INT J TUBERC LUNG DIS 12(9):1085–1091 © 2008 The Union

Cigarettes and waterpipe among medical students in : a cross-sectional study

M. Q. Almerie,* H. E. Matar,* M. Salam,* A. Morad,* M. Abdulaal,* A. Koudsi,* W. Maziak†‡ * Department of Family & Community Medicine, University, Damascus, † Syrian Centre for Studies, , Syria; ‡ Department of Health & Sports Sciences, Memphis University, Memphis, Tennessee, USA

SUMMARY

OBJECTIVES: To investigate tobacco use, beliefs and at- and 27%) compared to their younger counterparts (6.6% titudes among medical students in Syria. and 19.7%). Regular smoking patterns predominated for METHODS: A cross-sectional study of a random sample (62%), while occasional use patterns predomi- of 570 medical students (fi rst and fi fth year) registered at nated for waterpipes (83%). More than two thirds of stu- the Damascus University Faculty of Medicine in 2006– dents (69%) thought they might not address or would have 2007. We used a self-administered questionnaire for demo- diffi culty addressing smoking in their future patients. graphic information, smoking behaviour (, water- CONCLUSION: The level of tobacco use among Syrian pipe), family and peer smoking, attitudes and beliefs medical students is alarming and highlights the rapidly about smoking and future role in advising patients to quit changing patterns of waterpipe use, especially among fe- smoking. male students. Medical schools should work harder to RESULTS: The overall prevalence of tobacco use was tackle this phenomenon and address it more effi ciently 10.9% for cigarettes (15.8% men, 3.3% women), 23.5% in their curricula. for waterpipe (30.3% men, 13.4% women) and 7.3% for KEY WORDS: cigarette smoking; waterpipe smoking; both (10.1% men, 3.1% women). Both smoking methods medical students; prevalence; Syria were more popular among the fi fth year students (15.4%

TOBACCO USE is the leading preventable cause of at the development of tobacco use among medical death worldwide and, according to latest estimates, students and how their education may have infl uenced more than 80% of the 8.3 million tobacco-attributable their beliefs and practices. Evidence suggests that to- deaths in 2030 will occur in low- and middle-income bacco use remains widespread among medical students countries.1 This alarming prediction highlights the need despite their better knowledge of the risks involved.8,9 for developing nations to examine patterns and deter- This situation obviously represents a missed opportu- minants of tobacco use, understand local tobacco use nity and highlights the inadequacies of methods, develop effective cessation interventions teaching in medical curricula. The recent emergence and train their own tobacco control scientists.2 of waterpipe use in Syria and other Arab countries, In many developing countries, including Syria, and its associated claims of reduced harm, represent a physicians constitute an important asset in the fi ght new threat for tobacco control efforts in this region. against tobacco, owing to their status in the society as Today, young men and women in the are a credible source of health information.3 Studies have increasingly using waterpipes, a habit that they view repeatedly shown the positive role of physicians in as fashionable.10–12 infl uencing tobacco use in patients, assisting in their A recent study of tobacco use practices among uni- efforts and infl uencing national to- versity students in Syria showed worrying trends, bacco control policies.4–6 This positive role is clearly with 23% of students smoking cigarettes and 15% hindered by physicians’ own tobacco use, which places smoking waterpipes.13 No study, however, has docu- their messages at confl ict with their behaviour.7 In mented tobacco use, beliefs and attitudes among medi- Syria, respectively 41% and 11% of men and women cal students in this country. The importance of this physicians smoke cigarettes, testifying to the serious- knowledge in informing medical schools in Syria and ness of the problem.3 the surrounding region about the adequacy of their As tobacco use practices and beliefs about tobacco tobacco control training and curricula was the main are formed early in life, it would be interesting to look reason for conducting this study.

Correspondence to: Muhammad Qutayba Almerie, Department of Family & Community Medicine, University of Damascus, PO Box 11719, Damascus, Syria. Tel: (+963) 11 666 6223. Fax: (+963) 11 461 0922. e-mail: [email protected] Article submitted 2 February 2008. Final version accepted 19 May 2008. 1086 The International Journal of Tuberculosis and Lung Disease

METHODS Table 1 Patterns of use of tobacco among medical students in Damascus according to year of study at university (fi rst vs. fi fth) This cross-sectional study was carried out in 2006– 2007 among students at the Damascus University School of Medicine, Syria’s largest medical school established First year Fifth year Total ( n = 274) (n = 259) (N = 533) more than 100 years ago in the capital, Damascus. % % % Age, years (SD) 18.3 (0.7) 23.0 (0.9) 20.5 (2.5) Study design Smoking status The study cohort consisted of medical students in their Cigarette smokers fi rst and fi fth year registered at the Damascus Faculty Occasional 3.3 5.0 4.1 of Medicine for the university year 2006–2007. It was Regular 3.3 10.4* 6.8 thought that the 4-year interval between fi rst and fi fth Waterpipe smokers Occasional 17.2 22.5 19.7 years would give us information about smoking trends Regular 2.5 5.0 3.8 at different ages and levels of medical knowledge among Smokers of both cigarette the study target group. We aimed to recruit about half and waterpipe 5.1 9.8 7.3 of the students registered in these years, totalling 1173, First smoking attempt to have suffi cient numbers for sex- and smoking First cigarette (n = 17) (n = 40) (n = 57) ⩽9 years 17.7 7.5 10.5 method-based comparisons. Accordingly, 612 students 10–15 years 17.7 7.5 10.5 (364 males, 248 females; 320 fi rst year students, 292 16–18 years 58.8 40.0 45.6 fi fth year students) were randomly selected from the ⩾19 years 5.6 45.0* 33.4 First waterpipe (n = 53) (n = 71) (n = 124) university register and were invited to participate in ⩽9 years 7.6 0.0 3.2 the survey. Students were approached during the clin- 10–15 years 28.3 15.5 21.0 ical training sessions for fi fth year students and the 16–18 years 60.4 29.6* 42.7 ⩾ laboratory sessions for fi rst year students. Of these, 19 years 3.8 53.4* 33.1 Tobacco consumption by 570 students agreed to participate (93.1% response regular smokers, mean (SD) rate, male:female 340:230; fi rst:fi fth year 303:267) Cigarettes/day 12.1 (6.8) 11.1 (7.8) 11.9 (7.5) and provided adequate responses for the analysis. An Waterpipes/week 3.7 (3.0) 5.4 (5.6) 4.8 (4.8) anonymous self-administered questionnaire was used * P < 0.05 for comparisons across year of study (fi rst vs. fi fth). after verbal informed consent had been obtained, in SD = standard deviation. agreement with the protocol approved by the Review Committee of Damascus School of Medicine. smokers included subjects who did not smoke at the Questionnaire time of the survey. Those were further categorised into ex-smokers, who were formerly smokers but currently The questionnaire was developed in Arabic from rel- did not smoke, and never-smokers, who had never evant instruments used for the assessment of tobacco smoked at all. use, including the Global Health Professionals Survey (GHPS) and the Global Youth Tobacco Survey (GYTS), Statistical analysis in addition to previous questionnaires used in Syria Statistical analysis was performed using SPSS 13 soft- for the assessment of waterpipe smoking.12,14–16 ware (SPSS, Chicago, IL, USA). Continuous variables The questionnaire inquired about the participants’ were presented as means. Dichotomous variables were demographic details, their smoking behaviour (ciga- compared using the χ2 test, and continuous variables rette, waterpipe), smoking among family members using the t-test (Table 1). Univariate regression analy- and peers, attitudes and beliefs about smoking and sis was performed separately for cigarette and water- quitting, the role of students as future physicians in pipe smokers to assess correlates of smoking among advising their patients to quit smoking and the stu- students. Variables showing association in the univari- dents’ position on a in public places. Smok- ate analysis at P < 0.2 level were entered in two multi- ers were also asked about their fi rst smoking attempt, variate logistic regression models for cigarettes and tobacco consumption (number of cigarettes per day, waterpipe, separately. Adjusted odds ratios (ORs) and waterpipes per week), and preferred cigarette brands. 95% confi dence intervals (95%CIs) were reported for correlates of the outcome variable (current smoker, Defi nitions non-smoker). Tests were considered signifi cant when Smoking status was established in accordance with two-sided P value < 0.05. the World Health Organization (WHO) criteria for cigarette smoking and the criteria set by Maziak et al. RESULTS for waterpipe smoking:16,17 smokers were subjects who, at the time of the survey, smoked either regularly (⩾1 Of the 570 participants (average age 20.5 years, SD cigarette/day or ⩾1 waterpipe/week) or occasionally 2.5), the overall prevalence of tobacco smoking was (<1 cigarette a day or <1 waterpipe/week). Non- 10.9% for cigarettes (15.8% males, 3.3% females), Smoking among medical students in Syria 1087

Table 3 Multivariate logistic regression analysis for predictors of tobacco use among medical students in Damascus, Syria

OR* 95%CI Cigarette smoking Waterpipe smoker 10.10 5.24–19.47 Male sex 3.99 1.68–9.50 Fifth year* 2.75 1.42–5.33 Age, years 1.21 1.06–1.39 Waterpipe smoking Cigarette smoker 10.34 5.40–19.78 Male sex 2.36 1.43–3.91

* Because of multi-colinearity, year at university and age were entered in the models separately. OR = odds ratio; CI = confi dence interval.

Figure Smoking prevalence by sex and year at university, strat- ifi ed by method of smoking. fi fth year of study (χ2 = 51.9, P < 0.0001; χ2 = 57.8, P < 0.0001, respectively). Potential correlates of tobacco use among respon- 23.5% for waterpipes (30.3% males, 13.4% females) dents were assessed in Table 2. These include sex, age, and 7.3% for both (10.1% males, 3.1% females). The year of study (fi rst vs. fi fth) and use of other forms of total prevalence of any type of smoking was 27.1% tobacco (Table 2). In the multivariate logistic regres- (36.0% males, 13.6% females). Cigarette smoking sta- sion analysis, the same correlates were shown to be tus among medical students differed substantially by predictors of cigarette smoking, while only sex and use sex, with current smoking being reported by 15.8% of other forms of tobacco were predictors of water- of males and 3.3% of females (χ2 = 20.4, P < 0.0001; pipe use (Table 3). Figure, A). Waterpipe use was more popular among As for students’ attitudes and beliefs regarding students, but was still higher in male (30.3%) com- smoking, more than 90% of the respondents sup- pared to female students (13.4%, χ2 = 20.7, P < ported banning smoking in public places, with no dif- 0.0001; Figure, A). Both smoking methods (cigarette ference between smokers and non-smokers (Table 4). and waterpipe) were more popular among fi fth year Another interesting fi nding was the clear difference in students (15.4% and 27%) compared to the younger attitude towards male and female smokers: almost half fi rst year students (6.6% and 19.7%) (P < 0.001, P < of the respondents thought that male smokers looked 0.05 for cigarettes and waterpipe, respectively; Fig- less attractive, compared to 80% who thought that ure, B). Table 1 provides a detailed description of the female smokers looked less attractive (Table 4). About study population according to their smoking status three quarters of the respondents considered the water- and year of study (fi rst vs. fi fth). Cigarette to be more harmful than cigarettes, with no sig- was mostly a daily practice among smokers, while nifi cant difference between smokers and non-smokers waterpipe smoking was mainly occasional (Table 1). of either type (Table 4). Smokers’ attitudes towards Analysis across all age groups showed that both ‘age quitting showed that about half of students thought that at fi rst cigarette’ and ‘age at fi rst waterpipe’ were sig- quitting cigarettes or waterpipe would be diffi cult, with nifi cantly different between students in their fi rst and no difference according to smoking status. Cigarette

Table 2 Correlates of smoking among medical students in Damascus, Syria

Cigarette Waterpipe Smokers Non-smokers Smokers Non-smokers n (%) n (%) OR 95%CI n (%) n (%) OR 95%CI Sex (men) 5.44 2.42–12.23 2.82 1.78– 4.46 Men 51 (15.8) 272 (84.2) 97 (30.3) 223 (69.7) Women 7 (3.3) 203 (96.7) 29 (13.4) 188 (86.6) Year at university (fi fth year vs. fi rst) 2.60 1.45– 4.66 1.55 1.03–2.31 First year 6.6 (18) 256 (93.4) 55 (19.7) 224 (80.3) Fifth year 40 (15.4) 219 (84.6) 71 (27.5) 187 (72.5) Parent(s) smoke 22 (38.6) 191 (40.2) 0.88 0.49–1.54 19.5 (23) 66 (17.3) 1.16 0.68–1.96 Sibling(s) smoke 22.8 (13) 24.6 (110) 0.91 0.47–1.75 29.8 (36) 119 (31.0) 0.94 0.60–1.47 Close friend(s) smoke 52.3 (23) 45.6 (188) 1.31 0.70–2.43 67 (62.6) 228 (64.2) 0.93 0.60–1.46 Smoking other forms of tobacco 73.2 (41) 17.9 (81) 12.52 6.61–23.70 41 (33.6) 15 (3.9) 12.52 6.61–23.71 Age, years (SD) 21.5 (2.3) 20.4 (2.5) 1.21* 1.07–1.35 21.0 (2.5) 20.4 (2.5) 1.10 1.02–1.19

* Increment of 1 year in age. OR = odds ratio; CI = confi dence interval; SD = standard deviation. 1088 The International Journal of Tuberculosis and Lung Disease

Table 4 Beliefs and attitudes towards tobacco use among medical students in Damascus, Syria

Cigarette Waterpipe Smokers Non-smokers Smokers Non-smokers % (n) % (n) % (n) % (n) Q1 Should smoking be banned in public places? ‘Yes’ 94.8 (55) 90.5 (420) 91.7 (111) 91.1 (368) Q2 Will you advise patients in the future to quit smoking? Yes, in a totally objective way 42.9 (24) 30.6 (141) 34.2 (41) 30.3 (122) Sometimes, but it will not be easy 42.9 (24) 51.0 (235) 49.1 (59) 51.2 (206) No, I will not 14.2 (8) 18.4 (85) 16.7 (20) 18.5 (74) Q3 Do you think quitting smoking is diffi cult? 50.9 (29) 53.8 (238) 56.7 (68) 52.9 (202) Q4 Do you think smoking cigarettes is religiously unacceptable? 52.7 (29) 55.4 (253) NA NA Q5 Do you think smoking waterpipes is religiously unacceptable? NA NA 67.3 (74) 62.9 (234) Q6 Do you think a male smoker looks More attractive? 1.8 (1) 7.8 (36) 5.8 (7) 8.7 (35) Less attractive? 56.1 (32) 51.0 (235) 52.1 (63) 51.4 (206) The same? 42.1 (24) 41.2 (190) 42.1 (51) 39.9 (160) Q7 Do you think a female smoker looks More attractive? 1 (1.7) 6.3 (29) 5.7 (7) 6.5 (26) Less attractive? 52 (89.7) 78.6 (361)* 85.2 (104) 79.2 (316)* The same? 5 (8.6) 15.1 (69)* 9.1 (11) 14.3 (57)* Q8 Which do you consider more harmful, cigarette or waterpipe? No difference 2.2 (1) 17.1 (73) 13.2 (14) 17.3 (64) Waterpipe is worse 84.8 (39) 74.2 (317) 76.4 (81) 74.3 (274) Cigarette is worse 13.0 (6) 7.5 (32) 9.4 (10) 7.6 (28) Waterpipe is not harmful 0 1.2 (5) 1.0 (1) 0.8 (3)

* P < 0.05 for comparisons across smoking status for each method of tobacco use. NA = not applicable. smokers in our population generally favoured foreign and their belief was not affected by their waterpipe or brands (61%), while only 7% favoured local brands, cigarette smoking behaviour. In addition, age and to- and 32% had no preference. bacco use dynamics differed between the two methods of tobacco use and between waterpipe users in differ- ent grades, showing a changing picture and an increas- DISCUSSION ing uptake of waterpipes. This is likely to be a refl ec- This study of the smoking habits of medical students tion of an epidemic in progress, whereby stable age in one of the major universities in Syria presents unique and tobacco use patterns have not yet been reached. data about this key population for future health pro- The male-female ratio of cigarette and waterpipe motion in this country. It shows widespread smoking smoking in this group is also of interest. While ciga- in different forms among medical students, affecting rette smoking was more than fi ve times more common over a quarter of them. As noted before in Syria and among male than female students—a pattern compat- other Arab societies, the sex-related pattern in tobacco ible with the unfavourable perception of women smok- use was evident in this study, with men being more ing in Syrian and Arab societies19—the male-female likely to smoke cigarettes as well as waterpipes. Like- ratio for waterpipe use was a little more than two. A wise, the previously noted predominance of intermit- more tolerant attitude toward women waterpipe tent use of waterpipes compared to the more regular smoking may be one factor fuelling the spread of this use of cigarettes18 was observed in this study. This is method of tobacco use among women in Arabic and likely due to the social nature of waterpipe use and traditional societies,18 an argument supported by data the accessibility, time and setting differences between from neighbouring Lebanon and other Arab countries, the two methods of tobacco use.18 which show increasingly fewer sex differences in water- Nevertheless, the predominance of waterpipe use pipe compared to cigarette use.20–22 It is likely that as among our study population was an unexpected fi nd- the waterpipe has a longstanding association with the ing, as previous studies of tobacco use among university Orient and the , it is perceived by local pop- students in Syria showed a predominance of cigarette ulations to conform more closely to local traditions, smoking.13 We are not sure whether this phenomenon and is thus more acceptable for use by women than is a unique feature of this health-educated group or if ‘Western’ cigarettes.18 Also in support of this argument it is a refl ection of the rapidly changing dynamics of is the huge difference between cigarette and waterpipe the smoking epidemic among youth in Syria and other smoking observed in our study among female students, Arab societies. We favour the second explanation, as among whom waterpipe use was about four times more more students in our study said that they thought that common than cigarette smoking. This seems to refl ect waterpipe smoking was more harmful than cigarettes, changing dynamics among young people in Syria, as Smoking among medical students in Syria 1089 our previous study among university students was not smokers who are trying to quit.26 There also needs to able to show this sex-related trend in preference for be a stronger focus on positive youth development dur- tobacco use.13 ing the transition from youth to adulthood.27 This is- The proportion of cigarette smokers among Syrian sue could be incorporated into the students’ medical medical students (10.9%) was generally lower than education to help them mature from undergraduate those reported among medical students in neighbour- students into young doctors. ing countries: 29% in Saudi Arabia,23 14.4% in Paki- On a national level, policy makers should also be stan24 and 18.5% in Iran.25 This, however, should be alerted to tobacco in general, and in particular to the interpreted with caution, as the studies were conducted new emergence of waterpipe smoking, which has so at different times in a region with rapidly changing far escaped the regulations currently imposed on ciga- smok ing rates. Besides, the smoking habits of medical rettes, such as advertisement bans and the inclusion of students (10.9%) was below the level found among health warnings on tobacco products. university students in Syria (18.6%).13 This may ap- pear to be an indicator of more health-conscious atti- CONCLUSIONS tudes among medical students. As mentioned earlier, however, what argues against this explanation is the Despite the limitations of cross-sectional surveys and high proportions of waterpipe use among medical self-report, the current study provides pioneer infor- students despite their belief that waterpipe smoking mation about smoking practices and beliefs in this is more harmful than cigarettes. These observations group that represents the future of public health in highlight the possibility of waterpipe smoking spread- Syria. It shows widespread smoking, especially among ing rapidly among the educated youth of Syria, and in males, and a rapidly changing pattern of waterpipe many cases replacing cigarette smoking, as simultane- use, especially among female students. It also reports ous use was not common. the failure of medical education to encourage healthy A particularly discouraging fi nding is that more behaviour and attitudes towards the main preventable than two thirds of students believed either that they cause of ill health and mortality worldwide. Future would not discuss quitting tobacco use with their fu- studies should look more into the practices and beliefs ture patients or that it would be hard for them to do about tobacco use in medical faculty, curriculum com- so. This attitude did not differ a great deal across the ponents addressing smoking, smoking policies within smoking trends among the students, which indicates the university, and how these factors are refl ected in major inadequacies in addressing this issue in the med- student practices and attitudes. ical school curricula. The widespread waterpipe use among students, de- No policy is currently adopted by Syrian medical spite their awareness of its detrimental aspects, should schools to tackle the surge of tobacco consumption be a clarion call to health authorities in Syria and the among students. Although, by the end of their medi- Arab world to act rapidly to deal with this eminent cal training, students have a reasonable knowledge of epidemic. the association between smoking and different diseases, there is still a steady increase in smoking trends among Acknowledgements students as they progress through their medical train- The authors would like to thank the participating investigators, M K ing. This fi nding is alarming, and shows the failure of Hasoun, L Kharseh, R Qatramiz, H Jaber, W Alfahel, B Firwana, the medical school to encourage health conscious be- A Al-Moujahed and O Altayar, for their help in collecting the data and building the spreadsheets. They would also like to acknowl- haviour and attitudes among these future physicians edge Dr L Dayrani for her valuable feedback on the questionnaire and health educators. format. Dr Maziak and the Syrian Centre for Tobacco Studies are The medical school should consider providing bet- supported by a US National Institute on Drug Abuse (NIDA) grant ter education about the myths and hazards of tobacco (R01 DA024876-01). consumption and introduce a course of smoking ces- sation counselling skills into the curriculum. Preven- tive anti-smoking measures should be implemented References from the fi rst year of medical education. Otherwise, 1 Mathers C D, Loncar D. Projection of global mortality and an entrenched smoking culture may remain among burden of disease from 2002 to 2030. PLoS Med 2006; 3: e442. the students and jeopardise their future role as physi- 2 Maziak W, Arora M, Reddy K S, Mao Z. On the gains of seed- ing tobacco research in developing countries. Tob Control 2006; cians responsible for tobacco control programmes. 15 (Suppl 1): i3– 4. Another key component is to make the medical 3 Maziak W, Mzayek F, Asfar T, Hassig S E. 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RÉSUMÉ

OBJECTIFS : Examiner en Syrie chez les étudiants en mé- les deux modes d’utilisation (10,1% chez les hommes, decine les comportements d’utilisation, les croyances et 3,1% chez les femmes). Les deux types de fume sont plus les attitudes en matière de tabac. populaires chez les étudiants de 5ème année (15,4% et MÉTHODES : Il s’agit de l’étude transversale d’un échan- 27%) par comparaison à leurs collègues plus jeunes (6,6% tillon prélevé au hasard chez 500 étudiants en médecine et 19,7%). Les types de fume régulière sont prédominants (1ère et 5ème année) inscrits à la Faculté de Médecine de pour les cigarettes (62%), alors que les types d’utilisation Damas (2006–2007). Nous avons utilisé un questionnaire occasionnelle sont prédominants pour le narghilé (83%). auto-administré s’enquérant au sujet des informations dé- Plus de deux tiers des étudiants pensent qu’ils peuvent mographiques, du comportement tabagique (cigarettes ou avoir des diffi cultés en abordant le tabagisme—ou qu’ils narghilé) du tabagisme de la famille et des pairs, des at- ne l’aborderaient pas—chez leurs futurs patients. titudes et croyances au sujet du tabagisme et de leur rôle CONCLUSION : Le niveau d’utilisation du tabac chez les futur pour le conseil aux patients en matière d’arrêt du étudiants en médecine Syriens est alarmant et indique tabagisme. une variation rapide du type en faveur d’une utilisation RÉSULTATS : La prévalence globale d’utilisation du tabac du narghilé, particulièrement chez les étudiants de sexe est de 10,9% pour la cigarette (15,8% chez les hommes, féminin. Les écoles de médecine devraient s’attaquer avec 3,3% chez les femmes), de 23,5% pour le narghilé (30,3% force à ce phénomène et l’aborder de façon plus effi ciente chez les hommes, 13,4% chez les femmes) et de 7,3% pour dans leur curriculum.

RESUMEN

OBJETIVOS : Investigar las prácticas, opiniones y acti- con elementos de información demográfi ca, tipo de taba- tudes en relación con el consumo del tabaco de los estu- quismo (cigarrillo, pipa de agua), tabaquismo en la fami- diantes de medicina en Siria. lia y en los pares, actitudes y opiniones acerca del con- MÉTODOS : Fue este un estudio transversal de una mues- sumo de tabaco y de su futura función de consejería a los tra aleatoria de 570 estudiantes de medicina (de primero pacientes sobre el abandono del tabaquismo. y quinto año) inscritos en la facultad de Damasco entre RESULTADOS : La prevalencia global de consumo de ta- 2006 y 2007. Se aplicó un cuestionario autoadministrado baco fue de 10,9% para los cigarrillos (15,8% de los Smoking among medical students in Syria 1091 hombres y 3,3% de las mujeres), 23,5% para la pipa de tirían sobre el abandono del tabaquismo con sus futuros agua (30,3% hombres y 13,4% mujeres) y 7,3% para pacientes o que tendrían gran difi cultad en hacerlo. ambos (10,1% hombres y 3,1% mujeres). Ambos tipos CONCLUSIÓN : Es alarmante la frecuencia de taba- de consumo fueron más populares en los estudiantes de quismo en los estudiantes de medicina en Siria y se ob- quinto año (15,4% y 27%) que en los estudiantes más serva una rápida modifi cación de las costumbres hacia el jóvenes (6,6% y 19,7%). Predominó un consumo cor- consumo de pipa de agua, en particular en las mujeres. riente de cigarrillos (62%), mientras que el consumo de Este fenómeno se debería combatir con más empeño en pipa de agua fue ocasional (83%). Más de dos tercios de las escuelas de medicina y abordar en forma más efi ciente los estudiantes (69%) declararon ya sea que no discu- en el plan de estudios.