Tobacco use among Kyrgyzstan medical students: an 11-year follow-up cross-sectional study

Providing support and professional counseling are essential components of successful Framework Convention on Tobacco Control (FCTC) implementation, overall smoking prevalence reduction and achieving long-term goals in reducing the burden of smoking-related deaths and morbidity [1]. The role of medical professionals has been discussed widely and was considered no less important than the population-level interventions. High smoking prevalence among medicals in low-income countries, however, may impede proper interaction between a smoker willing to quit and a medical professional, where model behavior may play crucial role. Despite induction of advanced tobacco dependence treatment curricula in some institutions around the world, medical students may still exhibit high smoking prevalence and lack appropriate counseling skills. Our cross-sectional study of Kyrgyzstan medical students 11 years ago [2] revealed a worrisome trend in smoking prevalence increase with advanced years of study and low preparedness for counseling. At that time, daily smoking prevalence ranged from 9% at year 1 to 40% at year 6. Moreover, those students demonstrated relatively poor knowledge of the evidence of the association of smoking with disease. Thus, only 64% of current smokers agreed there existed 100% evidence of the association of smoking with morbidity.

Since then, new modules in medical student’s curriculum in Kyrgyz State Medical Academy were introduced and covered some of the tobacco dependence treatment options. Thus, four hours on tobacco control were introduced in the curriculum for year 5 students, as well as 18-h elective course on tobacco control was offered. Moreover, new clinical protocol on tobacco dependence treatment was discussed in the Department of Evidence-Based Medicine in the Ministry of Health and proposed with further approval. Considering local medications availability, this protocol recommended the use of cytisine as an add-on to structured counseling program, and the efficacy of this medication was confirmed in the local randomized controlled trial [3]. However, widespread use and marketing of waterpipe (hookah) for smoking and electronic cigarettes undermined effective tobacco restriction and ban activities on the national level, because the national law on tobacco control did not consider those. Aggressive marketing of waterpipe smoking in Kyrgyz Republic is mainly tailored at the most susceptible groups, such as students [4], including future medical professionals, because of high profits that the owners of small waterpipe cafes make. Unlike waterpipe, smokeless tobacco may cost much less to a user, nevertheless, its prevalence remains uncertain, and due to social pressure of being a role model medical student, students may use this form as an alternative to openly demonstrated conventional cigarette smoking.

Therefore, we planned this study with the aim to assess the effect of current curriculum on smoking behavior of medical students in Kyrgyzstan.

This is a follow-up of previously published study of Kyrgyz State Medical Academy medical students, in which we asked about self-reported smoking prevalence, waterpipe, smokeless tobacco and electronic cigarette use, verified rates with exhaled CO and also asked about the attitudes and knowledge of medical students. We identified new and emerging threat of dramatically high prevalence of wastepipe use. This product may even be a more popular tobacco product in medical students, whereas overall conventional smoking prevalence remained almost unchanged during the last 11 years.

Quite high weekly and monthly waterpipe smoking prevalence in this study (19%) is a novel finding, and may be indicative of two serious gaps in the training system and legislation. When the acting tobacco control law was discussed and later adopted in 2006, waterpipe smoking was probably not so prevalent, and the issue of its control was not properly addressed at that time. High prevalence in this study should foster wider discussion on the possible ways to combat growing epidemic of its use, starting with urgent amendments to the acting law to stop widespread advertisement and affordability. Because waterpipe use is strongly associated with cancer, respiratory disease and other health effects [5, 6], equal ban of waterpipe smoking should be immediately introduced in the local legislation in order to save lives now and promote healthier behavior in those who should initiate that, i.e. medical students. The evidence on the adverse effects of waterpipe smoking is sufficient, although underestimated [7], hence, more efforts are needed to translate this knowledge into mass campaigns and a clearer action plan.

Cigarette smoking in Kyrgyz students was comparable to that in many samples constructed from medical students around the globe, such as Turkish [8], German [9] students, healthcare professionals in Armenia [10], but lower when compared to a few neighboring countries of Asian region [11]. Waterpipe smoking prevalence studies differ in their estimates of current waterpipe smoking in various countries and population groups. Thus, a systematic review from 2011 showed that current waterpipe smoking prevalence was high in both school and university students, reaching 33% in Pakistan, remaining at a level of 6–8% in the United Kingdom [12], and the latter did not increase dramatically from 2008 [13]. In selected countries, nargile smoking prevalence was outstandingly high, such as in Jordan, where up to 53% of female students smoked [14]. In this survey, as compared to the study from eleven years ago, we did not demonstrate increasing daily smoking prevalence with advanced year of study, which may be indicative of some effect of recently introduced tobacco control syllabus at year 5 to cover basic tobacco control, identification and treatment of tobacco dependence. However, even despite that training, some 25% of sixth year medical students still considered poor or no evidence of harmful effects of tobacco. This leaves substantial potential for more intense intervention and reassessment of curriculum to close the gap of poor education. Such advanced training may be effective, since more than 60% of students on overall stated they needed more information on either smoking as a cause of disease or ways to treat dependence. The highest level of knowledge on FCTC and the statement that an advice should be given to every smoker to quit was recorded in 5-year students.

This study has a number of strengths. Unlike studies collecting data only from questionnaires, this study not only compared self-reported smoking prevalence, but also verified it with a biochemical marker, such as exhaled CO. Secondly, we used similar methodology and slightly amended questionnaire, as well as randomization and selection methods, which enabled unbiased comparison with the study undertaken 11 years ago. Besides, the use of a simple study design and its low cost are other essential strengths of this study, because this survey was performed in conditions of low resources, but with very high demand for reliable data to guide future interventions. Of note, very poor resources availability is a meaningful obstacle to conduct studies like this in low-income countries like Kyrgyzstan, especially cohort observations or intervention trials.

The limitations of this study originate from the study design. Because this is a cross-sectional survey, we could not ascertain the incidence of tobacco products use, therefore, we could not conclude at which year medical students increased cigarettes or waterpipe smoking intensity. We only reported prevalence of use, in order to guide prevention strategies and address most calling gaps in medical students training system. This type of study is still valuable to make comparisons with the similar design previous study, as we did. In the current study, we only compared daily and ever-smoking, which cannot fully reflect on current smoking, and given such limitation, smoking prevalence in this study should be compared to other studies only with a similar terminology. We only covered School of Medicine and could not engage students enrolled in the School of Dentistry and the School of Sanitation. Finally, our questionnaire was only available to students in Russian, which may have created additional barriers in understanding for those students, who were raised in purely Kyrgyz language environment, despite acceptable knowledge of Russian in all students a priori.

In conclusion, in this follow-up study we managed to ascertain prevalence of smoking and other tobacco products use, where smoking prevalence remained almost unchanged, but a new, almost uncontrolled, threat to public health in medical students was elucidated. Waterpipe smoke is a fast growing concern in the population of Kyrgyzstan medical students and should be addressed immediately. Current curriculum, although containing elements of tobacco control and tobacco dependence identification and treatment, is insufficient and calls for intervention that is more active.