Lived Experience of Smoking Students: A Phenomenological Study

Background : Considering the growing trend of smoking among university students and the important role of students in the future of society, it is necessary to recognize the components and dimensions of this behavior to design effective interventions. The aim of the present study was to investigate the lived experience of smoking students. Methods : This is a phenomenological qualitative study. The study population included students studying at Fasa University of Medical Sciences with smoking experience. Seven students were investigated using in-depth interviews and purposive and snowballing sampling. Sampling was continued until data saturation. Interviews were conducted and analyzed at the same time using Colaizzi method through MAXQDA software version 10. Results: The results of the present study indicated that the lived experience of smoking students consists of two main themes: positive experiences which included subcategories such as feeling peace, being prestigious, and attracting the attention of the opposite sex and negative experiences included subcategories of feeling guilty, physical-psychological problems, and social stigma. Conclusion: The results of the present study provide the basis for recognizing the problems of university students to reduce the smoking-related problems. These results can be used for educational and cultural interventions and emotional and social support as well as for improving the educational and life style.


Introduction
Smoking has been one of the major risk factors for cardiovascular, respiratory, cancer, and stroke diseases and has increased the risk of physical and mental damage. In addition, smoking is one of the most dangerous behaviors that negatively affects human health, and despite many efforts to prevent the spread of tobacco use, this factor is still recognized as one of the most important causes of death in the world (1,2). Cigarette smoking has a complex composition with more than 4000 different toxins. Smoking alone causes 90% of lung cancer, 80% of chronic bronchitis, and 25% of other lung-related diseases. None of the organs in the body are safe from the harmful effects of tobacco. Smoking causes death in various ways and, in fact, is one of the eight leading causes of death in the world (3). Previous relevant studies have revealed that 28.7% of smokers aged 18-24 years are students in the same age range (4). The results of the latest studies indicated the onset of smoking in adolescence and young adulthood and emphasized directing the attention on the prevention and control measures in this age group (5). The smoking rate among adults has decreased during the last 30 years, but the smoking prevalence among young people has increased, and the age of onset has reduced in developed and developing countries (6). The smoking prevalence in adolescence is a valuable indicator for predicting the future status of smoking-related harms and is important for health policy and planning (7). In this regard, the results of a study by Poyrazoğlu et al indicated the prevalence of hookah use among 32.7% of students (8). Taraghijah et al also found that the prevalence of smoking and hookah among students is 30.8% and 40.3%, respectively (9). There have been few studies on the motivation and causes of smoking use among adolescents and young people, and few studies have investigated the phenomenology of this issue. Most quantitative studies have investigated the effect of several psychological, behavioral, and demographic risk factors, including factors that may affect adolescents' smoking status. These factors included age, ethnicity, family structure, socioeconomic status of parents, personal income, parents' smoking, parental attitude, family environment,  attachment to family and friends, school factors, risky  behaviors, lifestyle, depression, unhappiness, self-esteem,  attitude, smoking friends, curiosity, peer pressure, mental  and psychological problems, relaxation, ignorance, and inexperience (10,11). Some students also reported that they started smoking to reduce their pain or stress in life, gain new experience, and try pleasure and entertainment (10,11). Understanding the experiences of students with smoking experience helps the researcher achieve a deeper understanding of the smoking status among medical students and personal and social relationships of these people, which will help discover the effect of this factor on students and provide solutions to this problem because the smoking-related problems and issues are unique to each individual. Further, the use of qualitative research to study the experiences of these students will reveal more angles of this type of experience and ways to adapt to them. Therefore, the present study has analyzed the lived experience of these students due to the importance of coping with smoking and all subsequent problems for society, university, and people.

Methods
This is a qualitative phenomenological study. Phenomenology is essentially the study of lived experiences within the world. Phenomenology refers to the world, as lived by one person, not the world or reality that is separate from an individual. Therefore, phenomenology seeks to reveal meanings behind individuals' lived experiences in everyday life (12).

Target Group and Sampling
The aim of the present study was to analyze the lived experience of students with more than three months of smoking experience. The participants included 17 students with more than three months of smoking experience in Fasa during April 2022. They were selected by purposive sampling and snowballs in which upon reaching the first participant, the next members were introduced by her/him, and subsequent interviews were conducted. Inclusion criteria included being a student, having more than three months of smoking experience, and willingness to participate in the study. Interviews continued until data saturation (13). Since no new code was extracted from the last two interviews, data saturation was obtained, and sampling was stopped. Interviews also continued until no new code was extracted from them.

Data Collection Instrument and Procedure
The data collection instrument included a demographic checklist including age, gender, household economic status, and student residence status. The unstructured indepth interviews were then conducted (14). The research question included: "Students' smoking experience". The interview was conducted by the first and second researchers who were both Ph. D students in the Health Education through an exploratory process in the university environment. Unstructured interview was used in order to make it easier for participants to respond to questions and to share their experiences easily. The researchers helped the participants to express their personal and student life experiences by asking in-depth questions without directing the discussion through unstructured in-depth interviews that were based on extensive and open-ended questions. While listening to, explaining, and reviewing the content, researchers also asked questions to follow up the next material. Thereby, the researcher entered into the student's world to fully access their experiences. After obtaining the written and oral consent from the individuals, the interviews were recorded, and immediately after being completed, they were carefully written and coded, and then the next interview was conducted. In the case of any ambiguity in the participant's statement, another interview was conducted to clarify this ambiguity. Interviews lasted 42 to 70 minutes, depending on the participant's interest in continuing the interview. All conversations were rewritten in the word software, and open coding was first performed using MAXQDA 10 software, and finally the main themes of the study were formed after each interview.

Rigor
To determine the study rigor, peer review and member check were used. In this way, the interview was recorded, the interview text was transcribed, and then it was reviewed by several experts. After data analysis, it was reinvestigated by quality colleagues. The transcript was also sent to the participants to confirm the results obtained by the researcher.

Data Analysis
Data analysis was carried out using Colaizzi's seven-step method as follows: 1. Reviewing important findings and empathizing with the participants in order to understand them, 2. Extracting important sentences related to the studied phenomenon, 3. Giving specific concepts to the extracted sentences; in other words, formulating the meanings, 4. Categorizing related concepts and formulas, 5. Combining the results in the form of a comprehensive description of the subject under study, 6.
Formulating a general description of the subject under study explicitly and clearly as the intrinsic structure of the phenomenon, 7. Returning the description of the phenomena to the participants to check the reliability of the results (15).

Results
The results revealed that the mean age of participants  Table 1.
As observed in Table 2, two main categories of positive and negative experiences were obtained from the results of qualitative phenomenology.
The first category, positive experiences, includes three subcategories: feeling peace, being prestigious, and attracting the attention of the opposite sex.

Feeling Peace
Feeling peace after smoking was one of the reasons for smoking mentioned by students.
"When I am stressed or upset and nervous, I smoke, and it makes me calm down" (p. 15).
"There are some problems that one cannot tell anyone and cannot think about, I have to be alone in the corner smoking and I feel peace" (p. 3).

Being Prestigious
Some participants reported being prestigious when smoking as part of their lived experiences.
"Smoking shows me more prestigious. Most of my prestigious friends are smokers" (p. 13).
"I even like to hold a cigarette, and when you smoke a pack of cigarettes, you feel you are prestigious and special" (p. 4).

Attracting the Opposite Sex
Both girls and boys in the present study had a good experience of smoking and attracting the attention of others, especially the opposite sex.
"When I smoke, girls pay more attention to me and look at me" (p. 17).
The second category, negative experiences, consists of three subcategories of feelings of guilt, physicalpsychological problems, and social stigma.

Social Stigma
It is difficult to accept smoking students in the university environment, and smoking in university environments and in places where students exist often causes others to stare at the smokers in an unpleasant way.
"When I want to smoke, I have to go to a corner where the professors and staff of the university do not see me.
Everyone looks at us as if we are improvident" (p. 2).
"It is better to find someone like you when you smoke so that you can smoke with because you are less stressed about being judged by others" (p. 6).

Feelings of Guilt
Most families are unaware of the smoking behavior of their children, and students feel guilty because of this behavior. Most students agree that if their parents find out that they are smokers, they will be upset and disappointed.
"When I smoke incessantly, I try to visit my hometown less frequently so that my parents do not notice it, because if they find out, they will be very upset, and I do not like this happens at all" (p. 10).
"My father always says that we devoted all our time and money to our children, and we had to go through many difficulties so that our children do not experience hardship. Now, he is very hopeful of my future and always says that he is proud of me because I am an honorable child. As a result, I think if he finds out that I smoke, he will be extremely disappointed with me" (p. 14).

Physical and Mental Problems
Physical and mental problems are one of the main concerns of smoking students about themselves.
"I do not know what will happen to my body in the future. I am harming my body every day by smoking. I will definitely have some lung diseases" (p. 1).
"The color of my both lips has changed, and I feel that others can notice that I am smoking. I also think that if I do not do it for a long time, I will be very nervous, and it seems that my body lacks or needs something" (p. 9).

Discussion
In order to achieve a deep understanding of smoking, the present study investigated the students' lived experiences of smoking. According to students' answers, the category of positive experiences included feeling peace, being prestigious, and attracting the attention of the opposite sex, while the category of negative experiences consisted of feeling guilty, physical and mental problems, and social stigma. Saboktakin rizi et al showed that students who have calm and satisfied families without stress are less  (17) and Afrasiabi & Madahi (18) also found that families who can provide peaceful conditions for their children, away from challenges and stress, are less likely to smoke and gain peace through this habit. Therefore, managing family peace and being rational in feeling satisfied can have a positive effect on an unwillingness to smoke. According to Kaplan and colleagues' theory of self-abasement (19), the decrease in overall self-esteem due to negative evaluations and criticism by other people is a major smoking risk factor. According to Epstein and colleagues' self-empowering approach (20), smoking is considered as a learned social behavior that is the result of the interaction between individual and social factors. Further, adolescents with poor social and individual skills not only are vulnerable to the incentives of tobacco use, but they also tend to use it as an alternative to adaptive coping strategies. It seems that being prestigious is also an alternative to the perceived weaknesses in the individual. One of the basic needs of human life is communication with others. Human beings constantly need communication with other people for their survival and progress during their life, and there is a close relationship between this interaction and health. All human beings seek to find people with whom they can feel happy, enjoy life, and achieve more benefits from their presence. Among human relationships, the need for communication with the opposite sex is also manifested at some point in human life, and this is the time when boys and girls tend to attract the attention of the opposite sex (21). In the present study, attracting the attention of the opposite sex was one of the sub-categories of positive experience. It seems that students try to look different and show off by smoking, and they consider this as a kind of strength and courage. The present study also manifested students' feeling about their parents. Students have deprived their parents of their dreams and frustrated them by smoking, while these parents devoted their sincere love to their children over the years and expected them to be healthy and beneficial in the future. Consequently, students suffer from severe psychological stress because they try to hide or justify this issue. The results of the present study indicated a relationship between the smoking tendency and physical and mental problems. Accordingly, if a student feels deprived or dissatisfied with his/her physical conditions and appearance or struggles with problems that cause psychological stress, he/she is more likely to smoke compared to other people (22). Therefore, students use tobacco to avoid unfavorable conditions and physical and mental problems and try to get rid of the physical and mental burden of their problems. As long as people are stigmatized, isolated, and rejected, they are likely to become more alienated and deviant. Stigmatized people are rejected by society; therefore, they need to accept the base of their deviance and play their role in accordance with this base (23). Hence, the consequences of stigmatization from other important others lead the person to more deviations, including smoking and other drugs.

Limitations and Strengths
The main drawback of the present study was limited access to smoking students who were willing to talk, so snowball sampling was used to solve this problem and have access to more people. The next limitation of the study was the nature of the qualitative study, that is, non-generalizability of the results of qualitative studies, because the results of this study depend on individual, cultural, and social conditions and even geographical factors. On the other hand, the results of this study can be considered a strength because environmental, cultural, and geographical variables, especially the specific group under study, were taken into account in the present study. It is suggested to use the results of the present study to improve the quality of issues related to students and universities. Further, interventions should be carried out on the results in subsequent studies to provide solutions to reduce the universities and students' problems.

Conclusion
The present study suggests that universities and smoking students face many problems and challenges, and many stimuli that reinforce this destructive behavior can cause serious problems for the smoking student and other students in the university. Therefore, the burden of conflicts between students and the university can be reduced by supporting the student community and taking various educational, cultural, and social measures in the form of individual interventions.