A prospective cross-sectional study was conducted among KKU students. One thousand four hundred students approached and 731 responded with a completed questionnaire. Among those 731 questionnaires, eight due to insufficient data were excluded. Out of 723 respondents 365 were smokers and 358 were non-smokers. Three hundred sixty-five smokers was included in the present study. The participants were gathered using a snowball sampling technique.

Students of KKU who were willing to participate in the study voluntarily were included. Informed consent was obtained from the student participants who were willing to participate in the study, after explaining the project objectives. The study excluded those who did not provide their consent and had incomplete questionnaires.

A well-structured, pre-validated nine self-administered online questionnaire (Google docs) was used. Students have responded to the modified Fagerstrom Tolerance questionnaire (mFTQ) in English. The responses were downloaded in an Excel sheet, which asks about their sociodemographic details, and social habits, especially tobacco consumption. The m FTQ is a widely used instrument to assess nicotine dependency (15). It consisted of seven questions related to the use of cigarettes, with scores ranging from 0 to 9. Question 1. “How many cigarettes a day do you smoke?” “2. Do you inhale?” “3. How soon after you wake up do you smoke your first cigarette?” “4. Which cigarette would you hate to give up?” “5. Do you find it difficult to refrain from smoking in places where it is forbidden (church, library, movies, etc.)?” “6. Do you smoke if you are so ill that you are in bed most of the day?” “7. Do you smoke more during the first 2 h than during the rest of the day?” All seven of the questions on this questionnaire use a five-point Likert scale, with the exception of the one about smoking during the first 2 h of the day. A score of mFTQ 0–2 suggests no nicotine dependence, a score of 3–5 suggests moderate dependence, and a score ≥6 usually indicates high dependence (15). Additional question about willingness to quit smoking among current smokers was added. The validation of mFTQ with salivary cotinine among adolescents found that the mFTQ scale (r = 0.40) is valid and applicable to smokers of adolescents (16). The participants were asked if they had any thoughts of giving up smoking, and their yes/no responses were recorded. This study, REC No. 2018-06-42, HA-06-B-001 was exempted by the KKU ethics committee.

One thousand four hundred people were approached, and 731 returned the questionnaire with completed responses. Unfortunately, eight questions were disqualified because the data was not full. The sample characteristics were assessed using descriptive statistics. The significant relationship between the mFTQ variables was evaluated using the chi-square test. Statistical significance was set at p < 0.01.

The scoring system of the mFTQ was used in the study. The percentage of respondents who indicated they were dependent on nicotine in response to particular questions is as follows. Several cigarette smoking in a day ranges: among the current smokers 56 (15%) were found to smoke over 26 cigarettes a day, 84 (23%) were found to smoke about 16–25 cigarettes a day, 225 (62%) were found to smoke < 15 cigarettes a day. About 267 (73%) were found to inhale cigarette smoke always and 98 (27%) of smokers never inhaled cigarette smoke. A total of 157 (33%) participants said they smoke within the first 30 min of waking up, and 57% (208) said they smoke after awakening but before midday, and more than 30 min.

A total of 162 (44%) were found to dread giving up their first smoke of the day and 203 (56%) were found to give up any other cigarette in the afternoon. One hundred and eighty-one (180) respondents (49%) found it difficult to abstain from smoking when they were ill and spent the majority of the day in bed, and 61% (221) of smokers stated they find it difficult to stop from smoking in public areas where it is prohibited (Mosque, libraries, etc.). Also, 49% (180) of respondents were discovered to smoke more during the first 2 h of the day. Out of 365 smokers, 216 (59%) smokers were willing to quit and 149 (41%) smokers are not willing to quit. The details are given in Table 2. mFTQ (n = 365) scores of 0–2 indicate no dependence, 3–5 indicate moderate dependence, and ≥6 indicate substantial dependence. Mean and standard deviation of no dependence 1.35 ± 0.74, moderate dependence 3.91 ± 0.81, substantial dependence 6.62 ± 0.72. The number of current smokers in each category; no dependence, moderate dependence, and substance dependence were 121 (33%), 175 (48%), and 69 (19%) respectively. The details are given in Table 3.

Relationship between mFTQ and the number of cigarettes per day among the respondents (p < 0.001). Relationship between mFTQ score and first smoke of your cigarettes (p < 0.018). Relationship between mFTQ and smoke in the morning among the respondents (p < 0.007). Relationship between mFTQ and the difficulty refraining from smoking in public areas among the respondents (p < 0.000). Correlation between mFTQ and the cigarettes would you hate to give up among the respondents (p < 0.202). The details are given in Table 4.

The study made use of the mFTQ scoring system. The proportion of respondents who responded favorably to particular questions about nicotine dependence. According to the study's findings, 62% of respondents smoked fewer than 15 cigarettes per day, 33% smoked between 16 and 25 cigarettes, and 15% smoked more than 26 cigarettes per day. This indicates the responders' high level of nicotine dependence. Nicotine dependency is directly correlated with this high daily cigarette usage (21).

About 73% of respondents were found to inhale cigarette smoke always and 27% of smokers never inhaled cigarette smoke. In total, 43% of subjects admitted to smoking within the first 30 min of waking up, and 57% said they smoke before midday, more than 30 min after awakening. This could be attributed to the fact that the plasma nicotine levels are short and half-lived so it declines immediately after they wake up. This may be the reason that they are tempted to smoke early in the morning (22). Consequently, a morning cigarette urge is one of the signs of nicotine dependence as reported by Lamin et al. (23).

A total of 162 (44%) were found to many find it difficult to put up their morning cigarette, and 203 (56%) were found to give up any other cigarette in the afternoon. In the same way, 54.0% of smokers answered hate to give up the smoke during the first 2 h of the day (18). Sixty-one percentage (221) of smokers said that they find it difficult to refrain from smoking in public places where it is forbidden (Mosque, libraries, etc), 49% (180) of the respondents found it difficult to refrain from smoking when they are ill, they spend the majority of the day in bed, and 49% (180) of the respondents were found to more smoking in first 2 h of the day (24). Seventy percent of smokers reported that it is difficult not to smoke in forbidden areas like mosques and libraries. When severely ill (and spending the majority of the day in bed), those who were diagnosed as full smokers said they would smoke (25).

mFTQ (n = 365) scores of 0–2 indicate no dependence, 3–5 indicate moderate dependence, and ≥6 indicate substantial dependence. Scores of no dependence, moderate dependence, and substance dependence were 121 (33%), 175 (48%), and 69 (19%), respectively. Similar results were reported by other studies that moderate nicotine dependence is high (26). Similar findings from earlier studies indicated that Thiruvananthapuram, Kerala's rural population had a high level of mild nicotine dependence (27). Another cross-sectional study revealed that among smokers, 34.4%, 39%, and 26.5% have no or mild, moderate, or severe nicotine dependency, respectively (28). According to a study conducted in Nepal, smokers with low degrees of nicotine dependence (4) had nicotine levels of 70.2%, medium (4–6), 52.8%, and high (7–10), 12.0% (29).

From the study outcomes, there was a strong correlation found between mFTQ scores and the number of cigarettes per day, mFTQ scores and first smoke of cigarettes, mFTQ scores and smoking habit in the morning, mFTQ scores and difficulty to refrain smoke from public areas. The findings of the present study explain that the higher number of cigarettes per day has a significant association with the mFTQ scores (23). Previous study shown that the mFTQ score often increased as the severity of the smoking is increased due to a strong linear connection between the two variables (p < 0.001) (25).

Out of 365, 216 (59%) smokers were willing to quit and 149 (41%) smokers are not willing to quit. This shows that college students in the KSA may be aware of the advantages of quitting smoking, and that in the future, effective education initiatives will be required to support them. This result is congruent with those of Majmaah University KSA where 71.8 percent of smokers in college had previously tried to give up smoking (18). Another study conducted in KSA revealed that 65% of smokers were ready to give up the habit (30). According to other studies, the majority of smokers had made at least one attempt to stop smoking (31). The readiness to give up smoking among patients in all categories, including those with mild, moderate, and severe nicotine dependence (28). After receiving smoking cessation education in schools, knowledge and attitudes about smoking harm prevention considerably improved. Numerous research have shown this improvement in awareness and attitudes toward smoking harm prevention. The organization plan activities that can improve the physical fitness and cardiopulmonary endurance of outpatients who are quitting smoking in clinics, as well as a series of smoking cessation education and training sessions (32).

The high prevalence of tobacco use and the affirmative responses provided by respondents who were smokers to the Fagerstrom questions suggest that tobacco use is becoming a serious issue in universities. The ambitious tobacco control initiatives developed by the health ministry must be implemented locally. The strict enforcement of the laws adopted with that purpose and a reduction in the supply and demand for tobacco products should be the objectives of the policies (33, 34) and antismoking programs.

This type of cross-sectional study has limitations, including recall bias. Moreover, the study's generalizability may be limited because its participants were college students from a single public university.