3.1 Study Setting
Our current study was conducted in Jordan, a middle-income country located in the Eastern Mediterranean Region. According to the latest statistics, the population count of Jordan is about 10.8 million (38). The official language of the country is Arabic.
3.2 Study Design and Participants
This study was a descriptive quantitative cross-sectional survey that spanned from March 9, 2021, to March 16, 2021. Data were collected utilizing an anonymous self-administered online questionnaire that was developed using Google Form® (A secure cloud-based survey tool). The questionnaire was delivered in Arabic, the national language of Jordan. Considering the control measures of the COVID-19 pandemic (e.g., physical distancing) and to reach participants from various regions in the country in a time-efficient way, the decision was made by the research team to collect the data using a web-based (online) survey tool. We advertised our study on various social media forums including Facebook®, WhatsApp®, LinkedIn®, and Twitter®. Employing a snowball convenience sampling technique, participants were recruited and further encouraged to share the survey link with their family members and social network.
Eligible participants should have been at least 18 years or older, able to read and understand Arabic and reside in Jordan. The nature of our study, its objectives, and eligibility criteria for participation were explained in the introductory letter of our survey questionnaire. Participation was voluntarily and individuals who were interested to get involved in the study have given online informed consent by declaring their eligibility and accepting to fill out the questionnaire. There were no incentives/rewards upon participation.
3.3 Assessment Tool and Measures.
A structured questionnaire was developed by the authors after reviewing relevant and related literature (19,35,37,39–48). The questionnaire comprised 39 single-answer items that were distributed over three sections as the following:
3.3.1 Sociodemographic, Health, and Smoking Profiles
The first section included 13 items that solicited data on the sociodemographic profile, health profile and smoking profile of participants. The sociodemographic data included age (in years), gender (female, male or prefer not to say), marital status (single or married), educational level (up to secondary school or higher education), residence area (rural or urban), employment status (unemployed, employed in the health sector, employed in non-health sector), and the number of household members (less than 3 persons, 3-5 persons or 6 persons and more).
In the health profile, we asked the participants to report their physical activity based on the WHO recommendation of whether they maintain at least 150 minutes of moderate-intensity aerobic activity in a week (Yes or No), history of chronic diseases like hypertension, diabetes, chronic respiratory diseases or any other chronic illnesses (Yes or No), history of laboratory-confirmed COVID-19 infection (Yes or No), and history of COVID-19 infection among family members in the same house (Yes or No).
Regarding smoking profile, participants were requested to report their current smoking status (past 30-day use) regarding combustible cigarettes (CC), waterpipe (WP), and electronic cigarettes (EC) which are the most popular smoking methods in Jordan. Accordingly, our study sample is represented by 1163 never-smokers, 1044 current smokers, and 217 ex-smokers.
3.3.2 Beliefs about Smoking and COVID-19
The second section of the questionnaire included 14 items that aimed to assess the participants’ attitudes and beliefs surrounding various smoking methods and COVID-19. The participants were instructed to answer these items based on their beliefs and opinions. The 14 items of this section were adapted from a study after obtaining the authors’ permission (19). The 14 items were distributed as the following: three items on the relationship between smoking CC, WP, or EC and risk of contracting COVID-19 (related, not related or I do not know), three items on the safety of smoking CC, WP or EC inside the residence place during the pandemic crisis (safe, not safe, I do not know), three items on the safety of smoking CC, WP or EC in public places during the pandemic crisis (safe, not safe, I do not know), one item on the safety of EC as a substitute to any other form of smoking products during the pandemic (safe, not safe, I do not know), three items on the general outcome of a CC, WP or EC smoker in case of contracting COVID-19 infection (similar to non-smokers, recover sooner, get worse). Lastly, the respondents were asked whether they believe that smoking or nicotine use could provide protection against COVID-19 (Yes, No, or I do not know).
3.3.3 Smoking Behavior and Quit Plans.
The third section of our survey questionnaire assessed the impacts of the COVID-19 pandemic on smoking behavior and quit attempts/plans through 12 items that targeted both, current smokers, and ex-smokers with six items for each. Current smokers were asked about how did the pandemic impact their smoking habits in comparison to their habits before the pandemic crisis (no change, increased consumption, decreased consumption, shifting to another smoking method, in an active quitting trial, or the initiation of smoking), and participants were requested to choose the most applicable scenario. Also, participants were asked if they consider/plan to quit smoking during the pandemic (Yes, No), if they intend to use smoking cessation tools (Yes, No), types of smoking cessation tools they intend to use (all that applies from: consulting a healthcare provider, behavioral advice, Nicotine Replacement Therapy (NRT), medications or using EC ), the primary motivation for planning to quit smoking (COVID-19 related reasons, or reasons not related to COVID-19), and the main driving reasons to quit smoking due to COVID-19 (all that applies from: to protect myself, to protect my family, due to pandemic measures such as mask-wearing and closure of cafes or due to economic impacts/financial constraints induced by the pandemic). In the same section, ex-smokers were asked to report if they have successfully quitted smoking during COVID-19 or before the pandemic (yes, no), if their successful quit attempts were due to COVID-19 related reasons or not, the main driving reasons behind their decision to quit smoking due to COVID-19 issues, their prospective plan concerning their smoking cessation (sustaining it even after the pandemic is over, or resuming smoking after the pandemic is over), if they have used smoking cessation tools (yes, no), and types of smoking cessation tools used (response choices were similar to those provided for current smokers).
3.4 Face/Content Validity and Pilot-Testing
The questionnaire was initially developed in English and evaluated by two academics in the field of tobacco research for content and face validity. Then, it was translated into Arabic by two independent academic translators using translation and back-translation techniques. To ensure clarity and understandability of the questionnaire’s items among the general population, it was piloted on 50 participants from various academic and professional backgrounds, and linguistic refinements were made as needed based on the feedback from the pilot-testing phase. The pilot responses were not included in the final analyses.
3.5 Sample Size
The required sample size was estimated to be 385 participants based on the Raosoft® software using a confidence level of 95%, response distribution of 50%, a margin of error of 5%. However, aiming at gathering a more comprehensive view regarding individuals’ beliefs and attitudes, and considering that randomized sampling was not feasible, we were committed to including as many participants as we can. Thus, a total of 2424 participants have enrolled in our study, considering the use of a time-efficient and widely accessible tool by most people in Jordan, i.e., an internet survey.
3.6 Data Management and Analyses
Completed responses were extracted from Google Form® as an Excel sheet for quality check, data cleaning, and coding. Then, the Excel sheet was exported into Statistical Package for Social Sciences version 24.0 (SPSS Inc., Chicago, IL, USA) for further statistical analyses. Mean and standard deviation was used to describe numerical variables, while categorical variables were reported as frequency and percentages. Pearson’s Chi-square test was employed to assess significant differences between smoking groups (never-smokers, ex-smokers, and current smokers) according to their sociodemographic profile, health profile, and beliefs surrounding smoking. Moreover, we estimated the adjusted Odds Ratio (aOR) and 95% Confidence Interval (95% CI) for smoking-related attitudes/beliefs using multinomial logistic regression, with smoking status (never-smokers, ex-smokers, and current smokers/reference) as a dependent outcome variable, while adjusting for sociodemographic and health factors. A p <0.05 was implemented for statistical significance.
3.7 Ethical Considerations
The protocol of this study was reviewed and approved by the institutional review board at Applied Science Private University in Jordan (Ref. 2021-PHA-7). In addition, the study was conducted conforming to the ethical standards of the Declaration of Helsinki. The survey questionnaire ensured the confidentiality and anonymity of the study participants. Participation was voluntarily and online written informed consent was obtained from all participants as a pre-requisite before answering the survey items.