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. 2022 Mar;21(3):271–282.

Prevalence of Cigarette Smoking and its Related Factors among Students in Iran: A Meta-Analysis

Marzieh Aslani 1, Mahboubeh Nazari 2, Hamidreza Jamaati 3, Omid Naseri 4, Sholeh Saedmoucheshi 5, Prashant Kumar Singh 6, Reza Ghanei Gheshlagh 7,✉
PMCID: PMC10073949  PMID: 37025309

Abstract

Background:

Smoking is a preventable cause of morbidity and mortality with an increasing prevalence in developing countries. The present systematic review and meta-analysis aimed to estimate the prevalence of smoking among college and high school students in Iran.

Materials and Methods:

Databases of Scopus, PubMed, Web of Science, Google Scholar, SID, and MagIran were searched with no time limitation. Observational studies published in Persian or English were included in the analysis. Time frame of the searches was from inception until 1 January 2021. The data was analyzed using random effects model, subgroup analysis, and meta-regression analysis. Heterogeneity among studies was examined using Cochran's Q test and I2 statistic.

Results:

A total of 63 articles with a sample size of 58742 were analyzed. The pooled smoking prevalence was found to be 13.56% (95% CI: 11.65–15.47). There was a significant increase in the prevalence of smoking among female students between 1998 and 2020. Regions 1 of Iran had the highest prevalence rates of smoking (Provinces of Alborz, Tehran, Qazvin, Mazandaran, Semnan, Golestan, and Qom). Smoking was more prevalent among college students (15.62%, 95% CI: 13.14–18.10) than in high school students (9.77%, 95% CI: 7.19–12.35).

Conclusion:

Given the relatively high prevalence of smoking among Iranian college and high school students, it is necessary to inform them about the harmful effects of smoking through training programs.

Keywords: Meta-Analysis, Cigarette Smoking, Prevalence, Students

INTRODUCTION

Smoking is a public health problem and a preventable cause of morbidity and mortality in the world (1) that leads to the death of 5–10 million people every year (2). It is the cause of 90% of lung cancers, 40% of other cancers, 75% of respiratory problems, 50% of cardiovascular problems, and 12% of total deaths (3). It is projected that smoking will lead to more deaths than AIDS, malaria, tuberculosis, maternal death, and accidents (4). One-third of the world’s population is smokers, of which about 80% live in developing countries (5). On average, every Iranian smoke 13.7 cigarettes per day, and every year, 30 billion cigarette sticks are smoked in Iran (6, 7).

The past few decades in the US have seen a steady decline in smoking rates in adults, but during the same period, smoking prevalence in students has heavily increased (8). In Iran, the smoking prevalence has been on the rise in the recent decades so that in 1990, about 10.7% of people aged 15–24 years (the high school and college age range) were smokers, and this increased to 17.1% by 2000 (9). A previous study showed that 22.9% and 19.8% of college students in Western and Eastern Europe were smokers, respectively (10). Results of a meta-analysis showed prevalence rates of 19.8 and 2.2% for smoking in Iranian male and female college students, respectively (11), while the prevalence of smoking in Iran’s general population is 11.9% (12). The high prevalence of smoking among students compared to that in other groups of adults is alarming, especially considering the fact that most of them do not pay enough attention to smoking-related health warnings (13). Many active smokers around the word develop this habit in their adolescence. Given that most smokers smoke their first cigarettes in high school years and after that, students should be the primary target population of smoking prevention programs. Various studies in Iran conducted on the prevalence of smoking in students have led to mixed results, reporting prevalence rates ranging from 2.2 to 34.9% (14, 15). Given the fact that the first step in understanding any problem is to know the current situation, estimation of the prevalence of smoking in Iranian students can help health authorities better manage this problem. Therefore, the goal of the present study is to estimate the prevalence of smoking in Iranian high school and college students and examine the related factors.

MATERIALS AND METHODS

The aim of the present systematic review and meta-analysis is to estimate the prevalence of smoking in Iranian high school and college students and the related factors based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines (16). The current study did not register in PROSPERO.

Inclusion and exclusion criteria

All the observational studies published in Persian or English focused on the prevalence of smoking in Iranian high school and college students were included in the study with no time limitation. The exclusion criteria were as follows: unavailable full texts, duplicated articles, and articles that did not provide the required information in the text.

Search strategy

Search for articles was conducted in Web of Science, PubMed, Scopus, Scientific Information Databases (SID), MagIran using the following keywords and their potential combinations: Student, Smoking, Cigarette, and Iran. Time frame of the searches was from inception until 1 January 2021. In addition, the article references were reviewed to find more related studies (Table 1).

Table 1.

Search strategy results in international databases

Scopus (TITLE-ABS(tobacco*) OR TITLE-ABS(“tobacco smoking”) OR TITLE-ABS(smoking) OR TITLE-ABS(“tobacco use*”)) AND AFFILCOUNTRY(IRAN) 4161
(TITLE(tobacco*) OR TITLE(“tobacco smoking”) OR TITLE(smoking) OR TITLE(“tobacco use*”)) AND AFFILCOUNTRY(IRAN) 955
PubMed (((tobacco[MeSH Terms]) OR (tobacco smoking*[MeSH Terms]) OR (smoking[MeSH Terms]) OR (tobacco use*[MeSH Terms]))) AND (iran) 922
(((tobacco[Title]) OR (tobacco smoking*[Title]) OR (smoking[Title]) OR (tobacco use*[Title]))) AND (iran) 726
WOS TI=(tobacco OR “tobacco smoking” OR smoking OR “tobacco use*”) AND CU=IRAN 1003
Refined by: Document type: (Article) 779
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Article selection

The results of the aforementioned databases were imported and managed using EndNote X9 (Thomson Reuters, New York, USA). Duplicate studies were excluded. In the next step, two researchers independently screened the studies by reviewing their titles and abstracts. Any disagreement in this step was resolved through discussion among the members of the research team

Data extraction

Article necessary intimation, including first author, year of publication, sample size (total, women, men), mean age of participants, education level (high school student or college student), study environment, prevalence of previous experience of smoking, prevalence of current smoking (total, women, men), and methodological quality were extracted by two researchers independently from each other. In order to examine the data extraction rigor, the correspondent author examined the data extraction for the first 20 articles.

Quality assessment

A modified Newcastle-Ottawa Scale (NOS) was used to assess the methodological quality of each article (Lo et This scale evaluates the quality of an article through three criteria: Selection, comparability and exposure. High-quality articles were defined as ≥4 stars (17).

Statistical analysis

In the present study, the point estimate and a 95% confidence interval were calculated for each selected study focused on the prevalence of smoking in high school and college students (18). In addition, the prevalence of smoking by gender was examined. Heterogeneity and inconsistency between studies were assessed using Cochran's Q Test and I2 statistic (19). Given the high heterogeneity among the studies, random effects model was used to combine them. In terms of heterogeneity, the studies were divided in three categories, including low (I2 value below 25%), average (I2 value between 25% and 75%), and high (I2 value above 75%) (19,20). For Cochran's Q test, P<0.1 indicated a significant level of heterogeneity (21). Sensitivity analysis was used to ensure the consistency of the results. In this study, subgroup analysis and meta-regression test were used to investigate the potential source of changes affecting the prevalence of smoking. Subgroup analysis was used to identify the source of heterogeneity by region (Iran’s five administrative regions), education level (high school or college) and language (Farsi or English) (22). Prevalence is presented in two ways in this article: current smoker and experimental smoker. Experimental smoker refers to people who have experienced smoking even once in their lifetime. In 2014, the provinces of Iran were included in a new classification by the Ministry of Interior of the Islamic Republic of Iran in the form of 5 regions according to the factors of proximity, geographical location and commonalities. Meta-regression analysis was employed to assess the relationship of smoking prevalence with article year of publication and mean age of participants. Publication bias was examined using a funnel plot and Egger's regression test. All the statistical analyses were performed using R, v.4.3.2.

RESULTS

In the primary search a total of 395 articles (73 from international databases and 320 from Iranian ones) were extracted. After excluding duplicate studies, titles and abstracts of 362 remaining articles were examined, and another 275 articles were excluded. The full texts of the 87 remaining articles were reviewed. In this step, articles not providing enough intimation were excluded, and 63 articles were included in the final analysis. The flowchart provided in Figure 1 shows the article search and screening process based on the PRISMA guidelines.

Figure 1.

Figure 1.

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The process of searching, screening and selecting articles

Study Characteristics

A total of 63 studies with a total sample size of 58742 were systematically reviewed. The lowest and highest sample sizes were for the studies conducted by Rahmanian (n=174) (23) and Habib (n=4591) (24), respectively. Among the studies, 48 were in Persian and 15 were in English. In addition, 28 studies had school students and 35 had college students as their participants. All selected studies were cross-sectional. Further details are reported in Table 2.

Table 2.

Article search and screening process

First Author Year Sample Place Prevalence
Total Male Female
Current smoker Experimental smoker
Masjedi (25) 2020 1075 Varamin - 9.2 - -
Khoshnevisan (14) 2020 290 Tehran 34.4 51.4 53 13.5
Miri-Moghaddam (26) 2019 500 Zahedan 15.2 - 26.5 8.7
Ansari (27) 2019 1094 Zahedan 10.1 22.6 14.5 4.6
Cheraghi (28) 2018 899 Ahvaz - 5.4 - -
Panahi (29) 2017 340 Tehran 23.8 17.1 - -
Karimi (30) 2017 842 Shiraz - 19.7 - -
Sahebihagh (15) 2017 476 Yazd 2.2 6.7 - -
Khoramdad (31) 2016 750 Shiraz - 15 15.3 12.2
Madani (3) 2016 2029 Bandar Abbas 8.5 23.2 13.7 3.4
Fazeli (32) 2016 361 Andimeshk 29.9 - - -
Attari (33) 2015 305 Esfahan 4.6 13.4 - -
Taheri (34) 2015 936 Mashhad 9.8 18.3 17.6 4.2
Jalilian (35) 2015 425 Kermanshah-Isfahan - 19.4 - -
Reisi (36) 2014 382 Isfahan 7.2 32.7 - -
Mohammadi (37) 2014 450 Babolsar 17.2 - - -
Bidel (38) 2014 1000 Ilam 1.3 11.4 - -
Barati (39) 2014 810 Hamedan 2.7 17.2 - -
Pirdehghan (40) 2014 460 Yazd 7 16.5 - -
Nazarzadeh (41) 2013 1064 Zanjan 10.8 23.4 - -
Shafiie (42) 2013 760 Bam 5.7 - - -
Nasirian (43) 2013 772 Kerman 15.8 - 25.4 6.3
Rezakhani Mogaddam (44) 2013 720 Tehran 22 - - -
Shahnazi (45) 2013 382 Isfahan 7.2 32.7 - -
Heydari (46) 2013 1271 Tehran 17 31.1 - -
Mokhtari (47) 2012 222 Guilan 23 - - -
Nazemi (48) 2012 1800 Shahrood 21.6 - 28.9 10.8
Nouri (49) 2012 1573 Tehran 17.2 - 37.4 4.2
Habib (24) 2012 4591 Tehran - - 12.1 5.3
Shamsipour (50) 2012 523 Tabriz 8.9 - 18 1.4
Aminoroaia (51) 2012 537 Isfahan 18.6 - - -
Tavakolizadeh (52) 2012 279 Gonabad 9.8 - 14.4 4.1
Morowatisharifabad (53) 2012 240 Maragheh - 15.4 - -
Ghodsi (54) 2012 222 Guilan 23 - - -
Roohafza (55) 2011 812 Isfahan 9.5 - 18.3 2.5
Jafari (56) 2011 400 Tehran 30.3 - 44.7 15.9
Moeini (57) 2011 900 Malayer - 14 - -
Kathiri (58) 2011 745 Ahvaz 19.1 44.1 - -
Ramezani (59) 2011 460 Kerman 12.1 52.8 - -
Heydari (60) 2010 1271 Tehran - 61.5 - -
Nazary (61) 2010 320 Semnan 14.4 29.4 - -
Ramezankhani (62) 2010 4523 Tehran - 25.5 - -
Rahmanian (23) 2010 971 Jahrom 9.7 21.3 14.2 3.3
Rahmanian (23) 2010 174 Jahrom 12.6 25.3 18.1 1.8
Moghadam (63) 2009 870 Birjand 31.5 - 39.9 25.5
Divsalar (64) 2008 1677 Kerman 11 - 21.5 2.4
Namakin (65) 2008 1233 Birjand 3.9 21.3 - -
Shoja (66) 2008 538 Golestan 6.2 83.5 17.3 0.8
Zia-ud-Din (67) 2008 860 Kerman - - 2.3 1.2
Divsalar (68) 2007 833 Kerman 21.5 - - -
Pasharavesh (69) 2007 3150 Kermanshah - 15 - -
Mohtasham Amiri (70) 2007 1297 Rasht 15 28.2 - -
Abedini (71) 2007 200 Bandar Abbas - 9 20 2.4
Majidpour (72) 2005 1106 Bandar Abbas 7.4 13.9 22 1.2
Kelishadi (73) 2004 1950 Isfahan 8.7 - 12.9 4
Mojahed (74) 2004 475 Zahedan - 15.5 2.3 0.4
Heidari (75) 2003 1095 Tehran 4.4 28.9 6 1.6
Masjedi (76) 2003 1066 Tehran 16.3 - 25.4 5
Zohoor (9) 2002 993 Kerman 13.4 - 21.7 5.2
Ayatollahi (77) 2002 1132 Shiraz 25.5 16.9 - -
Hasanzadeh (78) 2002 1086 Mashhad 10.9 - 15.45 1.9
Ahmadi (79) 2001 532 Shiraz 8.7 - 16.8 0.69
Afrasiabifar (80) 1998 693 Shiraz 9.1 - 15.4 0.7
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C: Current smoker; E: Experimental smoker

Prevalence of Current Cigarette Smoking

The prevalence of current cigarette smoking was reported in studies, and the pooled prevalence of smoking was found to be 13.56% (95% CI: 11.65–15.47) (I2 = 97.9%, P<0.001). The prevalence of smoking was higher in boys (20.35%, 95% CI: 16.74–23.96) than in girls (4.60%, 95% CI: 3.53–5.66) (p<0.0001) (Figure 2).

Figure 2.

Figure 2.

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The prevalence of smoking by gender (1: male and 2: female).

Regions 1 and 2 of Iran had the highest and lowest prevalence rates of smoking, respectively. In addition, there were significant differences between different regions of Iran in terms of smoking prevalence (Q=10.92, df=4, p-value=0.0275). Smoking was more prevalent among college students (15.62%, 95% CI: 13.14–18.10) than in high school students (9.77%, 95% CI: 7.19–12.35). There was no significant difference between regions of Iran in terms of smoking prevalence in boys (P-value: 0.0824), but smoking prevalence in girls was significantly different in various regions of Iran (P=0.0004) (Table 3).

Table 3.

The results of subgroup analysis

Category Number of studies Pooled prevalence (% [95% CI]) I2
Region* 1 Total 12 18.53 (13.74–23.32) 97.9%
Men 8 27.71 (18.74–36.68) 98.7%
Women 8 6.24 (3.86–8.62) 94.9%
2 Total 13 10.44 (8.06–12.83) 64.5%
Men 8 16 (13.99–18.01) 63.1%
Women 8 2.55 (1.33–3.77) 86.6%
3 Total 5 15.39 (11.20–19.58) 91.2%
Men 1 18 (13.19–22.80) -
Women 1 1.4 (0.05–2.74) -
4 Total 4 12.76 (5.71–19.80) 98.9%
5 Total 15 11.90 (8.73–15.6) 97.5%
Men 11 18.16 (11.78–24.53) 98%
Women 11 5.43 (3.30–7.56) 95.4%
Type University Total 32 15.62 (13.14–18.10) 97.2%
Men 19 24.69 (20.76–28.63) 94%
Women 19 5.18 (3.70–6.66) 94.6%
High school Total 17 9.77 (7.19–12.35) 97.9%
Men 9 11.49 (7.40–15.58) 97.2%
Women 9 3.64 (2.12–5.17) 92.8%
Language Farsi Total 40 13.53 (11.39–15.67) 98%
Men 21 19.56 (14.99–24.13) 97.9%
Women 21 3.84 (2.71–4.97) 94%
English Total 9 13.70 (9.11–18.30) 97.3%
Men 7 22.54 (16.61–28.47) 95.8%
Women 7 6.61 (4.95–8.28) 73.9%
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*

Region 1: Alborz, Tehran, Qazvin, Mazandaran, Semnan, Golestan, and Qom. Region 2: Isfahan, Fars, Bushehr, Hormozgan, Kohgiluyeh and Boyer-Ahmad, and Chaharmahal and Bakhtiari Region 3: West Azerbaijan, East Azerbaijan, Ardabil, Zanjan, Guilan, and Kurdistan. Region 4: Kermanshah, Ilam, Lorestan, Hamedan, Markazi, and Khuzestan. Region 5: Razavi Khorasan, North Khorasan, South Khorasan, Kerman, Yazd, and Sistan and Baluchestan.

Prevalence of Experimental Cigarette Smoking

In addition, the total prevalence of smoking in 37 studies was found to be 24.48% (95% CI: 20.06–28.89). Moreover, previous experience of smoking was higher in college students (19.82%, 95% CI: 1982–44.66) than in high school students (19.71, 95% CI, 16.73–22.69).

Meta-regression results

According to the results of univariate regression analysis, there was a significant relationship between total smoking prevalence and mean age of participants (P=0.039), and also a significant association between smoking prevalence in girls and article year of publication (P=0.032). In addition, publication bias was significant (P=0.001) (Figure 3).

Figure 3.

Figure 3.

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Publication bias

DISCUSSION

The study results showed that 13.56% of high school and college students were smokers, and 24.48% of them had previously smoked cigarettes. The prevalence of smoking in Iranian high school and college students was 9.77 and 15.62%, respectively. A review of the literature showed that the prevalence of smoking in high school students was higher in Iraq (15.3%) (81) and Nigeria (17.1%) (82) than in Iran. This finding can be attributed to the strict rules in Iranian schools in terms of smoking. The prevalence of smoking in Iranian college students is similar to that in Saudi Arabian (17.6%) (83), lower than that in Pakistani (23%) (84), and higher than that in Syrian students (10.9%) (85).

The prevalence of smoking was higher in college students than in high school students, perhaps due to the fact that compared to high school students, college students are more likely to move away from home for college; therefore, they are less controlled by their families and may feel more freedom to do what they want. In addition, consistent with the findings of previous studies, we found that the prevalence of smoking in female high school and college students was lower than that in male students (86). The lower prevalence of smoking in female students can be attributed to the fact that smoking is considered a stigma for women in Iran.

There was an increase in the prevalence of smoking in Iran between 1998 and 2020 (according publication years), including a 0.36% increase in its prevalence in girls. One possible reason for this increased prevalence is that girls may use smoking as a way of being accepted by their peers and others (87). In addition, some use smoking to control their weight (88). Smoking affects weight through increasing metabolism and reducing caloric absorption (89), and smoking cessation is associated with a 10-pound increase in weight after one year (90). There was also a relationship between participant age and prevalence of smoking, so that one year increase in age was associated with 1.02% increase in the chance of smoking cigarettes. It appears that smoking can induce a sense of independence in college students and make them believe that they are not being controlled by their parents anymore.

One of the strengths of this study is its novelty and comprehensiveness, which has provided the most up-to-date findings. The limitation of this study was that some studies did not fully report all the findings, so further analysis was not possible.

CONCLUSION

The prevalence of smoking in Iranian high school and college students is relatively high. Starting to smoke at this critical stage of life can make them increasingly dependent on nicotine and even vulnerable to drug abuse. Therefore, it is necessary to provide this age group with training programs on the harmful effects of smoking.

Acknowledgements

This study was part of an approved research proposal in Asadabad School of Medical Sciences. In this regard, the researchers thanked the Research Deputy of Asadabad School of Medical Sciences for approving this proposal.

Abbreviations

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

SID:

Scientific Information Databases

STROBE:

Strengthening the Reporting of Observational studies in Epidemiology

Footnotes

Ethics approval and consent to participate

This study was extracted from a research project the Asadabad School of Medical Sciences (No. IR.ASAUMS.REC.1399.026).

Funding

This study was funded by the Asadabad School of Medical Sciences. The funders had no role in the study design, data collection and analyzes, decision to publish, nor preparation of any content in the manuscript.

Availability of data and materials

The data that support the findings of this study are not publicly available. Data are however available from the authors upon reasonable request and with permission of Asadabad School of Medical Sciences.

Competing interests

None of the authors have competing interests.

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