European Journal of Public Health, Vol. 23, No.
2, 188189
The Author 2013. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
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Viewpoints
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Why do doctors and medical students smoke when they must know how
harmful it is?
Medical professionals, of all people, should know how harmful
smoking is. In Britain, almost no doctors smoke. Yet in many
countries, such as Italy, smoking is commonplace among medical
students and doctors. The question arises as to why this is so, and
what can be done about it. It is important to analyse this issue not
only for the health of medical professionals but also because if they
smoke themselves, they are in no position to advise or help their
patients to stop.
Tobacco products would not be sold legally if they were invented
todaythere is no other product on the market with such high
levels of known toxins and carcinogens!
The World Health Organization estimates that each year, more
than 5 million deaths worldwide are attributable to smoking.
According to the 2012 Eurobarometer Report Attitudes of
Europeans towards Tobacco, the prevalence of smoking in the
European population aged 15 years is 28%, with a maximum
observed in Greece (40%) and a minimum in Sweden (13%). Italy
(as the Netherlands) is classified fourth from the last with a
prevalence of 24%. The 2012 Italian DOXA survey, requested each
year by the Istituto Superiore di Sanita, reported a lower estimate
of 21%.
Nevertheless, according to a study published in 2010, the
prevalence of smoking among health professionals in Italy is 44%,
more than double that of the general population, and this is not only
due to the high prevalence in nurses (48.2%), but it is also observed
in medical doctors (33.9%), medical students (35%) and postgradu-
ate students (52.9%).1
This finding is not peculiar to Italy, as high prevalence of smoking
(29%) was also observed among medical students in Spain, Poland
and Germany.
Two different patterns of physician smoking prevalence seem to
exist: the first applies to most developed countries that have
experienced a steady decline, like USA, Australia and UK; doctors
have notably been among the first to reduce their smoking rate (now
<10%), usually preceding a decrease in smoking rate among the
general public. In this scenario, however, trends are not uniform
across all countries, and there are important exceptions like Italy,
France and Japan, where physician smoking prevalence rates are
>25%. On the other hand, some newly developing countries like
China, Bosnia/Herzegovina, Turkey and India have high male
smoking prevalence rates, approximately 50%.
The Italian experience is really peculiar: although Italy was the
third European country to enact smoking bans in all indoor public
places in 2005, and the overall smoking prevalence in the general
population seems to be slowly declining, the number of smokers in
the health occupations still remains high.
This is a key problem from a public health perspective, not only
because the physician is an important model for patients, colleagues
and medical students, but also because physicians personal
use of tobacco impairs interactions with patients about smoking.
Statistically significant associations have been observed between
physicians smoking status and beliefs and clinical practice in
an international survey of general and family practitioners. Pipe
and colleagues reported that smoking doctors were significantly
less likely to view smoking as harmful than their non-
smoking colleagues and less likely to discuss smoking at each
patient visit.
Moreover smoking physician were more likely than non-smoking
physicians to believe that they had other priorities than helping
patients to quit smoking (52% vs 44%; p < 0.001).2
Cessation counselling delivered by non-smoking general practi-
tioners resulted in higher rates of prolonged abstinence than when
counselling was delivered by smoking general practitioners.
In Italy, in 2012, only 14% of smokers had received unsolicited
advice to quit by their physicians, but this percentage has declined
from 20% in 2009, and smokers are less likely to receive such advice
when their physicians are smokers.
Given the overwhelming evidence of the health consequences of
smoking and the documented detrimental effect that smoking
physicians have on their ability to assist their smoking patients, a
paramount question arises: Why do physicians smoke?
Is it because they do not know or do not believe that smoking is
harmful?
Is it because they do not study this topic in their training as a
regular course and thus they do not consider it important?
Or, perhaps they consider it important, but not a priority. They
may think that helping a patient to quit smoking is doing
prevention, and prevention is not promoted by most physicians
who concentrate on treating their patients rather than helping
them to avoid becoming ill. A study from Japan found that 80%
of medical students did not consider counselling on smoking
cessation necessary as long as patients did not have smoking-related
diseases.3 But, in reality, smokers are already sick; they are affected
by nicotine dependence, which the World Health Organization and
the American Association of Psychiatry included, respectively, in
the International Classification of Diseases and in the Diagnostic
and Statistical Manual of Mental Disorders. Moreover, if they wait
until they have a smoking-related disease before they stop, a huge
amount of damage will already have been done, and they will have
lost significant life expectancy.
So, is it is just a question on how to focus on the smoking
problem?
It is of crucial importance to try to answer this question because it
could give important clues on how to intervene in the health
community and in the medical schools.
Recently, the COM-B (Capability, Opportunity, Motivation,
Behaviour) model has been proposed as a basis for analysing
behaviour with a view to finding ways of changing it.4
The primary goal is to determine what it would take to get a target
group to stop behaving in a way that is damaging or to start doing
something that would be beneficial; this implies to think about a
hierarchy of possible explanations. For example, when a group of
people are doing something harmful, one might think they never
heard it was harmful, or perhaps they heard it was, but did not
understand, or perhaps they understood, but did not believe it, or
perhaps they believed it, but did not think they personally would be
harmed and so on.
Which of these explanations applies would effect how one
intervenes to change the behaviour. For example, if ignorance was
the problem, it may be enough to provide better information.
Indeed, it seems that Italian medical students, like their European
mates, have limited knowledge: they underestimate the risks
associated with smoking, the smoking-related mortality and the
benefits of cessation.3,5 As suggested by the authors, this lack of

knowledge seems responsible for a fatalistic attitude toward tobacco
dependence.5
Improving knowledge will certainly increase awareness, but will it
be enough? Is a fatalist attitude really present? If yes, what would be
opportune to do?
It would be of great importance to understand what medical
students think and feel about smoking, and it would be interesting
for those who smoke to explore their inner position towards
smoking: do they smoke because they ignore the risk or because
they deny or even seek it? Or are they just fatalist, or do
they accept the risk but procrastinate the attempt to quit? We do
not know! To help find out, we could build a behavioural/
motivational ladder to locate their blockage for change. According
to the results of Grassi and co-authors, almost 45% of Italian medical
students tried to quit and relapsed in the past, 60% would like to give
up smoking altogether but 40% feel they are not ready to try.5 These
are important percentages that could mean that Italian medical
students are addicted and may require help specifically addressed
to them. Facing this issue would also fulfil the ethical obligation to
act in the best interest of public and patients health, as the smoking
status of physicians can impact their professional practice.2
References
1 Ficarra MG, Gualano MR, Capizzi S, et al. Tobacco use prevalence, knowledge and
attitudes among Italian hospital healthcare professionals. Eur J Public Health 2011;
21:2934.
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European Journal of Public Health, Vol. 23, No. 2, 189190
The Author 2013. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
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Is there an emergency of tobacco smoking among health professionals in the
European region?
Tobacco smoking can be considered the big killer and one of the
most avoidable risk factors for many human pathologies; so,
reducing and controlling tobacco smoking should be a primary
aim for a given population, and it seems urgent to implement all
the available tools such as health care, education and promotion,
politics, economy and media.
In many countries, the prevalence of tobacco smoking among health
professionals is extremely high, more than other professional categories,
and this could be partly attributed to a low weight that tobacco smoking
has in the medical curriculum of future physicians, which will
contribute in a determinant way to healthy choices of their patients.
Moreover, there is a large body of evidence that in some countries,
such as Italy and Australia, the percentage of smokers who received
advice to quit smoking from their family physician in the previous
year was low.
Coleman1 listed the following justifications by medical doctors
who do not intervene on this issue:
 The patient does not want to quit
 Quitting is not his/her priority
 Quitting smoking is time-consuming
 The patient is annoyed by not requested recommendations
 It is difficult to let the patient be aware of the importance of
quitting smoking
 Lack of strategies for approaching the smokers with no motivations.
The burden of tobacco prevalence among
health professionals
Looking at the prevalence of smoking among health-care profes-
sionals and medical students in the European region is not only a
Tobacco smoking among European health professionals 189
2 Pipe A, Sorensen M, Reid R. Physician smoking status, attitudes toward smoking,
and cessation advice to patients: An international survey. Patient Educ Couns 2009;
74:11823.
3 Raupach T, Shahab L, Baetzing S, et al. Medical students lack basic knowledge about
smoking: findings from two European medical schools. Nicotine Tob Res 2009;11:
928.
4 Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for
characterising and designing behaviour change interventions. Implement Sci 2011;6:
4252.
5 Grassi MC, Chiamulera C, Baraldo M, et al. Cigarette smoking knowledge and
perceptions among students in four Italian medical schools. Nicotine Tob Res 2012;
14:106572.
Maria Sofia Cattaruzza1, R. West2
1
Department of Public Health and Infectious Diseases, Sapienza University,
Rome, Italy and 2Health Behaviour Research Centre, Department of
Epidemiology & Public Health, University College London, London, UK
Correspondence: Maria Sofia Cattaruzza, Department of Public Health and
Infectious Diseases, Sapienza University, Piazzale Aldo Moro 5, 00185 Rome,
Italy, e-mail: mariasofia.cattaruzza@uniroma1.it
doi:10.1093/eurpub/ckt001
Advance Access published on 18 January 2013
useful exercise in knowing the burden of disease, but also an
attempt at the need for action in this sector.
Despite the fact that health-care professionals can play a key role
in tobacco usage prevention because they could be considered as
models, tobacco use prevalence is higher or at least equal to that
concerning the general population in several countries such as
Greece, Italy, Spain, Portugal, France and Poland.
Regarding medical students, a multicentre Global Health
Professions Survey conducted in 2009 among >1600 medical
students from Germany, Italy, Poland and Spain2 showed that
>20% of the students currently smoked cigarettes. Most of the
medical students recognized that they are a key role model in
society, and were aware that they might receive a specific under-
graduate training on counselling patients to quit smoking. However,
most of the students reported they did not receive such training in a
formal way during regular courses.
Smoking prevention and cessation training
Some examples of development of a curriculum at the under-
graduate level on smoking prevention and cessation programmes
do exist in some countries of the European region.3 Here are a
few examples:
In Italy, there is no formal course on tobacco smoking prevention
and control in the curriculum of medical students. A focus group
revealed that the following issues could be covered in such a course:
(i) nicotine addiction, (ii) epidemiology of tobacco smoking-related
pathologies, (iii) motivation for starting smoking, (iv) economic
aspects and (v) skills for treating a smoker who wants to quit. At
the end of the course on tobacco prevention and cessation, a final