Smoking Pattern in Students of a Selected Medical College in Bangladesh

Background: Smoking is a recognized harmful factor for general health. The prevalence of smoking is gradually increasing among the young people. Medical students are also vulnerable in this arena. Worldwide studies revealed that students start and continue smoking during their school and college periods. Objectives: To determine the current tobacco use among medical college students and to find out the risk factors associated with smoking and also to assess the knowledge of students regarding smoking. Materials and Methods: This cross-sectional study was conducted among medical students of different educational levels (first year to fifth year) in Enam Medical College, Savar, Dhaka during the period January to March 2012. An anonymous, pretested, selfadministered study questionnaire was distributed among the subjects. Data collected included smoking habits, demographic factors such as age, gender, parents’ occupation and monthly income. Study subjects were categorized as smokers, non-smokers and ex-smokers. Smoking-related knowledge was assessed and opinion regarding cessation of smoking was documented. The data were entered into the computer and statistical analyses were done using GraphPad Prism version 6.01. Results: Among the study subjects 290 were male and 202 were female. There were 79 (27.24%) smokers, 199 (68.62%) non-smokers and 12 (4.13%) ex-smokers among male and 197 (97.52%) non-smokers, 4 (1.98%) smokers and 1 (0.49%) ex-smoker in female. Regarding age, 196 (39.83%) students were below 20 years of age and 296 (60.16%) were more than 20 years of age. Most of the smokers (43.37%) are from affluent families. Influence of friends (44.57%) is the major reason of smoking followed by depression (27.71%). About 37.34% smokers have family members who are currently smoking. Regarding quitting smoking, 66% intended to stop smoking. The reasons for no intention to stop smoking include lack of incentive followed by addiction. There are significant differences among study subjects regarding smoking related knowledge. Conclusion: Even medical students are not fully aware of health consequences due to smoking and this lack of knowledge may lead to increase the number of smokers among students. Appropriate anti-smoking measures should be taken to create awareness about smoking and its health consequences and to reduce the incidence of smoking among the students.


Introduction
2020.If t he current tobacco use epidemic continues, more than 70% of these deaths are likely to occur in developing countries. 2cording to WHO, health professionals can have a significant influence (positive or negative) on the smoking habits of a community. 3Doctors who smoke tend to be more permissive, less inclined to advise their patients against tobacco use, and show a p assive attitude towards smoking. 4Medical science students, such as doctors, nurses, p harmacists or health administrators can p lay a central r ole in preventive programs due to their appropriate knowledge and attitudes. 5The college years are a formative period when m any young adults experiment with new ideas and behaviors that can have an impact on the rest of their lives.So medical schools can use the opportunity to reach students during their undergraduate years and address the subject of smoking. 6A multi-country survey (1986--1989) showed t hat medical students themselves lack adequate knowledge about smoking-related diseases and t obacco cessation techniques. 7 designed this study to determine the current use of tobacco among medical students in Enam Medical College Hospital to find out the risk factors associated with smoking and to assess their attitudes and knowledge regarding smoking.

Materials and Methods
This cross-sectional study was conducted among medical students of different educational levels (first year to fifth year) in Enam Medical College, Savar, Dhaka during the period January to March 2012.An anonymous, p r etested, selfadministered study questionnaire was distributed among the subjects.A modified version of the standard World Health Organization (WHO) questionnaire was used for this survey. 8Ethical approval was obtained from the appropriate authority.Total 492 students completed t he questionnaire.
Students were explained the purpose of the study and confidentiality was assured.Data collected included smoking habits, demographic factors such as age, gender, parents' occupation and monthly income.Study subjects were categorized as smoker, non-smoker and ex-smoker.Smokers were defined as respondents who were currently smoking, non-smokers as who never smoked and ex-smokers were defined as respondents who used to smoke before and currently not smoking.Smoking habit was assessed as: age of starting smoking and quantity of smoking.Students were also asked about reasons of smoking, presence of smokers in the family and smoking cost.Students' intention to quit smoking was also addressed.Smoking-related knowledge was assessed and t heir opinion r e garding cessation of smoking was documented.
The data were entered into t he computer and statistical analyses were done using GraphPad Prism version 6.01.The association between dependent and explanatory variables was assessed using χ 2 test.Statistical significance was set at p<0.05.

Results
In this study total population were 492.Among them 290 were male and 2 0 2 were female.All r e spondents completed questionnaire, giving a response rate of 100%.The high response rate minimized the risk of bias due to the population not being representative of the target population.There were 79 (27.24%) smokers, 199 (68.62%) non-smokers and 12 (4.13%)ex-smokers among male and 197 (97.52%) nonsmokers, 4 (1.98%) smokers and 1 (0.49%) ex-smoker in female.Regarding age, 196 (39.83%) students were below 20 years of age and 296 (60.16%) were more than 20 years of age.
Table I shows occupation and monthly income of the parents of the study subjects.There are no significant differences in term of occupations and monthly income of parents among the three groups of study subjects.

Discussion
In t his study 1 6 .9% of study subjects r e ported themselves as smokers.This is consistent with the study done in medical students in Riyadh, Saudi Arabia where the prevalence is 18%. 9Similarly it was 22% among Iranian dental students. 10In a review study of smoking in dental students in 19 countries, the prevalence was between 3% in Canada and 47% in Greece. 11 this study there were 79 smokers and 12 ex-smokers among 290 males and 4 smokers and one ex-smoker among 202 females.Male are predominant (27.24%).This is consistent with the study done in Turkey and Casablanca where prevalence of smoking among healthcare students were high in male students (28.3% and 16% respectively). 12,13 this study it was found that smokers and ex-smokers are from affluent families which was based upon their parents' occupation and monthly income.This may suggest that smokers can easily smoke as they do not have any financial constraint.
In our study, m ost of t he smokers (n=71) started smoking at the end of school tenure and beginning of college life.This was consistent with another study which found that most of the smokers started smoking prior to university. 14In contrast, in the study done by AlSwailem et al 15 it was found that current smokers started smoking after starting university.
In this study, 44.6% smokers mentioned that influence of friends was the major reason of smoking.A study done among medical students in Saudi Arabia found strong association of smoking and influence of close smoker friends. 16AlSwailem et al 15 also found association between smoking and influence of friends.
In our study, second reason of smoking was depression (27.71%).[19] In our study we did not find any association between smoking and presence of smokers in family members.About 62.65% study subjects did not have any smokers in family.AlSwailem et al 15 also did not find any association b e tween p r esence of smoking family members and smoking habits.In contrast, Dar-Odeh et al 20 reported significant association between students and parental smoking habits.
Smoking-related knowledge is important as it plays a great role to assess tobacco as risk factor and to take measures for control and prevention of smoking-related diseases.About 94% of smokers admitted that smoking is harmful for health and nicotine can cause cancer.This is consistent with the studies done by Saji et al 21 and Xu e t al 22 .In our study t here is statistically significant difference in knowledge about adverse health effects of smoking among smokers, non-smokers and ex-smokers groups.It is inconsistent with the study done by Merdad et al 16 who found no statistically significant findings between smokers and non-smokers in t heir knowledge about the harmful e ffects of smoking.
In this study 66% smokers intended to stop smoking.Memon et al 23 found that 47% of smokers wanted to stop smoking.Raina et al 24 revealed in a study that 53.3% cigarette users expressed the desire to stop smoking.All these studies indicate that there is a positive attitude towards quitting.
We have some limitations in this study.The findings of this study cannot be generalized t o t he whole population as it was conducted on a small sample.Our study was b ased on self-reported information on smoking, so there are chances of under-reporting of smoking status among the study subjects.
It is a matter of great concern that tobacco consumption is gradually increasing among the students of schools and colleges.Depression due to lack of healthy recreational activities, stressful social circumstances, peer pressure, less parental supervision and inadequate knowledge about risks of health due to smoking have a major contribution for involvement in such an injurious habit.Promotion of more anti-smoking campaign and establishment of smoking counseling centers in the academic institutions are necessary t o increase awareness r e garding smoking among t he young generation.

Table I :
Distribution of study subjects according to occupation and monthly income of the parents

Table
II shows the age of starting smoking in study subjects.There is no significant difference in starting age between smokers and ex-smokers.TableIIIshows number of sticks taken by the smokers daily.TableVshows distribution of study subjects according to presence of smokers in family.There is no significant difference in term of presence of smokers in family among the three groups.TableVIIIshows distribution of study subjects according to smoking cost in three groups.There is no significant difference in smoking cost among these groups.

Table VI :
Distribution of study subjects according to smoking cost