An international comparison of tobacco smoking, beliefs and risk awareness in university students from 23 countries

Aims To assess the prevalence of current tobacco smoking, associations with beliefs about the health benefits of not smoking and awareness of risks for lung cancer and heart disease in university students sampled from 23 countries, and to explore the utility of the World Health Organization (WHO) model of the world-wide tobacco epidemic in understanding differences between countries. Design Anonymous questionnaire survey. Participants A total of 19 298 university students (8482 men, 10 816 women) aged 17-30 years from 23 countries, studying courses unrelated to health. Measurements Standardized measures of smoking, wish to stop smoking, ratings of beliefs in the importance of not smoking for health and awareness of the influence of smoking on lung cancer and heart disease. Findings Prevalence varied widely, being highest in samples from South European countries and lowest in developing countries (Thailand, South Africa). The pattern of tobacco use and differences between men and women conformed largely to the WHO model. Health beliefs were associated strongly with smoking behaviour both within and between countries. Awareness of specific health risks of smoking was very variable, with particularly low levels in Asian, South American and developing country samples. Risk awareness was inconsistently related to behaviour. Conclusions The pattern of tobacco smoking in well-educated young adults appears to conform with wider international patterns of tobacco use. Awareness of specific health risks is poor, and modifying attitudes must be a central element in modifying tobacco use world-wide.