|Year : 2017 | Volume
| Issue : 4 | Page : 206-212
Cigarette smoking among medical students and some associated risk factors
Mira Maged Mohamed Abu-elenin1, Asmaa Abd Elraheem Omar Atalla2, Rania Mostafa El-Salamy3
1 Lecturer of Public Health and Community Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
2 Assistant Professor of Public Health and Community Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
3 Lecturer of Occupational Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
|Date of Submission||09-Jan-2017|
|Date of Acceptance||22-Apr-2017|
|Date of Web Publication||12-Mar-2018|
Mira Maged Mohamed Abu-elenin
Public Health and Community Medicine, Faculty of Medicine, Tanta University, Tanta
Background Tobacco is a leading cause of preventable mortality and morbidity. College students are at high risk of smoking as they are prone to higher availability of cigarettes. Although medical students are aware about the health hazards of tobacco smoking, they, as well as physicians, smoke.
Aim This study aimed to explore the characteristics of cigarette smoking problem and associated risk factors among medical students in Faculty of Medicine, Tanta University.
Materials and methods A cross-sectional study was carried out on students from Tanta University, Faculty of Medicine in Egypt. Multistage random sampling technique was used. A valid specially designed self-administered questionnaire was used to collect data including age, sex, parents’ education, smoking status, family member smoking habit, and self-reported causes of smoking.
Results Of 252 students, 138 were male and 114 were female. The prevalence of current smokers was 12% and ex-smokers was 6.3%; most of them were male (90.0%), and 13.1% were heavy smokers with a statistically significant association with higher parents’ education. The most commonly reported cause of cigarette smoking was stress (42%). There was a statistically significant association between quitting trials and cessation of this habit (P=0.01). Smoking habit among family members and the presence of smoking peers were significantly associated with smoking status (P=0.001, 0.008).
Conclusion Cigarette smoking is a common problem among medical students despite their awareness about the health hazards of tobacco. Specific training and counseling should be part of the curriculum at medical schools.
Keywords: cigarette smoking, medical students, smoking peers
|How to cite this article:|
Abu-elenin MM, Omar Atalla AE, El-Salamy RM. Cigarette smoking among medical students and some associated risk factors. Tanta Med J 2017;45:206-12
|How to cite this URL:|
Abu-elenin MM, Omar Atalla AE, El-Salamy RM. Cigarette smoking among medical students and some associated risk factors. Tanta Med J [serial online] 2017 [cited 2019 Jan 18];45:206-12. Available from: http://www.tdj.eg.net/text.asp?2017/45/4/206/227118
| Introduction|| |
Tobacco is a leading cause of preventable mortality and morbidity in the majority of developing countries , and although cigarette consumption has been decreasing in developed countries, it is increasing in low-income and middle-income countries .
About one billion men and 250 million women in the world are daily smokers: in particular, 35% and 50% of men and 22% and 9% of women in developed and developing countries, respectively .
By 2030, it is thought that about 70% of deaths due to smoking are expected to occur in developing countries, as the negative health outcomes of smoking are serious and have been well documented .
Smoking is associated with wide spectrum of diseases such as cancers, cardiovascular diseases, strokes, and pulmonary diseases . Cigarette smoke contains over 4,800 chemicals; of them, 69 chemicals cause cancer . Approximately 90% of lung cancer deaths and about 85% of chronic obstructive pulmonary diseases, emphysema, and chronic bronchitis deaths result from cigarette smoking .
Death at earlier age among smokers is more than among nonsmokers. Jha et al.  reported an average of 10 years earlier death among smokers than among nonsmokers; besides, early smoking initiation increases life-time duration of smoking and burden of smoking-related diseases .
Smoking also causes economic burden for the smokers and their communities. During the period 2000–2004, the loss of potential productive years, as well as healthcare cost in the USA, was ∼$193 billion . El-Ansari  reported that smoking also affects second-hand smokers, as an extra financial burden. Behan et al.  reported a loss of $10 billion owing to healthcare expenditure, morbidity, and mortality in second-hand smokers.
College students are at a high risk of smoking as they are prone to higher availability of cigarettes and there might be a intimate relation with smoking peers. At the same time, they are liable to socioemotional and educational challenges when they enter the university ,. Although medical students are aware about tobacco smoking health hazards, as well as seeing patients and death cases, during their practical training, they, as well as physicians, smoke .
Medical students will be responsible for providing healthcare to the community and can influence the future health policies of their countries ; besides, health professionals who smoke send an ambiguous message to patients whom they have encouraged to quit smoking .
The prevalence of smoking among medical students has been found to vary widely from country to country. In a systematic review of the literature by Smith and Leggat , it was shown that Australia and the USA, 2011, had lower smoking rate among their medical students (3%) , whereas a study in Japan in 2010 reported much higher rates and the prevalence was up to 58% .
One of the strategies to reduce smoking-related morbidity and mortality is to encourage the involvement of health professionals in tobacco use prevention and cessation counseling because medical professionals who smoke are more likely to hold attitudes that prevent them from providing patients with antismoking advice ; thus, it is suggested that healthcare students should be exposed to tobacco control policies and education from the outset of their training .
The WHO Framework Convention on Tobacco Control (FCTC) emphasizes the vital contribution of participation of health professional bodies, training, and healthcare institutions in tobacco control efforts .
Antismoking movements play an important role in educating the population about the product that kills more than AIDS, alcohol, road traffic accidents, homicides, suicides, illegal drugs, and fires together .
In spite of the great concentration on conducting researches that entail evaluation of smoking cessation interventions ,, it is much more important to prevent youth from ever smoke through continuous monitoring of risk factors for smoking among them to modify the modifiable factors and target who have nonmodifiable risk factors with health education and smoking prevention programs ,.
Abdulfatah  reported that the continuous cigarette price increases prevented 600 000 teens from taking up smoking in the USA, but the law regulations for prevention tobacco smoking cannot be too strict.
As medical students will be the future doctors and act as role models in their communities thereafter, it was necessary to explore the characteristics of cigarette smoking problem among medical students and the underlying risk factors.
| Materials and methods|| |
Study design and population sampling
A cross-sectional study was carried out at Faculty of Medicine, Tanta University, Egypt during the period from March to May 2015. A representative sample was taken by multistage random sample technique, each grade was divided into four sections, a section was randomly selected from each grade, and then participants were randomly selected. The sample size was measured using EPI info program (Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA) by doing optimum allocation according to the number of students in each (grade 1: 730, grade 2: 705, grade 3: 626, grade 4: 600, grade 5: 634, and grade 6: 639) in the academic year 2014/2015. Inclusion criteria: The study included only male and female Egyptian students from Faculty of Medicine, and international students were excluded. The study included 252 students and the nonresponse rate was 2.3%. A valid specially designed self-administered questionnaire was used. The questionnaire was tested for validity and reliability. Cronbach’s α reliability was 0.86.
Nicotine dependence was assessed by six scored questions, about difficulty to refrain from smoking in places where it is forbidden, smoking more frequently during the first hour after awakening than during the rest of the day, and which cigarette would you hate most to give up. The total score was 10, where a score of 0–2 indicates very low dependence, 3–4 indicates low dependence, 5 indicates medium dependence, 6–7 indicates high dependence, and 8–10 indicates very high dependence.
Statistical analysis was performed using v. 21 (SPSS Inc., Chicago, Illinois, USA). Numerical data were presented as mean and SD. Categorical data were presented as number and percentage distribution. χ2-test was used for statistical analysis, and when it was not appropriate the Monte Carlo exact test was applied. Level of significance was adopted at P value less than 0.05.
A current smoker is someone who smokes any amount of tobacco regularly or occasionally; an ex-smoker is someone who smoked occasionally or regularly in the past but now quit completely; and nonsmoker is someone who had never smoked before .
The participants were informed about the aim of the study to get their approval, and complete confidentiality was assured to all the students participating in the study.
| Results|| |
This study included 252 medical students from the first to the sixth grade, with age ranging from 18 to 25 years with a mean of 21±1.5 years. Half of the participants were male (50.4%). Regarding the smoking status, 206 (81.7%) were nonsmokers, 16 (6.3%) were ex-smokers, and 30 (12.0%) were current smokers. The distribution of smoking status was significantly mainly among male students, whereas it was nearly equal among the fourth, fifth, and sixth year students, as shown in [Table 1].
[Table 2] shows that the majority of fathers (90.0, 79.2%) for the ex-smokers and nonsmoker students were highly educated and the number of current smokers whose fathers’ received primary education were only two (6.2%) medical student, whereas the majority (81.2%) of them had highly educated fathers. The same was observed regarding the mothers’ education level.
[Table 3] shows that 68.8% of current smokers had fathers who were professionals, and only two students had fathers who were unemployed. Most of the nonsmokers (74.2%) had a professional father. More than half of the current smokers’ mothers had a professional job, and 37.5% were housewives.
One of the important findings from this study is the cause of smoking initiation among medical students; [Figure 1] shows that the most common and serious cause of smoking was stress (42%), and 23% reported that they smoke for entertainment.
Among the smokers, 57.3% of them used to smoke 1–10 cigarettes daily, 32.7% smoked 11–20 cigarettes daily, and only 13.1% were heavy smokers who smoke more than 20 cigarettes per day.
[Table 4] shows that all ex-smokers and most of the current smokers reported that they had smoking peers; also, half and more than one-third of their fathers were smokers, and this association was statistically significant. Regarding the nonsmokers, more than half of them reported that none of their family members smoke, but 81.2% reported that they had smoking peers and about 11.4% of nonsmokers mentioned that they had tried to smoke before, which makes them at risk to smoke later.
|Table 4 Smoking status among studied medical students, their family members, and peers|
Click here to view
[Table 5] explains the nicotine levels among studied students. Among the current smokers, 43% of students showed very low nicotine dependence level compared with the ex-smokers (83%). Among the ex-smokers, none had high or very high nicotine dependence level, whereas for the current smoker they were 6.25 and 18.75%, respectively, and this difference was statistically significant. There was a statistically significant association between quitting trials and cessation of this habit, where 50% of ex-smokers had succeeded to stop smoking from one trial, as shown in [Table 4].
|Table 5 Nicotine dependence level and quitting trials among current and ex-smokers|
Click here to view
| Discussion|| |
Smoking is not a new problem, but it has become a source of increasing concern owing to the increase in realization of its volume, especially among youth, and increased morbidity and mortality thereafter . In Egypt, smoking is a major public health problem with impacts on health, economy, and social aspects of the community. This situation is getting worse since 1990s, as it has become more prevalent among adolescents and young adults .
This study found that the prevalence of ex-smokers was 6.8% and current smokers was 12.0%. These percentages are higher than those previously found among younger-age Egyptian adolescents in Global Youth Tobacco Survey in 2005, in which the percentage of current smokers was 4.1% and for ex-smokers it was 13.6% ,, indicating that the problem increases on entering the university with reduced control over young adult behaviors during college time.
The prevalence of ex-smokers and current smokers is less than that found some years ago among nonmedical Egyptian university students (29.4%  and 20.2%, respectively, ). This may be because of more awareness of medical students regarding smoking consequences than other nonscience faculty students ,.
Although this prevalence of smoking is lower when compared with the general population, the Egyptian survey in 2007 revealed 22% for current smokers versus 17% for ex-smokers .
There was a statistically significant association between parents’ high educational level and parents’ professional jobs with students’ smoking status, and this agrees with the findings among United Arab Emirate university students  but disagrees with the results of 2007 Slovakia Global Youth Tobacco Survey ; although higher education meant more parents awareness, it is also associated with better socioeconomic condition and family welfare with shortage of parents’ supervision due to work.
Regarding mothers’ occupation, it was observed that among smoking students their mothers were either housewives or working in professional jobs; this may be because housewives are not aware about the rapid spread of smoking problem among youth and lower age of starting smoking, whereas mothers with a professional job are more busy with their career with no time to spend and to share activities with their sons; besides, they provide money for them. This status agreed with previous studies ,.
Regarding parental smoking habits, a statistically significant association was observed between smoking status and history of smoking of one family member, which could influence their decision to smoke. The presence of a negative role model within the family member, particularly the father, in our study strongly agrees with multiple researches among university and younger students ,,, as a risk factor for smoking initiation.
The majority of our study participants (80.5%) had smoking peers, which is considered to be a main motive for smoking initiation, and it drives attention for this important risk factor for getting back into this habit among the ex-smokers, which is considered as an obstacle for the current smokers to give up.
This percentage is much higher than that found in a previous Egyptian study in which participants with smoking friends represent 37%; also, other researches pointed to the strong influence of peers and friends ,,,. Therefore, observing and supervising the selection of friends in this age group is a very critical issue.
As expected, smoking was significantly more prevalent among males than among females. The females constituted 2.7% of smokers, which is the same as Pakistan and Egyptian studies , and much less than studies among United Arab Emirate university students, where female smokers constituted 8.9% , which can be attributed to high economic level in Gulf region.
In general, the Arab cultural norms make it less acceptable for females to smoke and it may be considered as a social stigma, whereas some cultures may promote smoking among men as mentioned for Chinese .
Various factors contribute and motivate medical students to smoke, such as stress, depression, part of entrainment, and so on. This study showed that the most reported causes were stress relief, followed by entertainment, sadness, and depression (42, 23, and 18%, respectively). The same was reported by a study in China, which showed that the major reasons for smoking among medical students were stress (42.8%), curiosity (34.4%), and loneliness (33.7%) . However, both Iraqi and Saudi Arabia medical students reported entertainment as the main cause of smoking for their smoking habit ,.
Among the nonmedical students, 23% of Egyptian university students smoke owing to feeling of gloominess and hopeless future, related to the political, economic, and social aspects of the community .
Quitting rate in the present study is considered to be high (43.7%), which was similar to a study among Chinese adults where it was also high (32%) . This matter is considered to be hopeful, although it disagrees with an Egyptian study in 2011, where it was 8.4% ; another Egyptian study in 2007 reported that 44% of smoking university students believed that quitting smoking is not possible at all .
An important positive observation in our study was that half of the ex-smokers succeeded to cease smoking from one trial and the other half from more than one trial, and a majority of the current smokers had tried to quit ([Table 5]); therefore, special training is required for medical students to assist them in giving up smoking.
For current smokers, the number of smoked cigarettes per day similar to that consumed by medical students in Iraq and Pakistan (57.7 and 55.0%, respectively) smoke (1–10 cigarettes per day) ,. Heavy smokers who smoke more than 20 cigarettes per day was 13.1% higher than that found by Fady et al.  among Iraqian medical students. However, consumption among nonscience faculty students was higher, whereas only 25% of smokers expire less than 10 cigarettes per day . This is because they are less aware of tobacco health hazards, and have more spare time and may be frustrated with less appreciation of the community for theoretical study.
However, in USA, the number of cigarettes smoked per day was less than 1 in 20% and less than 10 cigarettes per day in 80% of smoking university students .
It is important to mention that nicotine dependence was significantly very low and low among ex-smokers; this explains their success to quit. In addition, most of the current smokers had very low and low dependence level (43.7 and 18.75%, respectively). This finding is considered as a helpful factor for success of smoking cessation program when applied upon them.
This study revealed that cigarette smoking was a problem among medical students despite their awareness about tobacco health hazards. Family-related factors and sociodemographic factors were contributing to this problem, and the presence smoking peers had a great role in smoking initiation.
From this study, it is recommended to provide a free or low-cost help for students who are willing to quit cigarette smoking at medical schools and universities, and to encourage medical students to participate in educational projects to reduce the risk of smoking. In addition, it is important to encourage the role of the family to observe their children to detect this problem early at the proper time.
Also, the mass media should pay more attention to the negative consequences of this habit, and direct this message toward youth and college students.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]