Review of Respiratory Medicine - Volumen 25, N�mero 2 - June 2025

Original Articles

Epidemiological Aspects of Smoking in the Medical Staff of a Center in a Center of the Province of Córdoba, Argentina

Aspectos epidemiológicos del tabaquismo en el personal médico de un Centro de la Provincia de Córdoba, Argentina

ABSTRACT

Smoking continues to be the leading cause of preventable death globally. In Argentina, 22.1% of the adult population consumes tobacco. Previous studies have revealed that the prevalence of smoking among physicians is comparable to that in the general population with a similar socioeconomic status.

The objective was to determine the prevalence of smoking and epidemiological charac­teristics of smoking among the medical staff of the Hospital Tránsito Cáceres de Allende, a reference institution for respiratory diseases in the province of Córdoba (Argentina), which provides an interesting context in which to investigate these aspects.

Descriptive, prospective, cross-sectional study. The data was collected through surveys with 18 multiple choice questions.

The 142 medical professionals of the institution were included. Resulting in a prevalence of 20.4% of current smokers. Active smokers are younger doctors who started the habit on average at age 18, with a low Pack Year Index and low dependence, but a high precontemplation rate. There is a higher number of smokers in the Intensive Care Unit (ICU), operating room, and central emergency department. Former smokers (almost 27%) were generally older, started smoking at an earlier age and stopped more than 10 years ago. Knowledge about the risks of smoking was relatively high. The undergraduate program offered limited information on this topic and a significant number of profes­sionals showed interest in further training, providing a great opportunity to implement continuing education programs within the institution.

Key words: Smoking, Physician, Epidemiology

RESUMEN

El tabaquismo continúa siendo la principal causa de muerte evitable a nivel global. En Argentina, 22,1% de la población adulta consume tabaco. Estudios previos han revelado que los médicos presentan una prevalencia de tabaquismo comparable con la de la población general de nivel socioeconómico similar.

El objetivo fue determinar prevalencia de fumadores y características epidemiológicas del tabaquismo en el personal médico del Hospital Tránsito Cáceres de Allende. Institución de referencia en enfermedades respiratorias de la provincia de Córdoba (Argentina), por lo que presenta un contexto interesante para investigar estos aspectos.

Estudio descriptivo, prospectivo, de corte transversal. Los datos se recolectaron mediante encuestas con 18 preguntas de tipo selección múltiple.

Se incluyeron los 142 profesionales médicos de la institución. Resultando una pre­valencia de 20,4% de fumadores actuales. Los tabaquistas activos son médicos más jóvenes que iniciaron el hábito en promedio a los 18 años, con un Índice de paquete año bajo, dependencia baja, pero alta proporción de precontempladores. Mayor proporción de fumadores en UTI/UCI, quirófano y guardia central. Ex fumadores (casi 27%) en ge­neral más añosos, que comenzaron a fumar más tempranamente y dejaron hace más de 10 años. El conocimiento sobre los riesgos del tabaquismo fue relativamente alto. Baja información sobre esta temática en la carrera de grado e importante proporción de profesionales con deseos de capacitarse, propiciando una gran oportunidad para implementar programas de educación continua en la institución.

Palabras claves: Tabaquismo, Médico, Epidemiología

Received: 30/12/2024

Accepted: 31/04/2025

INTRODUCTION

Theoretical framework

Smoking continues to be the leading cause of preventable death globally. In Argentina, 22.1% of the adult population consumes tobacco, resulting in over 44,000 deaths annually, which represents approximately 13% of all deaths.^1,2 Although there has been a slow decline in smoking prevalence (from 25.1% in 2013 to 22.2% in 20181), there are still 9 million smokers in the country.

In the context of healthcare professionals in Argentina, previous studies have revealed that the prevalence of smoking among physicians is comparable to that in the general population with a similar socioeconomic status. It is observed that the most predominant specialties include psychia­trists, surgeons, anesthesiologists, obstetrician-gynecologists, and intensive care physicians, while pulmonologists, cardiologists, allergists, and pediatricians tend to smoke less.^3,4,5 This contrasts with the situation in developed countries, where smoking among healthcare professionals is sig­nificantly lower than in the general population.⁴ However, in some developing countries –especially those with insufficient regulation of tobacco use in public spaces– smoking among healthcare profes­sionals can be equal to or even higher than in the general population.⁴

A concerning aspect is that physicians who smoke tend to recognize smoking as an addictive behavior less frequently than those who don’t smoke, who often see it simply as a habit.^5,6 In addition, there is a lack of adequate training in the treatment for smoking cessation; less than 30% of physicians report having received relevant information during their education.^5,6 Data suggest that tobacco use often begins during adolescence and continues into the early years of professional training, partly due to limited education on the topic in universities.⁴

Although most physicians acknowledge the risks associated with both active smoking and environ­mental tobacco smoke, and support smoking bans in hospitals and public places, the implementa­tion of these policies is often insufficient.^3,5 The existence of smoke-free environments can reduce cigarette consumption by 30%, promote cessation, and contribute to a safer work environment.^6,7 Moreover, evidence indicates that physicians who smoke tend to show less commitment to fighting tobacco use and providing cessation counseling.⁵

The World Health Organization (WHO) em­phasizes the importance of healthcare personnel quitting smoking, given their crucial role as educa­tors in promoting healthy practices. In countries where smoking among healthcare professionals has declined, a broader reduction in tobacco use has also been observed.⁷ Therefore, understanding the prevalence, attitudes, and training related to tobacco use among medical staff can help develop programs aimed at reducing tobacco consumption among these professionals, with potential impact on their patients and the wider community.

The Hospital Tránsito Cáceres de Allende, a reference center for respiratory diseases in the province of Córdoba, provides a relevant setting for investigating these aspects. This study aims to explore aspects of smoking among the medical professionals of the center, considering that infor­mation about attitudes and behaviors related to tobacco use can significantly contribute to strate­gies for tobacco prevention and control in hospital settings.

Hypothesis

Smoking prevalence among medical professionals at Hospital Tránsito Cáceres de Allende is lower than in the general population.

Overall objective

• To determine the prevalence of smokers among the medical staff at Hospital Tránsito Cáceres de Allende.

Specific objectives

• To determine the prevalence of smokers, former smokers, and non-smokers among the medical staff, and analyze their distribution according to age, sex, age of smoking initiation, Pack-Year Index (PYI), medical specialty, and work area within the institution.

• To determine, among the smoking medical staff, the degree of physical dependence, their intention to quit, and their need for assistance in doing so.

• To determine if the medical staff received training on tobacco addiction during their undergraduate education, assess their basic knowledge on the subject, and explore their interest in receiving further information.

• To determine the frequency with which medical staff advise patients who smoke to quit (cessa­tion counseling).

• To assess the level of compliance with tobacco use restriction policies within the institution.

MATERIALS AND METHODS

Descriptive, prospective, cross-sectional study. Surveys conducted between September 2023 and June 2024.

Population

Medical professionals at the Hospital Tránsito Cáceres de Allende. Since the study included the entire group of effectors, the population constituted the study sample. Participants were categorized into three groups: smokers, former smokers, and non-smokers.

Inclusion criteria

The study included medical professionals from the Hos­pital Tránsito Cáceres de Allende, basing on the staff list provided by the institution.

Exclusion criteria

Non-medical professionals from the institution were excluded, as well as individuals who declined to participate, those who submitted incomplete surveys, or surveys that were named or otherwise identifiable.

Data collection

Data were collected through surveys administered by the investigators. They were anonymous, non-binding, and voluntary, previously pre-printed with 18 multiple choice close-ended questions (see Appendix 1).

Variables

– Sex: male or female

– Age.

– Medical specialties: categorized as clinical or surgical, with further specification.

– Primary work area: private physician’s office, inpatient wards, ICU, central emergency department, operating room, or other.

– Age of smoking initiation.

– Pack-Year Index (PYI): number of cigarettes per day per number of years smoking/20.

– Categories related to tobacco use: classified according to WHO recommendations.³ Categories were defined as follows:

• Smokers:

° Ever smoker: a person who has smoked at least 100 cigarettes, 20 cigars, or 20 pipes in their lifetime.

° Smoker: a person who smokes at the time of the survey.

° Daily smoker: a person who smokes at least one ciga­rette per day at the time of the survey.

° Occasional smoker: a person who smokes less than one cigarette per day at the time of the survey.

• Former smokers

° Former smoker: A person whose last cigarette was consumed more than 12 months before the time of the survey.

° Experimenter: a person who has smoked less than 100 cigarettes (or the equivalent in pipes or cigars) in their lifetime, and smokes less than one cigarette per day at the time of the survey.

• Non-smokers:

° Never smoker: a person who has never smoked in their lifetime.

– Degree of nicotine dependence: it is determined using the Abbreviated Fagerström Test⁹ (see Appendix 2), which takes into account the time elapsed after waking up until the first cigarette is smoked, and the number of cigarettes smoked per day. Dependence is classified as follows:

• High: 5 to 6 points

• Moderate: 3 to 4 points

• Low: 0 to 2 points

– Readiness or intention to quit smoking: based on the Transtheoretical Model developed by Prochaska and DiClemente^10,11, which classifies smokers according to their degree of willingness to make a serious attempt to quit, following these stages:

• Precontemplation: individuals in this stage have no intention of quitting smoking in the next six months.

• Contemplation: smokers are considering quitting within the next 6 months.

• Preparation: they plan to quit within the next 30 days.

• Action: the individual has quit smoking, but maintained abstinence for less than 6 months.

• Maintenance: the individual has quit smoking and re­mained abstinent for more than 6 months. A person is considered a former smoker after more than 12 months of abstinence.

– Need for help to quit smoking: yes, no

– General knowledge about smoking cigarettes is: habit, addiction, both, neither, don’t know.

– Training on tobacco use during undergraduate studies: yes, no.

– Interest in receiving information about tobacco use: yes, no, don’t know.

– Frequency of providing smoking cessation counseling to patients: always, sometimes, almost never, never.

– Compliance with tobacco use restriction policies at the institution: yes, no, partially.

Statistical analysis

The data were recorded on a form designed specifically for data collection and were analyzed using categorical meth­ods presented as graphs or tables as appropriate, showing frequencies and percentages. The results were expressed as mean ± standard deviation.

A statistical significance level of p < 0.05 was established for comparisons between groups using the Student’s t-test for continuous numerical variables, and the Chi-square test or Fisher’s exact test for proportions.

The software packages used were Excel^® and InfoStat-P UNC^® (both in Spanish for Windows^®), and Word^® was used for publication.

Ethical considerations

The work plan was approved by the Training and Teaching Committee of the Hospital Tránsito Cáceres de Allende and by the Adult Institutional Health Research Ethics Committee (IHREC) of the Ministry of Health of the Province of Córdoba (National Registry of Health Research [RENIS, for its acronym in Spanish] No. C0000152), Act No. 513. Data were collected anonymously for inclusion in a digital database, protected by statistical confidentiality. Informed consent was not required.

The survey was confidential and voluntary. Per­sonal data were protected in accordance with Na­tional Law No. 25.326 on Personal Data Protection.

RESULTS

General characteristics

The study sample consisted of a total of n = 142 professionals from the medical staff of the Hospital Tránsito Cáceres de Allende. Most were female, representing 54.9% of the total (45.1% were male). The mean age was 45.6 years (SD = 11.0), with ages ranging from 25 to 72 years.

The most common specialties were: internal medicine at 32.4% of the total (Table 1), traumatol­ogy at 10.6%, and both anesthesiology and general surgery at 6.3%. Other specialties appeared in smaller proportions.

Most professionals work in clinical spe­cialties (66.9%), while 33.1% are in surgical specialties.

Regarding the work area, 32.4% work in the operating room (Figure 1), 21.1% in the central emergency department, and 19.7% in private physician offices.

At the time of the survey, 20.4% of respondents reported that they were current smokers (n = 29) (Figure 4), and 26.8% were former smok­ers (n = 38). It is worth noting that among the former smokers, there were two physicians who had smoked at least once. 46.05% (n = 35) of the non-smokers (52.8%, n = 75), had never tried a cigarette in their life.

When comparing smoking status according to sex, no statistically significant difference was found between men and women (Table 2). Regard­ing age, the percentage of smokers was higher in the group aged 39 years and under (48.3%), while former smokers and non-smokers were between 40 and 59 years old. In this case, there was statistical significance.

The mean age of smoking initiation was 16.9 years (SD = 3.6) for former smokers, and 18.4 years (SD = 4.5) for current smokers. As for the IPA, the mean values were 18.4 for former smokers and 12.7 for current smokers (Table 3).

When correlating smoking habits with work areas, the highest number of smokers was found in the ICU, with 35.7% (Figure 2), followed by the operating room, with 30.4%. The lowest number was found in inpatient wards. This difference was statistically significant.

In a large percentage of current smokers, the degree of nicotine dependence was low (Figure 3), with Abbreviated Fagerström Test results ranging from 0 to 2 points.

The majority of former smokers quit the smok­ing habit more than 10 years ago (55.3%, Figure 4), and 18.4% quit between 5 and 10 years ago.

Regarding the willingness or intention to quit smoking (according to the Transtheoretical Model of Prochaska and DiClemente), 44.8% of smokers (Figure 5) were classified as precontemplators (smokers who are not considering quitting within the next 6 months), and 34.5% as contemplators (smokers who are considering quitting within the next 6 months).

All former smokers were classified as being in the maintenance stage.

Most smokers (75.9%) responded that they would probably be able to quit smoking without any assistance, while 24.1% said they might need help to quit.

When asked about their general knowledge about “smoking cigarettes”, 31% of all respondents considered it an addiction, 12.7% stated it is a habit, and 26.1% believed it is both.

All interviewees with the exception of one stated that passive smoking is harmful. When asked if they had received training in smoking during their under­graduate studies, 58.5% of the surveyed professionals responded affirmatively, while the remaining 41.5% said they had not received such training.

60.6% expressed a desire to receive information about it, while 35.2% responded negatively, and 4.2% said “I don’t know.” This variable showed no difference between smokers, former smokers, and non-smokers.

The majority of providers reported ‘always’ offering smoking cessation counseling to patients (74.6%), with ‘sometimes’ being the next most common answer (21.1%). Among the 25.4% of phy­sicians who provided counseling only ‘sometimes,’ ‘almost never,’ or ‘never’: 55.6% (n = 20) were non-smokers, 16.7% (n = 6) were former smokers, and 27.8% (n = 10) were smokers.

95.8% of professionals stated that tobacco use restriction policies are enforced at the institution (Figure 14), while 4.2% said that these policies are only “partially” (2.8%) or “never” (1.4%) followed.

DISCUSSION

Smoking remains a critical public health issue worldwide, and the medical staff are not exempt from its harmful effects. This study analyzes the prevalence of smoking among the medical staff at the Hospital Tránsito Cáceres de Allende, and compared the results with other national and international studies, as well as with current smoking-related policies and recommendations. This analysis reviews the general characteristics of smokers, former smokers, and non-smokers in our sample, comparing these findings with previous studies –such as the Argentinian studies Tamara I and II– and discusses the strengths and weak­nesses of our research.

Prevalence and characteristics of smoking

In our study, 20.4% of surveyed physicians were current smokers at the time of the survey, a per­centage that aligns with the rates observed in previous studies in Argentina and other develop­ing countries. According to the Tamara I study, the prevalence of smoking among physicians in Argentina in 2007 was 21.3%, a figure similar to what we found in our research.¹² In contrast, the Tamara II study, conducted in 2015, showed a prevalence decrease to approximately 17%.¹³ This downward trend observed in recent studies may reflect the effectiveness of tobacco control policies and educational programs implemented in the country.

The percentage of former smokers in our study (26.8%) is also consistent with data from the Tamara II study, which reported 24% former smokers among the physicians.¹³ In most societ­ies, physicians tend to quit smoking earlier than other occupational groups and the general public, likely due to their greater awareness of the medical consequences of smoking and their understanding of their responsibilities as health role models.¹⁴

The number of non-smokers in our sample (53.5%) aligns with data from the Tamara II study, which showed a non-smoking prevalence of approximately 54%.¹³ The concordance between these studies suggests a relatively stable trend in smoking rates among physicians in Argentina.

In our study we found statistically significance evidence that the work areas with the highest number of smokers were the ICU, operating rooms, and the central emergency department. In other words, professionals working in urgent care environments. This may be related, among other factors, to the nature of the tasks, emotional stress, and long working hours.¹² A Japanese study also showed a correlation between the number of on-call/night shifts and smoking behavior among physicians.¹⁵

Comparison by age and sex

The age-based analysis shows statistically signifi­cant evidence that the prevalence of smokers is higher in the group of physicians under the age of 39 (48.3%). This is consistent with the trend observed in the Tamara I study, where smoking was more prevalent among younger physicians, possibly reflecting early smoking initiation dur­ing medical training.¹² In contrast, the Tamara II study showed a decrease in smoking prevalence in groups of younger ages, suggesting a shift in the attitude toward smoking among newer generations of physicians.¹³

The lack of significant differences in smoking prevalence between genders in our sample is also consistent with the findings from other inter­national studies that did not show any notable disparity in smoking between male and female physicians.^14,15 However, some studies have ob­served higher smoking rates in male physicians. This could reflect cultural and social differences in the acceptance of smoking between genders.¹⁴

Dependence degree and motivation to quit smoking

The degree of nicotine dependence, measured by the Fagerström Test, showed that most current smokers in our study have low dependence. This is consistent with the findings of the Tamara I study, which showed that physicians who smoked tended to have low dependence.¹² The latter may be related to a greater likelihood of cessation, al­though the data suggest that a significant number of physicians are not considering quitting smoking in the short term.

Regarding the intention to quit, results show that 44.8% of smokers are classified as precontem­plators, meaning they are not considering quitting the habit within the next six months. This figure is consistent with the findings of the Tamara I study, which identified a high number of physicians in the precontemplation stage.¹² The fact that there is a considerable number of smokers in this stage may reflect the need for more effective interventions to motivate a change in smoking behavior.

Attitudes and knowledge about smoking

Knowledge of the risks associated with smoking among the physicians in our sample was relatively high; however, there is a significant number of professionals who still underestimate the addic­tiveness of nicotine.

Only 58% reported having received informa­tion in smoking during their undergraduate studies, so it is fundamental to strengthen these interventions and train healthcare professionals in effective counseling techniques, as well as to ensure access to high-quality smoking cessation programs.⁷ Moreover, the fact that more than 60% of physicians expressed a desire to receive more information about smoking suggests an opportu­nity to implement continuing education programs within the hospital.

Smoking cessation counseling and institutional policies

The high frequency of smoking cessation counsel­ing (74.6%) observed in our study is encouraging and aligns with the WHO recommendations that medical personnel should serve as role models for healthy behavior and provide cessation advice to patients.⁷

However, the fact that a number of physicians do not frequently offer cessation counseling (25.4%) highlights a potential area for improvement. Ad­ditionally, just over half of these physicians (55%) are non-smokers, which does not align with the studies that have concluded that smoking physi­cians are less likely to initiate smoking cessation interventions.¹⁴ Smoking physicians seem to be less willing to ask about tobacco use, recommend quitting, and provide evidence-based assistance compared to their non-smoking counterparts. Pre­vious studies, such as that by Salmerón-Castro et al have also suggested that the physician’ s attitude toward smoking can influence how frequently they provide counseling to patients.⁷ The overall compli­ance with tobacco consumption restriction policies within the institution (95.8%) is a positive sign and suggests that the regulations are well implement­ed. However, the fact that 4.2% reported partial or no compliance may indicate there are areas where policy enforcement needs to be strengthened and where the smoke-free environment in the hospital could be improved.

Strengths and weaknesses of the study

Regarding the strengths, the research included all medical professionals in the hospital, ensuring a complete representation of the target popula­tion. Multiple aspects of smoking were addressed, from prevalence to attitudes toward cessation and knowledge about the issue.

In addition, the comparison of our results with the Tamara I and II studies provides valuable con­text and allows for the assessment of consistency and trends over time.

However, although the sample includes all the physicians in the hospital, the overall size may limit the generalizability of the results to other in­stitutions, which could be considered a weakness. On the other hand, the cross-sectional nature of the study limits the ability to establish causality and long-term trends.

CONCLUSIONS

Smoking prevalence among the medical staff at our Center is notably similar to that of the general population in Argentina.

Active smokers are younger doctors, with no difference between sexes. They started smoking at a mean age of 18, have a low PYI and low de­pendence, but a high number of them are in the precontemplation stage. There is a higher propor­tion of smokers in the ICU, operating room, and central emergency department.

There was a high frequency of former smokers, who were generally older and had started smok­ing at an earlier age, and stopped more than 10 years ago.

Knowledge about the risks of smoking was rela­tively high. But only half of the medical staff had received information during their undergraduate studies. And a high percentage wishes to receive information at present.

Most physicians provide smoking cessation counseling to patients, but do not do so consis­tently.

Overall compliance with tobacco restriction policies at the institution is positive.

APPENDICES

APPENDIX 1: SURVEY

“EPIDEMIOLOGICAL ASPECTS OF SMOKING IN THE MEDICAL STAFF OF THE HOSPITAL TRÁNSITO CÁCERES DE ALLENDE.”

The survey is confidential and voluntary. It was approved by the Training and Teaching Committee of the Hospital Tránsito Cáceres de Allende and by the IHREC of the Ministry of Health of the Province of Córdoba.

Personal data will be protected in accordance with National Law No. 25.326 on Personal Data Protection.

APENDIX 2: ABBREVIATED FAGESTRÖN TEST

Conflict of interests

Authors have no conflict of interest to declare that are relevant to the content of this article.

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