Asad Khizar Malik  ( Final Year Students, Lahore, Pakistan. )
Asma Chaudhry  ( Final Year Students, Lahore, Pakistan. )
Aamnah Karamat  ( Final Year Students, Lahore, Pakistan. )
Nadia Arif  ( Final Year Students, Lahore, Pakistan. )
Muhammad Arshad Cheema  ( Academic Department of Surgery, Lahore, Pakistan. )
Abdul Rauf  ( King Edward Medical University, North Surgical Unit, Mayo Hospital, Lahore, Pakistan. )

Objectives: To observe the frequency of cigarette smoking in doctors and paramedics and study various variables associated with it.
Methods: An anonymous questionnaire was given to randomly selected 250 Doctors and 250 Paramedics at Mayo Hospital in 2009. Information about demographic characteristics, smoking status in family, number of cigarettes smoked per day, influence for starting smoking, reason for continuation of smoking and use of nicotine replacement therapy was obtained.
Results: A total of 234 questionnaires from doctors and 207 from paramedics were received back (88.2% response rate). There were 280 males (163 Doctors; 117 Paramedics) and 161 females (71 Doctors; 90 Paramedics). Eightyseven (37.18%) Doctors and 74 (35.74%) Paramedics were smokers with 82 (50.31%) male doctors and 5 (7.04%) females. Similar results were obtained in Paramedics 72 (61.53%) males and 2 (2.22%) females. Of the smokers, majority started smoking between 11-20 years age with 39 (44.83%) Doctors and 48 (64.86%) Paramedics. Twenty three (26.44%) Doctors and 31 (41.89%) Paramedics smoked 11-20 cigarettes per day.
Smoking was initiated due to the influence of friends by 48 (55.17%) Doctors and 56 (75.68%) Paramedics. Most smokers, 29 (33.33%) Doctors and 33 (44.59%) Paramedics found use of cigarette smoking as "Relaxing". Addiction was the main reason for difficulty in quitting cigarette smoking as reported by 33 (37.93%) Doctors and 31 (41.89%) Paramedics. Of the smokers, 61(70.11%) doctors and 50 (32.43%) paramedics had no intention to quit smoking in the next 6 months.
Conclusion: A significant number of doctors and paramedics, especially males, in Pakistan smoke cigarettes, which requires proper attention (JPMA 60:509; 2010).

Health Professionals are in an excellent position to have a prominent role on tobacco control.¹ They can increase awareness on hazards that tobacco consumption imposes on health through public education, better communication, and informational campaigns along with other demand reduction measures concerning tobacco dependence and cessation as they reach a high percentage of the population.¹ They have the opportunity to help people change their behaviour as they can give advice, guidance and answers to questions related to the consequences of tobacco use.¹ However, marked deficits are present in the amount and type of training medical practitioners receive in smoking cessation with little attention paid to determination of effective training methods.²
Tobacco use is the leading preventable cause of death globally, causing more than five million deaths a year.¹ There are more than 1.1 billion smokers worldwide, approximately one third of the global population aged 15 years and over (47% of men and 12% of women).³ Most smokers live in developing countries (800 million) and majority are male (700 million).³ Although smoking rates have decreased in developed countries in past years, there has been a corresponding increase in smoking rates in developing countries,⁴ where currently half of tobacco-related deaths occur.¹ Only 5% of the world\'s population lives in countries that fully protect their population with key measures that reduce smoking rates.¹
Tobacco use is very common in Pakistan and is consumed in a variety of ways, like cigarette smoking, chewing tobacco and cigar smoking. In addition to these, tobacco is smoked in unique local ways, which include "Bidi" (Tobacco rolled in dry leaves), "Huqqa" (Hubble - Bubble),5 and "Sheesha" which is an upcoming trend in higher social class.
In Pakistan during 1998, prevalence of smoking was around 36% in males and 9% in females.⁶ In developing countries like Pakistan with weak anti-tobacco legislation and lack of awareness among the people regarding smoking, the tobacco related diseases are also expected to show a significant increase in coming years. Tobacco use is not only capable of damaging nearly every organ of the human body but also causes at least 15 different cancers and is single-handedly responsible for 30% of all cancer related deaths.¹ The number of cases of lung cancers, chronic obstructive pulmonary disease and myocardial infarction all are increasing with the rise in sales of cigarettes.⁷ Moreover, lung cancer is the leading malignancy among the Pakistani males.⁸ Death rates from cancers of trachea, lung, and bronchus (69.2%) as well as of Lip, oral cavity, and pharynx (48.6%) are significantly high in population above 45 years of age worldwide.⁹ Tobacco-associated cancers are responsible for approximately half the tumours in males and a quarter in females.¹⁰
Staff members (Office staff/Paramedics) are, perhaps, more self reported smokers as compared to medical students and faculty members.⁷ This is possibly due to their stressful job and less knowledge about health as compared to medical students and faculty members.⁷ Smoking prevalence among health professionals is itself often a barrier for their involvement in tobacco control.¹ To devise a comprehensive plan to educate the Health Care Providers regarding the hazards of smoking and how to counsel the general public at large, it was necessary to find out what percentage of the Health professionals themselves smoked. In addition various variables like gender, age of starting to smoke, relation to smoking status in the family, number of cigarettes smoked per day, main influence for starting smoking, reason for continuation of smoking, use and usefulness of nicotine patches among the smokers were also identified. With this objective, the study was undertaken amongst doctors and Paramedics working at Mayo Hospital, Lahore.

The study involved distribution of a self administered anonymous questionnaire to a total of 500 subjects with ages between 18 - 60 years. The subjects recruited were Doctors and Paramedical Staff working at Mayo Hospital, Lahore during 2009. The questionnaire was designed according to the guidelines of World Health Organization (WHO). According to WHO, a cigarette smoker is a person who, at the time of survey smoked cigarettes either daily or occasionally. A daily smoker is a person, who smoked a cigarette at least once a day (except for people who smoked every day, but not on days of religious fasting were still classified as daily smokers). An occasional cigarette smoker is a person, who smoked cigarettes but not every day. A never-smoker was a person who had never smoked at all in his / her lifetime.⁷
Smoking status was based on self reported use of cigarettes. Information about the demographic characteristics, smoking status in the family, number of cigarettes smoked per day, influence for starting smoking, reason for continuation of smoking and use of nicotine patches/gums among the smokers was obtained.
Observer bias was kept to minimum by random selection of the subjects.
The data was put in Microsoft ® Access Sheet and the actual figures / percentages were obtained.

Five hundred employees (250 Doctors and 250 Paramedics) were asked to fill the self administered questionnaires and the results were analyzed for the frequency patterns. A total of 234 questionnaires from doctors and 207 from paramedics were received back (88.2% response rate). This made a total of 441 subjects of whom 280 were males (163 Doctors and 117 Paramedics) and 161 (71 Doctors and 90 Paramedics) were female.
Over all 87 (37.18%) Doctors and 74 (35.74%) Paramedics were found to be smokers. Smoking was prevalent in 82 (50.31%) male doctors and 5 (7.04%) in female doctors (Figure).


Similar results were obtained in Paramedics with higher rates in males (n=72, 61.53%) and less in the females (n=2, 2.22%) (Figure). It was also found that 111 (47.44%) Doctors and 99 (47.82%) Paramedics has a smoker in the family.
Of the Doctors who smoked, majority started smoking between 11-20 years (n=39, 44.83%) age and smoked 11-20 cigarettes per day (n=23, 26.44%). In case of smokers of Paramedical Group, most initiated smoking between 11-20 years of age (n=48, 64.86%) and smoked 11-20 cigarettes per day (n=31, 41.89%). A large number of smokers started smoking due to the influence of friends (Table-1).


One third of the doctors (n=29, 33.33%) found cigarette smoking "Relaxing". Similar was the case in of paramedical group (n=33, 44.59%). The other reason for continuing was addiction to the use of tobacco in both doctors (n=22, 25.29%) and paramedics (n=13, 17.57%).
Addiction was the main reason causing difficulty in quitting cigarette smoking in doctors. The other reason was Lack of Will Power (Table-2).


Of the smokers, 61 (70.11%) doctors and 50 (32.43%) paramedics did not intend to quit smoking in next 6 months. About 71 (81.61%) doctors and 68 (91.89%) paramedics had never tried to use the nicotine replacement therapy. Half of the doctors (6), who used nicotine replacement therapy found it more or less useful. Similar was the case with paramedics (n=3).

The purpose of this study was to know the frequency of cigarette smoking in employees working at Mayo Hospital, Lahore (Pakistan). Similar studies have been carried out in other parts of the world but none in past has been reported from any medical institute / hospital of Punjab (Pakistan).
A similar study was in Zia-ud-Din Medical University, Karachi⁷ showed that staff members (office staff/paramedics) were more (n=18, 46.15%) self reported smokers as compared to medical students and faculty members (p < 0.04). Moreover, Staff members were more males. Similarly, 5 (17.9%) Faculty members were self reported smokers. This study,7 however, had more frequency in case of staff members and less in faculty members.
Similar results were obtained in another study in which prevalence of smoking at Jinnah Postgraduate Medical Centre, Karachi was assessed11 in which smoking was more prevalent in the staff as compared to medical students and doctors.
The current study showed significant number of doctors (161, 36.5%) and paramedics smoking and neither do they intend to quit it. However, majority were males (n=154, 55%) which is a higher figure as compared to above mentioned studies. Frequency was less in case of females (n=9, 5.59%).
Alarming in this study were the high smoking rates among doctors (Males n=82, 50.31% and females n=5, 7.04%) who are supposed to be more knowledgeable on the hazards of tobacco and its dangers to human health. The value of the counseling offered to the patients regarding smoking is questionable if doctors themselves smoke.
The reason behind this trend might be stress of the jobs, as mentioned in other studies.^6,7 Lack of awareness is perhaps not much evident from the above results as doctors and paramedics are found to be smokers in almost the same numbers. However, there is a definite lack of specific training in smoking cessation techniques. The teaching methods used in this regard, if any being practiced in Pakistan, are proving ineffective in developing awareness for smoking cessation, especially in the health care providers.

There is a substantial trend of cigarette smoking in doctors and paramedics working in hospitals of Pakistan. If health care providers themselves smoke, how much can they help in educating masses regarding smoking cessation? It is essential to create awareness both in health care providers and general public regarding hazards of smoking and use of tobacco products as well as use of modern techniques for quitting smoking to curb the spread of this menace.
Recommendations:
1. Hazards of cigarette smoking and other tobacco products should be high lighted through the media, as nothing can substitute change of mind set towards smoking.
2. Public awareness campaigns to inform/educate the masses about the hazards of tobacco should be held regularly every year e.g. World Tobacco Day (May 31st), World Health Day (April 7th) etc.
3. The use of cigarettes and all tobacco products should be banned in all the educational institutes, hospitals and public places and law enforcing authorities should take strict action against people violating such a ban.
4. In all medical schools, special attention should be given to educate the students about the harmful effects of cigarette smoking and students should be encouraged to quit smoking.
5. Government should help smokers to quit smoking by increasing the availability of nicotine patches and counseling smokers to quit. Awareness programmes in this regard should be carried out, so that more and more smokers adopt this way of quitting.
6. Government should increase the present duty and sales tax on cigarettes. This might help to discourage the increasing trend of cigarette smoking, especially in the lower economic class.
7. Enhanced teaching, of an appropriate nature, at undergraduate and postgraduate levels is needed to educate the health officials regarding means to fight this problem.

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