OBJECTIVE: To determine the level of tobacco-related attitudes and practices among medical students who study in a designated 'No-Smoking University' in Pakistan's largest city, Karachi. It further highlighted some challenges for tobacco control at the university. METHODS: The study design adopted mixed methods. It commenced with an initial qualitative phase using in-depth interviews with medical students and university staff to refine and expand areas of enquiry for the development of a structured cross-sectional survey among second and fifth (final) year students. Thematic analysis was used to analyse qualitative data, while descriptive statistics and various statistical tests were applied to investigate differences along a number of parameters in the survey data. RESULTS: Overall smoking prevalence across both years was 14.5%; however, there was a sharp disparity along sex lines, with 32% of males and just 1% of females self-identifying as current or occasional smokers. Importantly, the majority of smokers initiated smoking after starting their medical education. Despite students' expressed expectations that they can and should be future non-smoking role models and advocates, their actual knowledge and practices - for males at least - were disappointing. Significantly fewer second year than final year students knew that Hamdard had been designated a 'No-Smoking University', and about half of the participants believed the university had 'effectively' controlled tobacco use on campus. A large majority supported stronger tobacco control measures at the university and in the wider society. CONCLUSION: This study highlights weaknesses in the measures taken for tobacco control on the university campus through the picture it provides of the presence of tobacco use, the on-campus initiation of smoking and the increase in smoking rates among final year students by comparison to those in the initial years of medical studies.