Prevalence, determinants, and perceptions of tobacco use among male college students in Puducherry: a mixed-methods study

Abstract

Introduction

Tobacco use remains a critical public health concern in India, particularly among young adults. Understanding the interplay of social, familial, and behavioural influences is vital for effective prevention. So, we aimed to estimate the prevalence of tobacco use among male college students in Puducherry and explore factors influencing initiation and maintenance.

Methods

A sequential explanatory mixed-methods study was conducted from November 2019 to December 2021, recruiting 750 male undergraduate students through a multistage random sampling technique from ten colleges across five academic streams. Quantitative data were collected using a validated, anonymous questionnaire adapted from the Global Adult Tobacco Survey-2 (GATS-2). Bivariate and Binary logistic regression analyses were performed to identify factors associated with tobacco use. Focus group discussions with users and non-users explored perceptions and experiences, analyzed thematically and integrated for triangulation.

Results

The prevalence of ever tobacco use was 10.7% (80/750), with 10.4% (78/750) being current users. Among ever tobacco users, 83.7% (67/80) used smoked forms. Initiation occurred mostly between 15 and 20 years (56/80, 70.0%) and was associated with curiosity and peer pressure. Higher odds of use were associated with older age (AOR 6.54, 95% CI 2.31–18.50), father’s tobacco use (AOR 3.94, 95% CI 1.56–9.96), and peer’s use (AOR 3.62, 95% CI 1.70–7.73); maternal education was protective (AOR 0.14, 95% CI 0.04–0.52). Qualitative themes highlighted peer/family roles, curiosity and media-related perceptions.

Conclusion

The prevalence of tobacco use among college students was 10.7%. Initiation and maintenance of tobacco use were associated with curiosity, peer influence, familial factors and media-related perceptions. Interventions must include family and peer engagement and enforce stricter controls on pro-tobacco media content.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s41043-026-01386-8.

Introduction

Tobacco use remains a major contributor to preventable morbidity and premature mortality worldwide [1]. Globally, tobacco accounts for over 8 million deaths annually, with India suffering an estimated 1.35 million tobacco-related deaths each year and a considerable loss of disability-adjusted life years (DALYs) [2, 3]. In India, tobacco use accounts for a significant proportion of the non-communicable disease burden and premature deaths [4]. National surveys such as the Global Adult Tobacco Survey (GATS-2) second round (2016-17) report that 28.6% of adults use tobacco in some form, while the National Family Health Survey (NFHS-5) reported a tobacco consumption among men to be as high as 39% [5, 6]. Evidence from the Global Youth Tobacco Survey (GYTS-4) further shows that initiation of tobacco use commonly occurs during adolescence, with a considerable proportion of students experimenting with tobacco before the age of 15 years [7]. Early initiation increases the likelihood of sustained use, making young adults a critical target group for prevention efforts [8].

India has implemented multiple tobacco control measures aligned with the World Health Organization Framework Convention on Tobacco Control (WHO FCTC), including Cigarettes and Other Tobacco Products Act (COTPA), which regulates advertising, mandates pictorial health warnings, and restricts tobacco depiction in media [9]. Additionally, the WHO MPOWER strategy emphasizes monitoring tobacco use and prevention policies as a key component for effective tobacco control [10]. Despite these measures, exposure to tobacco-related content through films, social media, and digital platforms remains widespread, potentially influencing perceptions and behaviours among young adults [11].

Existing evidence highlights the role of social and environmental determinants in shaping tobacco use. Peer and family influences are consistently identified as strong predictors of initiation and continuation [12]. In India, the tobacco imagery in films and online content remains widespread, subtly normalizing smoking despite regulations. In a Kerala-based study, exposure to smoking imagery in films corresponded with increased susceptibility to use among adolescents [13]. Moreover, over 11% of popularly viewed YouTube videos contain tobacco-related content [14]. Qualitative research reveals persistent enablers in Indian entertainment that allow tobacco imagery to continue, thereby undermining the intended preventive impact [15]. This creates a paradoxical situation in which youth are simultaneously exposed to health warnings and alluring portrayals of tobacco use, complicating behaviour change. Thus, the complexities of tobacco use initiation and maintenance among young adults require nuanced exploration. While quantitative studies have identified associated factors, they often lack contextual insights into the motivations and perceptions underlying tobacco use behaviours.

Furthermore, there is limited evidence from India integrating quantitative and qualitative approaches to examine these influences among college students comprehensively. In Puducherry, a city located on the southeast coast of India, which has a diverse student population and increasing access to digital media, such evidence remains scarce. Understanding the interplay of social, familial, and media-related factors in this setting is essential for designing context-specific and effective interventions [16].

Therefore, this study aimed to estimate the prevalence of tobacco use among male college students in Puducherry and to explore the social, familial, and media-related factors associated with its initiation and maintenance using a sequential explanatory mixed-methods approach. The qualitative inquiry was guided by quantitative findings to provide deeper contextual understanding.

Methods

Conceptual framework

The study was guided by a socio-ecological framework (Supplementary Figure

S1), recognizing tobacco use as a behaviour influenced by individual, interpersonal and environmental factors. Based on this framework, the quantitative questionnaire included variables related to individual factors (age, knowledge and perceptions), interpersonal influences (peer and family factors) and environmental influences (media-related factors) that may contribute to tobacco use initiation and maintenance.

Study design & duration

We adopted a sequential explanatory mixed method, combining both quantitative and qualitative approaches wherein the qualitative component was guided by findings from the quantitative phase to provide deeper contextual understanding of observed associations. The study was conducted among the college students in Puducherry, India over a period of two years, from November 2019 to December 2021.

Study setting and sampling frame

Puducherry, situated on the southeast coast of India, is a Union territory and features more than forty colleges across disciplines. Admissions to these colleges are managed through the Centralized Admission Committee (CENTAC) and the participating colleges were included in the sampling frame. The final selection comprised five streams: Medical, Dental, Engineering, Nursing & Paramedical and Arts & Science, with the exclusion of veterinary and Law colleges due to relatively small enrolment numbers. From each stream, two colleges (one government, one private) were selected using simple random sampling, leading to a sample of ten colleges representing the population diversity (Fig. 1). Apart from the exclusion of streams with low enrolment (veterinary & law), no additional exclusion criteria were applied during the selection of colleges.

Fig. 1.

Methodological framework of the sequential explanatory mixed methods design

Study population and eligibility

The target population consisted of male college students aged 18 years and above who were enrolled and had consented to the study in selected institutions. Female students were excluded due to the substantially lower prevalence of tobacco use among women reported in the GATS-2 survey, where overall prevalence among females is approximately 5% [5]. Given the narrower age range of college students, the expected prevalence in this subgroup would be even lower, which could limit meaningful analysis.

Sample size determination

The sample size was estimated based on GATS-2 survey, considering a hypothesized prevalence of 19% among college students [5], derived from the prevalence range of tobacco use reported for Puducherry. Utilizing OpenEpi (version 3.01) with a design effect of 2 and accounting for dropout and missing data rates (10% each), the required sample size was calculated as 750 participants.

Sampling technique

A multi-stage random sampling technique was adopted. The sampling frame comprised 40 colleges across seven streams under CENTAC, providing representative coverage of major professional and non-professional streams in Puducherry. The distribution included medical (7), dental (2), engineering (14), arts and science (5), nursing and paramedical (10), veterinary (1) and law (1) colleges. Streams with low student intake (veterinary and law) were excluded from sampling. From each of the remaining five streams, the colleges within each discipline were stratified by management (Government/Private), and one from each category was randomly selected per stream, resulting in a total of 10 colleges. In the second stage, 75 eligible students from each college were selected using a simple random sampling method (random number table) to ensure adequate representation. Classes were not separately sampled. Students who were unavailable, refused to participate, or were found to be ineligible (e.g., aged < 18 years) were replaced by the next randomly selected eligible participant from the sampling list.

Data collection

Quantitative component

After obtaining ethical clearance and institutional approvals, the student authorities were approached, who facilitated the recruitment of the participants. Recruited students were informed about the objectives and procedure of the study and a written informed consent was obtained. The questionnaire used for data collection was adapted from the GATS-2 India survey [5] with contextual modifications. The tool was assessed for face validity through expert review and was pre-tested among a subset of students to ensure clarity and relevance. To ensure privacy and minimize bias, questionnaires were made anonymous and administered in the absence of college authorities. Each student was allotted approximately 30 min to complete the survey. During pandemic related closure of institutions, data were collected electronically via Google Forms. At the institutional level, one selected college declined participation and was replaced by another randomly selected college from the same stratum. At the participant level, non-response was minimal as data were collected anonymously using an electronic questionnaire, which facilitated complete responses.

Qualitative component

The qualitative phase was guided by key quantitative findings, particularly the observed associations with peer influence, parental factors, perceptions regarding tobacco use, and media-related influences. These findings informed the development of qualitative probes and thematic exploration. The qualitative phase was undertaken to better understand the contextual and behavioural mechanisms underlying the quantitative associations and to explore factors that could not be fully captured through structured survey responses. A total of four focus group discussions (FGDs) were conducted remotely over the Zoom platform, comprising two groups of tobacco users and two groups of non-users. Each FGD included 6 to 8 participants (total n = 27). Participants were recruited from the same study population as the quantitative phase based on the willingness to participate; hence, representation across colleges was not proportionate. Although only four FGDs were conducted, discussions continued until thematic saturation was achieved, with no substantially new themes emerging in later discussions. Each session began with re-consent, with one expert moderating the session and another expert as note-taker. The FGDs explored specific themes such as initiation and maintenance of tobacco use, and the influence of peer, familial, and media factors, rather than repeating the entire quantitative questionnaire. Probes and follow-up questions were flexibly adapted during discussions to explore emerging issues in greater depth. The sessions were audio-recorded, manually transcribed, and analysed thematically, with coding disagreements resolved through discussion and consensus between the analysts. The FGD interview guide is provided as Supplementary Material.

Study variables

The dependent variable was tobacco use among college students, measured across categories: ever users, current users (regular/occasional), past users and never users. The independent variables included socio-demographic factors (such as age, domicile, socio-economic status classified into five categories using the modified BG Prasad scale (August 2021), religion, parental education), tobacco use by friends/family, awareness of health hazards, perceptions regarding tobacco use, and exposure to pro-tobacco advertisements and health warnings, all assessed through self-reported responses. For regression analysis, SES categories were collapsed into three groups (upper, middle, and lower) to ensure adequate cell sizes.

Operational definitions

Although standard epidemiological surveys commonly use a past 30-day recall period for defining current tobacco use, the present study assessed tobacco use status at the time of survey to better capture ongoing patterns of use among college students. Regular user is someone who, at the time of the survey, consumed/used any tobacco product at least once a day. Occasional user is someone who consumed any tobacco product at least once a week but not every day. Current users were defined as participants who reported using any tobacco product (smoked or smokeless) at the time of the survey, including both regular (daily) and occasional (weekly but not daily) users. Past user is someone who was formerly a regular user, or occasional user but currently does not consume tobacco at all. Never-user is a person who had never used any tobacco product as of the day of completing the questionnaire. The operational definitions were adapted from the GATS-2 survey India [5].

Data analysis

For analysis of quantitative data, the data were entered in Microsoft Excel 2010 and analysed using Statistical Package for Social Sciences version 16.0 (SPSS Inc., Chicago, IL, USA). The continuous variables were reported as Mean (± standard deviation); categorical variables were summarized as frequencies and percentages. Normality was tested using the Shapiro-Wilk and Kolmogorov-Smirnov tests. Group comparisons were done using Chi-square test with p < 0.05 indicating significance. Variables found significant in bivariate analysis (p < 0.05) and those considered epidemiologically relevant based on prior literature were included in the binary logistic regression model.

The qualitative data were analysed by two individual experts manually, both formally trained in qualitative data collection, analysis and reporting. After completing the discussions, the Zoom recordings and the notes were transcribed verbatim and then translated into English to facilitate analysis. The analysis was done through repeated reading and re-reading of the transcripts by both experts to ensure deep immersion in the data, allowing a comprehensive understanding of the participant perspectives. After initial familiarization, each expert independently conducted coding. The identified codes were then systematically compared, discussed, and consolidated by both experts to address discrepancies and ensure reliability. Disagreements in coding were resolved through discussion and consensus between the analysts. Through iterative analysis, codes were organized into meaningful categories/sub-themes, from which broader themes emerged, encapsulating the core aspects of tobacco use, barriers, and perceptions among college students. This multi-step analysis ensured that the findings were grounded in the data and that interpretive bias was minimized through triangulation and consensus-building between the analysts. An audit trail was maintained throughout the analysis process, documenting coding decisions and theme development to ensure transparency. The final thematic framework was reviewed and refined collaboratively, with constant reference to the raw data to support the credibility, dependability, and validity of the qualitative findings.

After separately analysing the quantitative and qualitative data, the two datasets were compared for convergence, divergence and complementarity. This joint analysis allowed for a comprehensive interpretation by combining statistical associations from the quantitative component with contextual insights derived from qualitative themes. Such triangulation enhanced the validity and depth of findings, supporting the exploration of the complex factors influencing tobacco use behaviour in the study population.

Ethical considerations

The ethical approval was obtained from the Institutional Ethics Committee (No.16/237/IEC-26/PP/2019) of Indira Gandhi Medical College & Research Institute, Puducherry. Each participant was provided with a detailed participant information sheet explaining the aim, study procedures, risks/benefits, confidentiality measures, and contact details of the investigators. Written informed consent was obtained before participation in the study, and a re-consent was obtained before the qualitative data collection. Anonymity was assured for all the responses.

Results

Socio-demographic characteristics

A total of 750 male students with a mean age of 20.2 ± 1.5 years were recruited. Half of them (377, 50.3%) were aged between 20 and 21 years and belonged to urban areas (441, 58.8%). The majority were day scholars (693, 92.4%). Most participants (525, 70.0%) perceived tobacco users as less attractive. A large majority (605, 80.7%) felt quitting tobacco is difficult and nearly half (353, 47.0%) believed resisting peer pressure is challenging (Table 1).

Table 1.

Socio-demographic characteristics, prevalence and perceptions of tobacco use among the participants, n = 750

Characteristic		Frequency (n)	Percentage (%)
Age group (in years)
	18–19	245	32.7
	20–21	377	50.3
	≥ 22	128	17.0
Religion
	Hinduism	634	84.5
	Christianity	52	6.9
	Islam	41	5.6
	Othersa	23	3.0
Socio-economic status
	Upper class	267	35.6
	Upper middle class	162	21.6
	Middle class	227	30.3
	Lower middle class	73	9.7
	Lower class	21	2.8
Domicile
	Urban	441	58.8
	Rural	309	41.2
Residential status
	Day scholars	693	92.4
	Hostellers	57	7.6
Educational qualifications of parents
Mother	No formal schooling	19	2.5
	School education	400	53.3
	Graduate and/ or above	331	44.2
Father	No formal schooling	8	1.1
	School education	373	49.7
	Graduate and/ or above	369	49.2
Ever use of tobacco
	Yes	80	10.7
	No	670	89.3
Perceptions related to tobacco usage
Tobacco users are more attractive	Agree	73	9.7
	Can’t say	152	20.3
	Disagree	525	70.0
It is difficult to quit tobacco	Agree	605	80.7
	Can’t say	82	10.9
	Disagree	63	8.4
It is difficult to resist peer pressure	Agree	352	47.0
	Can’t say	226	30.1
	Disagree	172	22.9

^aOthers included Buddhism, non-followers & participants who did not state their religion

Prevalence and patterns of tobacco use

The prevalence of ever tobacco use was 10.7% (80/750), with 10.4% (78/750) being current users. Smoking was the predominant form of use (67/80, 83.7%). Initiation commonly occurred between 15 and 20 years (56/80, 70.0%) and was primarily associated with by experimentation (62/80, 77.5%) and peer pressure (41/80, 51.3%). Tobacco use was frequently reported among friends (208/750, 27.7%). Despite high awareness of health hazards (688/750, 91.7%), less than half (34/80, 42.5%) had attempted quitting, with very few reporting successful cessation (2/80, 2.5%). (Table 2)

Table 2.

Pattern of tobacco use among the study participants & their acquaintances and knowledge regarding health hazards, n = 750

Characteristics		Frequency (n)	Percentage (%)
Current use of tobaccob
	Yes	78	97.5
	No	2	2.5
Type of tobacco usedb
	Smoke forms	67	83.7
	Smokeless forms	13	16.3
Frequency of tobacco useb
	Occasional use	45	56.3
	Regular use	33	41.2
	Past use	2	2.5
Age at initiationb
	Less than 15	15	18.8
	15–20	56	70.0
	More than 20	9	11.2
Reasons for initiationa, b
	Experimentation	62	77.5
	Peer pressure	41	51.3
	Imitation	10	12.5
	Stress	7	8.8
Tobacco usage among acquaintancesc
	Father	79	10.5
	Mother	13	1.7
	Siblings	22	3.0
	Other family member	108	14.4
	Friends	208	27.7
Knowledgec
	Good	688	91.7
	Some	52	6.9
	Poor	10	1.3
Attempt to quitb
	Yes	34	42.5
	No	46	57.5

^aMultiple response, ^bPercentages calculated among ever tobacco users (n = 80), ^cPercentages calculated using the total study population (N = 750)

Factors associated with tobacco use

On multivariable analysis (Table 3), older age (≥ 22 years), father’s tobacco use, and friends’ tobacco use were significantly associated with higher odds of tobacco use, while maternal education was protective. Perceptions also influenced tobacco use. Participants who disagreed that tobacco users are attractive had significantly lower odds of use, whereas uncertainty regarding the difficulty of quitting was associated with higher odds. Although some variables showed crude associations, they were not significant after adjustment.

Table 3.

Association between the socio-demographic factors, perceptions & tobacco usage by acquaintances with tobacco ever usage

Characteristics		COR (95% CI)	AOR (95% CI)
Age group (in years)
	18–19	1a	1
	20–21	2.46 (1.10–5.49)	0.87 (0.31–2.46)
	≥ 22	14.98 (6.77–33.16)	6.54 (2.31–18.50) b
Religion
	Hinduism	1a	1
	Christianity	3.58 (1.80–7.11)	2.55 (0.88–7.39)
	Islam	2.60 (1.14–5.91)	0.77 (0.25–2.39)
	Other	2.98 (1.06–8.35)	1.12 (0.25–5.06)
Socio-economic status
	Upper class	1	-
	Middle class	0.76 (0.44–1.32)
	Lower class	1.16 (0.59–2.28)
Domicile
	Urban	1	-
	Rural	1.40 (0.88–2.24)
Residential status
	Day scholars	1a	1
	Hostellers	3.09 (1.60–5.95)	1.76 (0.69–4.52)
Educational qualifications of parents
Mother	No formal schooling	1a	1
	School education	0.15 (0.05–0.40)	0.14 (0.04–0.52) b
	Graduate and/ or above	0.14 (0.05–0.39)	0.25 (0.06–1.05)
Father	No formal schooling	1a	1
	School education	0.21 (0.04–0.91)	-
	Graduate and/ or above	0.17 (0.04–0.76)	-
Knowledge
	Good	1a	1
	Some	4.33 (2.27–8.23)	1.30 (0.47–3.63)
	Poor	-	-
Tobacco usage among acquaintances
	Father	7.05 (4.11–12.09) a	3.94 (1.56–9.96) b
	Mother	-	-
	Sibling	17.55 (7.10–43.37) a	0.46 (0.08–2.84)
	Other family member	3.21 (1.90–5.43) a	1.38 (0.52–3.68)
	Friends	8.52 (5.08–14.28) a	3.62 (1.70–7.73) b
Perceptions related to tobacco usage
Tobacco users are more attractive
	Agree	1a	1
	Can’t say	0.55 (0.29–1.01)	0.13 (0.04–0.38) b
	Disagree	0.92 (0.53–1.60)	0.11 (0.04–0.29) b
It is difficult to quit tobacco
	Agree	1a	1
	Can’t say	2.33 (1.26–4.29)	5.77 (2.17–15.29) b
	Disagree	1.20 (0.52–2.76)	0.53 (0.01–2.93)
It is difficult to resist peer pressure
	Agree	1a	1
	Can’t say	1.20 (0.73–1.98)	1.99 (0.87–4.58)
	Disagree	0.37 (0.16–0.80)	0.42 (0.13–27.60)
Exposure to health warnings/anti-tobacco activities
	In their educational institution	1.56 (0.97–2.49)	-

^aChi-square p-value < 0.05 & statistically significant. ^bBinary logistic regression p-value < 0.05 & statistically significant. AOR – Adjusted Odds ratio, COR – Crude Odds ratio. Socio-Economic Status categories were collapsed for analysis: upper (upper + upper middle) and lower (lower middle + lower), based on modified BG Prasad classification.

Qualitative findings: themes and insights

Tobacco usage: initiation and maintenance

The qualitative analysis revealed three major themes (Table 4). Initiation of tobacco use was characterized by early onset, peer influence, curiosity and experimentation, family role modelling, and media influence. Participants described how tobacco use spans all age groups, with peer pressure being particularly influential: “My friend would say, ‘Hey dude come on try once; if you use this you will get a new feel…’” Curiosity drove experimentation: “I wanted to know what was there in it…” Family influence was evident in statements like “my father smokes…. why not me…”.

Table 4.

Themes, Sub-themes, Codes, and Illustrative Quotes from Qualitative Analysis

Themes	Sub-themes	Codes	Illustrative Quotes
Tobacco usage	Initiation of Tobacco Use	Early initiation, Lasts into old age, Peer influence, Curiosity & experimentation, Family member as role model, Media drives initiation, Tobacco portrayal in promotional materials/posters, Self-image	“…. I have seen people using tobacco products at all ages starting from young people to old-aged people…” “My friend would say,’ Hey dude come on try once; if you use this you will get a new feel……” “I wanted to know what was there in it…” “….my father smokes…. why not me……” “In my opinion about 70% of the impact to use tobacco is created by media only” “my friends say that they are very high and matured beings, and they consider themselves as yogis”
	Maintenance of Tobacco Use	Addiction and habit, Perceived benefit, Underestimated danger, Users unaffected	“I don’t want to stop it because I get that a thrill from smoking” “During exams I study in the night and I need some energy, so I smoke” “I know many people who smoke… nothing has happened to them.”
Protective factors against initiation	Awareness of harm	Cancer risk, Risk of respiratory diseases	“Many cancers like cancers in the mouth, lung cancer can occur” “The lungs get affected on smoking. It also affects the surrounding people”
	Parental influence	Strict parental control, Fear of punishment, Parent-child interaction, Residential status	“If I smoke my father will thrash me…I don’t smoke” “I share what happens in my class daily with my parents. A person who uses cigarettes may not share what happens daily in class. The parents must also spend time with their kids” “I stay in hostel. So there is no one to ask me”
	Supportive Peers	Peer protection, Friends discourage tobacco use	“My friends who were smokers would never allow me to smoke not even by mistake”
Influence of media	Awareness and Exposure to Warnings	Notices statutory warnings, Aware of tobacco health hazard banners	“I have seen the Mukesh ad during the start of the movie in theatres. I have also seen the ‘Tobacco use is injurious to health’ banner whenever a smoking scene comes in the movies.”
	Limited Attention and Impact	Warnings often ignored, Focus on actor’s style	“…everyone watches the style of the actor alone. The people do not notice the warning written….”
	Perceived Ineffectiveness	Ineffective warnings, Pro-tobacco portrayal outweighs warnings	“…. I don’t think it is useful…people see their favourite stars or characters; the people think it is fine to use tobacco getting influenced by it … using tobacco”
	Suggestions for Improvement	Ban on-screen-tobacco, Show relatable harms	“…. completely ensuring ban on showing the tobacco usage in media would be more effective rather than warning” “we show …. are extremes of tobacco use and the warning signals don’t show the everyday effects of tobacco”
	Emotional Reaction	Health warnings make uneasy	“health warnings …. I feel a bit uneasy. I used to think like, “I should not use; I may get those diseases if I use tobacco”
	Adaptation / Avoidance	Hiding warning labels, Impact fades over time	“after getting the tobacco products I’ll hide the health warnings” “…initial times I used to get scared of those health warnings …. nowadays the health warnings do not create much impact”

Maintenance of tobacco use was sustained by addiction, perceived benefits, and underestimated dangers. Users justified continued use for functional purposes: “During exams I study in the night and I need some energy, so I smoke.” Some expressed reluctance to quit: “I don’t want to stop it because I get that a thrill from smoking.” Risk denial was common: “I know many people who smoke… nothing has happened to them.”

Protective factors against initiation

Awareness of harm served as a protective factor, with students recognizing cancer risks and respiratory diseases: “Many cancers like cancers in the mouth, lung cancer can occur” and “The lungs get affected on smoking. It also affects the surrounding people.”

Parental influence emerged as a significant barrier through strict control and fear of punishment: “If I smoke my father will thrash me…I don’t smoke.” Parent-child interaction was crucial: “I share what happens in my class daily with my parents. A person who uses cigarettes may not share what happens daily in class.” Residential status affected parental supervision: “I stay in hostel. So there is no one to ask me.”

Supportive peers could also serve as protective factors: “My friends who were smokers would never allow me to smoke not even by mistake.”

Influence of media

Students showed awareness of statutory warnings and health hazard campaigns: “I have seen the Mukesh ad during the start of the movie in theatres. I have also seen the ‘Tobacco use is injurious to health’ banner whenever a smoking scene comes in the movies.”

However, limited attention and impact was evident: “everyone watches the style of the actor alone. The people do not notice the warning written…” Many perceived warnings as ineffective: “I don’t think it is useful…people see their favourite stars or characters; the people think it is fine to use tobacco getting influenced by it.”

Students suggested improvements, including complete bans on on-screen tobacco use: “completely ensuring ban on showing the tobacco usage in media would be more effective rather than warning.”

Adaptation and avoidance behaviors were reported: “after getting the tobacco products I’ll hide the health warnings” and “initial times I used to get scared of those health warnings…. nowadays the health warnings do not create much impact.”

Integration of quantitative and qualitative findings

The joint analysis revealed several patterns of convergence and divergence between quantitative and qualitative findings (Table 5, presented at the end of the manuscript as per journal guidelines).

Table 5.

Joint Display of factors associated with tobacco use among college students in Puducherry

Domains	Quantitative findings	Qualitative Themes/Sub-themes & Codes	Illustrative Quotes	Meta-Inferences
Socio-demographic factors	Older students (≥ 22 years) had higher odds of tobacco use (AOR 6.54, 95%CI 2.31–18.50). Mean age at initiation 17.5 (± 2.5) years. Religion was not significant after adjustment.	Themes: Initiation & Maintenance of tobacco usage Codes: Early initiation, Lasts into old age, Curiosity & Experimentation	“I wanted to know what was there in it…” “I just tried once. After that I used it only once in a while”	Convergence: Late adolescence and early adulthood is high-risk. Divergence: Religion significant in numbers but absent in narration and also after adjustment.
Residential & Family influence	Hostelers more likely to use (AOR 1.76). Father’s tobacco use also had higher odds (AOR 3.94). Siblings’ tobacco use not significant after adjustment. Higher mother’s education protective (AOR 0.14)	Theme: Parental influence Codes: Strict parental control, Fear of punishment, Parent-child interaction, Residential status, Family member as role model	“If I smoke my father will thrash me…I don’t smoke” “My father smokes and I too smoke. I am not doing anything different” “I stay in hostel. So there is no one to ask me”	Convergence: Family strongly shape use. Family both protective (strict parenting) and risky (role modelling). Educated/engaged parents reduce risk. Divergence: Students stress parental discipline not captured in quantitative results.
Peer influence	Friends’ tobacco use strongly associated (AOR 3.62).	Themes: Tobacco usage, Barriers to usage Codes: Peer influence, Peer protection, Friends actively discourage tobacco use	“My friend would say,’ Hey dude come on try once; if you use this you will get a new feel……” “My friends who were smokers would never allow me to smoke.”	Complementarity: Quantitative shows peers as risk; qualitative reveals peers can both pressurize to use and also protect against tobacco usage.
Knowledge & Awareness of health hazards	Poor awareness strongly linked to use (p < 0.001).	Themes: Tobacco usage, awareness of harm Codes: Underestimated danger, Users unaffected, Cancer risk, Risk of respiratory diseases	“I know many people who smoke… nothing has happened to them.” “Many cancers like cancers in the mouth, lung cancer can occur” “The lungs get affected on smoking. It also affects the surrounding people”	Convergence: Awareness gap is critical. Divergence: Denial undermines even good awareness.
Perceptions of tobacco use	Perceiving users as “attractive” → lower odds when disagreed (AOR 0.11). Belief “difficult to quit” increased odds (AOR 5.77).	Themes: Tobacco usage Codes: Perceived benefit, enlightened self-image	“During exams… I need some energy, so I smoke.” “I need some relief for which I use tobacco” “my friends say that they are very high and matured beings …consider themselves as yogis”	Convergence: Misperceptions sustain use. Divergence: Narratives emphasize functional use (stress relief).
Media & Health warnings	Mixed effectiveness; often no significant association.	Themes: Effectiveness of Health Warnings in Media & Packaging Codes: Warnings often ignored, Ineffective warnings, Pro-tobacco portrayal outweighs warnings, Impact fades over time	“…everyone watches the style of the actor alone. The people do not notice the warning written….” “…. I don’t think it is useful…people see their favourite stars or characters” “nowadays the health warnings do not create much impact”	Convergence: Media normalizes tobacco. Divergence: Warnings had temporary impact but faded over time.

Convergence was observed in multiple domains. Both datasets confirmed that late adolescence and early adulthood represent high-risk periods for tobacco initiation. Family influence showed consistent dual roles—both protective through education and engaged parenting, and risky through role modelling. Peer influence emerged as a significant factor in both analyses. Poor awareness and denial of health risks were consistently linked to tobacco use across both methodological approaches.

Divergence and complementarity provided additional insights. While quantitative analysis showed religion as initially significant but not after adjustment, this factor was notably absent from qualitative narratives. The quantitative data emphasized parental education as protective, while qualitative findings highlighted the importance of parental discipline and engagement—aspects not captured quantitatively. Most importantly, while quantitative analysis showed peer influence as a risk factor, qualitative findings revealed the nuanced nature of peer relationships, demonstrating that peers can both pressurize use and actively protect against tobacco initiation.

Meta-inferences from the integrated analysis suggest that tobacco use among college students is influenced by complex interplay of developmental, social, familial, and perceptual factors. The quantitative findings provide the statistical foundation for understanding risk and protective factors, while qualitative insights reveal the mechanisms and contexts through which these factors operate.

The fishbone framework (Fig. 2) visually represents these integrated findings, depicting both “push” factors (risks) and “pull” factors (protective elements) that shape tobacco use patterns among college students in Puducherry.

Fig. 2.

Force-field analysis using Fishbone Framework: Push (Red) and Pull (Green) Factors Shaping Tobacco Use among the College Students in Puducherry

Discussion

The current study provides an in-depth understanding of tobacco use patterns, perceptions and determinants among college students in Puducherry. The prevalence of ever use of tobacco (10.7%) among the study population aligns with reports of Indian college based surveys, which range between 5 and 15% [17–20]. The predominance of smoking forms, particularly cigarettes, and early initiation during late adolescence reinforce the vulnerability of this age group to experimentation and peer influence. These findings highlight the continued relevance of youth-targeted tobacco control measures despite high levels of awareness about tobacco harms [21]. Unlike many previous studies among college students in India, the present study integrated quantitative associations with qualitative exploration to better understand the contextual and behavioural dimensions of tobacco use. The widespread availability of single or loose cigarettes, although not assessed in this study, may further facilitate tobacco initiation and access among youth.

Socio-demographic and familial influences

Age was a consistent determinant of tobacco use with prevalence markedly higher among older students (≥ 22 years), which may reflect the cumulative risk of initiation with age as well as the transitional vulnerabilities associated with late adolescence and early adulthood. This aligns with the qualitative narratives of curiosity, self-image and experimentation in late adolescence suggesting that maturity is often misconstrued as readiness to smoke. Many global studies reported that tobacco use initiation predominantly occurs between 14 and 25, with most smokers starting before the age of 20 years. Prevalence of tobacco use rises with age during adolescence and peaks in young adulthood, reflecting both cumulative exposure and increased vulnerability during transitional life stages [22–24]. Religion initially appeared significant but lost its effect after adjustment, reflecting that cultural markers may have weaker predictive value than influences such as peers and family. The importance of parental tobacco habits is well documented in literature [25, 26], supporting our findings that parental tobacco use, notably fathers, increases risk, potentially through modelling normalized behaviour. However, the protective role of maternal education, though reported elsewhere [27, 28], emphasizes the vital contribution of mothers in preventive efforts, especially in Indian cultural contexts. This quantitative association complements qualitative insights on parental engagement and discipline as barriers, demonstrating that educational attainment translates into active parental guidance.

Knowledge, perceptions and tobacco use

Despite high awareness (91.7%) of tobacco hazards, misperceptions and tobacco use persisted. Qualitative findings revealed denial and selective ignorance as mechanisms undermining risk perception. Misperceptions around attractiveness and stress relief were quantitatively linked with higher use. This disconnect between the knowledge and behaviour is well-documented in prior research – smokers often acknowledge general risks but minimize their personal vulnerability, believing negative outcomes are less likely to happen to them or citing anecdotal evidence of unaffected smokers [29, 30]. This selective risk perception – sometimes called “optimistic bias” – undermines the impact of health knowledge on behaviour. Together, these findings highlight the need for interventions that go beyond information provision, addressing behavioural and psychological drivers of use. Despite several participants attempting cessation, the very low successful quit rate suggests challenges in sustained cessation support among young adults.

Peer and social dynamics

Peer influence emerged as one of the strongest predictors of tobacco use. Hostellers showed an increasing trend, possibly due to reduced parental supervision and heightened peer exposure. However, the qualitative strand highlighted the dual role of peers; where some friends encouraged tobacco use, while others actively discouraged the same. In rural Uttar Pradesh, tobacco use among friends was a significant predictor for tobacco consumption [12]. Qualitative studies from India reported this dual role, with social influence promoting tobacco initiation, while on the other hand, some friends who smoked discouraged taking up the habit, underscoring the complexity of peer networks [31], in agreement with the present study.

Media and institutional environment

The present study highlights the complex and paradoxical role of media. The participants reported that, although statutory warnings were widespread, they were often overlooked or overshadowed by glamorized portrayals in films and social media. This was due to desensitization from repeated exposure, exaggerated warnings as reported by the participants, and most importantly the warnings frequently compete with power cues – stylized portrayals of smoking in films, social media – that capture attention more strongly. These findings align with prior research that reveals complex media influence youth smoking behaviours, supporting the paradoxical nature of media messaging [32]. While exposure to tobacco imagery in films traditionally increases smoking uptake, a prospective study among Indian children found no significant association between film tobacco exposure and incident smoking, potentially due to mandatory on-screen health warnings [33]. However, young people consistently perceive smoking in media as normal and acceptable, identifying with stress-relieving and social aspects despite awareness of health risks [34].

Integrated insights

The joint analysis demonstrated strong convergence in factors like age, parental influence and peer dynamics; while divergence revealed areas where one of the methods added unique insights. For example, while quantitative models identified maternal education as protective, qualitative data highlighted how parental involvement and discipline exerted influence. Similarly, quantitative associations with peer tobacco use were enriched by qualitative accounts of peer protection. These complementarities strengthen the ecological validity of the findings and suggest that interventions must consider both structural determinants and lived experiences. The qualitative findings further explained the behavioural and contextual mechanisms underlying the quantitative associations.

Policy and practice implications

The interventions should prioritise the age group prone for risk-taking behaviours as the critical window for prevention. Family-based and peer-led interventions may be more impactful than awareness campaigns alone. Enhanced enforcement of tobacco control policies in educational institutions and residential settings such as hostels, may help reduce peer-driven initiation and use. Stricter regulation of pro-tobacco media portrayals and promotion of tobacco-free campus environments may further support tobacco control efforts.

Strengths and limitations

Strengths include a large sample size across diverse student groups of different streams, enhancing the generalizability of the findings. To reduce social desirability bias, particularly given the sensitive nature of tobacco use, data collection was conducted anonymously. The incorporation of a comprehensive mixed methods design, enabled triangulation of quantitative and qualitative findings, strengthening the overall credibility and depth of the study and providing a solid foundation for future research on youth tobacco use. This study has certain limitations that should be acknowledged. First, the study included only male students, limiting generalizability to the broader college population and precluding assessment of gender-specific differences in tobacco use. Second, there may have been some degree of social desirability bias in participants’ self-reported responses. However, efforts were made to minimize this through assurances of anonymity and the use of an anonymous data collection tool during the quantitative phase. Additionally, the COVID-19 pandemic posed logistical challenges and temporarily disrupted in-person data collection. To overcome this, the research team adopted digital tools such as Google Forms to continue data collection while maintaining participant safety and research continuity. The use of current tobacco use status rather than a standard past 30-day recall period may limit comparability with some epidemiological studies. Although data were collected through online platforms, participants were selected through a predefined sampling framework, minimizing potential selection bias. However, potential institutional-level clustering effects were not specifically explored. Some adjusted estimates showed wide confidence intervals, possibly reflecting smaller subgroup sizes and limited precision of certain estimates. The cross-sectional nature of the quantitative component limits inference regarding temporal relationships between associated factors and tobacco use. The study did not assess access to single or loose cigarettes, which may influence tobacco use patterns among youth. Additionally, awareness and utilization of tobacco cessation support services, such as quitlines and cessation clinics, were not explored.

Recommendations for future research

The integration of quantitative and qualitative findings provides a better understanding of tobacco use among college students, demonstrating that while statistical associations identify key determinants, underlying behavioural and social contexts shape how these factors operate in real-life settings. The findings highlight the need for targeted interventions, including campus-based peer-led programmes to address social influences, structured family engagement strategies to strengthen communication and supervision, and stricter enforcement of media regulations to limit exposure to pro-tobacco content, particularly on digital platforms. Integrating tobacco prevention modules into college health programmes and strengthening monitoring tobacco portrayal in entertainment media may further support tobacco control efforts.

Conclusion

Tobacco use among college students in Puducherry was associated with mainly by early initiation, curiosity, peer and family influences, and media portrayals, with qualitative findings further highlighting the influence of hostel-based peer environments; while parental education, supervision, and peer support acted as protective factors. Notably, despite good awareness of tobacco-related harms, misperceptions and denial have led to the continued use of tobacco products, highlighting the gap between knowledge and behaviour. The contradictory role of media – delivering warnings yet glamourizing their use through surrogate advertisements – further weakened prevention. Interventions must move beyond awareness to prevent initiation by addressing social and behavioural drivers, strengthening of family and peer-based protection and motivation to lead a tobacco-free life, and stricter enforcement of media-led advertisements, promotions and sponsorships.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

VM conceptualized the study, collected and analyzed data, and drafted the manuscript. CVK and JC conceptualized and supervised the study and provided review and guidance of the analysis. SG conducted data analysis. KV provided overall guidance and reviewed manuscript. All authors contributed to writing, reviewing, and editing of the manuscript, and read and approved the final version.

Funding

The current research did not receive any funding.

Data availability

Considering the sensitivity of the data, it can be provided only on reasonable request to the authors.

Declarations

Ethics approval and consent to participate

The ethical approval was obtained from the Institutional Ethics Committee (No.16/237/IEC-26/PP/2019) of Indira Gandhi Medical College & Research Institute, Puducherry. All procedures involving human participants were performed in accordance with the ethical standards of the institutional research committee and in accordance with the 1964 Declaration of Helsinki and its later amendments, most recently revised in October 2024. Each participant was provided with a detailed participant information sheet describing the study’s objectives, procedures, potential risks and benefits, confidentiality safeguards, and contact details of the investigators. Written informed consent was obtained before participation, and re-consent was obtained before qualitative data collection. Participation in the research was completely voluntary, and participants were informed of their right to withdraw at any time without any consequences. Anonymity was assured for all responses, and no personally identifiable information was collected.

Consent for publication

Not applicable. The study utilized an anonymous data collection tool, and no personally identifiable information of participants was obtained.

Competing interests

The authors declare no competing interests.