141

ORIGINAL ARTICLE
Willingness to smoke cessation among students of Medical
Universities in Karachi

Naseem Khan Achakzai, Syed Aqeel Akbar Shah Gillani, Attaullah Bangulzai, Rubina Mir, Noor
Khajjak, Zara Arshad, Tahira kamal

Abstract
Introduction: Smoking is a public health concern of high importance. Globally, the preva-
lence of smoking has decreased gradually over a period from 1990-2015. However, the total
numbers of smokers has increased over the same period. Currently, there are 1.1 billion
smokers in the world which risk to an increase in smoking related health issues in turn con-
tributes to increased burden of non-communicable diseases
Objective: To assist the willingness to smoke cessation among medical students and its associ-
ated factors.
Material and Methods: It is a cross-sectional study comprised of a self-administered Hamilton
Tobacco use questionnaire administered with eligible university students. Data was collected
from 266-participants after taking verbal informed consent. Data analysis was done using
SPSS version 20.
Results: A total of out of 266 respondents were taken for the study. In general, willingness
Received
to cessation smoke among medical students in Karachi was seen about 64% while high ratio
date:18th September, 2021
Accepted reported among female as compare to males. In MBBS students it is 64.9%, BDS 65.3% and
date: 10th April, 2022 55.8% among BS.
Conclusion: The high ratio of smoke cessation in female students is an indicator towards need
of massive behavioral change campaign in order to encourage medical students to quit ciga-
rette smoking and other tobacco related substances. It can be possible by provision of some
educational projects regarding the health hazards of smoking.

Keywords: Smoke cessation, cigarette smoking, medical students.

Introduction: causes of these deaths.3

Smoking is a Public Health concern of high
importance. Globally, the prevalence of smok- In 2012, Central and Eastern Europe followed
K, Pakistan ing has decreased gradually over a period from by Eastern Asia has the highest lung cancer
NK Achakzai mortality rates at 47.6 and 44.8 per 100,000
SAAS Gillani 1990-2015. However, the total numbers of
A Bangulzai smokers has increased over the same period.1 respectively.4 South-East Asia (SEA) region
R Mir Currently, there are 1.1 billion smokers in the hosts about one quarter of world’s population
N Khajjak
world.2 Increase in number of smokers leads and one-fourth of the total global smokers.
Z Arshad
T Kamal to an increase in smoking related health issues Within the South-East Asia region, the preva-
which in turn contributes to increased burden of lence (2011) of smoking is highest in Indonesia
Correspondence:
Dr. Amir Zeb Jadoon non-communicable diseases (like cardiovascu- (63.1%), followed by India (24.3%), Myanmar
Research Officer, EDO Eye lar disease, cancers etc) and premature death of & Nepal (15%), and Sri Lanka (0.4%).5 Accord-
Hospital, Wah Cantt: tobacco users. Globally, one of the six deaths are ing to WHO, the estimated prevalence of smok-
Cell No:+92 301-4708647
email:amirzebjadoon@ associated with cancer, and lung cancer, mainly ing in the South-East Asia region has decreased
gmail.com linked with tobacco use, is one of the leading over the last two decades with 15.8% in 2020,
Pak J Surg 2022; 38(3):141-146
Willingness to smoke cessation among students of Medical Universities 142
and is projected at 14.7% in 2025, against the set physical and psychological dependency and
target of 13.2% (SDG target 3a and the tobacco smoker lose his free will to quit smoking. This
reduction target under the Global Action Plan in turn makes the person unable to quit smoking
for the Prevention and Control of Non-commu- despite the wish to leave it once and for all.12 The
nicable diseases 2013–2020) for the region till available data in the United State suggests that
2025.6 out of the total 70% who intend to quit, only
2-3% of the tobacco smokers succeed in doing
The situation of smoking prevalence in Pakistan so, and 40% would relapse to routine smoking
is not much different as according to Pakistan after only a single day. Smoke cessation is not
Global Adult Tobacco Survey (GATS 2014), all-or-none approach, but it is an overlapping
19.1% percent of adults (age 15+) currently cycle of smoking and quit attempts that moves
use tobacco in any form (men 31.8%; women in a to-and-fro motion between different phases
5.8%).7 Likewise, the Pakistani youth is also not i.e., smoking & forced quitting, smoking & in-
protected from use of tobacco. Among youth tentional quitting, and smoking & intermittent
(ages 13-15), 10.7% use any tobacco product smoking before successful quitting.13
(boys 13.3%; girls 6.6%), 7.2% smoke tobac-
co, and 5.3% use smokeless tobacco. Also, the In Pakistan, limited data is available on the suc-
prevalence of smoking in university students is cess rate of smoking quit efforts. A local study
recorded at 15%(2008).8 in two cities of Pakistan (Rawalpindi and Islam-
abad) quoted that about one fourth of smok-
Tobacco kills over 163,600 people each year ers make a quit-attempt, and the success rate is
in Pakistan contributing to about 10.9% of all noted at 2.6%.14 The success of smoke-quitting
deaths, and 16.0% of all male deaths and 4.9% of efforts is linked with factors like individual’s will,
female deaths are caused by tobacco. The coun- motivation, perceived risk of smoking, and en-
try bears 1.6% of GDP as the economic cost vironmental factors among others. To the best
of smoking.9 In order to combat the situation, of our knowledge, Pakistan’s research data does
country has put in place various national laws, not provide adequate evidence on the proper
ordinances (Ordinance No. LXXIII of 1979; Or- understanding of the factors (individual, envi-
dinance No. LXXIV of 2002) and SROs (statu- ronmental, socio-economic) that positively or
tory notifications) for tobacco control. Also, the negatively affect an individual’s willingness, de-
Country ratified the WHO Framework Conven- termination and self-efficacy to quit smoking,
tion on Tobacco Control (FCTC) on November thus contributing to their relapsing behavior.14
3, 2004, and became a party of the Convention
February 27, 2005.10 To support Government’s This study aimed at determining the extent of
efforts, several tobacco cessation clinics also intention to smoke cessation among current
operate in the country to provide different treat- smokers studying at three Medical Universities
ment regimens to the smokers for helping them of Karachi and to find out the associated factors
to quit this addiction. These services include use that positively or negatively affect the smoking
of pharmacologic agents, nicotine replacement- cessation. The study results are likely to contrib-
therapies, and behavioural therapy trainings to ute to better contextualization of anti-smoking
develop self-efficacy for overcoming nicotine policies and in adequate enforcement of the
dependency.10 existing legal framework, thus contributing to a
notable reduction in smoking prevalence in the
Until 1988, smoking was merely considered a country.
habit, when US Surgeon General report of 1988
denied this previous myth; and identified ciga- Material and Methods:
rettes and other forms of tobacco as addictive It was a cross-sectional study comprised of a
due to presence of nicotine in them.11 This ad- Self-administered Hamilton Tobacco use ques-
dictive feature of nicotine puts the smokers into tionnaire administered with eligible university
Pak J Surg 2022; 38(3):141-146
143 NK Achakzai, SAAS Gillani, A Bangulzai, R Mir, N Khajjak, Z Arshad, T Kamal

This questionnaire was divided into three parts.

The first part captured socio-demographic char-
acteristics of the survey respondents like gen-
der, age, enrollment year and education level.
The second part comprised of questions related
to smoking status, type of smoke used, willing-
ness or intention to quit smoking, and the num-
ber and the types of methods applied to smoke
cessation attempts. The third and last part of
the questionnaire entailed questions to collect
data on the factors negatively impacting the
Figure 1: Consumption of additional substances rather than cigarette intention to quit. The willingness or intention
to smoke cessation was treated as a dependent
students. This study was conducted in three uni- variable and was measured on 10-point Likert
versities of Karachi namely Dow university of scale. Data analysis was done using SPSS version
Health Sciences (DUHS), Jinnah Sindh Medi- 20. Frequencies and percentages of all categori-
cal University ( JSMU), and Hamdard Univer- cal variables (such as gender, course etc.) were
sity (HU) between January to May 2020. The calculated. Factors associated with willingness
selection of these three universities was done to smoke cessation were analyzed. Mean and
‘purposively’ to ensure inclusion of both public Standard Deviations were calculated and with p-
and private universities who serve a majority of value was calculated for outcome variables.
city’s students of medical and allied subjects.
The first two universities represented public- Results:
sector and the last was from the private sector. A total of 266-students were assessed in the
All these universities are among the most dis- study from three different Universities of Health
tinguished and approved institutions in under- Sciences in Karachi i.e. Dow Medical College,
graduate, postgraduate, and diagnostic studies Dow International Medical College, Dow Den-
in medical and allied health subjects. tal College, Sindh Medical College and Ham-
dard College of Medicines & Dentistry. The
All the enrolled students of the three medi- gender distribution of the study showed that
cal universities were considered as the study major part of the sample collected was Male
population. Sample size was calculated using a students, 237(89.1%) while female were only
weighted prevalence of cigarette smokers (i.e., 29(10.9%). The sample was collected from
15.2%) listed in nation-wide survey on smoking the bachelor’s students so they all belong to
in the general population in 2012.15 The confi- approximately the same age group. In the col-
dence level was set at 95% with margin of error lected sample 157(59.02%) were students of
of 5%. The sample size was calculated to be 199 MBBS, 75(28.19%) were BDS students while
using an Open-Epi software. This sample size 34(12.78%) were from BS (DUHS) program.
was increased to a total of 266 students to over- Participants were randomly selected but the as-
come the chance of non-response. Non-proba- sessment of year of study results showed that
bility consecutive sampling was used to collect 27.8% students belonged to 2nd year while lower
the data. Only those students, who were current ratio 15.4% were from fifth year of study.
smokers at the time of study, were interviewed
until the desired sample size was achieved. Out of 266 students 27 smoke only cigarettes
while 239 students consumed some other addi-
The tool used for collecting data was a Self- tional substances rather than cigarette, its detail
administered Hamilton Tobacco use question- is shown in below figure 1:
naire that were distributed among all the eligible
students after taking verbal informed consent. The Mean scores and standard deviation of will-
Pak J Surg 2022; 38(3):141-146
Willingness to smoke cessation among students of Medical Universities 144
Table 1: Willingness to smoke cessation among students of medical Uni- ingness to smoke cessation of participants were
versities of Karachi calculated according to different characteristics.
Response of Willingness (n=266) In sex group the mean score was calculated for
Variables Yes No p.value male students was 3±4.3 and for females it was
Sex 4.42±4.6 with the p-value of 0.57. Students from
Male 149 (62.8%) 88 (37.13%) 0.34 different programs were taken for the study, the
Female 21 (72.4%) 8 (27.6%) calculated scores for these were MBBS 3.6±4.5,
Program BDS were 2.5±3.9 and for BS students it was
MBBS 102 (64.9%) 55 (35.1%) 0.89 2.9±4.4 and its p-value was 0.13. The calculated
MDS 49 (65.3%) 26 (34.7%) scores for the year of study shown that first year
BS 19 (55.8%) 15 (44.2%) students were 3.6±4.5, second year 3.21±4.4,
Year of Study third year students 2.5±4.1, forth year students
First 37 (65.5%) 21 (34.5%) 0.86 4±4.6 and fifth year students 2.8±4.1 and the p-
Second 48 (64.8%) 26 (35.2%)
vale for programs was 0.615. The mean scores for
Third 32 (61.5%) 20 (38.5%)
the additional substances were also calculated
Fourth 28 (68.3%) 13 (31.7%)
and found the near about values with each other
Fifth 25 (60.9%) 16 (39.1%)
in results i.e for Sheesha it was 3.18±4.3 with
Users of additional substances other than cigarette (n=239)
p-value 0.756, for Naswar it was 3.19±4.36 (p-
Sheesha 55 (56.7%) 42 (43.3%) 0.13
value = 0.175), Gutka was with scores 3.3±4.1
Naswar 4 (57.1%) 3 (42.9%) 0.72
(p-value =0.203), Betel nut (3.37±4.4 p-value =
Gutka 10 (66.6%) 5 (33.4%) 0.81
0.499) and for Supari scores were 3.37±4.41 p-
Pan 27 (69.2%) 12 (30.8%) 0.98
value = 0.276).
Betel nut 28 (65.1%) 15 (34.9%) 0.45
The assessment of willingness to smoke cessa-
Supari 30 (58.8%) 21 (41.2%) 0.46
tion among students of medical Universities of
Karachi showed that following results in table 1:

The mean scores of willingness to smoke ces-

sation was calculated by Fagerstrom Nicotine
Dependency Scale by with 95% of confidence
interval and the results are shown below in fig-
ure 2.

The data related to the attempt made by students

are also noted which is summarized below in the
Figure 2: Consumption of additional substances rather than cigarette graph (Figure 3)

Discussion:
The study was conducted to assess the willing-
ness or intention to smoke cessation to among
smokers medical students of three Universities
in Karachi. The study found the intention to quit
among medical students, higher ratio was ob-
served in female students with more than 72%,
among male medical students it was 62.8%.
Figure 3: Distribution of number of attempts made by students for smoke Willingness to quit among in MBBS students
cessation was noted 64.9% followed by 65.3% of Dental
students and 55.8% among BS students.
Pak J Surg 2022; 38(3):141-146
145 NK Achakzai, SAAS Gillani, A Bangulzai, R Mir, N Khajjak, Z Arshad, T Kamal

Pakistan faces a high burden and growing trend A study on Saudi students discovered that 8.9%
of cigarette smoking among young adolescents. attendants were current smokers, because there
Cigarette smoking is plaguing not only the less is no stern legitimate age for obtaining cigarettes
educated but also educated sects of the society. in the Kingdom of Saudia Arabia.11
Even Health care providers are not spared by this
nuisance with an alarming rate of 37% among Currently more than 1.3 billion adults are smok-
medical doctors and 36% in paramedics.7 ers all around the world with total smoking prev-
alence of 29% (47% of men and 10.3% women
Attitude towards giving up smoking, the main of age 15 and above smoke). More than 900 mil-
reasons for those who quit smoking was to se- lion out of 1.3 billion live in under developed
cure their own health (99%). Two third of the countries.12
students gave up smoking for the reasons they
believed in not to bother others i.e passive smok- Intention to quit among first year students were
ing. Half of the ex-smokers had the desires of observed 65.5%, in second year 64.8%, third
addiction with motives to quit smoking habits. year 61.5%, forth year 68.3% and 60.9% in final
About 40% medical students mentioned reason year. A similar study among medical and dental
as the high cost of tobacco products to quit, 63% students conducted in different area reported
of the study physicians aged above 40 reported the prevalence of cigarette smoking to be 35.7%
to quit to set an exemplary role for children and and 42.9% respectively,13 similarly another study
patients but interests in such role is less men- held in a private medical college reported preva-
tioned by medical students and house officers.8 lence of smoking 26% among male and 2% fe-
male medical students. Quitting rates among
Literature review studies on prevalence of smok- medical students reported around 3%.14 Preva-
ing among medical students published over the lence of smoking is not same globally, in Chi-
past 30 years indicated unique variations in nese female student’s 26% and 69.9 male medi-
prevalence rates among various countries which cal students, in Iranian medical students 14.4%,
range from 3% of USA to 58% in Japan. Stud- while percentage among female Saudi medial
ies in Brazil noted a downwards tendency of students is 4.3%.15
smoking among medical students. Tobacco use
among medical students over the past 50 years Smoking is considered as the paramount cause
has decreased but still it is running as a major of death in the USA with 14.6 per 1000 is the
cause of preventable disease, and because of mortality rate for men and 6.7 per 1000 for
the role which has to be played by these future women. In advanced countries there is ban on
physicians in the community. If the adviser phy- smoking in public places, but in other hand in
sicians themselves are smokers then, it is less under developed country like in Pakistan is fac-
possible to convince smokers to quit smoking ing an enhanced trends of smoking. Tobacco
through them.9 addiction in Pakistan is largely prevalent and is
about 33% in men of middle aged class. In the
The provision of knowledge to people locally recent past some preventive measures were be-
along with firmed and trusted information about ing applied in order to reduce its prevalence.
the injurious conditions of tobacco, smoking re- Nationwide health hazards of smoking appre-
lated to health including the advantages to quit hension programs, along with its restriction of
smoking as result leaded to cessation adopted publicity on local TV networks. Despite of all
commonly. The cessation rates in those coun- the relevant struggles, it is still highly prevalent
tries (high income) are 30%, 15% in Thailand, among students, especially more in non medical
9% and less than 5% in China and India respec- to medical students.16
tively. The physicians in developed countries ex-
hibit an exemplary role through quitting smok- Conclusion:
ing.10 The overall cessation rate of smoke among par-
Pak J Surg 2022; 38(3):141-146
Willingness to smoke cessation among students of Medical Universities 146
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