Association between loneliness and cigarette smoking attitudes among university students in Iran: a cross-sectional study


  • The study findings have significant implications for university students and the health system.

  • With the type of cross-sectional design, the longitudinal changes are not controlled.

  • The self-reported data may pose a potential risk to the validity of the measurements.

  • The influence of social desirability bias should be considered, as it may impact the accuracy of responses in self-report questionnaires, particularly given that the participants were studying in a health-related field.


Cigarette smoking is the most preventable cause of death and premature disability and poses one of the greatest public health challenges worldwide1 and one of the main risk factors for a healthy lifestyle.2 The serious health consequences of cigarette smoking often appear later in life. Smokers have a higher risk of developing cancer, chronic lung disease, heart disease and stroke.3 Additionally, some health consequences of smoking, including alcohol use, risky driving, relational abuse, depression and reduced exercise, can appear soon after smoking initiation.4

During the last two decades, cigarette smoking has experienced a global increase in use, particularly among youth in low-income countries.5 6 In recent years, smoking prevalence in Iran has also increased, especially among youth and women, and smoking ages have decreased.7 A meta-analysis found that the smoking prevalence of students in Iran was 7.9%. 10.6% of men and 4.5% of women were smokers. Furthermore, the prevalence of smoking among students in the northern regions of Iran was 22.4%, which was higher than in other regions of this country. Men in the northern (22.4%) and women in the western regions (5.3%) were more likely to smoke.8 Smoking prevalence among Iranian youth has increased from 2.5% to 17%. Furthermore, the speed of becoming a smoker adolescent in Iranians is high.9 Smoking behaviour, attitude and social norms about smoking vary greatly across countries and cultures. University students generally had positive results in preventing and stopping Cigarette Smoking Attitude (CSA).10–12 For instance, the results of a study in Lithuania indicated that dental students had positive attitudes towards smoking cessation in their patients.13

Therefore, it is important for those who are interested in cigarette smoking control to discover associated factors with smoking and identify strategies to strengthen interventions for smoking cessation. Also, smoking prevention in non-smoker population is essential. The sociocultural environment influences attitudes, values and behaviour. Additionally, loneliness has been identified as an important social determinant of youth health risk behaviours and smoking cigarettes.14

Loneliness is an unpleasant mental experience that results from the difference between the expected social status and the current state of the individual.15 Feelings of loneliness as a debilitating mental state and weakness in interpersonal relationships are common among students.16

Over 15% of students reported feeling lonely, with figures worse for Asian, Black, and Minority Ethnic, disabled and international students, and those living at home.17 A study at Maragheh University in the northwest of Iran found that 50.5% and 31.6% of students had moderate and severe loneliness, respectively, with gender being a predictor.18 Also, around 10.5% of the general population in the western Mid-Germ had loneliness.19 It is recommended that universities pay more attention to the mental health status of students and teach effective coping strategies to them. In addition, they should execute the university’s intervention plans. In this case, mental health nurses and community health nurses can help students to talk about their mental issues and change their behaviour and lifestyle.20

Only a few empirical studies have examined the relationship between loneliness and attitude towards smoking; however, available evidence has suggested that loneliness has a significant influence on smoking behaviour.16 21 Some studies showed that loneliness and smoking are likely associated,22 23 yet others fail to find an association.24 25 There are no adequate studies in Iran. Our study aimed to investigate the association between loneliness and attitudes towards smoking status among Iranian university students.


Study design and participants

From September to December 2019, a cross-sectional study was conducted at Tabirz University of Medical Sciences, Iran. All full-time students at the university (bachelor, dentist, pharmacy and medical) were eligible to participate, except those with a severe illness that prevented them from answering the questionnaires, students in clinical fields and those who did not answer the questionnaires completely or did not provide informed consent to participate in the study.

The sample size was calculated 558 students, considering a level of significance of 0.05, a 0.95 CI, a 0.04 effect size and a 0.95 ability to indicate the population. To ensure an accurate representation of the population, one or two classes from each faculty were randomly chosen using the proportional sampling method. All students in the selected classes (n=580) were invited to participate in the study, with an additional 5% added to account for expected attrition. Of those, 24 declined the invitation to participate in the study, and 556 students filled out the questionnaires. After excluding 18 incomplete questionnaires, 538 were available for analysis (response rate: 92.8%).

Data collection tools

The data in this study were collected using demographic information, CSA scale and the Loneliness questionnaire, using self-administered survey.

The demographic information questionnaire

The form was composed of age, sex, marital status, residence, faculty, current year at university and experience of cigarette smoking.

CSA scale

The scale developed by Riahi et al in 2009 was used to evaluate CSAs in students.26 This questionnaire consists of 32 questions, divided into 3 distinct categories: cognitive (9 questions), emotional (11 questions) and behavioural (12 questions). According to psychologists, attitude is a durable system that includes three cognitive, emotional and behavioural dimensions. The cognitive dimension consists of personal opinions and beliefs; the emotional dimension is a kind of emotional feeling that is linked to our beliefs, and the behavioural dimension is the readiness to respond in a particular way. The items scored with (1) disagree, (2) no agree no disagree and (3) agree. The score of each item was 1–3 and the total score of the instrument ranges from 32 to 96, (32–53) indicating negative attitude, (54–74) indifferent attitude and (75–96) positive attitude.26 The instrument’s reliability was assessed using Cronbach’s α by Riahi et al, for CSA the scale (total), and cognitive, emotional and behavioural dimensions were 0.87, 0.74, 0.82 and 0.87, respectively. Also, in this study, the obtained values were 0.91, 0.75, 0.88 and 0.90, respectively. Here are some examples of CSA scale:

Cognitive category: smoking is only harmful if it continues for a long time. Smoking two cigarettes can also lead to addiction. Emotional category: smoking cigarette is an interesting and exciting experience. Smoking cigarette is a good way to reduce mental tension. Behavioural category: I enjoy friendship and socialising with smokers; when I am with my friends, I am willing to smoke with them.

Loneliness questionnaire

The revised version of the University of California Los Angeles Loneliness Scale was used to measure subjective feelings of loneliness.27 This scale contains 9 positive and 11 negative items ranging from 1 (never) to 4 (always). The overall score ranges from 20 to 80 and a higher score represents a higher level of loneliness. The cut-off values for the scale were calculated using the mean, and a score of 42 or more (out of a total of 80 standard loneliness scores) was taken as experienced loneliness.28 Some examples of the items in this questionnaire include the following: (1) My interests and ideas are not shared by those around me, (2) It is difficult for me to make friends, (3) I feel completely alone. The test–retest reliability of the scale was verified by Russell et al as 89%.29 The validity of the loneliness scale was also validated by Alaviani et al.18 Cronbach’s alpha was 0.98 for the Loneliness scale in the present study.

After obtaining informed consent, the participants were assured the confidentiality and anonymity of the data.

Data analysis

Data were processed, coded and analysed using SPSS V.22 software. Descriptive statistics, such as frequency, mean, percentage and SD, were used to summarise the students’ general characteristics, their attitudes towards cigarette smoking and their loneliness. One-way analysis of variance and an independent t-test were used to compare demographic variables and attitudes towards cigarette smoking. Variables with a p value <0.1 (age, gender, year of study, history of cigarette smoking) were candidates and were included in the multivariable linear regression analysis as potential confounders. Pearson’s correlation analysis was used to examine the association between loneliness and attitudes towards cigarette smoking. In addition, a multivariable linear regression analysis was performed to test the association between loneliness and attitudes towards cigarette smoking. The level of statistical significance was set at p <0.05.

Patient and public involvement

No patient involved.


The demographic information of the study participants is shown in table 1. From a total of 538 participants, 301 (59.9%) students were young women. The mean age of the students was 22.2±2.9 years. 282 (52.4%) of the participants aged 21 and lower years. Only 56 (10.4%) of the students were married and 370 (87.9%) of them were living with their families. 131 (24.3%) students experienced cigarette smoking. In terms of university-related characteristics, 205 (38.1%) of the students were studying in the faculty of medicine.

Table 1

Demographics information of participants and analysis of CSA score according to variables (n=538)

Total scores of loneliness, CSA and its subscales are presented in table 1. The mean scores of loneliness and CSA were 41.42±11.29 and 48.64±11.28, respectively.

The Pearson correlation reflected a significant positive correlation between loneliness and attitudes towards cigarette smoking (r =0.289, p <0.001). The results of the multivariable linear regression analysis are shown in table 2. With the control of demographic covariates, the model indicated that loneliness was positively associated with CSAs. The attitude towards cigarette smoking was more positive among male students than among female students (B =0.10, 95% CI 0.05 to 0.15). The year of the study was significantly associated with CSAs (B =−0.15, 95% CI −0.25 to −0.04). First-year students showed a negative attitude compared with those in the fourth year and above. In addition, students who had (current or past) smoking experience showed a more positive attitude towards smoking than those without smoking experience (B =0.33, 95% CI 0.27 to 0.39).

Table 2

Multivariable linear regression of the relationship between cigarette smoking attitudes and loneliness


This research was conducted to determine the association between attitudes towards smoking and loneliness in university students.

Based on the results of the study, it was found that most of the students had a negative attitude towards cigarette smoking, with 26.4% of the students also reporting feelings of loneliness. Furthermore, the study results revealed a significant positive correlation between loneliness and attitudes towards cigarette smoking. Additionally, the attitude towards cigarette smoking was found to have a significant relationship with factors such as sex, year of study and history of cigarette smoking.

About attitude towards smoking, the lowest score was related to the cognitive dimension, which is consistent with previous studies. For instance, a study among dental students showed their positive attitude towards smoking cessation and avoidance. In Latvia and Lithuania, dental students stated that smoking prevention and cessation should be part of training for healthcare staff.13 30

Learning can play an important role in smoking; however, this requires a positive attitude towards smoking cessation among students.13 A study by Hohman et al showed that antismoking messages can have a significant impact on adolescent behaviours.31 A study in Iran indicated that students’ attitudes and knowledge were moderate about the effects of smoking.32 In contrast, a study conducted in Indonesia found that the majority of students were aware that cigarette smoking causes heart disease, lung cancer, addiction and health problems, and it is harmful during pregnancy.33 This conflict can be due to the different education and health system of Indonesia and Iran.

The current study showed that high feeling of loneliness, being a senior student, male sex and having had a smoking experience are associated with more positive attitudes towards smoking. So the students with a high feeling of loneliness held more positive attitudes towards cigarette smoking. Based on the results of the present study, 26.4% of the students’ felt lonely, and students who indicated that they had smoked cigarettes before or now felt more lonely compared with non-smokers. This result is consistent with other similar studies. For instance, the results of a study among students at a Chinese university found that students who smoke had significantly higher loneliness scores than non-smokers.16 The results of another study demonstrated that smokers suffer from higher psychological problems than non-smokers.34

This study found that compared with male students, CSA was more negative among female students. A systematic review of cigarette smoking prevalence among Iranian adolescents and young adults also found that cigarette smoking is prominent among Iranian young adults, particularly boys and university students35 while a study in Lithuania showed that there was no relationship between gender and smoking attitudes.13

Also, freshman students had more negative attitudes towards smoking than fourth-grade students. A study of Yemen university students showed that smoking rates increased with years of study and age, establishing a significant association between student age and smoking propensity (p <0.001).36 This may be due to older students’ prolonged contact with older smokers in the university environment (teachers, friends, workers, etc) which could strongly influence their attitudes, and possibly because of family pressures against smoking in young people, which decrease as individuals become more free.

The results of the present study showed that there is a significant correlation between a smoking experience (current or in the past) and the attitude towards smoking. This is consistent with a study in Indonesia, which found that the attitudes that can lead to smoking behaviour in students differ significantly between current smokers and non-smokers in most cases. It was found that smokers were more curious about cigarette smoking than non-smokers.33


The findings of this study revealed a significant positive association between loneliness and students’ CSA. These results raise important concerns for future healthcare providers and emphasise the need to address loneliness among university students.

Loneliness among university students is a pressing issue that requires attention from university managers and administrators. By recognising the detrimental impact of loneliness on students’ attitudes towards smoking, proactive measures can be taken to reduce students’ feelings of loneliness and prevent their inclination towards smoking. University managers should prioritise the improvement of recreational and cultural services, creating opportunities for social engagement and fostering a sense of community. By enhancing social support networks and promoting a supportive campus environment, universities can play a crucial role in reducing loneliness among students and subsequently improving their attitudes towards smoking.


There are some limitations in the study. For example, a cross-sectional design was used to examine the association between loneliness and smoking attitude. With this type of design, the longitudinal changes are not controlled. So, longitudinal studies are needed to examine sociopsychological factors in university students. In addition, a self-report questionnaire was used for data gathering. Social desirability is a factor that may affect the accuracy of the responses in self-report questionnaires, especially since the participants were studying in a health-related field. So, the participants were given privacy to complete the questionnaires, and the anonymity of the survey was ensured.

Data availability statement

Data are available upon reasonable request. For ethical reasons, the data sets generated/analysed as part of the current study are not publicly accessible but can requested from the corresponding author upon justified request. (The Ethics Committee of Tabriz University of Medical Science has limitations on the availability of data.)

Ethics statements

Patient consent for publication

Ethics approval

The Vice-Chancellor has approved the current research project for the Research and Ethics Committee of the Medical University of Tabriz with the code IR.TBZMED.REC 1398.673. Participants gave informed consent to participate in the study before taking part.


We thank the students, who participated in this study.

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