Brifish lourrid of Medical Edirccrrion, 1975, 9, 17-21
The medical school and smoking' ANDREA KNOPF2 Department of Social Research, University Hospital of South Manchester, Christie Hospital and Holt Radium Institute, Manchester Key words *SCHOOLS, MEDICAL SMOKING/ 'OCCUT SOCIAL BEHAVIOUR STRESS, PSYCHOLOGICAL PEER GROUP HEALTH PERSONNEL TAPE RECORDING QUESTIONNAIRES SMOKING/pTeV STUDENTS, MEDICAL ENGLAND
ATTITUDE OF
The need to discourage medical students from smoking has been emphasized by the Royal College of Physicians (1971). I t might be thought that the sheer quantity of information and clinical experience to which they are exposed during training would be sufficient to dissuade them, but the evidence is to the contrary (Bynner, 1967; Mausner, 1966). Medical training does more than simply supply knowledge : it transmits the norms and values of the profession. As Merton (1957) points out, such learning occurs not only as part of a deliberate teaching process, but also through 'sustained involvement in that society of medical staff, fellow-students and patients which makes up the medical school as a social organisation' (pp. 41-42). Horn and Waingrow (1966) suggest that an important step in changing smoking behaviour is the creation of a social climate in which smoking is not acceptable. This paper will examine the social environment provided by the medical school as it relates to smoking.
Sample and method Tape-recorded interviews were conducted, in 1971. with a 15 per cent random sample of medical students at the University of Manchester, stratified by year. Of 108 students originally selected, 92 (including substitutes) responded (8496). Most nonrespondents were in the first and second clinical
The study was financed by a grant from the Department of Health and Social Security. ?Requests for reprints of Social Research. Manchester, Christie Institute, Withington,
to Miss A. Knopf, Department University Hospital OE South Hospital and Holt Radium Manchester M20 9BX.
years. The interviewees were exactly divided between preclinical students (year 1, n = 24; year 2, n = 22) and clinical students (year 3, n = 15; year 4, n = 15; year 5, n = 16), and included 34 women. Preclinical women were overrepresented in the sample. In addition, a questionnaire was sent to all ManChester medical students (response 91 %, n=658). Some reference will be made here to the findings, but a fuller account appears elsewhere (Knopf and Wakefield, 1974).
Findings The questionnaire survey indicated that among Manchester medical students, 61 per cent were non-smokers, 10 per cent ex-smokers, and 29 per cent smokers, of whom three-fifths smoked every day. At each stage of the course some took up smoking or increased their consumption, while others gave up or decreased their intake, the balance being toward the former (particularly at the preclinical stage), so that there was a net expansion of the smoking habit during training. The interviews provide a means OE looking at the social context of these changes. Of the 92 interviewed, 52 were non-smokers, 8 ex-smokers, and 32 smokers. Simply entering a university provides for some an increased opportunity to smoke once parental and school restrictions are left behind. The importance of the encouragement of peers and the social benefits of smoking are' well known (McKennell and Thomas, 1967; Williams, 1971). and the situation at medical school is no exception. Of the 37 students who were current smokers or had smoked regularly at some time during the course, 28 mentioned such influence (including 17
18
Andrea Knopf
increased opportunity), as playing a part either in their introduction to smoking or in their increased consumption since beginning their studies. Smokers and non-smokers alike recognized social advantages - the pleasures of smoking in company and feeling part of the group, an aid when meeting strangers and to relax socially, and for creating the right social image. ‘ . . . when we first came up to university, the initial thing, rather like me, looking good.’ (Year 2, ex-smoker). However, since smoking is a minority activity at medical school, not all its attributes are seen as socially advantageous by either smokers or non-smokers, who pointed out that it was dirty and irritating to others, had a poor social image, or was non-conformist behaviour at medical school. However, only 5 students (including 2 non-smokers), felt that these undesirable features, or that their friends were non-smokers, had had a direct bearing on their behaviour. Nevertheless, it is probably true that nonsmokers were reinforced in their behaviour because they had fewer friends who smoked. (Half the smokers but less than a third of the nonsmokers said 50 per cent or more of their friends were smokers.) Smoking also has an important psychological component, being used as a method of coping with stress (Tomkins, 1968; McKennell and Thomas, 1967). Twenty-three students mentioned some aspect of the environment of the medical school as a source of pressure relevant to their behaviour. Some are faced with problems of adjustment to a new life when they enter the medical school or a new phase of the course. Examinations were important, being mentioned by more than a third of those with smoking experience and especially by final-year students. ‘ . . . it’s the exams that stop you giving up.’ (Year 5, regular smoker). In addition, work, studying, the need to concentrate, worry about health, the pressures of clinical work, and student life in general, all contribute to environmental stress. Dissection has been suggested as anxiety provoking (Miller, 1961), but there was little evidence for this. As opposed to too much work. the problem of boredom was also a factor:
‘ It helped me in the first year, Something to do with my hands - I was a bit nervous. If I was bored I used to smoke while I was waiting for something to happen.’ (Year 3, ex-smoker). Whereas smokers and non-smokers were equally aware that smohng could have general psychological benefits, smokers were considerably more likely to mention the environment as a source of strain leading to increased smoking. Within the university it is only in the faculty of medicine that factors discouraging smoking might be expected. The questionnaire survey showed that the main expansion of knowledge about the effects of smoking occurs in the clinical period, but superior knowledge did not lead to a lower incidence of smoking among the students as a group. Nevertheless, the interviews indicated that some individuals are affected by the information or clinical experience they gain: 8 students said that some aspect of the course had been relevant to their decision to give up or cut down. In the preclinical section, smoking is most often discussed during dissection, though not all tutors take the opportunity of finding, for instance, a diseased or blackened lung to raise the subject, and though non-smokers were put off by such sights, little long-term impact was made on smokers. In the clinical section, information is provided more systematically and students gain direct experience with patients. Again, the tendency seems to be that most non-smokers were confirmed in their behaviour but that for many smokers the information and experience, though recognized as important, came too late for them to change what had become a wellestablished habit. Apart from health considerations, 4 students said they would like to give up (or had done so) because they wanted to set an example to their patients. Two-thirds of those interviewed thought doctors less likely to smoke than the general public, though less than half knew this as a fact rather than as a matter of opinion, and of these a few felt their personal experience differed from what they had been told. ‘They just said they think fewer doctors supposedly smoke . . . because of the health effects, but there again you see various
The medical school alld smoking
people walking around the medical school smoking - the staff and so on.’ (Year 1, non-smoker) Twenty-one students (mainly in the clinical years) said that they had been advised that smoking was inappropriate for a doctor, whereas 24 said they had not, most of the rest saying smoking had not been discussed on a personal level. Sixty-four accepted the view that the doctor should set an example to his patients and 15 accepted it with qualifications. Smokers were more likely than non-smokers to qualify their answer or reject the idea altogether, less than half of them agreeing without reserve. Thirtynine students thought the doctors role need not interfere in his private life, but very few thought smoking in front of patients acceptable. The teaching staff provide both the information and act as role models from whom the students learn acceptable behaviour. All but nine interviewees were aware of at least some member of staff who smoked (including pipe smokers). Thirteen students, mainly preclinical, expressed surpise at this; indeed, for some it was quite contrary to what they had expected. ‘ Well, I would have thought before I came to medical school that less doctors smoke than actually do smoke.’ (Year 1, non-smoker). Not everyone took this view : ‘ I think the teaching staff as a whole set a very good example.’ (Year 5, non-smoker). Estimates of the proportion of staff who smoked varied from ‘one or two’ to ‘the majority’. Preclinical students were especially likely to mention anatomy tutors (not necessarily because they are more likely to smoke, but because students have more contact with them in a fairly informal setting), but staff at all levels, from professors downwards, were known to be smokers. Fifty-eight students said they were aware of the attitudes of at least some teachers. There were more mentions (34) of anti-smoking attitudes among staff, or attempts at dissuasion (of varying degrees of decisiveness), or of staff who smoked but said they wished they did not, than there were of a more favourable view of
19
smoking being presented. Nevertheless, 9 students mentioned staff who smoked while teaching, 10 had heard a teacher justify smokmg to them, and 8 thought the way they were taught was affected by staff smoking behaviour. Thus, an ambivalent picture is presented to students. Finally, there remains the image of the institution as a whole. More than half the preclinical students and two-thirds of the clinical students thought the medical school had no policy at all about smoking, and most of the rest thought the only policy was one of h o smoking’ in lecture theatres - and that was not always enforced. Even then, some thought this restriction was mainly because of the fire hazard. ‘ I get a feeling that they would not like us to smoke. There is supposed to be no smoking in the lecture theatres for one thing, but I believe that’s partly for insurance reasons. But I’ve not heard of anything definitely stated.’ (Year 3, non-smoker). Students were divided about whether change was needed but, in any case, few wanted to see more restrictions, the main suggestion being more information early in the course. At least one student thought the solution lay in a different direction. ‘ I get the impression it’s frowned on, but there’s nothing much you can really do about it. I suppose they’d have to do something about the staff first, and it would be very difficult to d o that.’ (Year 2, regular smoker). Discussion Although the medical school provides for many students a setting unfavourable to smoking, for some non-smokers and many smokers countervailing tendencies are at work, leading to an expansion of the habit. Peer and social factors may either encourage or discourage smoking, depending on individual circumstances, but in general those elements operating in favour of smoking seem to have a greater impact. Furthermore, they act together with stressful aspects of medical school life to encourage smoking, especially in the early stages. Almost inevitably students will experience some stress during their studies. But are
20
Andrea Knopf
smokers particularly prone to stress? Or have they merely chosen smoking as one way of relieving the tensions they share with their colleagues? Certainly the smokers interviewed were more likely to mention environmental pressure, but the non-smokers were equally aware of the tension-relieving advantages of cigarettes. Other studies (Veldman and Bown, 1969; Thomas, 1973) indicate that smokers are more likely to be aware of stress, but Mausner and Platt (1971) suggests a wider explanation : the habit is supported by the regular confirmation of the smoker’s expectation that it will achieve valued ends, ends, moreover, that the nonsmoker shares: pleasure, the reduction of tension, good fellowship. ‘Reinforcing these is the expectation . . . [that smoking] does not really threaten their own health, their sense of selfesteem, or their ability to lead comfortable and attractive lives’ (p. 81). It might be supposed that the medical school environment would not offer such reinforcement, but this is only partly true. A medical education provides the necessary information about smoking, but only some students relate this to themselves sufficiently for it to change their behaviour (though it may well prevent non-smokers from taking up the habit). However, Hochbaum (1965) points out that fear of disease may prompt smokers to give up, but is often insufficient to enable them to continue to do so and therefore other rewards, psychologically more immediate, are necessary. It is in this area that the medical school fails to establish a climate in which the individual would feel more strongly motivated by such psychosocial rewards. Members of staff present an inconsistent picture both of behaviour and attitudes to students. Furthermore, those teachers who try to dissuade them are following the conventional medical line, doing what might be expected, whereas those who do the unexpected - smoke or justify the habit - are likely to make an impact out of all proportion to their numbers. Considerable ambivalence is created. Most students accept in theory that not smoking is part of the doctor’s role, but the idea that doctors should set an example is not consistently presented. This indecisiveness (by some), together with his experience of doctors who smoke, allows the student who smokes to deny
the relevance of his personal behaviour to his future role, at a time moreover when he is becoming increasingly cynical about his responsibilities in general (Eron, 1955). Nor is the situation ameliorated by the general perception of the policy (or lack of it) of the medical school, as one of no more than mild disapproval extending no further than in many public places and institutions. Most students opposed further restrictions, but more effort could be made to enforce those already in operation. More important, a more forthright declaration of attitude, especially early in the course - perhaps during the freshen’ introductory sessions -would be of value. Every effort should be made to advise all members of staff of the inappropriateness of smoking in front of students, and to encourage those who try to dissuade students from smoking, especially with regard to their future responsibilities to continue to do so, in order to avoid the present duality. summary To examine the social environment of the medical school as it relates to smoking, tape-recorded interviews were conducted with 92 medical students at the University of Manchester. The medicaI school provides a social setting unfavourable to smoking for many students, but for some non-smokers and many smokers countervailing forces lead to an expansion of the habit during training. Increased opportunity, the influence of peers and social factors, together with environmental stress, tend to encourage smoking. The necessary information about smoking is provided and this influences some, but in general the medical school fails to establish a social climate in which smokers would feel more strongly motivated to give up. Although most students accept in theory that non smoking is part of the doctor’s role, this idea is not consistently presented to them during the course. Furthermore, it is not always seen in practice to be adhered to by members of staff, their role models, thus enabling the student who smokes to deny the relevance of his personal behaviour to his future role. Nor is this ameliorated by the students’ perception of policy in the medical school as one of. at most. mild disapproval.
The medical school and smoking
I should like to thank Dr John Wakefield and Professor Alwyn Smith for their advice and collaboration, and Dr F. Beswick, Executive Dean, and the administrative staff of the Medical School for their co-operation. Mrs J. Ciements undertook some of the preliminary work. I am particularly grateful to all students who took part i n the study.
References Bynner, J. M. (1967). Medical Students’ Attitides Towards Smoking. H.M.S.O.: London. Eron, L. D. (1955). The effect of medical education on medical students’ attitudes. /ournu/ of Medical Edircarion, 30, 559-566. Hochbaum, G. M. (1965). Psychosocial aspects of smoking with special reference to cessation. American Joitrnal of Public Health, 55, 692-697. Horn, D., and Waingrow, S.(1966). Some dimensions of a model for smoking behaviour change. American Jortrnal of Prrblic Health. 56, 21-26. Knopf, A., and Wakefield, J. (1974). Effect of medical education on smoking behaviour. British loirrnal of Preventive and Social Medicine. 28, 246-25 1. McKennell, A. C., and Thomas, R. K. (1967). Adtrlts’ and Adolescenis’ Smoking Habits and A tritrrdrs. H.M.S.O.: London. Mausner, J. S . (1966). Smoking in medical students. Archives of Environmental Health, 13, 51-60. ,
21
Mausner, B., and Platt, E. S . (1971). Smoking: A Behavioural Analysis, Pergamon Press : New York. Merton, R. K. (1957). Some preliminaries to a sociology of medical education. In The Stirdent Physician, pp. 3-79. Ed. by R. K. Merton, G . Reader, and P. L. Kendall. Harvard University Press: Cambridge, Massachusetts, Miller, G. E. (1961). (Ed.). Teaching and Learning in Medical School. Harvard University Press : Cambridge, Massachusetts. Royal College of Physicians (1971). Smolfing and Health N o w . Pitman Medical and Scientific Publishing Company: London. Thomas, C. B. (1973). The relationship of smoking and habits of nervous tension. In Sm0kin.e Behaviour : Motives and Incentives, pp. 157-170. Ed. by W. L. Dunn. V. H. Winston: Washington D.C. Tomkins, S. (1968). A modified model of smoking behaviour. In Smoking, Health and Behuviour, pp. 165-186. Ed. by E. F. Borgatta and R. R. Evans, Aldine Publishing Company : Chicago. Veldman, D. J., and Bown, 0. H. (1969). Personality and performance characteristics associated with cigarette smoking among college males. Journal of Consulting and Clinical Psychology, 33, 109-119. Williams, T. M. (1971). Summary and implications of review of literature related to adolescent smoking. U.S. Department of Health, Education and Welfare. National Clearinghouse for Smoking and Health.
The medical school and smoking' ANDREA KNOPF2 Department of Social Research, University Hospital of South Manchester, Christie Hospital and Holt Radium Institute, Manchester Key words *SCHOOLS, MEDICAL SMOKING/ 'OCCUT SOCIAL BEHAVIOUR STRESS, PSYCHOLOGICAL PEER GROUP HEALTH PERSONNEL TAPE RECORDING QUESTIONNAIRES SMOKING/pTeV STUDENTS, MEDICAL ENGLAND
ATTITUDE OF
The need to discourage medical students from smoking has been emphasized by the Royal College of Physicians (1971). I t might be thought that the sheer quantity of information and clinical experience to which they are exposed during training would be sufficient to dissuade them, but the evidence is to the contrary (Bynner, 1967; Mausner, 1966). Medical training does more than simply supply knowledge : it transmits the norms and values of the profession. As Merton (1957) points out, such learning occurs not only as part of a deliberate teaching process, but also through 'sustained involvement in that society of medical staff, fellow-students and patients which makes up the medical school as a social organisation' (pp. 41-42). Horn and Waingrow (1966) suggest that an important step in changing smoking behaviour is the creation of a social climate in which smoking is not acceptable. This paper will examine the social environment provided by the medical school as it relates to smoking.
Sample and method Tape-recorded interviews were conducted, in 1971. with a 15 per cent random sample of medical students at the University of Manchester, stratified by year. Of 108 students originally selected, 92 (including substitutes) responded (8496). Most nonrespondents were in the first and second clinical
The study was financed by a grant from the Department of Health and Social Security. ?Requests for reprints of Social Research. Manchester, Christie Institute, Withington,
to Miss A. Knopf, Department University Hospital OE South Hospital and Holt Radium Manchester M20 9BX.
years. The interviewees were exactly divided between preclinical students (year 1, n = 24; year 2, n = 22) and clinical students (year 3, n = 15; year 4, n = 15; year 5, n = 16), and included 34 women. Preclinical women were overrepresented in the sample. In addition, a questionnaire was sent to all ManChester medical students (response 91 %, n=658). Some reference will be made here to the findings, but a fuller account appears elsewhere (Knopf and Wakefield, 1974).
Findings The questionnaire survey indicated that among Manchester medical students, 61 per cent were non-smokers, 10 per cent ex-smokers, and 29 per cent smokers, of whom three-fifths smoked every day. At each stage of the course some took up smoking or increased their consumption, while others gave up or decreased their intake, the balance being toward the former (particularly at the preclinical stage), so that there was a net expansion of the smoking habit during training. The interviews provide a means OE looking at the social context of these changes. Of the 92 interviewed, 52 were non-smokers, 8 ex-smokers, and 32 smokers. Simply entering a university provides for some an increased opportunity to smoke once parental and school restrictions are left behind. The importance of the encouragement of peers and the social benefits of smoking are' well known (McKennell and Thomas, 1967; Williams, 1971). and the situation at medical school is no exception. Of the 37 students who were current smokers or had smoked regularly at some time during the course, 28 mentioned such influence (including 17
18
Andrea Knopf
increased opportunity), as playing a part either in their introduction to smoking or in their increased consumption since beginning their studies. Smokers and non-smokers alike recognized social advantages - the pleasures of smoking in company and feeling part of the group, an aid when meeting strangers and to relax socially, and for creating the right social image. ‘ . . . when we first came up to university, the initial thing, rather like me, looking good.’ (Year 2, ex-smoker). However, since smoking is a minority activity at medical school, not all its attributes are seen as socially advantageous by either smokers or non-smokers, who pointed out that it was dirty and irritating to others, had a poor social image, or was non-conformist behaviour at medical school. However, only 5 students (including 2 non-smokers), felt that these undesirable features, or that their friends were non-smokers, had had a direct bearing on their behaviour. Nevertheless, it is probably true that nonsmokers were reinforced in their behaviour because they had fewer friends who smoked. (Half the smokers but less than a third of the nonsmokers said 50 per cent or more of their friends were smokers.) Smoking also has an important psychological component, being used as a method of coping with stress (Tomkins, 1968; McKennell and Thomas, 1967). Twenty-three students mentioned some aspect of the environment of the medical school as a source of pressure relevant to their behaviour. Some are faced with problems of adjustment to a new life when they enter the medical school or a new phase of the course. Examinations were important, being mentioned by more than a third of those with smoking experience and especially by final-year students. ‘ . . . it’s the exams that stop you giving up.’ (Year 5, regular smoker). In addition, work, studying, the need to concentrate, worry about health, the pressures of clinical work, and student life in general, all contribute to environmental stress. Dissection has been suggested as anxiety provoking (Miller, 1961), but there was little evidence for this. As opposed to too much work. the problem of boredom was also a factor:
‘ It helped me in the first year, Something to do with my hands - I was a bit nervous. If I was bored I used to smoke while I was waiting for something to happen.’ (Year 3, ex-smoker). Whereas smokers and non-smokers were equally aware that smohng could have general psychological benefits, smokers were considerably more likely to mention the environment as a source of strain leading to increased smoking. Within the university it is only in the faculty of medicine that factors discouraging smoking might be expected. The questionnaire survey showed that the main expansion of knowledge about the effects of smoking occurs in the clinical period, but superior knowledge did not lead to a lower incidence of smoking among the students as a group. Nevertheless, the interviews indicated that some individuals are affected by the information or clinical experience they gain: 8 students said that some aspect of the course had been relevant to their decision to give up or cut down. In the preclinical section, smoking is most often discussed during dissection, though not all tutors take the opportunity of finding, for instance, a diseased or blackened lung to raise the subject, and though non-smokers were put off by such sights, little long-term impact was made on smokers. In the clinical section, information is provided more systematically and students gain direct experience with patients. Again, the tendency seems to be that most non-smokers were confirmed in their behaviour but that for many smokers the information and experience, though recognized as important, came too late for them to change what had become a wellestablished habit. Apart from health considerations, 4 students said they would like to give up (or had done so) because they wanted to set an example to their patients. Two-thirds of those interviewed thought doctors less likely to smoke than the general public, though less than half knew this as a fact rather than as a matter of opinion, and of these a few felt their personal experience differed from what they had been told. ‘They just said they think fewer doctors supposedly smoke . . . because of the health effects, but there again you see various
The medical school alld smoking
people walking around the medical school smoking - the staff and so on.’ (Year 1, non-smoker) Twenty-one students (mainly in the clinical years) said that they had been advised that smoking was inappropriate for a doctor, whereas 24 said they had not, most of the rest saying smoking had not been discussed on a personal level. Sixty-four accepted the view that the doctor should set an example to his patients and 15 accepted it with qualifications. Smokers were more likely than non-smokers to qualify their answer or reject the idea altogether, less than half of them agreeing without reserve. Thirtynine students thought the doctors role need not interfere in his private life, but very few thought smoking in front of patients acceptable. The teaching staff provide both the information and act as role models from whom the students learn acceptable behaviour. All but nine interviewees were aware of at least some member of staff who smoked (including pipe smokers). Thirteen students, mainly preclinical, expressed surpise at this; indeed, for some it was quite contrary to what they had expected. ‘ Well, I would have thought before I came to medical school that less doctors smoke than actually do smoke.’ (Year 1, non-smoker). Not everyone took this view : ‘ I think the teaching staff as a whole set a very good example.’ (Year 5, non-smoker). Estimates of the proportion of staff who smoked varied from ‘one or two’ to ‘the majority’. Preclinical students were especially likely to mention anatomy tutors (not necessarily because they are more likely to smoke, but because students have more contact with them in a fairly informal setting), but staff at all levels, from professors downwards, were known to be smokers. Fifty-eight students said they were aware of the attitudes of at least some teachers. There were more mentions (34) of anti-smoking attitudes among staff, or attempts at dissuasion (of varying degrees of decisiveness), or of staff who smoked but said they wished they did not, than there were of a more favourable view of
19
smoking being presented. Nevertheless, 9 students mentioned staff who smoked while teaching, 10 had heard a teacher justify smokmg to them, and 8 thought the way they were taught was affected by staff smoking behaviour. Thus, an ambivalent picture is presented to students. Finally, there remains the image of the institution as a whole. More than half the preclinical students and two-thirds of the clinical students thought the medical school had no policy at all about smoking, and most of the rest thought the only policy was one of h o smoking’ in lecture theatres - and that was not always enforced. Even then, some thought this restriction was mainly because of the fire hazard. ‘ I get a feeling that they would not like us to smoke. There is supposed to be no smoking in the lecture theatres for one thing, but I believe that’s partly for insurance reasons. But I’ve not heard of anything definitely stated.’ (Year 3, non-smoker). Students were divided about whether change was needed but, in any case, few wanted to see more restrictions, the main suggestion being more information early in the course. At least one student thought the solution lay in a different direction. ‘ I get the impression it’s frowned on, but there’s nothing much you can really do about it. I suppose they’d have to do something about the staff first, and it would be very difficult to d o that.’ (Year 2, regular smoker). Discussion Although the medical school provides for many students a setting unfavourable to smoking, for some non-smokers and many smokers countervailing tendencies are at work, leading to an expansion of the habit. Peer and social factors may either encourage or discourage smoking, depending on individual circumstances, but in general those elements operating in favour of smoking seem to have a greater impact. Furthermore, they act together with stressful aspects of medical school life to encourage smoking, especially in the early stages. Almost inevitably students will experience some stress during their studies. But are
20
Andrea Knopf
smokers particularly prone to stress? Or have they merely chosen smoking as one way of relieving the tensions they share with their colleagues? Certainly the smokers interviewed were more likely to mention environmental pressure, but the non-smokers were equally aware of the tension-relieving advantages of cigarettes. Other studies (Veldman and Bown, 1969; Thomas, 1973) indicate that smokers are more likely to be aware of stress, but Mausner and Platt (1971) suggests a wider explanation : the habit is supported by the regular confirmation of the smoker’s expectation that it will achieve valued ends, ends, moreover, that the nonsmoker shares: pleasure, the reduction of tension, good fellowship. ‘Reinforcing these is the expectation . . . [that smoking] does not really threaten their own health, their sense of selfesteem, or their ability to lead comfortable and attractive lives’ (p. 81). It might be supposed that the medical school environment would not offer such reinforcement, but this is only partly true. A medical education provides the necessary information about smoking, but only some students relate this to themselves sufficiently for it to change their behaviour (though it may well prevent non-smokers from taking up the habit). However, Hochbaum (1965) points out that fear of disease may prompt smokers to give up, but is often insufficient to enable them to continue to do so and therefore other rewards, psychologically more immediate, are necessary. It is in this area that the medical school fails to establish a climate in which the individual would feel more strongly motivated by such psychosocial rewards. Members of staff present an inconsistent picture both of behaviour and attitudes to students. Furthermore, those teachers who try to dissuade them are following the conventional medical line, doing what might be expected, whereas those who do the unexpected - smoke or justify the habit - are likely to make an impact out of all proportion to their numbers. Considerable ambivalence is created. Most students accept in theory that not smoking is part of the doctor’s role, but the idea that doctors should set an example is not consistently presented. This indecisiveness (by some), together with his experience of doctors who smoke, allows the student who smokes to deny
the relevance of his personal behaviour to his future role, at a time moreover when he is becoming increasingly cynical about his responsibilities in general (Eron, 1955). Nor is the situation ameliorated by the general perception of the policy (or lack of it) of the medical school, as one of no more than mild disapproval extending no further than in many public places and institutions. Most students opposed further restrictions, but more effort could be made to enforce those already in operation. More important, a more forthright declaration of attitude, especially early in the course - perhaps during the freshen’ introductory sessions -would be of value. Every effort should be made to advise all members of staff of the inappropriateness of smoking in front of students, and to encourage those who try to dissuade students from smoking, especially with regard to their future responsibilities to continue to do so, in order to avoid the present duality. summary To examine the social environment of the medical school as it relates to smoking, tape-recorded interviews were conducted with 92 medical students at the University of Manchester. The medicaI school provides a social setting unfavourable to smoking for many students, but for some non-smokers and many smokers countervailing forces lead to an expansion of the habit during training. Increased opportunity, the influence of peers and social factors, together with environmental stress, tend to encourage smoking. The necessary information about smoking is provided and this influences some, but in general the medical school fails to establish a social climate in which smokers would feel more strongly motivated to give up. Although most students accept in theory that non smoking is part of the doctor’s role, this idea is not consistently presented to them during the course. Furthermore, it is not always seen in practice to be adhered to by members of staff, their role models, thus enabling the student who smokes to deny the relevance of his personal behaviour to his future role. Nor is this ameliorated by the students’ perception of policy in the medical school as one of. at most. mild disapproval.
The medical school and smoking
I should like to thank Dr John Wakefield and Professor Alwyn Smith for their advice and collaboration, and Dr F. Beswick, Executive Dean, and the administrative staff of the Medical School for their co-operation. Mrs J. Ciements undertook some of the preliminary work. I am particularly grateful to all students who took part i n the study.
References Bynner, J. M. (1967). Medical Students’ Attitides Towards Smoking. H.M.S.O.: London. Eron, L. D. (1955). The effect of medical education on medical students’ attitudes. /ournu/ of Medical Edircarion, 30, 559-566. Hochbaum, G. M. (1965). Psychosocial aspects of smoking with special reference to cessation. American Joitrnal of Public Health, 55, 692-697. Horn, D., and Waingrow, S.(1966). Some dimensions of a model for smoking behaviour change. American Jortrnal of Prrblic Health. 56, 21-26. Knopf, A., and Wakefield, J. (1974). Effect of medical education on smoking behaviour. British loirrnal of Preventive and Social Medicine. 28, 246-25 1. McKennell, A. C., and Thomas, R. K. (1967). Adtrlts’ and Adolescenis’ Smoking Habits and A tritrrdrs. H.M.S.O.: London. Mausner, J. S . (1966). Smoking in medical students. Archives of Environmental Health, 13, 51-60. ,
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