INTRODUCTION

Cigarette smoking, or tobacco use as is known in other fields, is considered an important aspect within the priorities and strategies of countries in terms of public health,¹,² since the scientific evidence has documented the association between tobacco use and various illnesses, such as respiratory diseases;³ in terms of the stomatognathic system,⁴ it has been associated to oral cancer, periodontal disease,⁵ and conditions such as halitosis.⁶ The World Health Organization, in its Global Status Report on Noncommunicable Diseases (2010),¹ states that around 6 million people die from tobacco use each year, both for direct and indirect consumption, which could bring the number closer to 8 million by the year 2030. This same institution mentioned, in another report on smoking (2013),² that 12% of the deaths that occurred that year in adults over 30 years of age may be attributed to smoking.

In Colombia, according to global data from the Ministry of Health in its National Survey on Public Health (Encuesta Nacional de Salud Pública, ENSP-2007), the prevalence of smoking among the population aged 18 to 69 years is 13% (men: 20%, women: 7%).⁷ This problem has been characterized for the university population (professors, students, and other employees), and there are local studies available in different cities of the country.⁸,⁹,¹⁰,¹¹,¹²,¹³,¹⁴,¹⁵ It is worth noting that some studies focus on students in the field of health.¹³,¹⁴,¹⁵ Overall, the prevalence of consumption depend on geographical area, type of indicator, and the surveyed population.

Chapter II of Act 1335 of July 21, 2009 identifies the need to establish policies and strategies for the control of smoking, as well as educational programs for the control of tobacco use. These measures are carried out jointly by the Ministry of Health and Social Protection (Ministerio de Salud y Protección Social) and the Ministry of National Education (Ministerio de Educación Nacional).¹⁶ These national policies are related to global strategies such as the Framework Convention for Tobacco Control (FCTC)¹⁷ and the Monitor, Protect, Offer, Warn, Enforce, Raise strategy (MPOWER).¹⁸ One of the most significant advances of the FCTC is the paradigm shift, developing a regulation strategy based on the reduction in cigarette demand and supply. The MPOWER strategy brings about a set of measures intended to monitor consumption, protect people from tobacco smoke, offer help in quitting the habit, alert of its dangers, and enforce bans on advertising, promotion and sponsorship of tobacco use.

As of 2003, the Universidad de Antioquia School of Medicine started a research line on tobacco use, which led to the creation of “ACigarette and Smoke- Free Area”, one of the first programs of this kind in the country. Since 2008, this school has become a smoke-free area,¹⁹ in compliance with Resolution 1956 of the Ministry of Social Protection, on the need to create smoke-free areas in academic institutions.²⁰ This is an educational project seeking to establish an institutional anti-smoking policy within Universidad de Antioquia and to educate health staff in the proper management of smokers by means of curricula, promotion of healthy lifestyles with no tobacco use, and recreational activities that promote tobacco cessation and its prevention. Similarly, the program assists other academic units in the implementation of new smoke-free areas.

The School of Dentistry, by means of Agreement 177 of the Board of Directors (January 23, 2012),²¹ was declared “a smoke-free area”, implementing actions to comply with the law. An important step for the achievement of plans based on social reality and people’s needs involves the characterization of the problem within the School. Therefore, this study is aimed at determining the frequency of cigarette smoking among members of the Universidad de Antioquia School of Dentistry, as well as its related factors.

METHODS

This was a cross-sectional study. The study population included staff from Universidad de Antioquia School of Dentistry (professors, undergraduate and graduate students, and administrative staff). This study is part of a larger project seeking to create smoke-free areas, with the participation of different academic units, such as the Schools of Medicine and Dentistry and the Office for University Welfare. Therefore, sampling was not conducted, but the largest possible number of people was included through different educational workshops and meetings by population groups. 706 people participated in the study with 74.3% overall response rate (professors: 43%, undergraduate students: 83%, graduate students: 87%, employees: 90%). Data collection was conducted between the months of April and June 2012.

A self-completion questionnaire was used (which is available and can be requested to the authors), containing demographic information, cigarette smoking characteristics, weight and height data, and relationships with co-workers and classmates. Specifically, the following variables were used in this study: 1) age: ≤ 24, 25-40, over 41; 2) marital status: single, married, in cohabitation, other (divorced, widow/er); 3) relationship to the School of Dentistry; 4) physical activity (yes/no); 5) personal relationships: very kind, kind, average, not very kind, conflicting, and 6) body mass index (BMI), which was calculated using this formula: Using this information, and complying with the WHO standards,²² the following characteristics were established: a) underweight: BMI ≤ 18.50; b) normal weight: BMI between 18.50 and 24.99; c) overweight: BMI between 25.00 and 29.99); d) obesity: ≥ 30.00.

Regarding cigarette smoking, two variables were considered: prevalence (P: current consumption), obtained from the question “Do you smoke currently?”, and experience (E: current or past consumption), obtained from the question “Have you ever smoked?” Additionally, the following smoking-related variables were used: 1) would you consider smoking sometime in your life? (yes/no); 2) people who smoke near you: family, partner, colleagues, other persons; 3) time with the habit (years): ≤ 5, 6-9, ≥10; 4) type of consumption: daily, ≥ 3 times a week, once a week, occasionally/socially; 5) with regard to the habit of smoking: trying to quit, have tried to quit, have used some method to quit, have not considered quitting. Two questions for ex-smokers were included: 6) time when you quitted the habit: in the last year, in the last 5 years, in the last 10 years, more than 10 years ago, and 7) reason to quit: health reasons, considered it a bad habit, personal reasons, aesthetics, social reasons.

An initial description of the variables was conducted, calculating absolute and relative frequencies and using Chi square tests for distribution of frequencies. The analyses were carried out separately for men and women. This was followed by a multivariate analysis to study the association between experience and prevalence of the habit of smoking to sex, physical activity, and BMI, through logistic regression, calculating crude and adjusted Odds Ratio (ORc and ORa, respectively) by different socio-demographic variables and related variables, and with 95% confidence intervals (95% CI).

This study meets the ethical requirements for research in health, in accordance with national²³ and international²⁴ laws and regulations. This study was approved as part of a program instituted by the School’s directives and with the anonymous, confidential and voluntary participation of study subjects. Partial feedback of the findings was offered to various members of the School of Dentistry, and as a follow up there will be a health promotion program aimed at interesting participants, according to their own interests and motivations.

RESULTS

Table 1 shows sample distribution, as well as smoking prevalence and experience in relation to the variables under study. Prevalence and experience are more common among men, especially in single men aged 24 years. Prevalence is higher in professors, and experience is most common among undergraduate students; it is also more frequent among respondents who are not physically active. Regarding BMI classification, the two smoking categories appear in overweight and underweight persons. In the case of women, current and past cigarette consumption are present in greater proportion among those older than 41 years old, who are married (prevalence), widowed or separated (experience), as well as among employees and women who do not get physical activity (prevalence), and are overweight (prevalence) or obese (experience).

Figure 1 shows the different associations of smoking prevalence and experience to sex, physical activity, and BMI. Sex was significantly associated with smoking, being higher in men (P: ORa 5.34; 95%IC 2.73-10.45 and E: Ora 2.93; 95%IC 2.08-4.14). Physical activity also had statistically significant association for prevalence (ORa 5.78; 95%IC 2.02-16.53), which means that people who do not get physical activity are more likely to smoke cigarette. In the case of BMI, while there were associations, these were not significant in either the crude nor the adjusted model, except in the case of experience in relation to obese people in the crude model (this association disappears when adjusting by logistic regression).

^a OR adjusted by age, marital status, and weight classification b OR adjusted by sex, age, marital status, and weight classification c OR adjusted by sex, age, marital status and physical activity

Figure 1 Multivariate analysis of smoking prevalence and experience by sex, physical activity, and weight classification. School of Dentistry, Universidad de Antioquia, 2012 

Finally, Table 2 shows the percent distribution of variables related to cigarette smoking. Nearly a quarter of men and 8% of women have considered smoking sometime in their lives (statistically significant differences p < 0.0001). In a higher proportion, they reported the presence of co-workers or classmates smoking near them (M: 25%, W: 16% with statistically significant differences p = 0.007) or other person who do (M: 20%; W: 25% without statistically significant differences p = 0.10). Slightly over half of the men reported smoking daily, and 38% of women smoke casually or socially. More than 75% of both sexes are considering or have tried quitting. As for the ex-smokers, a little more than 60% of men and women quitted 5 years ago or less, and 61% of men and 72% of women quitted because they considered it a bad habit.

DISCUSSION

The main findings of this study suggest that the prevalence and experience of cigarette smoking are influenced by socio-demographic factors and clinical parameters. The analysis segmented by sex shows differential characteristic, with tobacco use being higher in men. The lack of physical activity was significantly associated with the highest prevalence of current cigarette smoking among both men and women. A good part of respondents has considered smoking at some point in their lives (especially men), and a quarter of the smoking population has considered quitting.

A large proportion of women consider themselves social smokers. Our explorations allow concluding that this is the first study in the School of Dentistry which evaluates smoking among different groups (professors, students, and employees) in a comprehensive manner.

A smoking prevalence of 13.8% was found in men and 3.9% in women, and these results were lower in comparison with population data supplied by the ENSP-2007,⁷ although both studies agree that prevalence is higher among men. A smoking experience of 52.9% was found in men and 28.4% in women, and these results are higher than those reported in a study on professors, students, and employees from Pontificia Universidad Javeriana;⁸ both studies found differences according to respondent type (differences were higher among students).

Prevalence of tobacco use was 16.9% in men and 3.2% in undergraduates of the Universidad de Antioquia School of Dentistry. These results were lower than those reported by a study carried out at a private university in Barranquilla,¹² and by another study on factors of cardiovascular risk in young university population from Cartagena.²⁵ The differences observed in these studies are mainly related to the demographic and academic characteristics of students (as their study population includes students initiating university life). Concerning the studies on population in the health areas, tobacco use was lower than that reported by the medical students from Pontificia Universidad Javeriana,¹⁴ and somehow higher (in the case of men) than the level reported in a study in Cali.¹⁰ A study conducted at the Universidad de Antioquia School of Nursing¹³ reported a prevalence of 20.7% in men and 13.0% in women; while the percentages reported by this institution were higher, the studies in both schools agree in the differences found by sex.

Smoking at the Universidad de Antioquia School of Dentistry (considering both prevalence and experience) is higher among women who are in non- teaching and administrative positions. These results are consistent with those reported by Universidad Santiago de Cali.⁹ A study aimed at identifying the prevalence and associated factors of daily tobacco use among adult females from Bucaramanga²⁶ found a slightly lower prevalence (6%) than that reported by the School of Dentistry in its non- teaching staff. The literature reports the existence of social differences related to sex and social class or socio-economic position.²⁷ In addition, there may be factors related to the consumption of alcohol and caffeine, and the presence of poor mental health.²⁶

The differences observed by sex in the overall results and those discriminated by participating staff type can be analyzed and supplemented by new qualitative studies that allow to understand the perceptions of men and women on the habit of smoking and its originators. Similarly, it is important to identify causes and explanations based on the current legislation and its acceptance by the population. Gender as a transversal category serves as a variable to establish differences in terms of self-care practices and lifestyles between men and women, as well as the roles they play in society and their impact on knowledge, attitudes, and practices concerning smoking.

A significant association was found between current tobacco use or its prevalence and the absence of physical activity. In this regard, previous studies show that tobacco use is associated to other unhealthy lifestyles, such as sedentarism,²⁸ poor nutrition,²⁹ and other aspects related to the presence of stressors in the workplace or employment conditions.³⁰ Specifically in the student population, a study conducted in dental students from Saudi Arabia found out that a high proportion (47.8%) of smokers reported stress as the main reason for smoking.³¹ Future studies should focus on factors associated with tobacco use and characteristics related to the presence of stressors in the workday or school day and physical, mental and psychosocial health conditions. Regarding the relationship between cigarette smoking and body mass index, the associations were not significant, agreeing with the literature on this matter.³²,³³

Finally, some factors related to the period of time smokers have had the habit were analyzed. In the case of smokers, a good proportion has been smoking for quite a long time, and more than half of them smoke daily. On the other hand, ex- smokers generally quitted recently (less than one or five years ago). Many smokers have tried or wanted to quit for different reasons. Knowing the profile of smokers’ behavior, as well as their habits and lifestyles, is important for effective intervention strategies based on the social reality of the persons directly involved. New studies based on qualitative strategies are needed, in order to recognize the perceptions and beliefs of individuals concerning smoking. Similarly, it is necessary to assess the impact of measures and strategies implemented institutionally for promoting smoking cessation.

It is important to note the strengths and limitations of this study. It included a big proportion of the School of Dentistry population groups, allowing a comprehensive approach to the study population, since the literature focuses mostly on students. The measuring instruments were standardized and reviewed by means of a pilot test, avoiding bias for the most part. One of the limitations was the overall percentage (25.7%) of the study population who did not respond to the questions (differential by population groups), which must be taken into account for the cautious interpretation of findings. However, considering the characteristics of the surveyed population, our findings are adjusted to the social reality of the institution. Finally, we cannot deny the possibility of errors associated to the implementation of a self-completion survey-an instrument commonly used in studies with this type of questionnaires. The relation between BMI and smoking prevalence and experience was not clear enough, and no causality can be established due to the cross-sectional nature of the study. This study established the group that most commonly smokes or has smoked according to BMI. Other analyses conducted by the research team found no significant associations between smoking and inappropriate weight according to the WHO standards. With the abovementioned limitations, this study offers an interesting view that can be used in intervention studies consistent with the strategies proposed by national and international agencies.

In order to promote equity in health, alternatives to the approach to tobacco use should be offered by establishing epidemiological surveillance systems that lead to a deep understanding of the problems, promoting comprehensive access to strategies of education and health promotion in health care centers and schools, establishing mechanisms for reducing the prevalence of tobacco use among groups considered to be vulnerable, and generating cross-sectoral governmental policies.³⁴