---
title: "Tobacco use among Lebanese university students: prevalence, drivers, and campus policy implications"
id: "plos-one-4-prevalence-and-determinants-of-tobacco-use-among-university-students-in-lebanon"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-4-prevalence-and-determinants-of-tobacco-use-among-university-students-in-lebanon"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361138"
published_at: "2026-10-22T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Tobacco use among Lebanese university students: prevalence, drivers, and campus policy implications
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-4-prevalence-and-determinants-of-tobacco-use-among-university-students-in-lebanon
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0361138)
- **Published At:** 2026-10-22T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- The cross-sectional survey assessed perceptions, knowledge, attitudes, and behaviors toward **tobacco** and a **smoke-free campus policy** among students aged 17–30 at a large multicampus university in Lebanon. - Data collection occurred electronically across three campuses between 01/09/2023 and 31/12/2023; the instrument incorporated GATS, YTS and KAP items and was available in English and Arabic. - The study sample was drawn via stratified random sampling from an enrolled population of ~16,000 students; 480 students were initially invited and forced-response design was used to avoid missing items. - Reported campus **smoking** prevalence was 32.2%; 53.4% of current smokers reported at least one quit attempt in the prior 12 months. - Strong associations were observed between current **smoking** and having family members who smoke (OR 7.08) or friends who smoke (OR 12.20). - Experiencing social, emotional, or mental distress was associated with higher odds of **smoking** (OR 4.09). - Agreement with a **smoke-free campus policy** reduced odds of being a smoker (OR 0.58), while perceiving campus bans as unfair increased odds (OR 1.87). - The questionnaire captured product-specific use (cigarettes, waterpipe, e-cigarettes/vapes) but operationalized the primary outcome as a binary tobacco/nicotine-user variable to inform comprehensive policy measures. - Authors recommended multifaceted interventions: educational campaigns, stress-reduction services, workshops and cessation support to break stress–smoking links and support quit attempts. - Because the design was cross-sectional, reported associations do not imply causation; the authors called for further evaluation of campus smoke-free policies as part of broader tobacco control strategies.
## Clinical Analysis & Structured Key Points
Prevalence and determinants of tobacco use among university students in Lebanon: Implications for smoke-free campus policies | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Reader Comments Figures Figures Abstract Background The tobacco epidemic is a global public health threat, with addiction often starting in the early adulthood stage of life. The Middle East Region is slow in adopting smoke-free campus policies, and few studies have examined smoking attitudes and behaviors among university students and their perspective on such policies. Objective The objective of this study was to determine the perceptions, knowledge, attitudes, and behaviors toward smoking (used to denote using any tobacco products) and smoke-free campus policies among university students aged between 17 and 30 years old at a large multicampus academic institution in Lebanon. Methods The study utilized a comprehensive cross-sectional study design. The questionnaire used in this study included validated tools for assessing smoking behaviors, such as the Global Adult Tobacco Survey (GATS); the Youth Tobacco Survey (YTS); and the Smoking Knowledge, Attitudes, and Practices (KAP) survey, as well as sections for investigating attitudes toward smoking and the smoke-free campus policy. Results This study reports an alarming prevalence of smoking on campuses (32.2%), with more than half of the surveyed smokers reporting attempts to quit smoking in the past 12 months (53.4%). The factors significantly associated with smoking included having family (OR 7.08, 95% C.I (2.83–17.69) or friends (OR 12.20, 95% C.I (5.48–19.76)) who smoke, as well as experiencing social, emotional, or mental distress (OR 4.09, 95% C.I (1.74–9.63)). Further analysis revealed that agreement with a smoke-free university policy was a significant factor associated with reduced odds of smoking (OR 0.58 95% C.I (0.45–0.78)), whereas the perceived unfairness of smoking bans on campuses was associated with increased odds of smoking (OR 1.87, 95% C.I (1.34–2.61)). Conclusions The results highlight a promising window of opportunity to implement evidence-based interventions to support students in quitting smoking. Interventions include educational programs to raise awareness of the dangers of tobacco use and programs to break the association between exposure to stress and smoking. Such programs could include a combination of awareness programs and organizing stress-reducing services, workshops, and consultations. Because the design is cross-sectional, these findings describe associations rather than causal effects; they nonetheless support the further evaluation of smoke-free campus policies as one component of a broader strategy to lower students’ smoking rates, mitigate peer influence and foster healthier campus environments. Citation: Hijazi MA, Rahme D, Jammoul D, Al Jawiche L, Alameddine M (2026) Prevalence and determinants of tobacco use among university students in Lebanon: Implications for smoke-free campus policies. PLoS One 21(10): e0361138. https://doi.org/10.1371/journal.pone.0361138 Editor: Jad El Masri, Dana-Farber Cancer Institute, Harvard Medical School and THE Broad Institute of MIT and Harvard, LEBANON Received: June 10, 2026; Accepted: October 6, 2026; Published: October 22, 2026 Copyright: © 2026 Hijazi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All relevant data are within the paper and its Supporting Information files. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Background With more than 1.18 billion people referred to as regular smokers, the tobacco epidemic is one of the greatest public health threats worldwide [ 1 ]. According to the World Health Organization (WHO), smoking (used from this point forward to denote using any tobacco products) kills approximately eight million people annually, of which 1.2 million are due to exposure to secondhand smoke [ 2 ]. Active smoking is associated with numerous health concerns, most notably, twelve distinct types of cancer (mainly lung cancer), chronic obstructive pulmonary disease (COPD), emphysema, cardiovascular hazards, and cerebral and peripheral vascular diseases [ 3 – 5 ]. In addition to physical health impacts, smoking negatively affects the social wellbeing of smokers by reducing their social interactions and relationships, as well as altering their psychological and cognitive processes [ 6 , 7 ]. It is also associated with numerous mental health consequences, such as mood, anxiety, depression, and trauma-related disorders [ 8 ]. The detrimental effects of smoking are not limited to health consequences but also cause a heavy economic burden worldwide [ 9 ]. This economic burden also affects middle-income and low-income countries, resulting in substantial losses due to tobacco use [ 9 ]. In younger individuals, especially adolescents, smoking is driven by psychosocial motives. Recent studies reported that among young adults smoking starts for multiple reasons, including enjoyment and satisfaction, feeling mature and independent, relieving stress, feeling more secure, and for arousing curiosity [ 10 ]. Furthermore, the presence of a smoker in the family and the influence of peer pressure and social circles are significant motivators for young individuals to initiate the smoking habit [ 11 ]. Many reports have shown that smoke-free policies effectively reduce secondhand smoke (SHS) exposure and consumption among nonsmokers, encourage quitting attempts, prevent light smokers from becoming heavy smokers, minimize smoking relapse among smokers, and reduce exposure to thirdhand smoke [ 12 ]. A study from Georgia reported that a comprehensive smoking ban was followed by an estimated 10–20% reduction in hospital admissions for acute coronary events in the general population in the first year after the ban [ 13 ]. Considering that 99% of adult cigarette smokers first start smoking before the age of twenty-six and that many occasional smokers transition to daily smokers during young adulthood, universities and colleges could play crucial roles in protecting students from active smoking and secondhand smoke [ 14 ]. Tobacco-free and smoke-free policies at universities have been effective in decreasing exposure to secondhand smoke, reducing cigarette consumption, increasing active smokers’ intention to quit, and increasing the likelihood of cessation [ 15 , 16 ]. Unfortunately, the number of universities in the Middle East that are tobacco free is lower than elsewhere globally, and no published studies have yet evaluated their effectiveness in the region [ 17 ]. Lebanon is a small middle-income country (area 10452 km 2 ) in the Eastern Mediterranean Region with an estimated population of approximately six million citizens and an additional two million refugees [ 18 ]. The smoking rate in Lebanon is alarming, where it exceeded 38% among adults in 2020, which is the highest reported rate in the Middle East Region [ 19 ]. On average, a Lebanese smoker consumed 1,955 cigarettes in 2022 [ 20 ]. Smoking from Lebanon revealed that people from lower socioeconomic backgrounds had higher smoking rates, and the smoking prevalence increased among adolescents with poor parental relationships and those whose parents were smokers [ 21 ]. Education was an important predictor of cigarette smoking in Lebanon. Those with preparatory, primary or less than primary education is significantly more likely to smoke cigarettes than those with secondary education or higher [ 22 ]. For a decade, tobacco has been the top risk factor driving death and disability in Lebanon [ 23 ]. The country is third in the world in terms of cigarette consumption per capita, contributing to 3,500 annual deaths resulting from tobacco-related diseases [ 21 ]. The expenditure on tobacco in Lebanon is equal to that spent on recreation and furniture and is only 1% less than that spent on education [ 24 ]. It has been reported that ex-smokers’ and smokers’ absenteeism in Lebanon leads to a loss of production of $102.2 million per year. A ban on smoking in public places in Lebanon was declared in 1993, but it was inadequately enforced, leading to high smoking rates. In 1998, the Ministry of Public Health, in collaboration with the WHO, established the National Tobacco Control Program, and Lebanon ratified the WHO Framework Convention on Tobacco Control (FCTC) in December 2005. Finally, in 2011, the Lebanese Parliament passed a new tobacco-control act (Law 174), prohibiting smoking in all open public places, public transport, workplaces, and outdoor areas of education, health, and sports facilities. However, the act must be properly enforced [ 19 ]. Smoking further places a serious financial burden on families, especially with the multiple ongoing economic crises that Lebanon has encountered since October 2019 [ 25 ]. Among the forty-eight higher education institutions that exist in Lebanon [ 26 ], only a few universities have applied a successful smoke-free policy for students and staff [ 17 ]. Despite the release of tobacco control acts that prohibit smoking in closed areas, students and staff continue to smoke in various indoor and outdoor areas across campuses across the country. The objective of this study was to determine the perceptions, knowledge, attitudes, and behaviors toward smoking among the students of a large multicampus university in Lebanon with 16000 students. The secondary objective was to determine the enablers of and barriers to establishing smoke-free campuses at this university. Methods Study design This study utilized a cross-sectional design to evaluate tobacco use behaviors and attitudes among students from different faculties and different campuses at Beirut Arab University (BAU). Study setting The investigation was conducted across the Beirut, Debbieh, and Tripoli campuses of BAU to ensure a representative geographic distribution of the student population. Data collection was performed electronically using the SurveyMonkey platform between 01/09/2023 and 31/12/2023. The survey instrument was available in both English and Arabic, with an average completion time of approximately 10 minutes. To ensure linguistic accuracy and conceptual equivalence, the questionnaire underwent a rigorous translation and back-translation process. Prior to full implementation, a pilot test was conducted with ten students to validate the questionnaire’s clarity and flow; no significant modifications were required following this phase. Study size Sample size was determined based on the total university population according to the university database (approximately 16,000 students). Calculations indicated that a minimum sample of 317 students was required to detect a 30% smoking prevalence with a 95% Confidence Interval (CI) and a 5% margin of error. Participants and sampling Eligible participants included students actively registered at any BAU faculty who were conversant in either English or Arabic. Recruitment was managed through official university communication channels to ensure broad and equitable access. Specifically, the survey link was disseminated via institutional email lists and integrated into university-wide digital platforms, including Moodle and iConnect. To ensure the sample accurately reflected the university’s geographic and academic diversity, a stratified random sampling method was employed, with the sample size allocated proportional to the size of each campus. A total of 480 students were invited to participate via direct email invitation. To mitigate non-response bias and reach the target response threshold, a second and third wave of invitation links were issued to the sampled population. In accordance with the approved Institutional Review Board (IRB) protocol, all respondents were required to provide electronic informed consent; individuals who were unwilling or unable to provide consent were excluded from the study. In addition, to ensure data integrity and the completeness of the dataset, the digital questionnaire was configured to require responses for all items before the participant could progress to the next section. This setting was chosen to eliminate the risk of item-level missing data. Only individuals who successfully reached the final page of the survey and submitted their responses were included in the final analysis. Data sources and measurement Questionnaire development and validation. The questionnaire was developed by utilizing validated tools for assessing smoking behaviors such as the Global Adult Tobacco Survey (GATS), which is a standardized survey developed by the World Health Organization (WHO) [ 27 ]; the Youth Tobacco Survey (YTS), which was developed by the Centers for Disease Control and Prevention (CDC) [ 28 ]; and the Smoking Knowledge, Attitudes, and Practices (KAP) survey [ 29 ]. The validated tools were reviewed thoroughly, and the modified version of the questionnaire was subsequently developed by an expert panel of a pharmacist, an epidemiologist, and a public health professional. The questionnaire was a multi-component instrument designed to evaluate the behavioral and attitudinal landscape of tobacco use within the BAU community. The tool was organized into four sections to ensure a logical flow and minimize respondent fatigue, with the full instrument now provided in the Supplementary Appendix ( S1 File ). Measurement of variables. The first section captured socio-demographic and institutional variables, including participant’s age group, gender, and geographic campus location (Beirut, Debbieh, or Tripoli). Faculty affiliations collapsed into five major clusters: Medical, Sciences, Humanities, Engineering, and Others to facilitate comparative analysis. The second section performed a comprehensive behavioral evaluation and usage pattern analysis by utilizing a filtering question to identify respondents as current smokers or non-smokers. For current smokers, the survey identified specific nicotine delivery systems, including combustible cigarettes, e-cigarettes, vapes, waterpipes/shisha, cigars, and pipes, to provide a granular descriptive analysis of usage. Usage metrics were further quantified by capturing the frequency of use, and the chronological onset of the habit to assess the depth of nicotine dependence. Additionally, the etiology of smoking was explored by asking participants to identify primary drivers for initiation, such as social influences (family or friends), environmental factors (media and advertisements), or psychological factors like emotional or mental distress. To facilitate regression modeling, these specific products were aggregated into a binary “Tobacco/Nicotine User” variable. This operationalization aligns with the study’s objective to inform a comprehensive “smoke-free” policy that regulates all forms of inhaled nicotine regardless of the device type. The third section quantified health literacy by assessing the participants’ knowledge of tobacco-related morbidity, specifically asking if they believed smoking causes serious illnesses like stroke, cardiovascular diseases, lung cancer, and diabetes. This was operationalized by assigning one point for each correct identification, resulting in a cumulative knowledge score. Finally, the fourth section utilized Likert-type scales to measure attitudes toward institutional policy, evaluating the perceived impact of a smoke-free mandate on student quality of life and learning, as well as the level of support for specific restrictions on vaping and the prohibition of tobacco sales on campus. Variables. The primary outcome variable was smoking status, operationalized as a binary variable (tobacco/nicotine user versus non-user). Predictors and potential confounders included: Socio-demographic Factors: Age, gender, campus location, and faculty affiliation (clustered into Medical, Sciences, Humanities, Engineering, and Others). Behavioral & Environmental Factors: Frequency of use, age of onset, primary drivers for initiation (e.g., social or psychological distress), and exposure to secondhand smoke. Knowledge & Attitudes scores: A cumulative knowledge score based on tobacco-related morbidity (e.g., stroke, lung cancer) and Likert-scale attitudes toward smoke-free policies. Bias. Different types of bias were addressed through several measures. Stratified random sampling was conducted via official university channels, and non-response bias was minimized by implementing three iterative waves of recruitment until the target sample size was achieved. To reduce information bias and ensure instrument validity, the questionnaire was reviewed by an expert panel, and it underwent a formal English-Arabic translation with back-translation. Pilot study confirmed the clarity of the tool and its completion time. Data integrity was safeguarded by employing a “forced response” design on the SurveyMonkey platform, which required participants to answer all items before progressing thereby ensuring the integrity of the dataset. Statistical methods The data were analyzed via IBM SPSS Statistics version 27 [ 30 ]. Descriptive statistics were calculated for all the variables. Categorical variables are presented as frequencies and percentages, whereas continuous variables are presented as means and standard deviations. Inferential statistical tests were selected based on the research questions and the type and distribution of the variables. Continuous variables were tested for normality via visual inspection of histograms, skewness and kurtosis, and the Shapiro‒Wilk test. Bivariate analysis utilized Pearson chi-square tests to examine the associations between smoking status and categorically independent variables, including Faculty, Age, Gender, Knowledge of university smoking policy, Exposure to secondhand smoke on campus, University-provided education on tobacco hazards, Presence of smokers among family members or friends, and Social, emotional, and mental distress. Student’s t tests were used to compare knowledge assessment and policy agreement scores between smokers and nonsmokers. Multivariable logistic regression with backward stepwise elimination was conducted to identify significant predictors of smoking status. The variables with a p-value of less than 0.2, including significant ones from the bivariate analysis, were included in the logistic regression model to identify the significant factors associated with being smokers after adjusting for the other variables. Adjusted odds ratios with 95% confidence intervals were calculated to quantify the associations. Model fit was assessed using the omnibus test of model coefficients, the Hosmer–Lemeshow goodness-of-fit test and the Nagelkerke pseudo-R²; the latter is reported as an index of relative model fit and not as the proportion of variance explained. A p-value of less than 0.05 was considered statistically significant. For the purposes of the regression analysis, various forms of tobacco and nicotine delivery systems including combustible cigarettes, waterpipes (shisha), and electronic nicotine delivery systems (e-cigarettes/vapes) were aggregated into a single ‘smoking/nicotine use’ variable. This approach was chosen because the study’s primary objective was to assess barriers and enablers for a comprehensive smoke-free campus policy. Since such policies typically prohibit all forms of inhaled tobacco and nicotine products on university grounds regardless of the device type, grouping these behaviors allowed for a more policy-relevant an
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