Tobacco smoking among college students contributes to nicotine dependence, adverse health effects, and poor academic outcomes. Nicotine withdrawal symptoms such as impaired concentration, stress, and mood changes may negatively affect grades and attendance. Nicotine Replacement Therapy (NRT) may mitigate these effects.
To assess nicotine dependence, utilization of NRT, and its impact on academic performance among student smokers in Mangalore.
A cross-sectional survey was conducted among 75 student smokers aged 18-28 years using a structured online questionnaire. Nicotine dependence was assessed using the Fagerström Test for Nicotine Dependence. Academic performance and attendance before and after NRT use were compared. Data were analyzed using SPSS version 26.0 with χ2 tests.
Most participants were aged 21-24 years (70.7%), and 87.0% were male. Moderate nicotine dependence was observed in 41% of students. NRT was used by 75%, predominantly nicotine gum, 59%. Good academic performance increased from 14.3% before NRT to 46.4% after NRT (χ²=13.78, p<0.01), while poor performance decreased from 19.6 to 10.7%. Attendance also improved significantly (χ²=8.26, p=0.016). NRT users demonstrated better academic performance than nonusers (89.3 vs. 36.8%, p<0.001).
NRT use was significantly associated with improved academic performance and attendance. Pharmacist-led tobacco cessation interventions may benefit student health and academic success.
Abstract
Share on Mobile
Scan to access on mobile
Keywords
Academic Performance
Fagerström test for nicotine dependence
Grade Point Average
Nicotine Dependence
Nicotine Replacement Therapy
Tobacco smoking
INTRODUCTION
Tobacco smoking continues to be a significant global public health issue, with a notably high prevalence among adolescents and young adults, particularly those in higher-education institutions. The transition to higher education is frequently associated with increased academic demands, psychosocial stress, peer influence, and greater autonomy, all of which may contribute to the initiation and persistence of smoking behaviors (Arnett, 2000; World Health Organization, 2023). In India, tobacco use among young adults presents a substantial challenge due to its long-term health consequences, economic burden, and detrimental effects on quality of life and productivity (Tata Institute of Social Sciences, Ministry of Health and Family Welfare, and Government of India, 2018).
Nicotine dependence is a chronic, relapsing condition that negatively impacts both physical and psychological health. Among students, smoking has been associated with impaired concentration, heightened stress, anxiety, mood disturbances, and sleep-related issues, which may adversely affect academic engagement, attendance, and learning outcomes (Pasch et al., 2010a; Taylor et al., 2014a). Several studies have identified a significant correlation between smoking and poorer academic performance, including reduced Grade Point Average (GPA), decreased motivation, and impaired cognitive functioning (Bradley and Greene, 2013; Latvala et al., 2014).
Nicotine Replacement Therapy (NRT) is an evidence-based smoking cessation strategy that delivers controlled doses of nicotine without exposure to harmful tobacco combustion products. Commonly used forms include nicotine gum, transdermal patches, lozenges, inhalers, and nasal sprays (Stead et al., 2012). By alleviating nicotine withdrawal symptoms such as irritability, restlessness, and difficulty concentrating, NRT has been shown to support mood stability and cognitive performance during cessation attempts (Heishman et al., 2010). While the effectiveness of NRT in promoting smoking cessation is well established, limited research has explored its potential impact on academic performance among student smokers.
Academic performance is a multifactorial outcome influenced by mental health status, lifestyle behaviors, substance use, and overall physical well-being. Although international studies suggest that smoking cessation may improve cognitive and functional outcomes, evidence examining the relationship between nicotine dependence, NRT use, and academic performance remains scarce, particularly in the Indian context (Singh et al., 2019). Region-specific data are essential to understand local patterns of tobacco use and cessation practices among students.
Mangalore is a prominent educational hub in southern India with a diverse student population. Assessing smoking behavior, nicotine dependence, and utilization of NRT among students in this region is crucial for designing effective tobacco cessation strategies. Furthermore, pharmacists play a vital role in tobacco cessation through patient education, counseling, and appropriate guidance on NRT use, underscoring the relevance of pharmacy practice-based research in this area. Therefore, the present study was undertaken to generate evidence that may support student-focused tobacco control interventions and strengthen the role of pharmacists in smoking cessation services.
The main aim of the study is to assess nicotine dependence, utilization of nicotine replacement therapy, and its impact on academic performance among student smokers in Mangalore. There is a significant association between nicotine dependence and academic performance, and the use of nicotine replacement therapy is associated with improved academic performance among student smokers.
MATERIALS AND METHODS
Study Design and Study Population
A survey-based cross-sectional study was conducted to evaluate the impact of NRT on academic performance among student smokers in Mangalore, Karnataka, India. The study population included undergraduate and postgraduate students aged 18-28 years who were self-reported smokers and currently pursuing their academic programs in institutions located in Mangalore. Students younger than 18 years or older than 28 years, self-reported nonsmokers, and those unwilling to provide informed consent were excluded from the study.
Sample Size
The sample size for the study consisted of 75 student smokers, selected based on feasibility and voluntary participation among eligible students in Mangalore.
Study Materials and Data Collection
Participants were enlisted online after they expressed their consent to join the study. Data collection was carried out using a structured and prevalidated questionnaire, crafted to align with the study’s goals and distributed through Google Forms. The questionnaire included sections on demographic details such as age, gender, course, and year of study, as well as smoking history and nicotine dependence, which was measured using the Fagerström Test for Nicotine Dependence. Additionally, information on smoking cessation was gathered, covering reasons for quitting, use of supplementary cessation resources, and specifics about NRT, including past or current use, types of NRT products used, motivation for starting NRT, and nicotine withdrawal symptoms along with their perceived severity. Academic performance was evaluated through self-reported or documented GPA and attendance records. Furthermore, smoking-related health parameters, such as perceived stress levels, mental health status, and overall health status, were assessed.
Statistical Analysis
The collected data were entered into Microsoft® Excel and analyzed using the Statistical Package for the Social Sciences version 26.0. Descriptive statistics were summarized as frequencies and percentages. The χ2 test was employed to assess associations between categorical variables and to compare academic performance and attendance before and after the use of nicotine replacement therapy. All statistical analyses were two-tailed, and a p-value of less than 0.05 was considered statistically significant.
Ethical Approval
Ethical approval for the study was obtained from the Institutional Ethics Committee of the Shreedevi college of Pharmacy (SDCP/IEC/2024/06). Participation was voluntary, confidentiality and anonymity of participant information were strictly maintained throughout the study.
RESULTS
Sociodemographic Characteristics of Participants
A total of 75 student smokers participated in the study. Most participants were in the 21-24 years age group (70.7%), followed by 18-20 years (21.3%) and 25-28 years (8%). Regarding gender distribution, 65 (87.0%) participants were male and 10 (13.0%) were female.
Academic Background of Study Participants
The academic background of the participants showed representation from multiple health-science disciplines. Among the 75 participants, the highest proportion belonged to the medical Course 23 (31%), followed by pharmacy 20 (26%) and dental 11 (15%). Participants from physiotherapy 9 (12%), nursing 5 (7%), paramedical 2 (3%), and other courses 5 (6%) were also represented. With respect to the year of study, most participants were in their fourth Year 25 (34%), followed by interns 19 (25%). Participants from the second and third years each accounted for 10 (13%), while first-year 6 (8%) and fifth-year students 5 (7%) constituted smaller proportions of the study population.
Smoking Behavior and Nicotine Dependence
Stress relief was the most commonly reported reason for smoking among Participants 30 (40%), followed by peer Pressure 14 (19%) and Curiosity 13 (17%), mental health Issue 8 (11%) and other reasons 10 (13%). Assessment of nicotine dependence using Fagerström Test for Nicotine Dependence revealed that a majority of students had moderate dependence 31 (41%), while 24 (32%) exhibited low-to-moderate dependence. High and low nicotine dependence were observed in 10 (13%) of participants.
NRT Usage
Among the 75 participants, 56 students (75%) reported using nicotine Replacement Therapy, while 25% did not use any form of NRT. Among NRT users, nicotine gum was the most commonly used Product 33 (59%), followed by patches 11 (20%), lozenges 10 (18%) and Inhaler 2 (4%). The predominant motivation for initiating NRT was improvement in academic Performance 39 (70%), followed by improvement in overall Health 10 (18%) (See Table 1.
Comparison of academic performance before and after NRT use
Table 2 shows the comparison of academic performance among students before and after the use of NRT. Before initiation of NRT, most students had average academic Performance 37 (66.1%), while only 8 (14.3%) demonstrated good performance and 11 (19.6%) had poor performance. After NRT use, the proportion of students with good academic performance increased to 26 (46.4%), and those with poor performance decreased from 6 (19.6-10.7%). This improvement in academic performance after NRT use was found to be statistically significant (χ²=13.78, p<0.01).
Comparison of attendance levels before and after NRT use
Table 3 depicts the comparison of attendance levels among students before and after the use of NRT. Before NRT use, more than half of the students 30 (53.6%) had poor attendance, whereas only 9 (16.1%) had good attendance. Following the initiation of NRT, the proportion of students with good attendance increased to 19 (33.9%) and those with poor attendance decreased to 16 (28.6%). The observed improvement in attendance levels after NRT use was statistically significant (χ²=8.26, p=0.016).
Association Between NRT Usage and Academic Performance Category
Table 4 illustrates the association between NRT usage and academic performance category among the study participants. A higher proportion of NRT users 50 (89.3%) demonstrated good to average academic performance compared to 7 (36.8%) among non-NRT users. Poor academic performance was reported in 6 (10.7%) NRT users and 12 (63.2%) non-NRT users (χ² = 21.41, df =1, p<0.001).
Health and Psychological Outcomes of Study Participants
Table 5 summarizes the health and psychological outcomes of the study participants. Smoking-related health problems were reported by 31% of students, while 69% did not report any such conditions. With regard to psychological status, 43% of participants experienced moderate stress and 37% reported high stress levels. Mental-health assessment showed that most students had good to excellent mental health (69%), whereas 17% reported poor mental health. Among students using nicotine Replacement Therapy, 61% reported good to excellent overall health while on NRT.
Table 1: Nicotine Replacement Therapy Usage, Type, and Motivation Among Participants.
| Variable | Category | Frequency (n) | Percentage (%) |
|---|---|---|---|
| NRT usage status (n=75) | yes | 56 | 75 |
| no | 19 | 25 | |
| Type of NRT used (n=56) | gum | 33 | 59 |
| inhaler | 2 | 4 | |
| lozenges | 10 | 18 | |
| patch | 11 | 20 | |
| Motivation to use NRT (n=56) | improve health | 10 | 18 |
| improve academic performance | 39 | 70 | |
| socialization | 5 | 9 | |
| others | 2 | 4 |
Table 2: Comparison of Academic Performance Before and After NRT Use.
| Academic performance | Before NRT n (%) | After NRT n (%) | χ² value | df | p-value |
|---|---|---|---|---|---|
| Good | 8 (14.3) | 26 (46.4) | 13.78 | 2 | <0.01* |
| Average | 37 (66.1) | 24 (42.9) | |||
| Poor | 11 (19.6) | 6 (10.7) |
Table 3: Comparison of Attendance Levels Before and After NRT Use.
| Attendance level | Before NRT n (%) | After NRT n (%) | χ² value | df | p-value |
|---|---|---|---|---|---|
| Good | 9 (16.1) | 19 (33.9) | 8.26 | 2 | 0.016* |
| Average | 17 (30.4) | 21 (37.5) | |||
| Poor | 30 (53.6) | 16 (28.6) |
Table 4: Association Between NRT Usage and Academic Performance Category.
| Academic performance | NRT users n=56 (%) | Non-NRT Users n=19 (%) | χ² value | df | p-value |
|---|---|---|---|---|---|
| Good/average | 50 (89.3) | 7 (36.8) | 21.41 | 1 | <0.001* |
| Poor | 6 (10.7) | 12 (63.2) |
Table 5: Health and Psychological Outcomes of Study Participants.
| Variable | Category | Frequency (n) | Percentage (%) |
|---|---|---|---|
| Smoking-related health problems (n=75) | Present | 23 | 31 |
| Absent | 52 | 69 | |
| Stress level (n=75) | High | 28 | 37 |
| Moderate | 32 | 43 | |
| Low | 15 | 20 | |
| Mental health status (n=75) | Excellent | 22 | 29 |
| Good | 30 | 40 | |
| Fair | 10 | 14 | |
| Poor | 13 | 17 | |
| Overall health while using NRT (n=56) | Excellent | 10 | 18 |
| Good | 24 | 43 | |
| Fair | 16 | 28 | |
| Poor | 6 | 11 |
DISCUSSION
The current research examined the smoking habits, nicotine addiction, and use of NRT among student smokers, as well as their connection to academic performance. Most participants were aged 21-24, with a higher number of males, aligning with the findings of Arnett (2000) and Alqahtani et al., (2023), which suggest that young adulthood is a particularly vulnerable time for tobacco use, especially among males. Similar demographic trends have been observed in Indian college studies listed in PubMed and Scopus, which highlight gender differences in smoking rates (Singh et al., 2019).
The greater number of students from medical and pharmacy programs in this study is consistent with the research by Al-Haqel et al., (Al-Haqel et al., 2024) and Singh, Pal, Mehta, and Kapil (2019), which showed that health-science students often smoke despite knowing the health risks. Factors such as academic stress, extended study hours, and clinical duties have been identified as significant contributors to this behavior among healthcare students (Pasch et al., 2010b).
In this study, stress relief was the primary reason for smoking, followed by peer influence and curiosity. This is supported by Taylor et al., (2014b), whose meta-analysis found a strong link between smoking, stress management, and mental-health outcomes. Similar findings have been reported in university studies indexed in Google Scholar, where smoking was used as a maladaptive coping mechanism for academic and psychological stress (Patton et al., 2005).
The Fagerström Test for Nicotine Dependence indicated mainly moderate levels of dependence, aligning with the research of Heishman, Kleykamp, and Singleton (2010) and Rath, Villanti, Abrams, and Vallone (2012), who found that young adult smokers typically show low-to-moderate dependence that can be effectively addressed with pharmacological treatments. This degree of dependence offers a chance for early cessation efforts, particularly through the use of NRT.
A significant observation from the study is the high rate of NRT usage, with nicotine gum being the most frequently chosen form. This trend is supported by findings from Stead et al. (2012) and Abbas, Al-Qerem, Saadeh, Abughosh, and Alzoubi (2023), who noted that nicotine gum is favored for its convenience and quick alleviation of withdrawal symptoms. The main reason for starting NRT in this study was to enhance academic performance, indicating a growing awareness of how nicotine withdrawal can affect concentration and learning.
The statistically significant improvement in academic performance following NRT use corroborates earlier research by Bradley and Greene (2013), which found that healthier lifestyle choices are linked to better academic success. Neurocognitive research by Barr et al. (2011) further elucidates this improvement by showing that nicotine withdrawal hampers attention and working memory, while controlled nicotine delivery via NRT aids in stabilizing cognitive functions. Similarly, attendance rates significantly increased after starting NRT. This result is in line with Latvala et al., (2014), who demonstrated that smoking negatively impacts educational engagement and attendance. The improved attendance among NRT users may be due to reduced withdrawal symptoms, better mood regulation, and enhanced overall functioning. The association analysis showed that NRT users were significantly more likely to achieve good to average academic performance compared to nonusers. This supports evidence from Scopus-indexed studies indicating that unmanaged nicotine dependence negatively affects academic outcomes, while cessation support can mitigate these effects (Alqahtani et al., 2023; Latvala et al., 2014). The findings underscore the importance of incorporating pharmacist-led tobacco cessation services in academic settings.
Regarding health and psychological outcomes, a significant portion of students reported moderate to high stress levels, consistent with Pasch, Laska, Lytle, Moe, and Perry (2010b). However, most NRT users reported good to excellent overall health, supporting evidence from Taylor et al., (2014b) and Stead et al., (2012) that smoking cessation is linked to improved physical and mental health.
Significance of the Study
This study highlights the association between NRT use and improved academic performance and attendance among student smokers. It underscores the importance of addressing nicotine dependence within educational settings and emphasizes the role of pharmacists in tobacco cessation counseling and NRT management.
LIMITATIONS
The cross-sectional design limits causal inference. Self-reported measures of academic performance and health outcomes may introduce recall bias. The relatively small sample size and single-center setting may limit generalizability.
FUTURE DIRECTIONS
Future research should adopt longitudinal or interventional designs with objective academic indicators such as GPA and attendance records. Multicenter studies and evaluation of structured pharmacist-led cessation programs are recommended to assess long-term academic and health outcomes.
This study demonstrates that nicotine dependence is common among student smokers and that the use of nicotine replacement therapy is significantly associated with improved academic performance and attendance. Students using NRT showed better grades, higher attendance, and improved overall health compared to nonusers. These findings suggest that managing nicotine withdrawal through NRT may enhance concentration and academic engagement. Incorporating pharmacist-led tobacco cessation and NRT counseling programs within educational institutions could support both smoking cessation and academic success among students.
Acknowledgments
We express our heartfelt gratitude to the Almighty for blessing us with good health, wisdom, and strength throughout the course of our project. We extend our sincere thanks to Dr Jagadish V Kamath, Principal of Shree Devi College of Pharmacy, Mangalore, and the Shree Devi Education Trust for their continuous support and encouragement. We are also deeply grateful to the Indiana Hospital and Heart Institute, Mangaluru, for providing the necessary resources and cooperation that made this study possible.
Conflict of Interest
The authors declare that there is no conflict of interest.
References
Abbas, M., Al-Qerem, W., Saadeh, R., Abughosh, S., Alzoubi, K.. (2023). Knowledge and perception of NRT among medical students. Journal of Family Medicine and Primary Care, 12(1), 1-7.
Al-Haqel, A. M., Aljohani, N. J., Althubaiti, A., Alshareef, R., Almutairi, S., Alshammari, A.. (2024). Tobacco and nicotine use among health students. Frontiers in Public Health, 12, 1348370.
Alqahtani, J. S., Aldhahir, A. M., Alanazi, Z., Alsulami, E. Z., Alsulaimani, M. A., Alqarni, A. A., AlAhmari, M. D.. (2023). Impact of smoking status and nicotine dependence on academic performance of health sciences students. Substance Abuse and Rehabilitation, 14, 13-24. https://doi.org/10.2147/SAR.S393062
Arnett, J. J.. (2000). Emerging adulthood: A theory of development from the late teens through the twenties. American Psychologist, 55(5), 469-480. https://doi.org/10.1037/0003-066X.55.5.469
Barr, M. S., Farzan, F., Rusjan, P. M., Chen, R., Fitzgerald, P. B., Daskalakis, Z. J.. (2011). Nicotine effects on cognition and brain activity. Neuropsychopharmacology, 36(11), 2399-2409.
Bradley, B. J., Greene, A. C.. (2013). Do health and education agencies in the United States share responsibility for academic achievement and health? A review of 25 years of evidence about the relationship of adolescents’ academic achievement and health behaviors. Journal of Adolescent Health, 52(5), 523-532. https://doi.org/10.1016/j.jadohealth.2013.01.008
Heishman, S. J., Kleykamp, B. A., Singleton, E. G.. (2010). Meta-analysis of the acute effects of nicotine and smoking on human performance. Psychopharmacology, 210(4), 453-469. https://doi.org/10.1007/s00213-010-1848-1
Latvala, A., Rose, R. J., Pulkkinen, L., Dick, D. M., Korhonen, T., Kaprio, J.. (2014). Drinking, smoking, and educational achievement: Cross-lagged associations from adolescence to adulthood. Drug and Alcohol Dependence, 137, 106-113. https://doi.org/10.1016/j.drugalcdep.2014.01.016
Pasch, K. E., Laska, M. N., Lytle, L. A., Moe, S. G., Perry, C. L.. (2010a). Adolescent sleep, risk behaviors, and depressive symptoms: Are they linked?. Journal of Adolescent Health, 47(6), 554-561.
Pasch, K. E., Laska, M. N., Lytle, L. A., Moe, S. G., Perry, C. L.. (2010b). Adolescent sleep, risk behaviors, and depressive symptoms. Journal of Adolescent Health, 47(6), 554-561.
Patton, G. C., Coffey, C., Carlin, J. B., Sawyer, S. M., Lynskey, M.. (2005). Reverse gateways? Frequent cannabis use as a predictor of tobacco initiation and nicotine dependence. Addiction, 100(10), 1518-1525. https://doi.org/10.1111/j.1360-0443.2005.01220.x
Rath, J. M., Villanti, A. C., Abrams, D. B., Vallone, D. M.. (2012). Patterns of tobacco use and dual use in young adults. Nicotine and Tobacco Research, 14(6), 699-706.
Singh, V., Pal, H. R., Mehta, M., Kapil, U.. (2019). Tobacco consumption and awareness of tobacco hazards among college students in Delhi. Indian Journal of Community Medicine, 44(2), 131-135.
Stead, L. F., Perera, R., Bullen, C., Mant, D., Hartmann-Boyce, J., Cahill, K., Lancaster, T.. (2012). Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews, 11, CD000146. https://doi.org/10.1002/14651858.CD000146.pub4
(2018). Global adult tobacco survey GATS-2 India 2016-17.
Taylor, G., McNeill, A., Girling, A., Farley, A., Lindson-Hawley, N., Aveyard, P.. (2014a). Change in mental health after smoking cessation: Systematic review and meta-analysis. Addiction, 109(9), 1473-1482.
Taylor, G., McNeill, A., Girling, A., Farley, A., Lindson-Hawley, N., Aveyard, P.. (2014b). Change in mental health after smoking cessation. Addiction, 109(9), 1473-1482.
(2023). WHO report on the global tobacco epidemic 2023: Protect people from tobacco smoke.