September - December 2003: 
Volume 16, Issue 3

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Evaluation of smoking habits in students of the Athens Medical School - Clinical Study
ABSTRACT. Smoking is considered responsible for the death of millions of people every year around the world. The aim of this survey was to evaluate the smoking habits of medical students at the University of Athens, since they are expected to have leading role in antismoking campaign due to their doctor status in future. A 32-item anonymous questionnaire was distributed to a random sample of 418 students, 231 males and 187 females, at Athens Medical School, irrespective of the semester they attended. Statistical analysis was performed using the SPSS program. Sixty-eight percent of the students were found to have tried smoking; of them, 40% are regular smokers, 47% occasional and 13% ex-smokers. Thirty five per cent of smokers started smoking at some age between 15-18 years and 27% are light smokers (1-10 cigarettes daily). Males reported that the main reason for starting smoking was pleasure (32%), whereas females said it was anxiety (28%) or curiosity (28%). Smoking habit is related to alcohol consumption (p=0.0001). Lastly, 8% of the students are unaware of the adverse effects smoking has on health. In conclusion, more efforts to educate students about the harmful consequences of smoking are needed, so as to reduce the percentage of smokers among medical students. Pneumon 2003, 16(3):314-321.
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According to World Health Organization (WHO) data, smoking is considered responsible for the death of millions of people around the world every year and is undoubtedly associated with cardiopulmonary morbidity and mortality1.

In particular, it is estimated that in the 20th century some 100,000,000 deaths associated with tobacco use, whereas in Europe alone smoke-related deaths are reported to be 1,200,000 annually and are expected to reach 2,000,000 by year 2020.2 As regards the incidence of lung cancer, studies conducted in North America, Europe and Japan indicate that 83-92% of lung cancer cases in men and 57-80% of lung cancer cases in women are attributed to smoking2.

Despite the serious health problems associated with smoking, the incidence of smoking is high. In the European Union, 42% of males and 28% of females are regular smokers2. In Greece, 46% of males and 28% of females smoke3. The incidence of smoking among doctors is similarly high; in our country, it is reported to be 40% among all doctors4. This has been a source of considerable concern, since doctors are expected to play a leading role in the educational efforts aiming to limit the spreading of the smoking habit. A study conducted in Great Britain has confirmed the strong impact of the participation of doctors in smoking cessation educational programs5.

A relevant survey showed that Greek doctors who were smokers themselves tended to underestimate the effects of smoking on health and, consequently, understate them when patients consulted them about smoking-related subjects. In fact, quite a few thought that providing information about the risks of smoking is a waste of time and will have no effect whatsoever. On the contrary, non-smoking doctors valued patient education about the risks of smoking. A survey conducted on Italian pulmonary medicine specialists concluded to similar results; smokers were found to underestimate their educative role about the harmful effects of smoking in a greater extent compared to their non-smoking counterparts7.

Since doctors are expected to play a leading role in the promotion of antismoking attitudes, the aim of the present survey, which was designed and conducted by the Laboratory of Physiology, University of Athens, was to evaluate the smoking habits of students at the Medical School of the University of Athens, as well as record the reasons that led them to smoking and their awareness of the harmful effects of smoking on health.


The survey was conducted from the beginning of the year 1999 through the end of the year 2000. Our subjects were 430 randomly selected students at the Medical School of the University of Athens. Our sample included students who either attended any of the courses in the twelve-semester curriculum of the school or had completed clinical practice and only had to pass some courses in order to graduate. All subjects were requested to anonymously complete a special questionnaire designed by the Greek Antismoking Society and intended to record smoking habits of general population. This questionnaire is comprised of 32 items that relate to smoking habits and knowledge about the effects of smoking on health.

In particular, the first part of the questionnaire is concerned with demographic data (age, gender, place of residence, semester attended by the respondent), as well as with information related to family environment (occupation and educational level of the respondent's parents) and the medical history of the respondent's parents.

The second part of questionnaire comprehensively investigates smoking habits (age at initiation of the habit, past smoking habits, number of cigarettes smoked daily at present, daily intake of nicotine, money spent on smoking), the motive for starting smoking, the influence of family and friends on starting this harmful habit, and efforts of the respondent to quit smoking. Needless to say that only smokers had to complete this part of the questionnaire.

The last part of the questionnaire inquired into the respondent's awareness of the harmful effects of tobacco use, the association of smoking with alcohol consumption, and the attitude of the respondent towards banning smoking in public places. All students (both smokers and non-smokers) completed this part of the questionnaire.

Twelve questionnaires were excluded from statistical analyses owing to invalid completion. Hence, responses from 418 medical students, of which 231 (55%) were male and 187 (45%) female, were entered for statistical analysis.

Statistical analysis: Descriptive measures of quantitative variables are reported as mean±1 standard deviation (SD). Differences were evaluated using chi square test with Yates' correction. The statistical package SPSS (SPSS Inc., IL, USA) was used for all statistical analyses. A P value lower than 0.05 was considered statistically significant.


Data analysis showed that of a total of 418 medical students, 283 (68%) have tried smoking; 40% have become regular smokers and 47% occasional smokers, whereas 13% define themselves as ex-smokers (Table 1). 135 (32%) students have never smoked. Regular, occasional and ex-smokers comprise 28%, 32% and 8% of the total of the 418 medical students questioned, respectively.


Table 1. Smoking habits of students who smoke

Smoking habits                   Regular smoking             Occasional smoking            Smoking cessation

  283 (100%)                            115 (40%)                          132 (47%)                           36 (13%)


Male smokers

163 (58%)                                 72 (44%)                            69 (42%)                            22 (14%)

Female smokers

120 (42%)                                 43 (36%)                            63 (52%)                            14 (12%)


Of the 283 smoking medical students, 163 (58%) are male and 120 (42%) female. The respective figures in non-smokers are 68 (50%) and 67 (50%). There is no relationship between gender and regular smoking (p=0.14) or between gender and occasional smoking (p=0.23). Age of starting smoking is 10-14 years in 5%, 15-18 years in 35% and 19 years or older in 19% of smoking students; 31% have not answered this question (Figure 1A). There is no relationship between gender and age of starting smoking (p=0.4). As regards daily cigarette consumption, 22% smoke 1-10 cigarettes (light smokers), 22% smoke 11-25 cigarettes (moderate smokers) and 6% over 25 cigarettes (heavy smokers) daily; the remaining 45% have not responded to this question (Figure 1B). Daily cigarette consumption is not associated with gender (p=0.4).

Figure 1. Distribution of smoking students according to age of starting smoking (A) and daily cigarette consumption (B).

However, age of starting smoking has been found to be associated with daily cigarette consumption (p=0.01). Students who started smoking at a younger age (10-14 years old) smoke more cigarettes daily than their counterparts who started smoking at the age of 19 years or older.

Reasons for starting smoking cited by males include pleasure (32%), stress management (25%), curiosity (24%), influence of peers (14%) and other (5%) (e.g. risky habit, example of parents/teachers). Females responded that they started smoking in order to relieve stress (28%); out of curiosity (28%); for the pleasure of it (25%); because they were influenced by their peers (17%) or because of various other reasons (2%) (Figure 2B).

The majority of smoking students responded that they were not influenced by tobacco advertisements in their decision to start smoking (76%); 5% responded that they were indeed influenced and the rest (19%) did not give any response. The effect of tobacco advertising was not related to gender (p=0.375).

As regards the place where they smoked for the first time, 26% responded it was a recreation site; 19% smoked their first cigarette in their home and 4% in a friend's home. Forty per cent of smoking students did not answer this question (Fig 2C). There is a positive relationship between alcohol consumption and tobacco use (p= 0.0001); smoking students were found to consume more alcohol than non-smoking students (Figure 3).

Figure 2. Distribution of smoking students according to reasons for starting smoking (A and B) and the place where they smoked for the first time (C).


Figure 3. Distribution of students according to smoking habit and alcohol consumption.

The question of whether they are bothered by the smoke of others or not was given a positive answer by 94%, a negative answer by 5% and no answer by 1% of the total of students (Figure 4A). Gender was not related to being bothered by smoke (p=0.645). It was, however, found that students who smoke only a few cigarettes daily are more frequently bothered by smoke compared to those who smoke many cigarettes (p=0.0082). There was also a relationship between age of starting smoking and being bothered by the smoke of others (p=0.003); i.e. those students who started smoking as adults appear to be more frequently bothered by the smoke of others compared to their counterparts who started smoking at a younger age.

Seventy four per cent of all medical students questioned believe that smoking in indoors private or public places should not be allowed; 23% feel that it should be allowed, whereas 3% did not answer this question (Figure 4B). As regards awareness of the harmful effects of smoking on health, 66% of all students consider them selves aware, 8% unaware and 26% gave no answer (Figure 4C).

Lastly, the questionnaire addressed the issue of smoking cessation and the following responses were recorded: i) 39% intend to quit smoking within the next 10 years, ii) 26% have tried to give up smoking, iii) 19% managed to quit smoking for a few months and iv) 13% have definitively given up smoking.

Figure 4. Distribution of students according to whether they are bothered by the smoke of others (A), their view on smoking prohibition in indoors private or public places (B) and awareness of the harmful effects of smoking on health (C).


The present survey has shown that 28% of all students at Athens Medical School are regular smokers. This high rate of smokers is a cause of concern since these students are the future doctors who are expected to assume a large part of the responsibility to educate the community and lead the fight against smoking.

Furthermore, a quite high percentage of students (32%) were found to smoke occasionally, i.e. not daily. These students are on the verge of either becoming regular smokers or quitting smoking. Hence, it is believed that if these students are provided with more information about the harmful effects of smoking, we may be able to increase the percentage of those who quit smoking.

The rate of smoking students at Athens Medical School is nevertheless higher compared to respective rates reported from Medical Schools in other countries, such as the Czech Republic8, Hungary9, Brazil10, Asia11 and USA12. A possible explanation for this difference is that the percentage of smokers in the general Greek population is similarly reported to be higher compared to respective percentages in other countries3.

Daily cigarette consumption was found to be small to moderate in the majority of students; only 6% are heavy smokers. This may be a consequence of their spending a great deal of time in places where smoking is not allowed, i.e. hospitals, outpatient clinics, laboratories.

It is noteworthy that most of those who smoke heavily have started smoking at an early age (10-14 years). This finding is consistent with other surveys conducted in Greece and abroad13-15 and pinpoints the need to direct educational efforts about the health risks associated with smoking at early ages so as to prevent the initiation of smoking.

Our survey revealed that the reasons that led medical students to smoking include stressful events, curiosity and pleasure; the majority of the students deny that tobacco advertising influenced them, which is in sharp contrast with the responses given by students in other countries.18 However, it has been shown that tobacco advertising has a strong subliminal effect19,20. In consequence, medical students at the University of Athens may actually be unaware of the effect tobacco advertising has been having on them since their childhood years using appropriate stimuli and projecting models of behavior that subliminally prompted them to start smoking. A survey conducted on 3385 school age children in Seville showed that tobacco advertising encouraged children to start smoking using messages that promoted smoking as a means of emancipation and independence. Conclusively, tobacco advertising is so successful in promoting tobacco use at youth that its well-designed and skillfully covered ways are sometimes not realized at all.

Interestingly, 39% of smokers intend to quit smoking within the next 10 years and 26% have already tried to give up smoking. This means that these persons wish to quit smoking and have tried not to smoke, but their addiction to nicotine may make it difficult for them to stop smoking. It is suggested that the implementation of a special smoking cessation program using nicotine substitutes (e.g. nicotine gum, patches etc), as the one implemented in the USA, may help these students quit smoking. An encouraging and promising finding of our survey is that the overwhelming majority (94%) of medical students (smokers and non-smokers) are bothered by the smoke of others (passive smoking) and 74% believe that smoking should not be allowed indoors and in private places. This may be a result of their awareness of the effects of passive smoking on health, i.e. cardiovascular and respiratory morbidity23,24, as well as delivery of small for gestational age infants25. Medical students should disseminate their knowledge about smoking-related health risks to their patients and the general public, so as to increase public awareness and encourage the community to accept the ban on smoking in public places, not as a restrictive measure but as a measure to protect public health.

Another interesting finding is that although 66% of medical students say that they are aware of the association of smoking with early death, they still continue to smoke. A possible explanation is that since they are very young, they feel that death is a remote event; hence, the argument that "smoking leads to an early death" does not seem to have a dissuasive effect. Subsequently, short-term harmful effects of smoking should form the basis of messages to deter young people from smoking, as messages that inform about the effects a young person will experience in the near future rather than many years later are expected to be more effective.

Surprisingly enough, 8% (34) of respondents state that they are not aware of the harmful effects of smoking on health. Providing that all respondents were students of medicine, this rate is evaluated as particularly high and, most likely, reflects the inadequate education of young people about smoking-related issues. Therefore, educational efforts should be enhanced with appropriate effective programs, like the one implemented in France26 that led to a reduction in cigarette consumption by 11.1%, or another relevant program implemented in the USA27.

As regards medical students in particular, a program specifically designed to provide them with the education they need to handle their smoking patients effectively and dissuade them from smoking should be conducted. Such a program has been implemented in the Medical School of Brazil.

Conclusively, the important role of educating medical students about smoking-related health risks in the fight against smoking is highlighted, since medical students of today will be called upon to lead by either their non-smoking example or their clinical advice and practice the way to the reduction of tobacco use and smoking cessation.


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