Abstract
Despite extensive global research on second-hand smoking (SHS) exposure, there is a noticeable lack of studies focusing on the knowledge and attitudes of university students in Bangladesh. This cross-sectional study aimed to address this gap by assessing the levels of knowledge and attitudes towards SHS exposure among university students in Bangladesh. Utilizing a convenience sampling technique, data were collected from 383 university students, encompassing socio-demographic information, as well as knowledge and attitude-related inquiries. Statistical analyses were conducted using SPSS software, including independent t-tests and analysis of variance (ANOVA) and multiple linear regression. The findings revealed that participants exhibited a moderate level of knowledge and attitude towards SHS exposure. Multiple linear regression identified age, gender, mother’s education, and self-rated health status as significant predictors of knowledge, explaining 12.9% of its variance (R2 = 0.129, F = 6.117, P < .001). Furthermore, age, gender, and living with parents emerged as significant predictors of attitude, explaining 14.7% of its variance (R2 = 0.147, F = 7.165, P < .001). The study highlights the need for interventions aimed at enhancing awareness and fostering positive attitudes towards SHS exposure among university students in Bangladesh. It is recommended that university authorities organize seminars and implement health education initiatives targeting vulnerable populations to address the findings and promote a smoke-free environment on campus.
Keywords
Previous research demonstrates that SHS exposure poses significant health risks, such as respiratory diseases and cardiovascular conditions. Although public health campaigns aim to address these issues, awareness and attitudes toward SHS exposure, particularly among university students, vary globally. There has been a focus on understanding these attitudes to improve prevention strategies, yet knowledge and perceptions of SHS among university students in Bangladesh remain under-researched.
This study examines the knowledge and attitudes of university students in Bangladesh toward SHS exposure, a topic that has received limited focus in this context. We explore factors associated with SHS knowledge and attitudes and explain how cultural influences, health risk awareness, and smoking behaviors impact these perceptions. By providing a baseline information of these influences, this research highlights critical knowledge gaps and misconceptions about SHS among this demographic, offering direction for future educational and preventive initiatives.
The findings indicate substantial misconceptions and limited awareness about SHS risks among university students in Bangladesh, highlighting a need for targeted educational campaigns. These should focus on addressing cultural norms and social factors that contribute to SHS exposure in university settings. Policymakers should consider implementing stricter regulations around smoking in public spaces on campuses, and health practitioners could incorporate SHS awareness into broader smoking prevention programs aimed at young adults, promoting a healthier campus environment.
Introduction
In the current era, the prevalence of smoking among the youth has become a pressing public health issue, drawing concern worldwide. Recent data indicate a staggering figure of over a billion smokers globally, with the numbers escalating rapidly. Smoking, recognized as a leading cause of various severe health ailments such as premature mortality, cardiovascular diseases, respiratory illnesses, and cancer, poses a significant threat to public well-being. 1 A comprehensive analysis of the dose–response relationship between smoking and 36 health outcomes, finding strong evidence linking smoking with 8 major health issues, including cardiovascular and respiratory diseases. While 21 outcomes showed weak-to-moderate associations with smoking, 7 had no clear link, highlighting the complexity of smoking’s health impacts and the importance of updated data for public health policy and smoking cessation initiatives. 2 While, a recent systematic review and meta-analysis suggests that reducing cigarette intake by over 50% lowers lung cancer risk by 28%, with an even greater reduction of 40% for those transitioning from heavy to light smoking, and a modest reduction in cardiovascular disease risk of 22% was observed only in heavy-to-light smokers. 3
Beyond the direct health impacts on smokers, the perils extend to non-smokers through second-hand smoking (SHS), commonly known as environmental tobacco smoke. Environmental tobacco smoke comprises a combination of sidestream smoke (emitted from the burning end of a cigarette) and mainstream smoke (exhaled by the smoker). This toxic mixture contains thousands of harmful chemicals, including carcinogens and fine particulate matter, which can linger in the air and be inhaled by non-smokers. Short-term exposure to SHS can cause irritation of the eyes, nose, and throat, as well as symptoms such as headaches, dizziness, asthma, and nausea. Prolonged exposure significantly elevates the risk of developing coronary heart disease and lung cancer by 25% to 30% and 20% to 30%, respectively. 1 It causes around 600,000 premature deaths annually, with women and children disproportionately impacted, particularly in regions where home and school smoke-free policies are limited 1 . Without effective tobacco control measures, projections suggest a staggering 3 million deaths by 2050. 4 However, the detrimental effects of SHS extend beyond physical health, seeping into psychological well-being. Studies have established a significant association between SHS exposure and psychological distress, compounded by the potential impacts of nicotine on blood pressure and heart rate.5,6 Long-term exposure to SHS further diminishes dopamine receptor availability, with dopamine levels linked to heightened rates of mental health issues such as depression and anxiety.7,8
Globally, SHS exposure poses a significant public health threat across diverse populations. Studies from Nepal, 9 India, 10 and Malaysia 11 reveal high SHS exposure rates among youth and college students, often despite awareness of its risks. Similarly, research from Portugal 12 and Jordan 13 indicates that even educated individuals face SHS exposure and show limited proactive avoidance due to cultural or social factors. In Bangladesh, only two studies were conducted, which emphasizes critical gaps in SHS knowledge. For instance, Sultana 14 found that only 30.5% of youth aged 15 to 24 years, had adequate SHS awareness, with knowledge linked to age and education; while Rahman et al. 15 reported that 49% of married women were exposed to SHS at home, with low knowledge particularly among lower socioeconomic groups. These findings highlight the urgent need for targeted education and stronger anti-smoking policies in Bangladesh, yet research remains limited, especially regarding other populations like students.
Despite the serious health risks of SHS, increasing awareness and fostering positive attitudes toward its prevention could significantly reduce its short- and long-term impacts. Given the high tobacco use among youth in Bangladesh,16 -18 there is an urgent need for targeted studies to assess SHS exposure, knowledge, and preventive behaviors across various demographics. However, comprehensive research on SHS knowledge and attitudes among university students remains limited. Therefore, this study aims to evaluate the overall knowledge and attitudes toward SHS among university students, exploring their associated factors. By focusing on this underexplored population, the findings intend to inform targeted interventions and policy measures to mitigate the pervasive threat of SHS exposure among youth.
Methods
Study Participants and Procedure
This cross-sectional, descriptive study was conducted among students at Jahangirnagar University, Dhaka, Bangladesh, from April 18 to June 2, 2022. The aim was to gather insights into students' knowledge and attitudes towards second-hand smoke. Data were collected using a semi-structured questionnaire, employing a convenience sampling technique to recruit participants. Prior to the study, participants were thoroughly informed about the study's confidentiality, purpose, and nature, in accordance with the Helsinki Declaration guidelines of 2013. To ensure ethical compliance, written consent was obtained from all participants, affirming their voluntary participation and their right to withdraw from the study at any point.
The inclusion criteria for participation in this study was, (i) participants must be currently enrolled in a university program in Bangladesh, (ii) aged 18 years or older to ensure informed consent and legal adulthood, and (iii) must consent to participate in the study voluntarily. While they were excluded if (i) individuals who are not currently enrolled in the university program, (ii) were under 18 years old to adhere to ethical standards and informed consent limitations, (iii) who fail to complete the questionnaire or provide missing or inconsistent data. Out of the total responses, 383 completed questionnaires were retained for final analysis after excluding incomplete responses (n = 12).
Sample size calculation
To determine the sample size for this study, we used the formula:
Where, P is the estimated prevalence, Z represents the Z-score corresponding to the 95% confidence level, and E is the desired margin of error. With an assumed prevalence (P) of 0.30 [Sultana], a 95% confidence level (Z = 1.96), and a margin of error of 5% (0.05), the calculated sample size was 323. To account for a potential 10% non-response rate, the final sample size was adjusted to 355. In this study, a total of 395 responses were collected, of which 383 were included in the final analysis.
Measures
Sociodemographic factors
The questionnaire gathered information on gender, age, religion (Islam, Hinduism, and others), place of residence (on-campus or off-campus), living arrangements (with or without parents), parental education levels (no education, primary, secondary, higher secondary, graduate, Quranic/Arabic, don’t know), self-rated health status, and monthly family income. Monthly family income was categorized into several classes based on a 10,000 BDT interval.
Knowledge related questions
Participants’ knowledge was assessed through 16 items, with responses categorized as correct, incorrect, or not sure. For example, 1 question asked, “Does second-hand smoke come from the side-stream (the burning end) of a cigarette?” Each correct response was awarded 1 point, while incorrect or unsure responses received 0 points, resulting in a total score ranging from 0 to 16. Higher scores indicated greater knowledge. The questionnaire on knowledge of SHS was prepared following the previous literature19,20. The Cronbach’s alpha for the knowledge-related questions was 0.76.
Attitude related questions
Attitudes toward second-hand smoke were assessed using 12 items, with responses recorded on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). For instance, 1 statement was, “Second-hand smoke is harmful to health.” The total attitude score ranged from 12 to 60, with higher scores indicating a more positive attitude towards avoiding second-hand smoking. The questionnaire on attitudes of SHS was prepared following the previous literature19,20. The Cronbach’s alpha for the attitude-related questions was 0.91.
Statistical Analysis
Data were analyzed using the Statistical Package for Social Science (SPSS) version 25 after cleaning by Microsoft Excel 2019. Descriptive statistics (i.e., frequency, percentage, mean & standard deviation), independent t-test, and Analysis of Variance test (ANOVA) were performed to investigate the mean difference with study variables considering knowledge and attitude as dependent variables. The data were normally distributed and multicollinearity-related issues (i.e., VIF and tolerance test) were absent. In addition, a multiple linear regression was conducted to examine the predictive factors of knowledge and attitude. A P-value <.05 was set as statistically significant.
Ethical Consideration
The study adhered rigorously to ethical standards outlined in the Helsinki Declaration 2013, ensuring the protection and well-being of human participants. Ethical approval was obtained from the thesis committee the Department of Public Health and Informatics, Jahangirnagar University, Dhaka, Bangladesh. Prior to participating in the study, all participants were provided with detailed information regarding the study’s objectives, procedures, and potential risks and benefits. Informed consent was obtained from each participant prior to survey administration, ensuring their voluntary participation and right to withdraw from the study at any stage.
Results
Characteristics of the Participants
A total of 383 participants partook in this study. About 68.7% were males (n = 263) and the rest were females (31.3%). Most participants belonged to the age group of 21 to 25 years (76.2%), whereas 21.9% and only 1.8% were equal or less than 20 years, and more than 25 years, respectively. Most of the participants were Muslims (87.5%) and 11.5% were Hindus. About 38% were first-year students, 82% resided on the campus, 32.9% of participants' fathers graduated, and 30.3% of mothers studied up to the secondary level. Additionally, 85.4% rated their health status as good and 33.9% had a monthly family income between 20,000 and 30,000 BDT (Table 1).
Mean Differences of Second-Hand Smoking Knowledge and Attitudes Scores.
University students in Bangladesh demonstrated a moderate level of knowledge and attitudes toward SHS exposure. The mean knowledge score was 8.64 (SD = 3.40) out of 16, while the mean attitude score was 46.13 (SD = 9.04) on a scale of 12 to 60.
Mean difference second-hand smoking knowledge and attitudes scores
The analysis of knowledge and attitude scores toward second-hand smoking across different demographic factors reveals significant variations. In terms of gender, male students scored slightly higher in knowledge, while female students had higher attitude scores, though neither difference was statistically significant. Age was a significant predictor, with students aged 20 or below demonstrating the highest knowledge (9.92 ± 3.76) and attitude (49.82 ± 8.16) scores compared to older age groups, with both differences being statistically significant (P < .001). Religion also showed a significant association, where Muslim students had higher knowledge (8.87 ± 3.367) and attitude (46.63 ± 9.16) scores compared to Hindus, with P-values of .002 for both.
Educational status impacted attitudes significantly (P = .008), with first-year students scoring the highest in attitudes (48.10 ± 9.15), though the effect on knowledge was not significant (P = 0.069). Place of residence influenced knowledge scores, as students living on-campus scored higher (8.84 ± 3.26) than off-campus students (7.78 ± 3.89), with a significant difference (p = 0.014), although attitudes did not differ significantly (P = .519). For living with parents, those not living with parents scored higher in attitudes (47.58 ± 7.82) than those living with parents (42.07 ± 10.84), with a significant difference in attitudes (P < .001), but not in knowledge (P = .544).
Parental education also played a role, whereas no formal education of both father and mother were significantly associated with higher knowledge scores. Self-rated health status showed that students rating their health as good had significantly higher knowledge scores (8.78 ± 3.41 vs 7.82 ± 3.25; P = .049), although the difference in attitudes was not significant (p = 0.389). Finally, monthly family income was a significant predictor for both knowledge and attitudes, with students from families earning less than 10,000 BDT showing the highest knowledge (9.92 ± 3.01) and attitude (50.38 ± 7.32) scores, with P-values of .003 and .006, respectively (Table 1).
Predictive factors of second-hand smoking knowledge and attitudes
The regression analysis for SHS knowledge revealed that the model explained 12.9% of the variance in knowledge scores (R² = 0.129, adjusted R² = 0.108), and was statistically significant (F = 6.117, P < .001). Significant predictors included age, gender, mother’s education, and self-rated health status. Younger students had higher knowledge scores (β = −.171, P = .011), as did female students compared to males (β = −0.150, P = .002). Additionally, lower maternal education was associated with higher knowledge (β = -.135, P = .029), and students with better self-rated health had greater knowledge (β = .120, P = .015).
In terms of attitudes toward SHS, the model explained 14.7% of the variance in attitude scores (R² = 0.147, adjusted R² = 0.127) and was statistically significant (F = 7.165, P < .001). Significant predictors included age, gender, and living arrangements. Younger students demonstrated more favorable attitudes toward avoiding SHS exposure (β = −.195, P = .004). Gender was also significant, with females showing stronger attitudes against SHS than males (β = −.126, P = .010). Furthermore, students not living with parents had more proactive attitudes toward SHS (β = .249, P < .001) (Table 2).
Predictors of Second-Hand Smoking Knowledge and Attitudes.
1 = Male, 2 = Female; b1 = Islam, 2 = Hindu, 3 = Others; c1 = On campus, 2 = Off campus; d1 = Yes, 2 = No; e1= No education, 2 = Primary, 3 = Secondary, 4 = Higher secondary, 5 = Graduate, 6 = Quranic/Arabic, 7 = Don’t know; f1 = Poor, 2 = Good; g1 = Less than 10,000, 2 = 10,000 to 20,000; 3 = 20,000 to 30,000; 4 = More than 30,000.
Discussion
The findings of this study indicate that university students in Bangladesh possess a moderate level of knowledge and attitudes toward SHS exposure, with an average knowledge score of 8.64 (SD = 3.40) out of 16, and an attitude score averaging 46.13 (SD = 9.04) on a scale of 12 to 60. These scores suggest a reasonable understanding of SHS risks and a moderately favorable attitude toward avoiding exposure, though there is room for improvement. Compared to prior studies, these findings underscore a relatively moderate awareness level in this population, necessitating targeted interventions to improve knowledge and attitudes. Another study reported that among youth, 30.5% demonstrated good SHS knowledge, 50% had average knowledge, and 19.5% had poor knowledge. 14 Globally, several studies have examined knowledge and attitudes towards SHS, highlighting both similarities and variations in awareness and behaviors across different populations. For instance, contrasting trends have been observed across regions, which contextualize the findings of the current study. A study among undergraduate students found that only 3% demonstrated adequate knowledge, 10% had a favorable attitude, and 3% held a positive perception of SHS risks, with significant correlations observed between SHS knowledge, perception of avoidance, and attitudes toward avoiding SHS exposure. 19 Another study reported that 66.2% of participants practiced adequate SHS exposure avoidance, with 53.7% displaying good knowledge and 46.3% expressing a positive attitude towards SHS. 20 In Nigeria, 63% of non-smokers demonstrated good knowledge of SHS, and 65.4% held a positive attitude towards avoiding SHS, with an understanding that the heart and lungs are the primary organs affected. 21 These global findings provide a benchmark for evaluating the moderate levels of knowledge and attitudes observed among Bangladeshi university students, emphasizing the need for targeted educational interventions to enhance SHS awareness and preventive behaviors in this population.
Age and gender emerged as significant predictors of both SHS knowledge and attitudes in this study. Younger students, particularly those aged 20 or below, demonstrated higher knowledge and more favorable attitudes toward avoiding SHS exposure. This finding suggests that younger individuals may be more receptive to information about the harmful effects of SHS, possibly due to greater exposure to educational campaigns or heightened awareness in recent years. This age-related trend aligns with results from Sagar et al 9 in Nepal, where younger students showed a higher awareness of SHS risks than their older peers. However, gender differences in the study revealed that male students exhibited higher knowledge scores compared to females, aligning with findings from Mustafa et al., 22 which reported greater awareness of the harmful effects of smoking among male students. These observations suggest that demographic factors, such as age and gender, play a critical role in shaping SHS awareness and attitudes, highlighting the need for demographic-specific interventions. Furthermore, 90.5% of male respondents felt a responsibility to promote smoking cessation, indicating positive attitudes toward tobacco control. 22 These findings suggest that male students might be more informed about SHS risks, possibly due to greater exposure in social settings, warranting further investigation. This complex relationship between gender, knowledge, and attitudes highlights the need for tailored SHS education strategies that effectively address both genders, promoting proactive health behaviors across the student population.
This study identified mother’s education as a significant predictor of SHS knowledge, with students whose mothers had lower education levels unexpectedly showing higher knowledge scores. This finding suggests that these students may seek health information independently or engage more actively in community discussions about SHS. Additionally, living arrangements significantly influenced SHS attitudes, with students not living with their parents demonstrating more proactive attitudes toward avoiding SHS exposure. This may indicate that independence empowers students to make healthier choices regarding SHS. While prior studies, such as those by Sultana 14 and Rahman et al., 15 link higher parental education with greater health awareness, the current findings suggest that social factors can drive SHS knowledge even among students with less educated mothers. These results add a unique perspective to the existing body of research, suggesting that social dynamics and individual agency can influence health awareness irrespective of traditional predictors such as parental education.
The analysis revealed that self-rated health status is a significant predictor of both SHS knowledge and attitudes among students. Those who rated their health as good displayed higher knowledge scores and more favorable attitudes toward avoiding SHS exposure. This suggests that individuals who perceive their health positively are more proactive in seeking information about health risks, including SHS, and are more inclined to adopt behaviors that mitigate these risks. This is supported by previous research, such as Gharaibeh et al., 13 which found that individuals with better self-rated health had greater awareness of SHS dangers, and Rahman et al., 15 who noted that females with a positive health perception exhibited better knowledge and attitudes towards SHS. The significant relationship between self-rated health and both knowledge and attitudes highlights the role of personal health perceptions in shaping responses to smoking-related risks. Recognizing this can help public health campaigns target individuals based on their health perceptions, encouraging a proactive approach to SHS exposure. This highlights the importance of educational initiatives that not only inform about SHS but also aim to enhance health perceptions, thus empowering students to make informed decisions and adopt healthier lifestyles. This study benefits from a diverse sample of university students, providing insights into SHS knowledge and attitudes among this demographic. Utilizing a comprehensive questionnaire and robust statistical methods enhances the validity of the findings. However, the study’s cross-sectional design limits causal inference, and convenience sampling may introduce selection bias. Self-reporting may lead to response bias, and the study's single-site nature may restrict generalizability. Besides, unmeasured confounding variables could influence the results. Despite these limitations, the study contributes valuable insights into SHS awareness among university students in Bangladesh. Future research should focus on exploring causal pathways through longitudinal studies and expanding the scope to include diverse settings, ensuring a more comprehensive understanding of SHS knowledge and attitudes among youth populations.
Conclusions
In conclusion, this study provides valuable insights into the knowledge and attitudes toward second-hand smoking among university students in Bangladesh. The findings reveal moderate levels of knowledge and attitudes, with age, gender, mother’s education, and self-rated health status identified as significant predictors. Younger students and those with less-educated mothers demonstrated higher knowledge scores, while female students showed greater awareness of SHS risks. Additionally, living arrangements and socioeconomic factors influenced attitudes toward SHS. These results underscore the need for targeted educational interventions to improve SHS awareness among university students, with particular emphasis on demographic factors. Addressing these gaps in knowledge and attitudes can help tailor public health initiatives to promote smoke-free environments and reduce SHS-related health risks among young adults in Bangladesh.
Questionnaire
Section-01: Socio-demographic Information
1. Gender
a) Male
b) Female
2. Age………..
3. Religion
a) Islam
b) Hindu
c) Others
4. Educational status
a) 1st year
b) 2nd year
c) 3rd year
d) 4rth year
e) postgraduate
5. Place of residence
a) On campus
b) Off campus
6. Do you Live with your parents?
a) Yes
b) No
7. Father’s education status?
a) No Education
b) Primary
c) Secondary
d) Higher secondary
e) Graduate
f) Quranic /Arabic
g) Don't know
8. Mother’s education status?
a) No Education
b) Primary
c) Secondary
d) Higher secondary
e) Graduate
f) Quranic /Arabic
g) Don't know
9. Self reported Health status.
a) Poor
b) Good
10. Monthly Family income
a) <10,000
b) 10000-20000
c) 20000-30000
d) >30000
Section-02: Knowledge related Questions:
1. Second-hand smoke comes from the side-stream (the burning end) of a cigarette?
a) Correct
b) Incorrect
c) Not sure
2. Second-hand smoke comes from the exhaled mainstream (the smoke puffed out by smokers) of cigarettes
a) Correct
b) Incorrect
c) Not sure
3.Long-term exposure to second-hand smoke will not be harmful to my health?
a) Correct
b) Incorrect
c) Not sure
4. A lit cigarette burning in an ashtray will not affect the health of people nearby?
a) Correct
b) Incorrect
c) Not sure
5. There is no safe level of exposure to secondhand Smoke?
a) Correct
b) Incorrect
c) Not sure
6. Second Hand Smoke does not contain nicotine.
a) Correct
b) Incorrect
c) Not sure
7. There are more than 3000 chemicals hazardous on health in cigarettes?
a) Correct
b) Incorrect
c) Not sure
8. Second-hand smoke is a toxic mixture consisting of carcinogens.
a) Correct
b) Incorrect
c) Not sure
9. Long-term exposure to second-hand smoke decreases lung function among second-hand smokers.
a) Correct
b) Incorrect
c) Not sure
10. Long-term exposure to second-hand smoke contributes to a high incidence of lung cancer among second-hand smokers.
a) Correct
b) Incorrect
c) Not sure
11. Passive smokers are more likely to have heart disease.
a) Correct
b) Incorrect
c) Not sure
12. Second hand smoking can increase risk of Hypertension?
a) Correct
b) Incorrect
c) Not sure
13. Second hand smoking can increase risk of Stroke?
a) Correct
b) Incorrect
c) Not sure
14. Long-term exposure to second-hand smoke exposure during pregnancy contributes to low birth weight.
a) Correct
b) Incorrect
c) Not sure
15. Smoking in the home affects children’s health.
a) Correct
b) Incorrect
c) Not sure
16. Second hand smoking can cause asthma among children?
a) Correct
b) Incorrect
c) Not sure
Section-03: Attitude-related Questions:
1. Secondhand smoke harmful to health?
a) Strongly Disagree
b) Disagree
c) Undecided
d) Agree
e) Strongly Agree
2. Smoke from other people’s cigarettes will shorten my life?
a) Strongly Disagree
b) Disagree
c) Undecided
d) Agree
e) Strongly Agree
3. I dislike my friends smoking around me.
a) Strongly Disagree
b) Disagree
c) Undecided
d) Agree
e) Strongly Agree
4. I normally reduce the duration of conversation with my friends who smoke?
a) Strongly Disagree
b) Disagree
c) Undecided
d) Agree
e) Strongly Agree
5. I will not go near my friends when they are smoking.
a) Strongly Disagree
b) Disagree
c) Undecided
d) Agree
e) Strongly Agree
6. I try to spend as little time as possible in places where smoking is prevalent.
a) Strongly Disagree
b) Disagree
c) Undecided
d) Agree
e) Strongly Agree
7. I ask my friends to put their cigarettes out when they are talking to me.
a) Strongly Disagree
b) Disagree
c) Undecided
d) Agree
e) Strongly Agree
8. Smoking should be banned in all public places.
a) Strongly Disagree
b) Disagree
c) Undecided
d) Agree
e) Strongly Agree
9. Banning smoking in public places will protect the health of non-smokers.
a) Strongly Disagree
b) Disagree
c) Undecided
d) Agree
e) Strongly Agree
10. All cigarette advertisements should be banned.
a) Strongly Disagree
b) Disagree
c) Undecided
d) Agree
e) Strongly Agree
11. Anti-smoking campaign is not enough to address the problem solving.
a) Strongly Disagree
b) Disagree
c) Undecided
d) Agree
e) Strongly Agree
12. Government should be strict in enforcing nonsmoking policy in public places.
a) Strongly Disagree
b) Disagree
c) Undecided
d) Agree
e) Strongly Agree
Footnotes
Acknowledgements
The authors thank all the participants and team members involved in the project.
Author’s Contribution
This study was initially conceptualized by MMI, with supervision of MSM. The project was implemented by MMI and assisted by FAM, and MAM, under the supervision of MMA and MSM. MMI handled data entry and conducted the formal data analysis and reporting. The primary draft was authored by MMI, FAM, and MAM, with comprehensive revisions and assessments from MMA and MSM. MMI and MAM prepared the revised manuscript, and MSM supervised the overall project. All authors approved the final version of the study.
Availability of Data and Materials
The datasets will be made available to appropriate academic parties upon request from the corresponding author.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. ALmerab has to acknowledge that the funding support from currently receiving as Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2025R563), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.
Ethical Approval and Consent to Participate
The study adhered rigorously to ethical standards outlined in the Helsinki Declaration 2013, ensuring the protection and well-being of human participants. Ethical approval was obtained from the thesis committee from the Department of Public Health and Informatics, Jahangirnagar University, Dhaka, Bangladesh. Prior to participating in the study, all participants were provided with detailed information regarding the study's objectives, procedures, and potential risks and benefits. Informed consent was obtained from each participant prior to survey administration, underscoring their voluntary participation and right to withdraw from the study at any stage.
Consent for Publication
Not applicable.
