INTRODUCTION
The prevalence of tobacco use remains alarmingly high across the globe, with statistics indicating 942 million male and 175 million female smokers aged ≥15 years1. The tobacco use epidemic stands as a paramount global public health issue, as highlighted by the World Health Organization (WHO), which reports an annual death toll exceeding 8 million, with a staggering 50% mortality rate among its users2. In the Middle East, tobacco use rates remain noteworthy, with Egypt having the highest male smoking prevalence in the region at 44.5%1. Within the Gulf Region, Saudi Arabia holds the highest male smoking prevalence at 24.9%1, while Qatar reports an overall tobacco use prevalence of 25.2%, with 21.5% attributed to smoked tobacco3. Among Qatar’s tobacco users, cigarette smoking accounts for 42.8%, followed by waterpipe smoking at 20.9%, pipe smoking at 3.2%, and electronic cigarette usage at 2%3.
Studies reveal high tobacco smoking prevalence among university students across various Middle Eastern countries, including Egypt, Kuwait, and Saudi Arabia, where prevalence rates range between 42.3% and 46.7%4. A study conducted among Qatar University students has shown that the prevalence of tobacco use among the study participants is around 25.6%, and that waterpipe, traditional cigarettes, and electronic cigarettes were the most common types used, respectively5,6.
Quitting tobacco contributes significantly to the reduction in the risk of developing multiple diseases and therefore increases life expectancy7. Encouragingly, global trends show an increasing number of former smokers compared to current smokers since 20028, with a majority of adult smokers expressing a desire to quit9. However, understanding the obstacles to quitting tobacco is essential for developing effective tobacco control interventions. And since the benefits are greater for those who quit earlier9, it is crucial to explore the barriers faced by young adults in quitting tobacco.
A systematic review reported stress management, lack of support, and the high acceptability of smoking within communities among the barriers to quitting tobacco across different vulnerable populations10. Other barriers that were found unique to certain vulnerable groups included cultural values that promote sharing, kinship and reciprocity, and the maintenance of cultural identity10. A study conducted in Bahrain has shown that the main barriers to quitting tobacco smoking among young adults were the enjoyment of smoking, the loss of a way to handle stress, and nicotine cravings11. Another study was conducted on a group of young smokers from the public and university students in Saudi Arabia reported that the most common reasons to continue smoking were tension and anxiety, boredom, and to increase pleasure and concentration, and boost self-confidence12.
Setting the context
In 2019, the largest national university in Qatar joined the fifth cohort of the Tobacco-Free Generation Campus Initiative, a program of the American Cancer Society’s Tobacco Control Center that provided funding to support the implementation of 100% smoke- and tobacco-free policies on university campuses13. Following that, quantitative research was conducted on campus to assess the prevalence of tobacco use and its determinants among students5,6, in addition to examine their knowledge and attitudes towards the existing smoking policy and the implementation of a 100% smoke- and tobacco-free policy on campus13,14. A recent qualitative study, built on a systematic review from the Middle East about the factors associated with tobacco cessation programs’ effectiveness15, has investigated the barriers preventing a sample of these tobacco user students from seeking the help of clinical cessation services. The study pointed out an important cultural barrier preventing them from seeking the services, which is the masculine culture that prohibited men to seek cessation help and social stigma around Arab women’s tobacco use16. Building on that, we recognized the need to dig deeply about the barriers to quit tobacco use among this population and the different contexts and ecologies shaping these barriers. Exploring these multifaceted barriers is vital for planning effective and evidence-based tobacco control interventions that are targeted and culturally sensitive, and informing services and policies on campus.
Theoretical perspectives
Two theories were applied to construct the interview guide and inform the analysis plan in the study. The Health Belief Model (HBM) was applied to capture individual factors that may prohibit tobacco users from quitting, including their perceptions of the health risks of tobacco use, and their willingness to quit17. The main premises of the socio-ecological model (SEM) were applied to understand how other contexts prohibit the participants in our study from quitting18. SEM demonstrated how these prohibitors are shaped by factors embedded at different levels, including the individual, behavior and lifestyle, and sociocultural factors.
METHODS
This study employed a qualitative design and was conducted at Qatar University in 2022, exploring university students’ perspectives on tobacco use and quitting attempts. Adopting an inductive approach, the study aimed to capture rich, in-depth insights free from pre-existing assumptions, using a naturalistic perspective suited to complex social phenomena19.
Within the timeframe of January to February 2022, this qualitative investigation was carried out among university students in Qatar, forming a segment of a broader qualitative research endeavor focused on unravelling the factors influencing tobacco use, tobacco quitting, and the pursuit of clinical cessation help among university students16. Qualitative studies serve as valuable tools for furnishing detailed portrayals of intricate phenomena, capturing singular occurrences, and amplifying the voices of marginalized perspectives19. Moreover, an inductive methodology was adopted, wherein the researcher refrained from preconceived notions and remained receptive to comprehending novel phenomena and addressing the research inquiry19.
Participants
Participants meeting the following criteria were recruited: 1) actively enrolled in university; 2) current or past users of tobacco; and 3) aged ≥18 years. As defined by the Centers for Disease Control and Prevention (CDC), a current smoker is an adult who has smoked 100 cigarettes in his/her lifetime and currently smokes, while a former smoker is an adult who has smoked at least 100 cigarettes in his/her lifetime but has ceased smoking at the time of the interview20.Through these criteria, we aimed to explore the barriers and challenges to quitting tobacco from the viewpoints of both current and former users.
The decision to include past tobacco users in this study, despite the potential for recall bias21, is justified by the need to understand the full spectrum of tobacco use behaviors and the complexities surrounding cessation experiences. Research shows that former smokers can provide valuable insights into their quitting processes, which can inform current cessation strategies22.
Flyers were distributed on both male and female campuses at the university, and announcements were posted on various social media platforms to invite students to participate during the spring semester of 2022. The materials explained the study’s objectives and inclusion criteria, providing contact information for interested individuals or those with questions. Additionally, we employed a snowball sampling method to reach participants who might be harder to engage due to the sensitive nature and societal stigma surrounding our topic23.
Potential participants were screened for eligibility, and verbal consent was obtained before scheduling interviews based on their language preference (Arabic or English) and interview format preference (face-to-face on campus or online via Microsoft Teams).
Data collection
This research received approval from the Institutional Review Board of Qatar University (IRB 1644-EA/21). Data collection involved semi-structured interviews with probing inquiries employed to delve deeply into participants’ perspectives, attitudes, beliefs, and spontaneous viewpoints regarding the barriers to quitting tobacco use.
An interview guide (see Supplementary file), informed by a review of literature on tobacco use and cessation barriers and the main premises of the HBM and SEM, was constructed in English, translated into Arabic by the primary author, and back-translated by the corresponding author to ensure clarity. The guide was iteratively refined, incorporating additional probing questions to enhance the depth of understanding during interviews.
The HBM, originally developed by Rosenstock24, emphasizes that individual health behavior decisions are influenced by their perceptions of susceptibility, severity, benefits, barriers, cues to action, and self-efficacy. For this study, the HBM guided the questions related to participants’ perceived risks of tobacco use (e.g. ‘Do you think tobacco affects you negatively? If yes, how?’), perceived benefits and barriers to cessation (e.g. ‘What is stopping you from quitting tobacco use?’ and ‘What methods/services do you believe will help you quit?’), and self-efficacy in quitting (e.g. ‘Do you think you are able to quit tobacco use?’). This theoretical lens allowed the research to identify misconceptions about tobacco-related health risks and the psychological barriers to cessation.
On the other hand, the SEM considers health behaviors within the broader context of interpersonal, organizational, community, and societal influences25. Incorporating the SEM, the interview guide included questions addressing the role of social networks and cultural factors, such as family and friends’ tobacco use (e.g. ‘Do you have family members/friends who use tobacco? Did any of them try quitting?’), peer pressure (e.g. ‘What caused you to relapse?’), and cultural norms (e.g. ‘How do you believe the culture is influencing your decision to quit?’). The SEM framework also informed the exploration of environmental and institutional factors, including the potential impact of a tobacco-free campus policy (e.g. ‘Do you support the enforcement of a 'No Smoking' policy on QU campus?’).
Participants were queried about their tobacco usage patterns, types of tobacco products used, initiation age, current frequency and settings of use, past cessation attempts, methods utilized for quitting or attempting to quit, and reasons for relapse. Additionally, participants were asked about their perceptions regarding the health implications of tobacco use, current desires to quit, and the influence of family, peers, and culture on smoking and cessation behaviors.
Interviews, conducted by members of the research team, ranged from 40 to 75 minutes and were digitally recorded for subsequent verbatim transcription. No incentives were offered to participants, who were informed of the option for further interviews to clarify raised issues. Data collection continued until saturation was achieved26. To safeguard participant confidentiality, numerical identifiers were assigned to each participant. Data were securely stored on password-protected devices accessible only to the research team.
Transcription was done in participants’ original languages, with Arabic quotes translated into English and included as illustrative examples to support identified themes. Transcripts were formatted into Microsoft Word tables following the suggestion of LaPelle27, comprising participant numbers, theme/code numbers, interviewer questions/participant responses, and sequence numbers. Each question or utterance from either party was recorded in a separate row, facilitating data coding, table merging across participants, and diverse data sorting approaches27.
Data analysis
Thematic analysis was employed to discern patterns and extract significant insights from participant responses19. The coding phase initiated the analysis process, involving an examination of interview content to assess response relevance28. Initially, open coding was utilized to pinpoint codes, major themes, and subthemes in the initial transcript, forming the basis for constructing a codebook. During this phase, statements addressing research inquiries were highlighted, labelled with colors and numbers, and each code was assigned a unique identifier (e.g. code no. 2.00). Iterative adjustments and refinements were made to codes until the final refined set was established.
Subsequently, axial coding, the second level, aimed at delineating relationships between codes to establish categories29. Following the completion of coding for all transcripts, consensus was reached on the definitive list of themes and subthemes, which were synthesized into a comprehensive depiction of the phenomenon. Data analysis of transcribed interviews was conducted in their original languages to ensure accuracy of interpretation.
To bolster coding credibility, the initial two authors independently coded the first interview, subsequently reconciling any discrepancies through discussion. The interview guide was adapted, incorporating probing questions to elicit richer data, while the codebook facilitated coding of subsequent transcripts. Emerging themes and subthemes were seamlessly integrated into the evolving codebook.
Code definitions were aligned with the study’s objectives, with regular meetings among researchers to refine codes and themes, adhering to the recommendation of Miles and Huberman30 for intercoder reliability of 80% agreement. In total, seven codes were established, with only one instance of disagreement regarding code wording. Inter-rater reliability (IRR) was calculated using the formula: (Number of agreed codes/Total number of codes) × 100%, yielding an IRR of 85.7%30.
RESULTS
The study comprised 20 actively enrolled students at QU, including 16 men and 4 women, who were current or former tobacco users. Their ages ranged from 20 to 31 years, representing diverse nationalities such as Qatari, Syrian, Palestinian, Egyptian, Moroccan, Jordanian, and Pakistani. Cigarettes (95%) and waterpipes (95%) were the most commonly used tobacco products among participants. However, e-cigarettes, pipe, and nicotine pouches were also used. Eighteen were current tobacco users with varying frequencies, while two had successfully quit with abstinence periods of 6 weeks and 6 months, respectively. Nineteen of the 20 participants had attempted to quit tobacco use at least once (see Table 1 for participants’ characteristics).
Table 1
Characteristics of participants in a qualitative study conducted at Qatar University, 2022 (N=20)
The variations in tobacco use frequency as well as tobacco products used among the participants may be attributed to several factors. One potential justification is that participants were at different stages of the quitting process as can be explained by the Transtheoretical Model (Stages of Change). For example, according to Etter31, individuals in the ‘pre-contemplation’ stage, characterized by a lack of motivation to quit, tend to exhibit higher levels of tobacco consumption. Moreover, participants who reported only waterpipe use in our study, either have waterpipe as the product they are trying to quit, or they have switched to waterpipe during their journey to quit cigarettes smoking. It is documented in the literature that people in their quitting journey might change from smoking cigarettes to using waterpipe or other products (e.g. electronic cigarettes) as they perceived them as less harmful to their health32.
Various themes identified during the analysis explored the obstacles hindering participants from quitting tobacco use. Employing the fundamental principles of the Health Belief Model (HBM) and Socio-Ecological Model (SEM) aided in consolidating our thematic findings, with barriers predominantly situated within individual and sociocultural contexts. (see Table 2 for frequency and quotes of themes).
Table 2
Key themes identified from qualitative interviews conducted at Qatar University, 2022 (N=20)
Prohibitors to quitting tobacco use
The primary impediments recognized in quitting tobacco use encompassed: 1) perceived willingness and readiness to quit tobacco use; 2) misconceptions regarding tobacco-related health risks; 3) relying on tobacco use for stress relief and negative emotions; 4) being discouraged by friends to quit tobacco use; 5) family tobacco use; and 6) masculine culture that praises male smoking behavior (see Table 2 for frequency and quotes of themes).
Perceived willingness and readiness to quit tobacco use
Half of the participants emphasized the significance of willingness as a pivotal determinant for successful tobacco cessation. Specifically, eight participants expressed that without this willingness, all quitting endeavors would be futile. They underscored that irrespective of the quitting methods employed, success hinges fundamentally on one’s initial willingness and desire to quit. These individuals accentuated the primacy of personal motivation in tobacco cessation, surpassing external influences. Therefore, besides the absence of willingness posing a substantial barrier, the perception of its importance constitutes a barrier.
The majority of participants (n=15) conveyed their current lack of readiness to discontinue tobacco usage, despite seven of those expressing a desire to quit. They elucidated that, despite their intention, they presently lack the mental preparedness required for cessation. Participants articulated that relinquishing smoking entails a challenging decision demanding time, resilience, and a compelling motivator. Some noted their youthfulness as a reason for postponing cessation to continue enjoying social activities, while others cited their hectic lifestyles as a hindrance to prioritizing health concerns and quitting efforts. Additionally, two participants envisaged quitting in the future, particularly upon having children, to avoid harming them.
Misconceptions regarding tobacco-related health risks
While most participants acknowledged the detrimental impact of smoking on their health, a minority (n=4) expressed a lack of perceived significant health effects from smoking at present. Among them, two attributed their belief to the infrequency of their tobacco use, noting the absence of evident adverse effects or physical illness. One participant opined that the impact of smoking is less severe on youth compared to older individuals, thus feeling less urgency to quit at present.
Another participant held the belief that engaging in regular physical activity mitigates the significant health effects of smoking. They expressed confidence that physical exercise serves to detoxify their body and cleanse their lungs of cigarette tar and other toxins, effectively ‘balancing out’ or reversing the damage caused by smoking.
Relying on tobacco use for stress relief and negative emotions
Another barrier reported by most participants (n=14) was their reliance on smoking as a coping mechanism for stress. These individuals expressed that smoking assists them in managing various stressors encountered in academic, social, or occupational contexts. Some believed that abstaining from tobacco would exacerbate their inability to cope with stress and navigate pressure, asserting that smoking enables them to remain focused and composed. Many participants also highlighted stress as a contributing factor to multiple relapses following cessation attempts. Moreover, several participants mentioned using smoking as a means to alleviate anger and escape from problems, expressing concerns that without smoking, their anger issues would intensify, and they would struggle to cope with mental distress.
Being discouraged by friends to quit tobacco use
All participants mentioned having friends who smoke. Some participants (n=5) highlighted the necessity of distancing themselves from their smoking peers and refraining from socializing with them as a crucial step toward quitting. This social influence emerges as a significant barrier to cessation and a prominent factor contributing to relapses. Many participants underscored that the presence of smokers in their social milieu serves as a primary reason for their continued smoking behavior. They noted that observing their friends smoking prompts an urge to smoke, even when they did not previously feel the need or the craving to do so.
Additionally, many participants highlighted smoking as a social activity they engage in with their friends. They remarked that gatherings devoid of smoking tend to be dull, and that smoking enhances the enjoyment of their social interactions. Some participants noted feeling obliged to accept a cigarette when offered by a friend, regardless of whether they felt the desire to smoke. Furthermore, one male participant suggested that declining a cigarette offered by a friend could be perceived as disrespectful.
Family tobacco use
Among the 20 participants, 14 reported having at least one immediate family member who smokes tobacco. Among the remaining six participants, three mentioned having relatives outside their immediate family who smoke. Furthermore, six participants with smoking family members admitted that their families’ smoking habits have encouraged them to start smoking themselves and prohibited them from quitting.
Masculine culture that praises male smoking behavior
Cultural norms that glorify smoking have created societal pressures, particularly for males, concerning tobacco quitting. Participants acknowledged that smoking is culturally perceived as a masculine trait and that they believe it helps boost a man’s self-confidence. Most of our male participants who endorsed this theme has mentioned a perceived relationship between smoking and having certain traits such as independence, recklessness, and a sense of ‘coolness’.
In addition, five of our male participants reported that when they inform their friends of their attempts to quit smoking, their friends ridicule them for their decision.
DISCUSSION
This study aimed to explore the major barriers to quitting tobacco use among university students in Qatar. Applying the main concepts of HBM and SEM, the findings showed that these barriers are multidimensional and shaped by individual, behavioral, social, and cultural factors (Figure 1 in the Supplementary file depicts these factors).
The center of the model represented the individual barriers. Participants clearly undermined cessation efforts in the absence of willingness and the lack of readiness to quit. According to previous research, the perceived importance of willingness poses a barrier to successful quitting, since believing that willingness is necessary was found to undermine the cessation attempts33. An intervention study assessing the factors related to the readiness to quit tobacco use among young adults has shown that older age is positively associated with readiness to quit smoking. Smokers who were ready to quit were significantly older than those who were not ready34. Some of our participants who stated that they are not ready to quit tobacco use have mentioned that they believe they are still young and that they plan to quit when they get married and have children. Health promotion messages can be created to enhance quitting tobacco use among university students by clarifying that the presence of willingness to seeking tobacco cessation is important; however, quitting tobacco is multifactorial that requires the presence of other support factors to be effective and successful.
It is documented in the literature that low risk perception of tobacco use is a barrier to smoking cessation10, which is consistent with our findings. A study about the perceptions of the relative harm of cigarettes among US youth has found that the majority of youth perceived the harmfulness of cigarettes as dose-dependent35. In alignment with this finding, some of our participants attributed claims of their health not being significantly affected by tobacco to the low frequency of smoking. This reflects that participants in our study have a low level of knowledge in regard to hazards and addiction associated with tobacco use.
The second level of the model is representing the barriers shaped by behavior and lifestyle of the participants. The barrier addressed by most of our participants was relying on tobacco to cope with stress caused by busy work and study schedules; this was recognized as a barrier to smoking cessation in many studies in the literature10,36. In fact, a study assessing the quitting barriers among young adults in the US has identified the ‘loss of a way to handle stress’ as the second most common barrier to quitting smoking36. In addition, other studies reported that managing emotions and mood was also a barrier10,37, which also aligns with our findings.
The third level of the model is representing social networks as a barrier. Friends’ smoking behaviors have been recognized as a barrier to quitting in many studies36-38. In fact, one study has identified it as the topmost common barrier to cessation among young adults36. In our study, some participants have attributed their relapses to seeing their friends smoke, and have stated that being surrounded by smokers is a major barrier for them to seek tobacco cessation. In addition, one study in Malaysia has addressed the ‘cigarette culture’ where offering a cigarette to a friend is considered as a token of friendship38. This finding is consistent with our theme of peer pressure as a barrier to quitting tobacco. Moreover, tobacco use among family members and its influence on young adults’ tobacco use and their intention to quit have been documented in the literature39, which aligns with our findings. Smoker students in our study reported that tobacco use among their family members and other relatives was a strong predictor for their tobacco use and a barrier to quitting. Thus, tobacco-prevention strategies should focus on involving the entire family.
Finally, the upper level in the figure is addressing the Arab culture as a barrier to tobacco cessation. Previous research has recognized cultural values of self-reliance and independence as barriers to smoking cessation among some vulnerable groups10, which was reflected among some of our male participants as a barrier to quitting due to the social pressure of the masculine Arab culture.
Implications for research and practice
More qualitative research is needed to understand the family role in influencing tobacco quitting among young adults in Qatar considering the important role of family in the Middle East, and specifically the Gulf region, in influencing health behaviors among the young generation40. There is also a call to conduct research among women in this region to explore how the prevailing social norms and stigma around women using tobacco affects their decision-making to quit. In addition, quantitative research can be conducted to examine students’ readiness and its determinants among those who are trying to quit smoking, which would support professionals working with young adults who are trying to quit tobacco use. Future quantitative research is needed on the barriers to smoking cessation.
Health education campaigns on campus and through the university social media platforms can be organized to enhance health literacy and fight the misconceptions related to health risks associated with tobacco use among students. Inviting families to join campus campaigns is crucial considering the influence of family members’ tobacco smoking behavior on their youth tobacco use and their intension to quit. These educational campaigns can also aim to change the cultural beliefs and attitudes related to tobacco use, especially among male student smokers. Moreover, the findings inform mental health services on and off the university campus about the mental health needs of students which were preventing them from quitting tobacco use. The findings will inform the implementation of a tobacco-free campus policy and support the health-promoting campus initiative at Qatar University41.
Strengths and limitations
The use of inductive, qualitative approach has allowed us to gain a rich description and a better understanding of the different prohibitors to quitting tobacco use among university students in Qatar. Our study contributes to the limited literature available on the relevant perceptions of young Arab smokers and their experiences with quitting tobacco use. Moreover, applying triangulation in the methodology is considered a strength in our study. Triangulation was applied in the data analyses in which two researchers conducted independent analyses and met later to discuss any conflict and reached agreement. In addition, two theories (HBM and SEM) were applied to construct the interview guides and informed the analyses.
On the other hand, one of the main limitations in this study was the low recruitment of Qatari participants, both male and female, and the low recruitment of female participants. This was due to the cultural taboo around smoking, especially in the Qatari culture. Another limitation was the potential recall bias within the two former smokers within our sample, which may have affected the reliability of their accounts21.
CONCLUSIONS
This study helped explore the various prohibitors to quitting tobacco use among university students in Qatar. The individual prohibitors included perceived willingness and readiness to quit tobacco use and misconceptions regarding tobacco-related health risks. Related to behavioral and lifestyle factors, participants reported that relying on tobacco use to cope with stress and negative emotions was a prohibitor to quit. Moreover, participants claimed that peer pressure, family tobacco use, and the Arab masculine culture that praises male smoking behavior were the sociocultural prohibitors to quit tobacco. The findings highlight the need to design cultural-sensitive, and family-based interventions to support youth quit tobacco use.
