Role of family and peers in the initiation and continuation of smoking behavior of future physicians.

BACKGROUND: Globally researchers have long back noted that the trend of substance use was on the rise particularly in the student population.
OBJECTIVE: To find out the prevalence and determinants of smoking practices among undergraduate medical students.
MATERIALS AND METHODS: A cross-sectional study was conducted among undergraduate medical (MBBS) students of a tertiary care medical college using a predesigned and pretested semi-structured self-administered anonymous questionnaire.
RESULTS: Among 182 participants, 55 (30%) were smokers; 85.45% were regular smokers; majority in the age group 20-22 years (70%); mostly males (98%). No significant difference was observed among urban and rural students, and religion had no association. The practice of smoking for last 6 months to 1 year was in 43.6% and 40% smoked less than 6 months. Half of them (50.9%) smoked 5-9 cigarettes per day. Peer pressure was significantly high in smokers (83.6%); 42% had other addictions. The effect of parental smoking on smoking habits of the participants was quite evident among smokers (82%), which was significantly higher than nonsmokers (χ(2) = 63.49, P < 0.05). Peer pressure was the most important risk factor (57.69%) of initiation of smoking habit followed by parental influence (16.49%). Among morbidities of smokers, 60.6% were suffering from regular cough, 6% from bronchitis, and 2% had asthma.
CONCLUSIONS: Our survey conducted on budding doctors surprisingly showed that undergraduate medical students smoke so much.

Smoking, the modern epidemic, has crossed its peak in developed countries, showing an upward trend in the developing countries that adversely affects health, starting from smokers cough and ends in lung cancer. More than 25 diseases are now known or strongly suspected to be causally related to smoking.[1] Use of tobacco is the second major cause of death in the world and reduced life expectancy.[23] World Health Organization (WHO) estimated that there are about 100 million smokers in the world. Globally 47% of men and 12% of women smoke. In India, 65% of all men use some form of tobacco, among which 35% by smoking, 22% use smokeless tobacco, and 8% both.[4] WHO experts also included prevalence of tobacco use among subgroups, such as physicians, nurses, other health workers, so on.[5] The rates of substance abuse vary from one study to the other as different substances and different definitions of substance abuse have been used in each of them. The problem is spreading to all socioeconomic groups; illicit drug trade is spreading to small towns and rural areas, new and multiple drug use has increased among the adolescents and the youth.[6] Globally researchers have long back noted that the trend of substance use was on the rise, particularly in the student population.[7] Premature initiation of substance use is usually associated with an unfortunate prognosis and a lasting pattern of behavior.[8] Medical students belong to that age group when lifestyles, both healthy and unhealthy, are formed. Being future doctors, they are the role models for patients. But, if they themselves are entangled in the web of dependence of tobacco, then the smoking cessation program will be a failure. With this background the present study was carried out with the objectives to find out the prevalence and determinants of smoking practices among undergraduate medical students in a tertiary care teaching institute in West Bengal.

Materials and Methods

Study design and settings

A descriptive observational cross-sectional epidemiological study was conducted among 182 undergraduate medical (MBBS) students of a tertiary care medical college of West Bengal of the academic session 2007-2008 and 2008-2009.

Study period

Time for study was February-March, 2010.

Study instrument

The predesigned and pretested data collection tool adopted during data collection was a questionnaire that was developed at the institute with the assistance from the faculty members and other experts. This semi-structured self-administered anonymous questionnaire contained questions relating to the sociodemographic situation prevailing in east India. By initial translation, back-translation, re-translation followed by pilot study the questionnaire was custom-made for the study. The questionnaire had two parts: The first part was on socioeconomic and demographic characteristics. This included the variables age, sex, religion, community status, educational status, and per capita monthly income. The second part was on the smoking pattern. A pilot pretesting study was carried out among 20 similar students in other years. Following this, rectification of the questionnaire was done by necessary correction and modification and then structuring of questions were done before final data collection.

Main outcome variables

Prevalence and determinants of smoking practices.

Sampling design

Everyone was selected from two classes sent to our department for routine class. They were feasibly approachable. All students of these two classes were sample frame and census population of these two classes participated in the study.

Data collection procedure

Institute Ethics Committee approved the study. Date and time was fixed up. There were 200 students in the academic year 2007-2008 and 2008-2009. All the participants were briefed about the purpose of the study and were ensured strict confidentiality and then verbal informed consent was taken from each of them before the data collection. The participants were given the options not to participate in the study if they wanted. The participants were requested to fill in the predesigned, pretested, and semi-structured questionnaire containing both open-ended and close-ended questions. The participation was voluntary and not compulsory. The unwilling participants and absent students for consecutive days of data collection were excluded in the study. They were told not to write their names to maintain the anonymity and confidentiality. Parental tobacco use was defined as habit of smoking tobacco by either or both parents. Out of 200 students, 182 were found to respond finally. The principal investigator collected the data and disseminated the information on morbidity in health education sessions to complement the findings of the study.

The following criteria of smokers were used:[9]

Nonsmoker: One who had never smoked.

Occasional smoker: One who smokes less than once a week, on special occasions or has only puffed few times.

Regular smoker: One who smokes daily.

Statistical analysis

The collected data were thoroughly cleaned and entered into Excel spread sheets and analysis was carried out. Compilation of data were done through tabulation and then proper statistical tests were applied in data interpretation.

Results

Among 182 participants, 55 (30%) were smokers; among smokers, 47 (85.45%) were regular smokers and 8 (14.55%) were occasional smokers. Majority of smokers were in the age group of 20-22 years (70%). Most of them were male (98%). No significant difference was observed among urban and rural students and religion had no association. Among smokers, majority (43.6%) was in the practice of smoking for last 6 months to 1 year and 40% smoked for <6 months; very few (5.5%) smoked for more than 5 years [Table 1].

Table 1

Duration of smoking among medical students

It was found that more than half of the responding (50.9%) students used to smoke 5-9 cigarettes per day; 23.6% is <5% and 25.5% consumed 10 or more per day [Table 2].

Table 2

Distribution of students according to the number of cigarettes smoked per day

Among smokers, peer pressure was found in 83.6% cases, whereas among nonsmokers peer pressure was present in only 7% cases. The peer pressure was significantly high among smokers (χ2 = 116.81, P < 0.05) [Table 3].

Table 3

Distribution of students according to the presence or absence of peer pressure

Forty-two percent students had other addiction. Among smokers, almost 70% had other addiction and among nonsmokers only 30% had other addictions. Other addiction was significantly higher among smokers than nonsmokers (χ2 = 24.39, P < 0.05) [Table 4].

Table 4

Distribution of students according to any other addiction

Effect of parental smoking on smoking habits of the participant was quite evident among smokers (82%) that was significantly higher than nonsmoker (χ2 = 63.49, P < 0.05) [Table 5].

Table 5

Effect of parental smoking on smoking habits of the medical students

It was seen that peer pressure was the most important risk factor (57.69%) of initiation of smoking habit followed by parental influence (16.49%) [Table 6].

Table 6

Distribution of risk factors among participants for initiation of smoking

We also inquired them about their awareness on the widely advertised adverse health effects of cigarette smoking, most of the students responded that they knew about lung cancer, heart problems, bronchitis, asthma, hypertension, and others. Lastly, they were asked about any problem faced due to smoking. Majority (60.6%) responded that they were suffering from regular cough. About 6% students were suffering from bronchitis and another 2% had asthma. About 31.4% responded that they had no health problems.

Discussion

In the present study, we tried to find out the overall prevalence of tobacco smoking practices among undergraduate medical students who were the role models for their patients.

The WHO study report on youth and drugs supported our finding that youngsters first try drugs on an experimental basis often motivated largely by curiosity and peer pressure, which is one of the most important reasons for initiation of substance use.[7]

In our study sample, the overall prevalence of smoking was 30%. In a study at Lucknow by Kumari, the prevalence was almost similar, that is, 25.2%, which was also comparable to a study conducted at Pakistan (22%).[1011] The corresponding figure of tobacco use in other studies done at Kerala was 14.7% and Orissa 12.4%.[1213] Another study by Medical cadet Virendra Singh showed that it was 46%.[14] Among the 55 smoker students, 47 students (85.45%) were regular smokers and 8 students (14.55%) were occasional smokers, which has increased enormously from another study reported from West Bengal three decades back where only 3.2% of the males were current smokers.[15]

The smoking rate among female students was found lower in our study, which was similar to other studies. A study on smoking among medical students in Pakistan revealed that the proportions of eversmokers among males and females were 48.3% and 6.7%, respectively, and of current smokers were 23.2% and 1.3%. The proportion of males and females smoking daily was 14.7% and 0.7%, respectively.[16] However, as compared to a previous survey, there was a slight increase in smoking rates among female students, probably due to improvement in women's social status and empowerment.

There was no association between the residential background and tobacco smoking habit. Other studies also showed similar results.[16] Religion had no association in our study, comparable to a study done at Lucknow.[10] The main factor for initiating the use of tobacco was peer pressure in our study. Other studies also showed similar cause for initiation of smoking.[7] This effect of peer pressure was a very serious concern. In the present study, there was a significant association between presence of a smoker in the family and smoking behavior of the students. Many other studies also showed this trend.[10141718]

A questionnaire survey was conducted among all medical students with at least 2 years of medical education studying at 3 medical colleges in Pakistan. Of the 1529 respondents (544 males and 985 females), 21.5% were eversmokers (smoked at least once in their lifetime): 9.1% current smokers (including 5.7% daily smokers), 0.7% exsmokers, and 11.7% occasional smokers. The proportion of nonsmokers who knew about the addictive and harmful nature of cigarette smoking was higher than that among the smokers.[16]

Use of substances by family members and peers having a significant relationship with that of substance use among the students was also found in studies from India. In an Indian study the researchers observed that family members and friends were found to have a considerable influence not only on initiation but also important sources for money as well as the substance. Easy availability in the neighborhood was also an important correlate to continuation of substances. It was concluded in that study that family environment as well as peer groups has an important bearing on initiation and continuation of substance use. Experimentation of substance use motivated by peer groups is common among adolescents and starts early in life. Hence, it is necessary to provide health promotion programs directed toward students and their families, which encourage attitude shaping among school children toward self-confidence and adequacy.[19]

Users are mainly responsible for influencing their peers and close contacts into taking up the habit, as was seen in the present study as well as in other studies. Influence of peers and close contacts who use substances were usually responsible for initiating their use in others and this was evident in the present study as well as in related studies.[2021]

From the present study, it was also found that medical students were aware about the adverse effects and health hazards of smoking. Our study as well as other studies showed that smoking was significantly associated with other addictions. We could reveal the dilemma of substance use among undergraduate medical students in eastern India. We also observed that use of the substance by close relations had a significant impact on its use by their children.

We had several limitations. We could not do multivariate analysis to assess the impact of different factors that could have interfered in the final outcome analysis. The study findings also gave us hints that in spite of behavior change communication (BCC) against drug addiction, such as campaigns, education, and legal prohibition of production and sales, and restrictions of smoking at public places, there had not been any considerable decline in the use of tobacco smoking.

Future direction of the study

Future directions of the study should focus on primary prevention. Health impact due to tobacco may be bigger than projected if these young doctors continue to consume tobacco as idols for the society at large. Further epidemiologic exploration and interventions to curb tobacco use among the growing future generations is the call of the day.

We recommend that prevention of initiation of smoking should merit more attention since this will improve the outcome of a dream of smoke free society on a long run.

Early onset of smoking habit calls for effective measures directed against the younger age groups. Educational intervention at the school level might appear as one of feasible measures to prevent initiatives toward the use of substances. Caregivers should be motivated to share a healthy relationship with their children and give more time to them, especially in the growing stages when deviant behavior can influence them easily. Effective control can be achieved by education, advocacy, and legislation on the hazards of substance use among students, and this is the most effective educational measure to control it.

Conclusion

Our survey conducted on budding doctors surprisingly showed that smoking is prevalent among undergraduate medical students. The findings not only reflect their attitude toward tobacco but also send a misleading message to the public. Early recognition of the extent and pattern of substance use among them can improve scopes for holistic approaches before solutions become easier said than done.