk factors for starting smoking are being impulsive, using alcohol regularly, and getting poor grades in school. Forty-four percent of the teens started smoking before entering high school, 43% started during high school, and 14% started sometime in the 6 years post-high school [20]. In a study conducted in the United Kingdom, 53% of adolescents reported having smoked at least one whole cigarette by the age of 16 years [21]. Another study from Panatto et al. in Italian students reported that 59.5% of students had tried smoking, while 35.6% defined themselves as current smokers while the mean age of initiation was 13.5 years for males and 13.9 years for females, reporting similar results with our findings [22].

Media, telecommunications, and other interventions (such as TV, radio, newspapers, telephone, the Internet, social media) usually have positive effects in reducing smoking prevalence especially when delivering smoking cessation messages and counseling support. In the present study, 45% of the smokers had tried to quit smoking in the past 12 months and 53% had received anti-cigarette information from newspapers or magazines, while 58% had watched anti-cigarette information on television. Meantime, 43% of the smoking participants had thought to quit smoking because of health warnings and anti-cigarette information. A study conducted in Australia by Borland et al. demonstrated that those living in regions exposed to the antismoke campaign were more advanced in thoughts about quitting. Of the responders, 33% progressed toward cessation and 21% regressed [23]. Gibson et al. indicated that the campaign in the United States significantly predicted four behaviors, i.e., using help, seeking advice from a doctor, using medication, and making a quit attempt. After adjusting for prior use of help (3 months “before the campaign period”) and other confounders, each additional campaign exposure per week was associated with an 8% increase of smoking cessation [24].

The last decade some European countries, and especially Greece, suffered a huge financial crisis with many social problems. In comparison with some European countries, the majority of Greek students cover the financial cost for the student period from their family budget. A plethora of studies indicated that the financial crisis can lead to high unemployment rates, which can also correlate to higher smoking prevalence [25, 26]. Another important result of the present research is the impact and the financial cost per week of each smoker student. Sixty-eight percent of the smokers were spending 3–10 € per week and 24.5% spend 10–20 € per week followed by a minority (7.5%) that were spending up to 20 € per week. Saridi et al. from another Greek study in students showed that the financial crisis did not lead the students to change their smoking habits [14]. Siahpush et al. in a study from Australia demonstrated that on average a smoker who quits smoking is expected to have a 25% reduction in the odds of financial stress [27].

5 Conclusions

This study has several potential program and policy implications. Smoking prevention programs tailored specifically to undergraduate students may be needed. In particular, education about the dangers of smoking may be effective when undergraduate students are starting new life at universities. Educating undergraduate students, young adults, and parents about the dangers of secondhand smoke may not only benefit students but may also prompt cessation. Finally, there is an emergent need to continue to promote smoke-free environments in places where undergraduate students work and play, at work, campuses, in restaurants, bars and nightclubs, or at home. Furthermore, the supporting and the implementation of ban law for smoking must be continued. These results need to be interpreted with caution and the associations observed need to be investigated further.

5.1 Limitations

Our study has several limitations. The local sample of the participants is an important limitation, while the distribution of the sample (with the majority being females) is another limitation. Another limitation of this analysis includes that self-reported data may be subject to recall bias, and finally, the use of a convenience sample may limit the generalizability of the findings.