Despite extensive data indicating that health-care. A Comparison of Smoking Habits Among Medical and Nursing Students*

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1 A Comparison of Smoking Habits Among Medical and Nursing Students* Ashwin A. Patkar, MD; Kevin Hill, MD; Vikas Batra, MD; Michael J. Vergare, MD; and Frank T. Leone, MD, FCCP Objective: The approach and credibility of future physicians and nurses as treatment providers for smoking- and tobacco-related diseases may be influenced by their smoking habits. We compared smoking habits among medical and nursing students, and examined whether these habits changed during the course of education for each cohort. Method: Over 1,100 medical and nursing students from a university were surveyed in year 2000 using a questionnaire that included the Fagerstrom test for nicotine dependence (FTND). Results: A total of 397 medical students and 126 nursing students completed the survey. Significantly fewer medical students (3.3%) smoked compared to nursing students (13.5%). Also, significantly more nursing students were former smokers (17.8%) than medical students (9.8%). The severity of nicotine dependence, as indicated by the total FTND score as well as scores on five of the six items on the FTND, was significantly lower among medical students compared to nursing students. Smoking or quit rates did not differ across class years in both groups; however, unlike nursing students, time since quitting significantly differed across class years for medical students. Although smoking habits appear to change little during the course of education for both medical and nursing students, many smokers may have quit just prior to entering medical school but not nursing school. Conclusions: The findings confirm the continuing decline in smoking among medical students in the United States; however, increased efforts to promote tobacco education and intervention among nursing students seem necessary. Nevertheless, both groups appear to have the potential to be credible advisors to patients and public regarding smoking cessation. (CHEST 2003; 124: ) Key words: medical students; nicotine; nursing students; smoking; tobacco Abbreviations: df degrees of freedom; FTND Fagerstrom test for nicotine dependence Despite extensive data indicating that health-care providers can help smokers to quit, medical and nursing practitioners have generally not been proactive in providing smoking cessation services to patients. 1 3 Inadequate undergraduate education about tobacco treatment has been reported to be one of the many factors that may contribute to the missed *From the Department of Psychiatry and Human Behavior (Drs. Patkar and Vergare), Division of Critical Care (Drs. Batra and Leone), Pulmonary Allergic and Immunologic Diseases, Department of Medicine (Dr. Hill), Jefferson Medical College and Thomas Jefferson University, Philadelphia, PA. This work as performed at Thomas Jefferson University and Jefferson Medical College, Philadelphia, PA. Manuscript received October 10, 2002; revision accepted March 26, Reproduction of this article is prohibited without written permission from the American College of Chest Physicians ( permissions@chestnet.org). Correspondence to: Ashwin A. Patkar, MD, Associate Professor of Psychiatry, Thomas Jefferson University, 833 Chestnut St East, Suite 210E, Philadelphia, PA 19107; ashwin.patkar@ mail.tju.edu opportunities by health practitioners to provide effective tobacco-treatment interventions to their patients. 4 In an attempt to improve the participation of health-care providers in smoking cessation efforts, the National Cancer Institute recommended including tobacco-treatment education in the curricula of all US medical schools by However, several more recent reports 6 8 suggest that the overall rate of inclusion of tobacco control training in medical as well as nursing school education continues to remain relatively low, the focus is somewhat superficial, and few schools actually teach specific smoking cessation interventions. Over the past 50 years, tobacco use among medical students in the United States has steadily declined, and surveys have found that only 2 to 10% of the graduating medical students in the United States used tobacco compared to smoking rates of 25% in the general population during the 1990s. 9,10 Relatively less data are available on smoking trends in CHEST / 124 / 4/ OCTOBER,

2 nursing students in the United States, but reports 11,12 indicate that prevalence rates of smoking range from 15 to 25%. In 1999, a multidisciplinary model to offer smoking cessation services and develop smoking-related education and research activities was established at Thomas Jefferson University, Philadelphia. An important mission of this center was to improve curricula for smoking-related education for medical and nursing students in the university. We believed that prior to implementation of new curricula, basic information about tobacco smoking among medical and nursing student population would be important since their approach and credibility as treatment providers may be influenced by their own smoking habits. Additionally, the information on possible differences in smoking habits of medical and nursing students may help to individualize the educational program for medical and nursing students, as emphasized by the National Cancer Institute expert panel on promoting undergraduate education in smoking cessation. 5 Alhough sufficient data about smoking habits of medical and nursing students exist, frequently the data collection instruments did not include assessments of severity of smoking. Also, relatively few studies have reported on smoking habits of these groups in the United States during recent years, a period marked with increasing public attention focused on smoking cessation. Moreover, data on systematic comparisons of medical and nursing students from the same university during the same time period are very limited. The purpose of the study was to investigate the smoking habits of medical and nursing students enrolled in a major university in the United States, and to examine whether smoking habits changed during the course of education for each group using a cross-sectional survey approach. Setting Materials and Methods The study was conducted at the Jefferson Medical College and College of Health Professions, which are a part of Thomas Jefferson University, a not-for-profit, private health-care oriented university in Philadelphia. Both colleges are fully accredited for their medical and nursing education programs and enroll students from diverse backgrounds and geographic regions of the United States. A total of about 880 medical students and 280 nursing students were enrolled in the two colleges at the time of the study. Approximately 6% of the medical students and 25% of the nursing students belonged to ethnic minority groups (African American, Hispanic American, American Indian), and nearly 50% of the medical students and 85% of nursing students were women. The Institutional Review Board of the university approved the study. Data Collection Medical and nursing students were surveyed using anonymous questionnaires in the last 3 months of the year Attempts were made to survey all students without using any randomization schemes. The questionnaires were handed to students at classroom lectures with a drop box facility outside the classrooms for returning the forms. Survey forms were also kept in campus mailboxes, and an unmarked internal-mail envelope was provided for the forms to be returned. Since the third-year and fourth-year medical students were often in off-campus locations, surveys were also sent via . To avoid duplicate responses, specific instructions were provided at the beginning of the survey to complete the questionnaire only once and to disregard the survey if they had previously participated in the study. No incentives were provided for completing the questionnaires. The questionnaire included demographic details, graduating class year, and the Fagerstrom test for nicotine dependence (FTND), a widely used and validated 6-item questionnaire to assess severity of smoking. 13 This is a modified version of the Fagerstrom tolerance questionnaire, 14 and the scores range from 0 to 10 (Table 1). Patients who had not smoked in the previous 12 months or longer were asked to rate themselves as former smokers, while those who had smoked 100 cigarettes in their lifetime were asked to consider themselves nonsmokers. Additional smoking data included duration of smoking, number of quit attempts, and smoke-free duration for former smokers. The entire questionnaire could be completed in 10 min. During the development of the questionnaire, feedback from students was Table 1 The FTND* Questions Score 1. How soon after you wake up do you smoke your first cigarette? 5 min 3 6to30min 2 31 to 60 min 1 60 min 0 2. Do you find it difficult to refrain from smoking in places where it is forbidden? Yes 1 No 0 3. Which cigarette would you hate most to give up? The first in the morning 1 Any other 0 4. How many cigarettes per day do you smoke? to to Do you smoke more frequently during the first hours after waking than during the rest of the day? Yes 1 No 0 6. Do you smoke if you are so ill that you are in bed most of the day? Yes 1 No 0 *This is a modification of Fagerstrom tolerance questionnaire. It allows physicians to classify smokers according to their level of nicotine dependence. A score 4 suggests a low level of nicotine dependence, and a score 6 usually indicates a high level of nicotine dependence Clinical Investigations

3 encouraged regarding potential intrusiveness of individual questions and completion time for the questionnaire. A sample questionnaire was piloted on a group of medical students prior to initiation of the survey. Data Analysis Data from incomplete or illegible surveys were discarded. Comparisons between medical and nursing students were performed using independent t tests (two tailed) or analysis of variance for continuous variables and 2 tests for categorical variables. The Fisher exact test was applied when the cell sizes were small. Correlations between continuous variables were performed using Pearson product moment correlations. Statistical analysis was performed using SPSS 9.0 software (SPSS; Chicago, IL). Results Of a total of 820 medical students (93.2% of enrolled students) and 250 nursing students (89.3% of enrolled students) surveyed, 397 medical students (48.4%) and 126 nursing students (50.4%) returned a completed, legible survey; the response rate was not statistically different. Among the medical students, the median age was 24 years, 212 students (53.4%) were women, nearly 80% were white, 3% were African American, and 14% were Asian. One hundred five nursing students (83.3%) were women, with a median age of 25 years; approximately 70% were white, 13% were African American, and 7% were Asian. As expected, there were significantly more women in the nursing student sample compared to the medical student population ( , degrees of freedom [df] 1, p 0.001). Also, the ethnic distribution differed between the two groups; the nursing students had significantly higher proportion of African-American individuals and fewer Asians and whites compared to medical students ( , df 2, p 0.001). Female smokers had higher mean FTND score ( ) than male smokers ( ) [t 2.83, p 0.01]. Women also smoked more cigarettes per day (14.4) than men (9.3) [t 1.94, p 0.05], and reported smoking more often (t 2.21, p 0.05) and sooner (t 2.75, p 0.01) after waking up in the morning. Women also found that morning cigarettes were difficult to give up (t 2.08, p 0.05); however, there were no gender differences in smoking despite being ill, smoking in forbidden places, the duration of smoking, quit attempts, or plans to quit. There were no significant associations of FTND scores with age (r 0.11, p 0.05), or ethnic background ( , df 2, p 0.05) of smokers. Smoking Habits of Medical and Nursing Students Table 2 summarizes the differences in smoking characteristics between the medical and nursing Table 2 Comparison of Smoking Habits Between Medical and Nursing Students* Smoking Variables Medical Students (n 397) Nursing Students (n 126) 2 or t Test Current smokers 13 (3.3) 17 (13.5) Former smokers 39 (9.8) 22 (17.4) 4.70# Total FTND score Smoking on waking up Difficulty in giving up morning cigarette Difficulty in stopping smoking in restricted places Number of cigarettes smoked Smoking during earlier # part of the day Smoking while ill # Number of quit attempts Plans to quit in the next 8 (61.5) 5 (29.4) mo Duration of smoking, yr Duration of quitting, yr *Data are presented as No. (%) or mean SD. Current and former smokers. Current smokers. Former smokers. p for 2 df 1, for t tests df ranged from 60 to 90. Values represent scores obtained on individual items on the Fagerstrom questionnaire. p 0.01 for 2 df 1, for t tests df ranged from 60 to 90. Values represent scores obtained on individual items on the Fagerstrom questionnaire. #p 0.05 for 2 df 1, for t tests df ranged from 60 to 90. Values represent scores obtained on individual items on the Fagerstrom questionnaire. students. No significant differences were observed in FTND scores, number of quit attempts, or duration of smoking between current smokers and former smokers among medical as well as nursing students. Therefore, the two groups were collapsed for statistical comparisons for these variables. As seen in Table 2, significantly fewer medical students smoked compared to nursing students; furthermore, medical students who smoked were less severely nicotine dependent compared to smokers from the nursing student population, as indicated by the total scores on FTND. Significantly more nursing students had quit smoking (former smokers) compared to medical students. Comparing individual items on the FTND, nursing students obtained significantly higher scores on five of the six items: smoking on waking up, difficulty in giving up the morning cigarette, number of cigarettes smoked, smoking while ill, and smoking during earlier part of the day. There were no signif- CHEST / 124 / 4/ OCTOBER,

4 icant differences in the number of current smokers who planned to quit in the next 3 months or in the duration of quit time for former smokers between medical and nursing students. Consistent with gender differences between medical and nursing students, a higher proportion of nursing student smokers were women (89.7%) compared to medical students who smoked (57.6% women) [ , df 1, p 0.01]. We then compared smoking habits across class years of education. Due to a smaller number of responses from the third-year and fourth-year classes, the two classes were combined for the purpose of data analysis. The results are summarized in Table 2. We expected that as medical and nursing students progressed through the course of education, the increasing knowledge of smoking related diseases and environmental pressures would lead to increased quit rate. While no students reported to have commenced smoking after starting medical school, no significant differences were observed in the number of smokers or former smokers, mean FTND scores, and immediate plans to quit across various class years (Table 3). Interestingly, the mean time since quitting was 1.6 years for the first-year medical class, 2.4 years for the second-year class, and 3.5 years for the third-year and fourth-year classes (F 248.2, df 2,36, p 0.001). Moreover, post hoc comparisons indicated that all three groups significantly differed from each other in terms of quit time (p 0.001). Since the study was conducted at approximately 6 to 9 months into the academic year, it seems that former smokers may have quit within 12 months before entering medical school. No such differences were observed among former smokers in the nursing school. Table 3 Comparison of Smoking Across Class Years in Medical and Nursing Students* Variables Year 1 Year 2 Years 3 and 4 Medical students Current smokers Mean FTND score Plans to quit in 3 mo Former smoker Time since quitting, yr Nursing students NA Current smokers 10 7 Mean FTND score Plans to quit in 3 mo 3 2 Former smokers 8 14 Time since quitting, yr *Data are presented as No. or mean SD. NA not applicable. p values not calculated due to small sizes. One-way analysis of variance, F 248.2, df 2,36, p p values are not significant for all other comparisons. Nursing education comprised of 2 years of school. Discussion In the current climate of disease prevention and health promotion, smoking behaviors of future physicians and nurses have become increasingly important. Doctors and nurses are expected not only to offer care for their patients, but also to model the advice they offer. 15 Moreover, studies 5,16 have found that the practices and behaviors of their health-care providers can significantly influence health-related behaviors of patients. Substance abuse has long been a concern among physicians, and epidemiologic studies 17,18 have tracked the use of alcohol, tobacco, and illicit substances among medical students and physicians. Results from this study confirm the continuing decline in smoking among medical students in the United States. The 3.3% rate of smoking among medical students from our sample in 2000 is substantially lower than the 10 to 15% rate reported in early 1990s, 16,9 and is comparable to the 2% prevalence rate found in 1996 in other surveys of US medical students. 10 Notably, the smoking rate is 3 to 10 times lower than prevalence rates reported in surveys of medical students from Europe, Asia, and South America during similar time periods It was also encouraging to note that among medical students who smoked, the mean FTND score was 2.3, indicating a low level of nicotine dependence. Though the 13.5% smoking rate among nursing students was less than the prevalence rates reported in other studies 11,12 of nurses and nursing students, it was about four times higher than that observed among medical students. Equally concerning was the finding that the smokers from the nursing student group smoked more cigarettes per day and were more severely nicotine dependent compared to medical students. Nurses who smoke have been reported to be less likely to positively influence patients who smoke, and various factors such as inadequate information about health effects of smoking, peer influences, high levels of stress, and educational factors have been implicated as possible explanations for continued smoking in this population. 22 In our sample, women smoked more cigarettes per day and had a higher FTND score than men. While gender differences could partially explain the smoking differences between medical and nursing students, it seems that knowledge of smoking and attitudes toward smoking as well as personal beliefs about roles as future physicians may have contributed to the significantly lower smoking among medical students. While very few studies have directly compared medical students attitudes toward smoking with those of nursing students, the latter have been reported to be less aware than medical students of their role and re Clinical Investigations

5 sponsibilities to provide smoking cessation treatment. 19 In related studies, only 25% of nursing students considered medical smoking cessation approaches to be effective, 23 and 40% considered advising healthy smokers to quit. 19 In contrast, 90% of medical students believed in taking a more active role in providing smoking cessation for patients and believed that doctors ought to set a good example to patients and other health workers by not smoking. 24 However, other studies of physicians and nurses have found no differences in their attitudes toward smoking, 25 and it is possible that other risk factors for smoking such as parental smoking, peer influences, and alcohol use may have also contributed to the differences in the two groups. 26 It was encouraging to note that no medical students reported that they began smoking after joining medical school. We expected that the increasing knowledge about adverse effects of smoking and increased patient contact would lead to increased quit rates as the students progressed through their education; however, little change in smoking habits, including plans to quit, was observed during the course of medical and nursing education, consistent with studies 27,28 that have found that medical and nursing students smoking habits were not modified by their education programs. It must be noted though that these studies did not include a structured curriculum about smoking during the course of education. Instead, it appears that many smokers might have quit just prior to entering medical school since the mean time since quitting for former smokers consistently increased from 1.6 to 2.4 years and then to 3.5 years as medical students advanced from first year to second year and then to third and fourth years. However, this finding should be considered preliminary since our survey was cross-sectional, the numbers of former smokers were small, and definitive conclusions may require longitudinal studies with larger sample sizes. If the finding is confirmed, it may suggest that medical students are influenced in their decision to quit smoking by the prospect of beginning their training to be future physicians. As a follow-up study, we plan a more comprehensive and longitudinal assessment of smoking habits of medical students during their medical school years. Results from this study must be interpreted in light of the limitations of a self-report survey design. These include recall and nonresponse bias and reporting errors. 29 The main limitation was that approximately 50% of sample did not return the survey, introducing a nonresponder bias that may have affected the findings. Also, due to our attempt to maintain anonymity, the possibility of some degree of duplication of surveys cannot be excluded. Though the Fagerstrom questionnaire has been shown to be a reliable and valid measurement of nicotine dependence, 13 it is possible that underreporting of severity of smoking may have occurred because of negative associations with tobacco use. 30 Finally, the response rate from the third-year and fourth-year medical classes was lower than the firstyear and second-year classes, most likely due to their primary off-campus clinical rotations that made delivery of the questionnaires at classes difficult. Nevertheless, the study provides information about smoking using standardized and widely used assessment instruments, and did involve a reasonable sample size of students whose demographics and enrollment patterns appear comparable to other medical and nursing schools in Northeastern United States. For example, enrollment data for the medical college indicate that 20% of all applicants to medical schools in the United States apply to Jefferson Medical College, and the medical students surveyed represented 39 states in the United States. Therefore the data may be representative of smoking behaviors among medical and nursing schools in this geographic region of United States. Conclusions The low rate and severity of smoking among medical students may have an impact on public health, since the health practices of physicians have been found to influence patient behaviors and are also noticed by the general public. The relatively less-encouraging smoking data among nursing students suggest the need to promote tobacco education and intervention efforts in this population. Nevertheless, both groups have substantially lower smoking rates than the general population and appear to have the potential to be credible advisors to patients and the public regarding tobacco use. 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