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ORIGINAL ARTICLE

JIACM 2012; 13(3): 189-94

Habits and beliefs pertaining to tobacco among undergraduates of


a medical college in the state of Uttarakhand
Pradeep Aggarwal*, Saurabh Varshney**, SD Kandpal***, Pratima Gupta****

Abstract
Background: Tobacco surveillance among medical students offers an opportunity to assess the preparedness for tobacco control
among future healthcare professionals in India. The purpose of the present study was to evaluate the use of tobacco in the
undergraduate medical students and to assess the factors influencing medical students to indulge in tobacco use.
Objective: To assess the prevalence of tobacco use among undergraduate students and to assess the attitude and awareness towards
participating in tobacco cessation.
Material and methods: A cross-sectional questionnaire-based study to assess the prevalence of tobacco use among undergraduate
students of Himalayan Institute of Medical Sciences, Dehradun (Uttarakhand State) was conducted from January 2010 to January
2011. A pre-designed structured questionnaire was used to study various correlates of the tobacco use. Data was collected and
analysed. Global Health Professional Students Survey (GHPSS), questionnaire given by the Centers for Disease Control (CDC),
Atlanta, USA, which is a standard pre-tested questionnaire for assessing prevalence of tobacco use among health care professionals
around the world was used.
Results: Overall, 386 of 400 eligible students (97%) participated in the survey. The mean age and standard deviation of the study
group was 21.47 3.70 years. The rates of smoking among male medical and female medical students were 38.6% and 6.5%,
respectively (p < 0.001). A 6-times higher tobacco use was found among male medical students as compared to females. Out of the
386 participants, current tobacco use (last 30 days) was reported by 11.1% of students. About 21.7% of students had never used
tobacco. More than 80% favoured a ban on tobacco sales to adolescents, tobacco advertising, and tobacco use in public places.
Over 90% reported interest in further training in tobacco control. There was a familial aggregation of the use of tobacco. The
factor initiating the use of tobacco was peer pressure in most of the cases.
Conclusion: This study reflects an alarming situation and demands urgent measures to be adopted by health professionals, who
happen to be health promoters and health role models for the society.
Key words: Tobacco, smoking, medical student, undergraduate.

Introduction
Tobacco is the leading preventable cause of death and
more than five million people die globally from the effects
of tobacco every year more than that of HIV/AIDS,
malaria, and tuberculosis1. Tobacco is a serious threat to
health2 and a proven killer3 and ranks second as a cause
of death in the world4. Evidences accumulating since early
1950s indicate that more than 25 diseases are now known
or strongly suspected to be causally related to smoking5.
WHO estimates that unless the current smoking pattern
is reversed, tobacco will be responsible for 10 million
deaths per year in the next decade, with 70% of them
occurring in developing countries. In India tobacco kills
0.8 - 1.0 million people each year and many of these
deaths occur in people who are very young6. Currently,
about one-fifth of all worldwide deaths attributed to
tobacco occur in India. More than 8,00,000 people die and
12 million people become ill as a result of tobacco use

each year in India as per WHO projection. We will have


the highest rate of rise in tobacco-related deaths during
the period 2020 - 2030 compared to all other countries/
regions.Youth in general and adolescents in particular fall
prey to this deadly habit with severe physical,
psychological, and economic implications. Among the
youth, students are particularly involved due to increasing
academic pressures and uncertain career. Encouragement
from peer group, the lure of popularity, and easy
availability of tobacco in different forms makes teenagers
easy prey. In India, approximately 5,500 children and
adolescents start using tobacco products daily, some as
young as 10 years7. The majority of users have first used
tobacco prior to the age of 18 years8. Teaching about the
effects of use of tobacco is essential for medical college
students, because they would be physicians, future
teachers, and responsible citizens and will hold key
positions to lead tobacco cessation programmes in our

* Assistant Professor, ** Professor and Head, Department of ENT,*** Professor and Head,
Department of Community Medicine, **** Professor and Head, Department of Microbiology,
Himalayan Institute of Medical Sciences, Jolly Grant, Doiwala, Dehradun-248 140, Uttarakhand.

community. So they should not be sanctimonious. Health


professionals serve as role models for healthy behaviour
to the public. During routine visits, health professionals
can counsel patients on dangers of smoking and the
importance of quitting; and such counselling is one of the
most cost-effective methods of reducing smoking9. The
medical students who are future health professionals
ignore epidemiological evidence and continue to use a
substance that is harmful to health. It has been reported
that there is an increased trend of tobacco habits among
the healthcare students pursuing healthcare education
like any other youths. Little attention has been given to
the context of when and how healthcare students
undergo attitudinal and behavioural changes with respect
to their own smoking habits. Moreover, health
professionals, who happens to be health promoters/
educators and health role models for society in future can
have negative impact on society if they themself are
involved in tobacco consumption practice10. Hence, the
present study was undertaken to assess the prevalence
of tobacco use among undergraduate students and to
assess the attitude and awareness towards participating
in tobacco cessation and control activities, and to suggest
measures to involve healthcare professionals in tobacco
cessation and other anti-tobacco interventions.

Material and methods

used tobacco even once in their lifetime. Current Use


was defined as having used tobacco at least once in last
30 days preceding the survey. Never Use was defined as
having not used tobacco even once in their lifetime.
Survey tool
Global Health Professional Students Survey (GHPSS)
questionnaire given by the Centers for Disease Control
(CDC), Atlanta, USA, which is a standard pre-tested
questionnaire for assessing the prevalence of tobacco use
among health professionals around the world was used
after few modifications as per the local need, comprising
a total of 71 items in 06-paged structured questionnaire
for the present study. This questionnaire is also approved
by the World Health Organisation (WHO).
Statistical analysis
Statistical analysis of data was carried out by using Epi
Info, SPSS and Microsoft Excel statistical software. Data was
tabulated using frequency distribution tables. Frequency
of demographic characteristics, various tobacco related
findings were expressed as proportions (%). Mean and
standard deviation were used for quantitative data.
Association between independent factors and dependent
factors was determined using chi-square test. The level of
significance was taken at P value < 0.05.

It was a cross-sectional questionnaire-based study.

Results

Inclusion criteria

General

All the undergraduate medical students currently


studying in Himalayan Institute of Medical Sciences,
Dehradun, were included in the study. No sampling
technique was adopted and all students present in the
class were approached to get involved in the study, i.e.,
100% enumeration. After seeking administrative approval
and verbal consent of the participants, data was collected
from the students Ist year (Ist semester) to final
professional part II (9th semester) by using a
predesigned and pretested self-administered
questionnaire prepared in English on anonymous basis.

Table I: Distribution of study subjects according to age,


sex and bio-social profile.

The purpose of the study was briefed, confidentiality of


information was ensured, and purely voluntary nature of
their participation was explained to the students before
actual data collection. The data was collected regarding
age, sex, class/year of initiation of tobacco use, influencing/
precipitating factor behind initiation, form of product
used, frequency and pattern/mode of use, factors
influencing current use, their attitude toward future use,
and their knowledge about tobacco-related health
hazards and cessation. Ever Use was defined as having

190

MB,BS professional wise

Male
(n = 184)

Female
(n = 202)

Number %

Total
(n = 386)

Number % Number %

MB,BS Ist prof

65

43.9

83

56

148 38.4

MB,BS IInd prof

30

45.5

36

54.5

66

17.0

MB,BS Final prof Part I

50

54.3

42

45.7

92

23.8

MB,BS Final prof Part II

39

48.8

41

51.2

80

20.8

Age-wise (years)

Minimum

Maximum

Mean SD

17

36

21.47 3.709

Out of total 400, only 386 students participated in the


study (participation rate = 97%).
The age group of the students in the study was 17 - 36
years. The mean age and standard deviation of the study
group was 21.47 3.709 years.
When the respondents were asked about the family

Journal, Indian Academy of Clinical Medicine

Vol. 13, No. 3

July-September, 2012

history of smoking, 20.1% and 11.7% responded that one


or the other member in their family was presently using
smoke and/or smokeless form of tobacco respectively.
Ever users
Table II shows that out of the 386 participants, 84 (21.7%)
were found to be tobacco ever users, whereas 302
(78.3%) were non-users. 38.5% of males were ever users,
compared to 6.5% of females. There was a statistically
significant association between sex and tobacco ever
users (pd 0.05).

It was observed that maximum (63%) number of tobacco


ever users had initiated tobacco use in the age group of
16 - 20 years. It was also observed that females had
initiated tobacco use two years earlier than their male
counterparts with mean age of 14.38 6.292 years.
Table V: Distribution of ever users according to type
at first use.
Ever users
Type of tobacco

Male
(n = 71)
Number %

Female
(n = 13)

Total

Number % Number %

Table II: Distribution of study subjects according to


tobacco ever users.

Smoke tobacco

10

14.1

23.1

13

3.3

Smokeless tobacco

59

83.1

69.2

68

17.6

Ever user

No response

2.8

7.7

0.7

Male

Female

Total

Number

Number % Number %

Yes

71

38.5

13

6.5

84

No

113

61.5

189

93.5

302 78.3

21.7

X2 = 58.461, df = 1, pd 0.001.
Table III shows an increasing trend in the consumption of
tobacco among the ever users with an increase in MB,BS
professionals.
Table III: Distribution of ever users according to year
of MB,BS.
Ever user
Professional Wise

Male

Female

Number %

Total

Number % Number %

X =0.239, df=1, p = 0.6247

Out of 84 tobacco users, 17.6% were consuming


smokeless tobacco and only 3.3 % were consuming
tobacco in smoke form. There was a statistically significant
association between type of tobacco use and sex of
tobacco ever users. Both males (83.1%) and females
(69.2%) used more of smokeless tobacco compared to
smoked tobacco.
Current users
Table VI: Distribution of study subjects according to
current user.
Current user

Male

Female

Total

MB,BS Ist prof

23

15.5

1.3

25

16.9

(last 30 days)

MB,BS IInd prof

7.5

4.5

12.1

Yes

41

10.6

0.5

43

11.1

MB,BS Final prof Part I

23

25

3.2

26

28.2

No

27

6.9

2.1

35

9.1

MB,BS Final prof Part II

20

25

6.3

25

31.3

No response

0.7

0.8

1.6

Table IV: Distribution of ever users according to age


at first use.
Ever users
Age groups

Male
(n = 71)
Number %

Female
(n = 13)

Total

Number % Number %

Number %

Number % Number %

X = 4.372, df = 1, p = 0.0365

Among the respondents the current tobacco use was


reported by 11.1 % of students (10.6% males and 0.5%
females).

10 years

10.7

2.3

11

13.0

Table VII: Distribution of current users according to


year of MB,BS.

11 - 15 years

12

14.2

3.5

15

17.9

Current user prof wise

16 - 20 years

45

53.5

9.5

53

63.0

21 - 25 years

5.9

5.9

MB,BS Ist prof

12

48

13

52

Total

71

100

13

100

84

100

MB,BS IInd prof

50

50

Ever user age at first use

Male

Female

Number %

Total

Number % Number %

Male

Female

Overall

MB,BS Final prof Part I

12

46.1

3.9

13

50

Mean SD

Mean SD

Mean SD

MB,BS Final prof Part II

13

52

13

52

Total

41

48.8

2.3

43

51.1

16.10 4.963 14.38 6.292 21.60 3.369

Journal, Indian Academy of Clinical Medicine

Vol. 13, No. 3

July-September, 2012

191

It was reported that throughout the various professional


years of the MB,BS course, the students currently using
tobacco were found to be more or less 50% of ever users.
Table VIII: Distribution of current users according to
type at tobacco use in last 30 days.
Current user
(last 30 days)
Type of tobacco

Male

Female

Number %

Total

Number % Number %

Smoke tobacco

0.75

0.25

1.00

Smokeless tobacco

38

9.8

0.25

39 10.10

X =0.613, df=1, p = 0.4338

10.1% of current tobacco users were consuming


smokeless tobacco and only 1.0% were consuming smoke
tobacco.
Attitude
Table IX: Respondents vs Desire to start tobacco use.
Will you ever take up tobacco (desire to start)? (n = 302)
Response

Awareness
14.2% of the medical students were not aware about the
NHP related to tobacco use and 17.1% were also not
aware about any law related to tobacco use. 31.3% were
able to answer correctly the year in which law was
implemented.
It was also observed when the non-consumers were
inquired whether they would like to ever take up tobacco
use in future. Surprisingly, about 10% responded that they
were interested to take up tobacco use in future.
Table XI: Distribution of study subjects according to
their habits and beliefs pertaining to tobacco use.
Is there any National health programme related to
tobacco? (n = 386)
Responses

No

Yes

259

67.1

No

55

14.2

No Response

72

18.7

Is there any law related to tobacco? (n = 386)

Number

Yes

30

9.9

No

272

90.1

In the present study, the respondents who had never


taken up tobacco use in their lifetime (302), were inquired
whether they would like to start tobacco use in future.
Interestingly, 90% of them responded that they would
never take up tobacco use in their lifetime.

Responses

No

Yes

288

74.6

No

66

17.1

No Response

32

8.3

In which year was the law implemented? (n = 386)


Responses

No

2005

65

16.8

Table X: Tobacco ever users vs consider to quit tobacco.

2008 (correct response)

121

31.3

Responses

2009

83

21.5

Total

Quitting

Number

2010

13

3.4

Yes

35

41.6

No response

104

26.9

No

9.5

Current non-users

41

48.8

Who are the authorised personnel as per law to punish


the defaulters? (n = 386)

Total

84

100

Responses

No

All Gazetted Officers

27

7.0

Head of Institution or HR

12

3.1

Director, Health Services

46

11.9

All of the above

204

52.8

No response

97

25.1

Current users

Out of the total tobacco ever users, it can be seen that 41


(48.8%) were currently non users and out of the remaining,
i.e., current users, 41.6% intend to quit tobacco use in the
future, whereas 9.5% responded that they were not
interested to quit their tobacco use habit. Out of the
current non users41, 15 had used their will power and quit
tobacco use previously, whereas the remaining 26 may
have tried tobacco use on few occasions without getting
addicted to it. Therefore, the percentage of tobacco users
who had quit tobacco was 17.85%.

192

Discussion
The median age of the study subjects in the present study

Journal, Indian Academy of Clinical Medicine

Vol. 13, No. 3

July-September, 2012

was 21.47 years and age range being 17 - 36 years which


is almost similar to that observed by GSR et al11 and Sinha
et al12 (GTHPSS), who observed that the median age of
their participants was 21 years and age range being 17 26 years. The higher range in the age group in our study
was due to the fact that 15 out of 386 respondents
belonged to 31 years and above.
The prevalence of the tobacco ever use was found to be
21.7% in the present study as compared to 24%, 22.7%
and 14.7% by other researchers respectively11, 13, 14. In the
present study, a statistically significant association (X2 =
58.461, df = 1, pd 0.001) was found between sex (male
and female) and tobacco ever use, i.e., males were
significantly on the higher side (38.5%) as compared to
females (6.5%) among tobacco ever users which was also
observed by Sinha et al12 (GTHPSS).
63% of the adolescents in the age group of 16 - 20 years
were found to have initiated tobacco use anytime during
this age group which was in concordance with the
behavioural, psychological, emotional changes being
observed in the adolescent age group. This age group
needs to be tackled at this juncture only to prevent them
from becoming chronic smokers in their later life by
adopting Behavioural Change Communication strategies
urgently. Selokar15 had also observed that 57.1% of their
study population had initated tobacco use in 15 -20 years
age group and GSR et al11 had also observed that over
one-third of male ever users and 10% of female ever users
had started tobacco use after entering medical college
which perfectly coincides with the age group of 16 - 20
years observed in the present study. This may be due to
stress, anxiety, peer pressure, different environment, and
difficulty to adapt to new situations when they get
admission in a medical college, that the students start
using tobacco with a view to releasing their stress and
tension.
GSR et al11 had observed that the first tobacco product
used by their study population was cigarettes in men and
pan masala in women.Whereas in the present study 80.9%
of both males and females had tried smokeless tobacco
to start with, whereas 15.5% had tried smoke tobacco at
initiation. In current study family history of smoke form
of tobacco use was found to be 23.8% which was very
close to the observations made by GSR et al11.
Overall, 11.1% of the respondents were currently using
tobacco products, i.e., males 22.2%, and females 0.9%.
The findings of the present study are comparable to GSR
et al 11 who had observed that 8.7% of their study
population was currently using tobacco products.
Ranjeeta et al16 had observed that 28.8% of male study

Journal, Indian Academy of Clinical Medicine

population were currently using tobacco products which


is also in concordance with the present findings (22.2%).
10.10% of tobacco current users were consuming
smokeless form of tobacco as compared to smoke
tobacco (1.0%), and among these, 9.8% males were
consuming smokeless tobacco. Other researchers11, 14 have
documented lower use rate of smokeless tobacco (0.4%
and 2.7% respectively). On the contrary, Sinha et al12
(GTHPSS) have documented the smokeless tobacco use
rate to be as high as 24% among their study population.
Sinha et al12 (GTHPSS) have also documented that female
medical students were less likely than male medical
students to smoke cigarettes and use other tobacco
products.
In the present study, family history of tobacco use was
reported to be strongly associated (p 0.0001) with ever
tobacco use which was also reported by 17-19 further
substantiating the familial aggregation of the tobacco use.
The study subjects who intended not to quit tobacco use
in future should be the target of our counselling and
motivation for tobacco cessation activities as these are
the individuals who in future are liable to increase their
group and bring more non-smokers (already quit/non
users/never users) into the tobacco users group. At the
same time, counselling and motivation should also be
focused on the respondents who had never taken up
tobacco use in their lifetime as they may fall prey to the
temptations and peer pressure to use tobacco products
in their life time during circumstances of failure/success.
In the present study, it was observed that 41.6% of the
current tobacco users consider quitting tobacco, similar
percentages were quoted by other researchers in their
study population15, 20, i.e., 47.6% and 45%. In contrast to
this, Sinha et al12 (GTHPSS) found that nearly 70% have
considered quitting tobacco in the last one year. This
difference may be because they included third and fourth
year medical students only as the study population.
With the introduction of COTPA 2003 (Cigarettes and
Other Tobacco Products Act, 2003) there is prohibition of
smoking in a public place and the provision of a suitable
fine to a person found violating this act. Smokers have
shifted their habit from smoke tobacco to smokeless
forms of tobacco (gukta, khaini, etc.) which can be
consumed in public places also without being noticed and
at the same time it provides its consumers the desired
level of satisfaction and intoxication.

Recommendations
1. Develop and promote effective cessation programme

Vol. 13, No. 3

July-September, 2012

193

to reduce tobacco use among medical students.

5.

2. Strengthen knowledge of medical students on the


harmful effects of smoking and second-hand smoke.

Mackay J EM. The tobacco atlas 2002. Geneva: World Health


Organization; 2002. Available from: http://www.who.int/tobacco/
media/en/title.pdf.

6.

3. Improve curriculum and introduce a training


programme on tobacco hazards and cessation
approaches.

Chatterjee T, Haldar D, Mallik S et al. A study on habits of tobacco


use among medical and non-medical students of Kolkata. Lung
India: Official Organ of Indian Chest Society 2011; 28 (1): 5-10. Epub
2011/06/10.

7.

Patel DR. Smoking and children. Indian Journal of Pediatrics 1999;


66 (6): 817-24. Epub 2000/05/08.

Conclusion

8.

Patel DR GD. Substance abuse: A paediatric concern. Indian Journal


of Pediatrics 1999; 66 557-67.

The study reflects an alarming situation and demands


urgent anti-tobacco and tobacco cessation measures to
be adopted by health professionals, who happens to be
health promoters and health role models for society.

9.

Russell MA WC, Taylor C, Baker CD. Effect of general practitioners


advice against smoking. British Medical Journal 1979; 2 (6184):
231-5.

In conclusion, noteworthy tobacco use was found among


undergraduate medical students in the present study.This
harmful behaviour not only causes personal harm but also
reduces health professionals ability to motivate or counsel
the patients effectively. Comprehensive public health
initiatives are required to reduce prevalence of tobacco
use in which efforts should be focused on support for
cessation to health professional.

11. Ramakrishna GS, Sankara Sarma P, Thankappan KR. Tobacco use


among medical students in Orissa. The National Medical Journal of
India 2005; 18 (6): 285-9. Epub 2006/02/18.

Acknowledgement
The authors sincerely acknowledge the permission and
financial assistance granted by the Himalayan Institute
Hospital Trust (HIHT) University to conduct this study.

References
1.

Leung CM, Leung AK, Hon KL, Kong AY. Fighting tobacco smoking
a difficult but not impossible battle. International Journal of
Environmental Research and Public Health 2009; 6 (1): 69-83. Epub
2009/05/15.

2.

Ball K. Smoking spells death for millions. World Health Forum. World
Health Organization 1986; p. 211-6.

3.

Older J. Anti smoking language that the young understand. 1986;


7: 74-8.

4.

World Health Organization. Why is tobacco a public health


priority? 2012. Available from: http://www.who.int/tobacco/
health_priority/en/.

194

10. Prevention CfDCa. Global School Personnel Survey. Report. Atlanta


Office on Smoking and Health, Centers for Disease Control and
Prevention.

12. Sinha DN, Gupteshwar S. Tobacco Control in Medical Schools of


India. (The India Global Health Professional Students Survey). New
Delhi: MoHFW, GoI and World Health Organization, 2006.
13. Singh R KH, Jindal SK. Global Youth Tobacco Survey: A Report from
Jammu and Kashmir. J K Science 2008; 10 (2): 65-9.
14. Mony PK, John P, Jayakumar S. Tobacco use habits and beliefs
among undergraduate medical and nursing students of two cities
in southern India. The National Medical Journal of India 2010; 23 (6):
340-3. Epub 2011/05/13.
15. Selokar DS, Monal SN, Kukde M, Wagh VV. Tobacco use amongst
the male medical students, wardha, central India. International
Journal of Biological and Medical Research 2011; 2 (1): 378-81.
16. Kumari R, Nath B. Study on the use of tobacco among male medical
students in Lucknow, India. Indian Journal of Community Medicine.
2008; 33 (2): 100-3. Epub 2008/04/01.
17. Nawaz H, Imam SZ, Zubairi AB et al. Smoking habits and beliefs
of future physicians of Pakistan, section of pulmonary and critical
care medicine, Aga Khan University Hospital, Karachi, Pakistan.
International Journal of Tuberculosis and Lung Diseases 2007; 11:
915-19.
18. Singh SK, Narang RK, Chandra S et al. Smoking habits of the
medical students. Indian J Chest Dis Allied Sci 1989; 31 (2): 99-103.
Epub 1989/04/01.
19. Venkataraman S, Mukhopadhya AJM. Trends of smoking among
medical students. Indian J Med Res 1996; (104): 316-20.
20. Iqbal Singh, Anup N, BC M. Prevalence of Tobacco Habits Among
Health Care Students in Jaipur. J K Science 2010; 12 (3): 116-9.

Journal, Indian Academy of Clinical Medicine

Vol. 13, No. 3

July-September, 2012

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