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. Moreover, studies 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 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, and is comparable to the 2% prevalence rate found in 1996 in other surveys of US medical students. 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. 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 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. 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 responsibilities to provide smoking cessation treat-ment. In related studies, only 25% of nursing students considered medical smoking cessation approaches to be effective, and < 40% considered advising healthy smokers to quit. 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. However, other studies of physicians and nurses have found no differences in their attitudes toward smoking, 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. 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 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. 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, it is possible that underreporting of severity of smoking may have occurred because of negative associations with tobacco use. Finally, the response rate from the third-year and fourth-year medical classes was lower than the first-year 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. 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. Source
