Smoking is a prevalent global issue, with a significant risk factor for various non-communicable diseases necessitating prolonged, costly, and potentially devastating medical treatments. In addition, infectious diseases such as tuberculosis, COVID-19, and pneumonia in toddlers are often associated with active and passive smoking habits. The correlation is evident across diverse demographics, encompassing individuals of varying ages, professions, and genders. Therefore, this research aimed to explore and describe behavior of active smokers among campus members at various universities, focusing on the initiation, cessation, and influencing factors associated with smoking. A qualitative research design was used with a hermeneutic phenomenological approach, where information was provided by five active smoker informants. These individuals started smoking as teenagers, and the fluctuating patterns were influenced by health concerns or a perceived lack of significance attributed to smoking. However, the periods of abstinence were only temporary due to the pervasive influence of social and environmental factors. The initiation of smoking commonly started from the influence of close acquaintances, such as family members. Meanwhile, the process of quitting encountered numerous obstacles, primarily from potent social factors outweighing personal intentions. The implementation of smoking cessation strategies posed challenges due to the profound impacts of addiction, requiring unwavering determination, comprehensive plans, and diligent efforts.

Cigarettes and smoking behavior are risk factors for various chronic degenerative non-infectious diseases such as hypertension,1 heart disease, and stroke,2 diabetes mellitus,3 chronic obstructive pulmonary disease,4 and various types of cancer.5 These conditions are collectively classified under non-communicable diseases (NCDs).6 Cigarettes are recognized as a risk factor for acute disease among second-hand smokers, such as pneumonia in toddlers.7-9 In addition, smoking is also a risk factor for contracting COVID-19 with evidence showing elevated rates of hospitalization, severity, and mortality.10-12 Cigarettes serve as a gateway to drug use and result in significant economic losses.13

According to data from the World Health Organization (WHO) in 2021, more than 80% of the 1.3 billion tobacco smokers worldwide resided in countries with low and middle incomes. Furthermore, results from the 2021 Global Adult Tobacco Survey (GATS) reported that 34.5% of the Indonesian population were adult smokers, totaling 70.2 million. Over the past decade, there has been a significant increase in the number of adult smokers, rising from 8.8 million out of a population of 60.3 million in 2011 to 69.1 million in 2021. This increase represents approximately 28.96% of the population, as reported by the Central Statistics Agency.14

The absence of Indonesia’s ratification of the Framework Convention on Tobacco Control (FCTC) has contributed to the normalization of cigarettes and smoking behavior among members of the academic community, and this normalization has pervasive effects.15 To mitigate the widespread distribution of tobacco products, Government Regulation No. 109 of 2012 concerning the Safeguarding of Materials Containing Addictive Substances in the Form of Tobacco Products for Health mandates the establishment of Smoke-Free Zones, known as “Kawasan Tanpa Rokok” (KTR). These zones include various locations, such as educational institutions, health facilities, children’s playgrounds, places of worship, and public transportation areas. In the designated zones, the presence of ashtrays, smoke, odor, cigarette butts, advertisements, and the sale of cigarettes is strictly forbidden. The regulation shows the commitment to improving environments that promote public health and prevent tobacco use.16

The college campus is an important site for the facilitation of teaching and should be officially designated as a Smoke-Free Zone. In light of these regulations, educational institutions, and the administrations, are expected to show compliance. Campuses are integral components of higher education and are duty-bound to adhere to the mandate. Despite the majority of students being of legal adult age, ensuring the well-being of all parties remains important, showing the rationale behind the implementation of non-smoking areas across campus environments.

In practice, appropriate Tobacco Control Regulations (KTR) conducive to the educational environment have not been enacted in numerous academic institutions. Campuses with a focus on health sciences remain deficient in implementing or overseeing KTR, despite the explicit stipulations outlined in Government Regulation No. 109 of 2012. The prevalence and exposure to passive smoking in universities can be reduced with the assistance of tobacco control programs.17 In this context, basic information is collected from staff and students, to assess behavior and attitudes related to the implementation of tobacco control policies throughout campus.18-21 Therefore, this research aims to observe and describe the experiences of active smoking by students, lecturers, and educational staff, focusing on the initiation, cessation, and the associated influencing factors.

The research adopted a qualitative method using a hermeneutic phenomenological approach to comprehend the processes by which campus members initiate smoking, the nature of current habits, and inclinations toward cessation. Purposive sampling was used to select participants, comprising active smokers from various campus constituencies such as students, faculty, and administrative staff. Meanwhile, individuals who declined to participate in the research were excluded. The participants were drawn from three distinct cities, namely Surabaya, Tarakan, and Palangkaraya. The research used semi-structured, in-depth interviews conducted through face-to-face, telephone, or video calls, based on the preference of the participant, supplemented by non-participant observation of the activities. Subsequently, interviews were recorded, transcribed, and analyzed. Before commencement, informed consent was obtained from all participants, and the interview sessions commenced in early 2023 following approval.

Interpretative descriptive techniques were used to explore the data related to smokers’ experience regarding the initiation, cessation, and associated influencing factors. In addition, the results were audio recorded and transcribed, as well as analyzed using a flexible seven-step Interpretative Phenomenological Analysis (IPA) approach. Manual method of analysis was adopted using the following steps: i) Repeatedly reading the transcript compiled from the interview results, ii) Checking the meaning of the words and the language used at the exploratory stage, iii) Developing themes, iv) Looking for the same relationships between themes, v) Moving to the next case, v) Obtaining similar patterns between cases, and 7vii) Describing the main theme.

The three main questions that the participants were asked were: i) When did you start smoking and what was your experience? ii) How is your current smoking behavior and what are the supporting and inhibiting factors? iii) How do you plan to quit smoking?”

Table 1 presents the demographic characteristics of the study participants, including gender, age, marital status, occupation, education, and faculty origin. Based on data analysis from interview transcripts, three main themes were found, with 12 super-ordinate themes. A summary of the main and super-ordinate themes can be seen in Table 2. Table 3 shows the current smoking behavior of informants.

The initial exposure to smoking typically commenced with experimentation, where some participants perceived the act as a fashionable way to expand social circles. Conversely, the influence of peers led to the adoption of similar smoking behaviors, resulting in addiction.22-23

The influence of the family, particularly fathers, significantly impacts children and adolescents in smoking behavior. For instance, participant 3’s father, being a smoker, serves as a role model, thereby enhancing a predisposition towards active smoking. This phenomenon suggests a pattern where smoking behavior is perpetuated across generations through emulation within the family environment or the patron-client relationship with the father figure.24

The influence of family and environment plays an important role in shaping smoking behavior. Even though parental admonitions are important, the efficacy may be diminished when there is no frequency and substantive, logical reasoning. In this context, the pervasive influence of the environment often outweighs warnings, showing the profound impact of surroundings on individuals’ smoking habits.

Peer groups and the immediate environment contribute to the formation of smoking habits.25

The perception of smokers who felt positive about cigarettes and smoking habits can be shown by these various comments.26-27

Signs prohibiting smoking serve an important function by dissuading smokers. However, for heavy smokers, opportunities to smoke persist in solitary settings or company of friends, regardless of the presence of the signs.28

The daily consumption of individuals varies significantly in terms of quantity, brand, type, and associated costs. Individuals tend to consume larger quantities to satisfy cravings due to increased levels of addiction.29

The preference for filter cigarettes over “kretek” is often observed for various reasons, with health considerations being particularly important. Despite the inherent health risks associated with all types, individuals may prefer filter cigarettes due to the perception of posing a comparatively lesser risk to health.30

For students without personal income, the price of cigarettes serves as a significant deterrent against smoking. Conversely, individuals with personal income, regardless of social status, tend to show higher levels of consumption on average.

Quitting smoking poses a significant challenge for addicted individuals and the attempts are prompted by health concerns or financial strain. However, for smokers who have not committed to cessation, financial burden and the clear warnings on cigarette packaging serve as effective deterrents to continued smoking.

Many graphic warnings on cigarette packs are reported to have little impact on smoking habits due to a variety of reasons. Meanwhile, several responses were provided when participants were questioned about the impressions of pictorial warnings on cigarette packs.31

Qualitative research contributes significantly to the understanding of active smokers on campus, analyzing the diverse factors related to initiation and cessation. The results show that the age of the onset for smoking among participants varied widely from junior high school to college years as university students. Despite the perception that students, typically aged over 18, are considered adults, this does not imply implicit permission for smoking. However, the prevailing situation often reflects a relaxed attitude towards smoking. This is evident in the proliferation of cigarette butts and the commonality of smoking behavior with minimal restrictions in place. In this research, female representation as informants was challenging to recruit compared to men. In line with other previous results, female and male smokers were identified simultaneously (27). The perceptions among female smokers did not center on concerns regarding the risks of mortality or addiction but on positive associations with smoking activities.

Campus, as an educational institution, has the responsibility of implementing Smoke-Free Zones or “KTR” but there remains inconsistency in the enforcement. In non-health campuses, the absence of signposts prohibiting smoking and designated nonsmoking areas (KTR) is important. Despite the educational nature of campuses, adherence to regulations governing tobacco control is crucial and requires consistent enforcement.

Addicted students, staff, and lecturers frequently indulge in smoking on campus. This behavior is particularly evident in areas where there are no signs showing campus as a KTR zone. The preferred locations for smoking are secluded corners obstructed by walls or staircases, away from parking lots. The presence of signs and prohibitions is crucial since the absence provides a sense of freedom to smoke among campus residents.

The perception that smoking is fashionable and serves as a coping mechanism for stress relief and inspiration is widely accepted, enticing many individuals to become active smokers. This is often reinforced by attractive and misleading advertising signs. The context refers to the direct acceptance or uptake of something, influenced by sensory experiences. Perceptions regarding smoking, behavior, and the enforcement of KTR in educational settings are connected to patterns of attitudes concerning smoking habits.32-33

The positive perception of smoking among participants progressively reinforced favorable attitudes toward behavior. Therefore, the overpowering factor of nicotine addiction is often considered during pain or diagnosis of sickness. Instances of heart disease among participants occurred at 40 years of age, which is younger than the average age of developing the conditions, typically at 45 or older.6 In addition, heart disease diagnosis failed to prevent smoking habit of a participant since the act was resumed after a definitive therapy.16,34

Efforts to cease smoking remain a significant challenge for active smokers on campus. Therefore, a proactive role must be assumed in tobacco control by instituting designated No-Smoking Areas. This measure would effectively limit the areas where active smokers can indulge in the habit. Additionally, the installation of signs is crucial in improving a healthy campus environment. Many valuable lessons can be obtained through the successful implementation of KTR.35-37

In conclusion, this research was carried out to explore the factors contributing to individuals becoming active smokers, with a particular focus on social interactions and familial influences within the immediate environment. The awareness and acknowledgment of health and financial consequences associated with smoking habits were examined. However, there was a tendency to disregard the issue concerning active smokers. The implementation of smoking cessation strategies proved challenging due to the profound impacts of addiction without a resolute determination, comprehensive plans, and diligent efforts. This study is limited by the constraints of qualitative research, which generally hinders the generalization of results. Furthermore, the participants were drawn from diverse campuses in different cities, encompassing various types and classes.