Combustible cigarette smoking is the most attributable and preventable risk factor for adult mortality and morbid-ity in Romania and worldwide. Among health professionals, there is a paradoxically high prevalence of smokers in most European countries. Doctors need always to be health role models. As future physicians, medical students represent a primary target for tobacco-prevention programs, but they are also victims of the tobacco industry. The eternal ques-tion for all educational programs is whether the medical staff and students are prepared to deliver the anti-tobacco messages and to participate in activities in this domain.
The strategy of the tobacco industry is tricky and the pro-moting activities of the last years have changed radically. Multiple tobacco products, such as combustible cigarettes, electronic cigarettes (e-cigarettes), heat-not-burn (HNB) tobac-co products and others are used now worldwide(1,2). They start to promote their products (e-cigarettes, heat-not-burn tobacco) in famous medical journals. The promotion everywhere became extremely aggressive. The rapid increase in e-cigarette and HNB tobacco use underscores the lack of knowledge about the acute and chronic effects of this product on the human body(3). The awareness and use of heat-not-burn tobacco and e-cigarette is now a national problem for many countries. Health leaders, medical staff and academic journals should consider both the conflicts of interest and the ethics of endors-ing the substitution of tobacco products, as tobacco companies simultaneously work to promote cigarette smoking and to undermine tobacco control globally(4).
Of course, for the Romanian authorities, for the medical body and for the Romanian professors of Medicine it is also very important in this moment to know exactly whether the Romanian medical student is prepared, as a young doc-tor, to deliver the right messages for himself and for the population in the future. For the past two years, we made multiple studies and surveys (on questionnaires) on the behaviours and educational activities of students in the faculty of Medicine, coming from different years of study. We found that the prevalence of smoking in the first year of study was 46.8% (62.5% for females and 37.5% for males), in the fourth year – 41% (75.3% for females and 24.7% for males), and 49.3% in the fifth year (72.5% for females and 27.5% for males)(5). If we consider the fact that the course about smoking is held in the fourth year of study and that only very few faculties and departments have this as a compulsory course, we come to the conclusion that the training of these students is insufficient. As they go through medical school, the students’ knowledge of smok-ing-related diseases obviously increases. Looking at all the years of study, we found no changes in their behaviors: 43% of our students are smokers (32.8%) or ex-smokers (10.2%)(6). In other countries, the prevalence of smoking in medical students is very different: 21% of French students were regular tobacco smokers and 16% occasional smok-ers(7), 29.5% of the Italian students and 6.1% of the American ones(8), over 20% in Germany, Poland and Spain(9), over 18% in Norway and Hungary(10), 10% in Sudan(11) and 38.8% in Pakistan(12). Usually, the countries well known for their progress in tobacco control managed to diminish the number of smokers in their medical body. Regarding con-sumers of the trendy e-cigarette in Romania(13), we have 45.6% of them testing this product between one month and more than one year (36.6% consider this offer less danger-ous than the conventional cigarette and 37.1% made this move curiosity)(13). This mirage of the e-cigarettes is visible in many other countries. E-cigarette use is exponentially increasing among young adults (e.g., the number tripled between 2013 and 2014 in the US – CDC Newsroom releas-es, 16th April 2015) and the self-reported use of e-cigarettes among health professional US students was 3.5-6 times higher than previously reported among medical and nurs-ing students (2009-2017)(14). In US it’s a particular situation: 21.6% of adults aged 18-24 have at least once tried an e-cig-arette compared to 12.6% of the overall adult population in USA(15), and a scandal of invasion of “JUUL” e-cigarettes in youths was on the first pages of the medical journals. In other countries, the presence of e-cigarettes in medical students consumers is very different as percentage: from 0.9% in Norway (Nordic countries are also the lowest rank-ing in prevalence of classic cigarettes), Germany and Hungary(10) to 6.2% in Pakistan(12).
If I am looking at the level of education of our students, we can analyse the type of answers from our surveys. Regarding the law, even though 98% are supporting the actual tobacco control law, a third of the students have the feeling that this law doesn’t actually protect them and, even more, they are very shy as passive smokers in front of active smokers (only 41% have the courage to ask them to leave the place)(5). On the other hand, a bird’s‑eye view of their knowledge accumulated in the faculty is very disappointing: 16% are starting to smoke in the period of the faculty(5); the main reason for quitting smoking, its harmful action on health, is relevant for only 62.7% of the smokers(5); 52% are still thinking about remaining a smoker in the next year(5); only 36.8% have attended courses related to tobacco(6), and this happens even though 47.3% of them need more infor-mation about tobacco and smoking(6).
There are many solutions proposed in different countries to solve this multiple challenging problem of the medical students. Very eloquent is the Turkish experience. The preva-lence of smoking in Turkish students was 35% in 2007, 21% in 2009 and 8.1% in 2012(16). The pillars of this successful strategy were: lectures and conferences to prevent them from starting to smoke, regular monthly meetings of the group, annual symposiums and lectures related to the harmful effects of smoking, with students in the first three years of medical school and their future responsibilities as role mod-els in the community of health issues. Opening lecture to first-grade medical students may be also more influential, as they are highly motivated to become good physicians at this first step in medical school(16). In Portugal, there is an environmental health optional module, available for the medical students of the second and third years. The optional curriculum is another course for the fourth-year students aiming to build capacity in helping future patients to quit(17,18,19). In Finland, an Internet-based tobacco cessation model course has been developed(17,18,19). After looking at all this data, we have to reorganise our activities in Romanian medicine faculties and not only. First of all, we have to build the uniformity of our curriculum. This step is already ongo-ing. We probably need more optional courses on the dangers of tobacco. Also, counselling recommendations for quitting should be organised not only in the fourth year of study, but also in the first one. The second step(18,19) is to look at one of the most important recommendations made by all the experts: medical schools should organize anti-smoking groups led by voluntary faculty members, targeting to decrease the smoking rates of medical students. In this domain, the Romanian Society of Pneumology and our uni-versity succeeded to connect the Medicine Students Associations to all the important events conducted in the last two years, regarding: the implementation of the new law, participation to the meetings and round tables with the politicians and other NGOs for “2035 first generation with-out smoking” initiatives. Still, for the university body there are many other things left to be covered in the future.
The conclusions available also for the Romanian Medicine students are(20):
- There is a strong need to provide medical students with training in smoking cessation techniques;
- We need comprehensive programs of tobacco control among students and an unceasing effort to reduce the number of smokers in medical students, the mirrors of the anti‑tobacco activities of our country.
At least three open questions need to be addressed to professors, authorities, representatives of doctors, NGOs, in the next years:
- The first question is: what are the standards of a good professional?
- Is it possible to be a good professional without behaving according to what you profess?
- Is it, for example, possible to give professional advice about matters you personally do differently?
- Lee YO, Hebert CJ, Nonnemaker JM, Kim AE. Multiple tobacco product use among adults in the United States: cigarettes, cigars, electronic cigarettes, hookah, smokeless tobacco, and snus. Prev Med. 2014 May; 62:14-9. doi: 10.1016/j.ypmed.2014.01.014.
- Agaku IT, Filippidis FT, Vardavas CI, Odukoya OO, Awopegba AJ, Ayo-Yusuf OA, Connolly GN. Poly-tobacco use among adults in 44 countries during 2008-2012: evidence for an integrative and comprehensive approach in tobacco control. Drug Alcohol Depend. 2014 Jun 1; 139:60-70. doi: 10.1016/j. drugalcdep.2014.03.003.
- Chun LF, Moazed F, Calfee CS, Matthay MA, Gotts JE. Pulmonary toxicity of e-cigarettes. Am J Physiol Lung Cell Mol Physiol. 2017 Aug 1; 313(2):L193-L206. doi: 10.1152/ajplung.00071.2017.
- Elias J, Ling PM. Invisible smoke: third-party endorsement and the resurrection of heat-not-burn tobacco products. Tob Control. 2018; 0:1–6. doi: 10.1136/ tobaccocontrol-2018-054433
- Costache S, Deleanu O, Oprea C, Munteanu I, Mihălţan F. The influence of tobacco among medical students from “C. Davila” University of Medicine and Pharmacy. Communication at UMF Congress 2016 - Parliament House, Bucharest.
- Blidaru TC, Chirilă HC, Ulmeanu R, Mihălţan F. The opinion of Romanian medical students on tobacco consumption and the impact of the new anti- tobacco law. E-Poster UMF Congress 2018, Parliamant House, Bucharest.
- Gignon M, Havet E, Ammirati C. Alcohol, Cigarette, and Illegal Substance Consumption Among Medical Students – A Cross-Sectional Survey. Workplace Health & Safety. February 2015, vol. 63, no. 2, p.54-63.
- Armstrong GW, Veronese G, George PF, Montroni I, Ugolini G. Assessment of Tobacco Habits, Attitudes, and Education Among Medical Students in the United States and Italy: A Cross-sectional Survey. J Prev Med Public Health. 2017; 50(3):177-187.
- Cataruzza MS. Why do doctors and medical students smoke when they must know how harmful it is? European Journal of Public Health. 2013; Vol. 23, No. 2, 188–189.
- Balogh E, Faubl N, Riemenschneider H, Balazs P, Bergmann A, Cseh K, Horvath F, Schelling J, Terebessy A, Wagner A, Voigt K, Fuzesi Z, Kiss I. Cigarette, waterpipe and e-cigarette use among an international sample of medical students. Cross-sectional multicenter study in Germany and Hungary. BMC Public Health. 2018; 18:591.
- Elamin OEO et al. Cigarette smoking among medical students in the National Ribat University. Sudan J Paediatr. 2013; 13(2): 45–51.
- Iqbal N, Khan ZA, Hamza Amwar SM, Irfan O, Irfan B, Musthag A, Bibi M, Siddiqui F, Khan JA. Electronic cigarettes use and perception amongst medical students: a cross sectional survey from Sindh, Pakistan. BMC Res Notes. 2018; 11:188.
- Voicu A, Mihălţan F, Ulmeanu R. Student in Medicine and E-cigarette. E Poster UMF Congress 2018, Parliament House, Bucharest.
- Franks AM, Hawes WA, Mccain KR, Payakachat N. Electronic cigarette use, knowledge, and perceptions among health professional students. Currents in Pharmacy Teaching and Learning. 2017; 9, 1003–1009, http://dx.doi. org/10.1016 /j.cptl.2017.07.023
- Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, 2014. NCHS Data Brief. 2015; Oct. (217):1–8.
- İçli F, Çalışkan D, Gönüllü U, Sunguroğlu K, Akdur R, Akbulut H, Özkan A, Ölmez S, Gönüllü I, et al. Fighting Against Cigarette Smoking Among Medical Students: A Success Story. J Canc Educ. 2013, Nov. 29, 3, 458-63, DOI 10.1007/ s13187-013-0573-y.
- La Torre G, Kirch W, Bes-Rastrollo M, et al. Tobacco use among medical students in Europe: results of multicentre study using the global health professions student survey. Public Health. 2012; 126:159–64.
- La Torre G. Is there an emergency of tobacco smoking among health professionals in the European region? European Journal of Public Health. Volume 23, Issue 2, 1 April 2013, 189–190.
- Kralikova E, Bonevski B, Stepankova L, et al. Postgraduate medical education on tobacco and smoking cessation in Europe. Drug Alcohol Rev. 2009; 28:474–83.
- Mihălţan F. Medicine student and tobacco industry. Joint Session Romanian Cardiology Society – Romanian Society of Pneumology, National Cardiology Congress, 57 th Edition, 19-22 September 2018.