Public Institution Nicolae Testemitanu State University of Medicine and [600770]

Ministry of Health of the Republic of Moldova
Public Institution “Nicolae Testemițanu ” State University of Medicine and
Pharmacy of the Republic of Moldova

FACULTY OF MEDICINE

Department of Hygiene

DIPLOMA THE SIS

Evaluation of attitudes and experiences related to the use of
tobacco smoking among international students from SUMPh
“Nicolae Testemitanu”

Student: [anonimizat], group 1640

Scient ific advisor: Cebanu Serghei,
PhD, associate professor

Chisinau, 201 5

2 CONTENT

INTRODUCTION ………………………………………………………………. ……………………….. 3
Chapter I
SMOKING AS A PROBLEM OF PUBLIC HEALTH IN VARIOUS
COUNTR IES……………………………………………………………………….. 5
1.1 What is the smoking? ………………………………………………………. ……………………….5
1.2 The problem of smoking in Israel and the Republic of Moldova ………………10
1.3 Social stigma ……………………………………………………………………13
1.4 Health effects of smoking and regulation …………………………… ……………………….19
1.5 What are Electronic Cigarettes? …………………………………………………21
Chapter II
MATERIALS AND METHODS ……………………………………………………24
Chapter III
ASSESS MENT OF THE TOBACCO CONSUME OF I NTERNATIONAL
STUDENTS FROM SUMPh ,,N. TESTEMITANU" ……………… ……………… .25
CONCLUSIONS ………………………………………………………………………………………….. .35
PRACTICAL RECOMENDAT IONS ………………………………………………………….. …..36
REFERRENCES ………………………………………………………………………………………….. .37
ATTACHMENTS ………………………………………………………………………………………… .41

3 Introd uction
The world is in the midst of a smoking epidemic as multinational tobacco
companies turn to the developing world to replace diminishing markets in
industrialized nations (Petro, 1996) . It is predicted that during the first quarter
century, the number of smokers will increase by a half billion, and the number of
annual tobacco -related deaths will more than triple to 10 million, with developing
countries suffering the greatest impact (Mack ey, 1998) .
Tobacco use is the leading cause of avoidable death and disability throughout
the world. According to the estimation of the World Health Organization (WHO),
currently there are about 1.3 billion smokers worldwide including 1 billion men (47%
of the world’s male population) and 250 million women (12% of the world’s fe male
population). The death from tobacco consumption is now 5 million people a year.
WHO also estimates that by 2030, if present consumption patterns continue, the
number of deaths w ill nearly double, reaching close to 10 million annually with
approximately 70% of the deaths occurring in developing countries [1].
Worldwide, tobacco use causes nearly five million deaths per year. Current
trends show that tobacco use will cause more tha n 10 million deaths annually by
2020. Cigarette smoking is the leading preventable cause of death in the United
States. In the United States, cigarette smoking is responsible for about one in five
deaths annually, or about 438,000 deaths per year.
An estim ated 38,000 of these deaths are the result of secondary smoke exposure.
On average, smokers die 13 to 14 years earlier than nonsmokers. For every person
who dies of a smoking -related disease, 20 more people suffer with at least one serious
illness related to smoking. Cigarette smoking increases the time period during which
people live with a disability by about 2 years (CDC, 2007).
The study conducted by Morrow et al. (2002) indicated that when people start to
smoke at a younger age they are more likely to be addicted to nicotine and more
likely to die from tobacco -related diseases. For example, the likelihood of a 15 year

4 old person dying from cancer caused by cigarette smoking is 3 times higher than
someone who starts smoking cigarettes in their mid -20s [5 ].
To illustrate the magnitude of health consequences of tobacco use, it is often
stated that “more deaths are caused each year by tobacco use than by all deaths from
human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle
injuries , suicides, and murders combined [4, 6].”
Tobacco use is associated with increased risk of varying types of cancer, but
most prominently cancers of the respiratory system. Cigarette smoking increased the
risk of dying from lung cancer and there is a differ ent level of risk noted among
gender. One study showed that the risk of dying from lung cancer was 22 times
higher among male smokers and 12 times higher among female smokers than non
smokers [7].
Since carcinogens can be absorbed in the lung and distribut ed throughout the body,
cigarette smoking also increases the risk for many other types of cancers, including
cancers of the lip, oral cavity, and pharynx, esophagus, pancreas, larynx, uterine
cervix, urinary bladder, and kidney [8].
Research purpose
Evaluation of attitudes and experiences related to the use of tobacco smoking among
international students from SUMPh “Nicolae Testemitanu”

Research objectives
 Analysis of bibliographical sources concerning smoking as a problem of public
health ;
 Analysis of the data concerning the problem of smoking in Israel and the
Republic of Moldova;
 Assess the tobacco consume of the international students from SUMPh "N.
Testemitanu” ;
 Develop preventive measures on promoting and protecting the health of the
SUMPh "N. T estemitanu" international students .

5 Chapter 1
SMOKING AS A PROBLEM OF PUBLIC HEALTH IN VARIOUS
COUNTRIES
1.1.What is smoking?
Smoking is a practice in which a substance is burned and the resulting smoke
breathed in to be tasted or inhaled. Most commonly the substance is the dried leaves
of the tobacco plant which has been rolled into rice paper into a small, round cylinder
called a "cigarette". This is primarily practiced as a route of administration for what
has come to be termed " recreational drug use " because the combustion of the dried
plant leaves releases active substances into the body. In the case of cigarette smoking
these substances are contained in a mixture of aerosol particles and gasses and
include the pharmacologically active alkaloid nicotine ; the vaporization creates
heated aerosol and gas to form that allows inhalation and deep penetration into the
lungs where absorption into the bloodstream of the active substances occurs. In some
cultures, smoking is also carried out as a part of various rituals, where participants
use it to help induce trance -like states that, they believe, can lead them to " spiritual
enlightenment ".
Cigarettes are primarily industrially manufactured but also can be hand -rolled
from loose tobacco and rolling paper . Other smoking implements
include pipes , cigars , bidis , hookahs , vaporizers , and bongs . It has been suggested
that smoking -related disease kills one half of all long term smokers but these diseases
may also be contracted by non -smokers. A 2007 report states that, each year, about
4.9 million people worldwide die as a result of smoking [ Robert and Shiffman, Saul
(2007).
Smoking is one of the most common forms of recreational drug use. Tobacco
smoking is today by far the most popular form of smoking and is practiced by over
one billion people in the majority of all human societies. Less common drugs for
smoking include cannabis andopium . Some of the substances are classified as

6 hard narcotics , like heroin , but the use of these is very limited as they are usually not
commercially available.
The history of smoking can be dated to as early as 5000 BC, and has been
recorded in many different cultures across the world. Early smoking evolved in
association with religious ceremonies; as offerings to deities, in cleansing rituals or to
allow shamans and priests to alter their minds for purposes of divination or spiritual
enlightenment. After the European exploration and conquest of the Americas, the
practice of smoking tobacco quickly spread to the rest of the world. In regions like
India and Sub -Saharan Africa, it merged with existing practices of smoking (mostly
of cannabis ). In Europe, it introduced a new type of social activity and a form of drug
intake which previously had been unknown.
Perception surrounding smoking has varied over time and from one place to
another; holy and sinful, sophisticated and vulgar, a panacea and deadly health
hazard. Only relatively recently, and primarily in industrialized Western countries,
has smoking come to be viewed in a decidedly negative light. Today medical studies
have proven that smoking tobacco is among the leading causes of many diseases such
as lung cancer, heart attacks , COPD , erectile dysfunction , and can also lead to birth
defects . The inherent health hazards of smoking have caused many countries such as
Singapore to institute high taxes on tobacco products and anti -smoking campaigns are
launched every year in an attempt to curb tobacco smoking.
The history of smoking dates back to as ea rly as 5000 BC in shamanistic
rituals. Many ancient civilizations, such as the Babylonians, Indians and Chinese,
burnt incense as a part of religious rituals, as did the Israelites and the later Catholic
and Orthodox Christian churches. Smoking in the Amer icas probably had its origins
in the incense -burning ceremonies of shamans but was later adopted for pleasure, or
as a social tool.[3] The smoking of tobacco, as well as various hallucinogenic drugs
was used to achieve trances and to come into contact with the spirit world.
Substances such as Cannabis, clarified butter ( ghee ), fish offal, dried snake
skins and various pastes molded around incense sticks dates back at least 2000 years.

7 Fumigation ( dhupa ) and fire offerings ( homa ) are prescribed in the Ayurveda for
medical purposes, and have been practiced for at least 3,000 years while
smoking, dhumrapana (literally "drinking smoke"), has been practiced for at least
2,000 years. Bef ore modern times these substances have been consumed
through pipes , with stems of various lengths or chillums .
Cannabis smoking was common in the Middle East before the arrival of
tobacco, and was early on a common social activity that centered around the type of
water pipe called a hookah . Smoking, especially after the introduction of tobacco,
was an essential component of Muslim society and culture and became integrated
with important traditions such as weddings, funerals and was expressed in
architecture, clothing, lit erature and poetry. [Sander L. Gilman and Zhou Xun,
"Introduction" in Smoke , p. 20 –21]
Cannabis smoking was introduced to Sub-Saharan Africa through Ethiopia and
the east African coast by either Indian or Arab traders in the 13th century or earlier
and spread on the same trade routes as those that carried coffee, which originated in
the highlands of Ethiopia. It was smoked in calabash water pipes with terra
cotta smoking bowls, apparently an Ethiopi an invention which was later conveyed to
eastern, southern and central Africa. [Coe, Sophie D. (1994)
In 1612, six years after the settlement of Jamestown, John Rolfe was credited as the
first settler to successfully raise tobacco as a cash crop. The demand quickly grew as
tobacco, referred to as "golden weed", revived the Virginia join stock company from
its failed gold expeditions. In order to meet demands from the old world, tobacco
was grown in succession, quickly depleting the land. This became a motivator to
settle west into the unknown continent, and likewise an expansion of tobacco
production. Indentured servitude became the primary labor force up until Bacon's
Rebellion , from which the focus turned to slavery. This trend abated following
the American revolution as slavery became regarded as unprofitable. However the
practice was revived in 1794 with the invention of the cotton gin [ Cooper, William J
2001 ].

8 A Frenchman named Jean Nicot (from whose name the word nicotine is derived)
introduced tobacco to France in 1560. From France tobacco spread to England. The
first report of a smoki ng Englishman is of a sailor in Bristol in 1556, seen "emitting
smoke from his nostrils". Like tea, coffee and opium, tobacco was just one of many
intoxicants that was originally used as a form of medicine. Tobacco was introduced
around 1600 by French mer chants in what today is modern -day Gambia and Senegal .
At the same time caravans from Morocco brought tobacco to the areas
around Timbuktu and the Portuguese brought the commodity (and the plant) to
southern Af rica, establishing the popularity of tobacco throughout all of Africa by the
1650s .
Soon after its introduction to the Old World, tobacco came under frequent criticism
from state and religious leaders. Murad IV , sultan of the Ottoman Empire 1623 -40
was among the first to attempt a smoking ban by claiming it was a threat to public
morality and health. The Chinese emperor Chongzhen issued an edict banning
smoking two years before his death and the overthrow of the Ming dyn asty. Later,
the Manchu of the Qing dynasty , would proclaim smoking "a more heinous crime
than that even of neglecti ng archery". In Edo period Japan, some of the earliest
tobacco plantations were scorned by the shogunate as being a threat to the military
economy by letting valuable farmland go to waste for the use of a recreational drug
instead of being used to plant food crops [ Timon Screech, "Tobacco in Edo Period
Japan" in Smoke , pp. 92 -99]
Religious leaders have often been prominent among those who considered
smoking immoral or outright blasphemous. In 1634 the Patriarch of Moscow forbade
the sale of tob acco and sentenced men and women who flouted the ban to have their
nostrils slit and their backs whipped until skin came off their backs. The Western
church leader Urban VII likewise con demned smoking in a papal bull of 1590.
Despite many concerted efforts, restrictions and bans were almost universally
ignored. When James I of England , a staunch anti -smoker and the author of A
Counterblaste to Tobacco , tried to curb the new trend by enforcing a whopping

9 4000% tax increase on tobacco in 1604, it proved a failure, as London had some
7,000 tobacco sellers by the early 17th century. Later, scrupulous rulers would realise
the futility of smoking bans and instead turned tobacco trade and cultivation into
lucrat ive government monopolies [ Sander Gilman and Zhou Xun, "Introduction"
in Smoke , p. 15 -16].
By the mid -17th century every major civilization had been introduced to tobacco
smoking and in many cases had already assimilated it into the native culture, despite
the attempts of many rulers to stamp the practice out with harsh penalties or fines.
Tobacco, both product and plant, followed the major trade routes to major ports and
markets, and then on into the hinterlands. The English language term smoking was
coined in the late 18th century, before then the practice was referred to as drinking
smoke .
Tobacco and cannabis were used in Sub -Saharan Africa, much like elsewhere
in the world, to confirm social relations, but also created entirely new ones. In what is
today Congo , a society called Bena Diemba ("People of Cannabis") was organized in
the late 19th century in Lubuko ("The Land of Friendship") . The Bena Diemba were
collectivist pacifists that rejected alcohol and herbal medicines in favor of cannabis
[Allen F. Roberts, "Smoking in Sub -Saharan Africa" in Smoke , pp. 53 –54]. The
growth remained stable until the American Civil War in 1860s, from wh ich the
primary labor force transition from slavery to share cropping . This compounded with
a change in demand, lead to the industrialization of tobacco production with the
cigarette. James Bonsack , a craftsman, in 1881 produced a machine to speed the
production in cigarettes [ Burns, Eric., 2007 ].
In the 19th century the practice of smoking opium became common. Previously
it had only been eaten, and then primarily for its medical properties. A massive
increase in opium smoking in China was more or less directly instigated by the
British trade deficit with Qing dynasty China. As a way to amend this problem, the
British began exporting large amounts of opium grown in the Indian colonies. The

10 social problems and the large net loss of currency led to several Chinese attempts to
stop the imports which eventually culminated in the First and Second Opium Wars .
Opium smoking later spread with Chinese immigrants and spawned many
infamous opium dens in China towns around South and Southeast Asia and Europe.
In the latter half of the 19th century, opium smoking became popular in the artistic
community in Europe, especially Paris; artists' neighborhoods such
as Montparnasse and Montmartre became virtual "opium capitals". While opium dens
that catered primarily to emigrant Chinese continued to exist in China Towns around
the world, the trend among the European artists largely abated after the outbreak of
World W ar I. The consumption of Opium abated in China during the Cultural
revolution in the 1960s and 1970s. [Jos Ten Berge, "The Belle Epoque of Opium
in Smoke , p. 114]
1.2. The problem of smoking in Israel and the Republic of Moldova.
In Israel, smoking prevalence among males had remained relatively constant at
30% in the years 1994 –2004. Among females the prevalence has declined slightly
from 25% in 1998 to 18% in 2003. For youth, 14% smoked at least once per week in
a 2001 publication [ Meijer B. Branski D. Kerem E. , 2001 ].
In 2005, research has shown that Israeli youths have begun to use bidis and hookah ,
as alternative methods of tobacco use. In 1990, smoking was the cause of about 1,800
male deaths in Israel which was around 12% of all male deaths. Smoking has not
been found to be signi ficant cause of death among Israeli women. The average
number of cigarettes smoked per Israeli stands at 2162 .
There are several anti-tobacco use legislations in effect. For instance, advertising is
prohibited in youth publications and is forbidden on television and radio. in addition
to substantial increases in tobacco taxes, although comparatively the prices are still
among the lowest compared to all of the European countries. In addition, until 2004,
there was no minimum age requirement for buying tobacco products in
Israel , however, an amendment to the tobacco marketing and advertisement law that
became effective at 2004 has limited the sale of tobacco to people above the age of

11 18 [Tobacco or Health: A Global Status Report ,Centers for Disease Control and
Prevention (CDC) ].
According to Israel Central Bureau of Statistics , the smoking rate in the Israeli adult
population in 2009 was 20.9%, down from 34% in 2000. A Minist ry of Health
nationwide survey conducted in 2011 found that 20.6% of the population aged 21 and
older were smokers. The highest percentage of smokers was among Arab males, 44%
percent of whom smoked, though this figure is down from 50% in 1996 [I sraeli
Ministry of Commerce and Industry ].
In the Republic of Moldova t he rate of smoking among young people is a large cause
for concern. In 2008, 13.4% of young respondents stated they consume tobacco (boys
= 20.8%, girls = 7.1%), although if compared with the data from 2004, the trend is
not ascending and there is even a smal l decrease in the number of smokers among
boys (from 23 to 18.5%). For girls the data did not change very much (from 6 to
5.6%).
Among school children who have ever smoked, 49.2% started smoking before the
age of 10 (54.1% boys and 40.5% girls). One pupil in ten uses other forms of tobacco
consumption other than that of cigarette smoking. There are 20.3% of pupils who are
exposed to cigarette smoke at home and 57% outside the home.
One or both parents of almost half of pupils (47.6%) are smokers. When buyin g
cigarettes from commercial units, two thirds of the pupils (70.7%) had never been
refused them due to their age. A high number (79.6%) of pupils had tried to quit
smoking [Global Youth Tobacco Survey (GYTS). Factsheet, Ages 13 –15. Geneva,
World Health Or ganization and Centers for Disease Control and
Prevention,2008.].Costs, health effects and cost -effectiveness of tobacco control
strategies in the Republic of Moldova
Smoking among medical students.
z
With a view to understanding the changes that occur over time in tobacco
consumption prevalence, Lopez proposed a widely accepted descriptive model for

12 determining the population level of tobacco consumption. Examining the prevalence
and mortality attributable to smoking, he describes four stages of the tob acco
epidemic, from the initial increase in tobacco consumption by the population to an
eventual decline in smoking prevalence and smoking -related mortality. The four
stages correspond to the initial increase of smoking prevalence among men, followed
by th e increase among women, and the increase over the course of time of the
smoking -related mortality among men, followed by that among women [Lopez AD,
Collishaw NE, Piha T. A , 1994 ]. According to the prevalence of smoking data
presented above, it appears tha t smoking prevalence among adults in the Republic of
Moldova has reached the maximum peak and a decline has already begun, i.e.
according to the Lopez model of tobacco epidemic, the Republic of Moldova is at the
end of the second stage and the beginning of the third stage.
At the population level, smoking prevalence also varies among different
socioeconomic groups, undergoing modifications at corresponding levels at different
stages of a tobacco epidemic. Lopez assumes that as countries progress in a tobacc o
epidemic, smoking prevalence will become more evident in groups with lower
socioeconomic status.
At the second stage of the epidemic, smoking prevalence reaches a similar rate
in all categories of the population and is potentially even higher among group s with
high socioeconomic status. This situation changes at the second and third stages,
when the decrease of prevalence is more evident in groups with higher
socioeconomic status. The results of the Moldova Demographic and Health Survey
2005 show that the re are significant differences in the inequality index with regard to
smoking that depend on the level of education and economic welfare. A higher
prevalence of smoking is recorded among men wi th lower socioeconomic status,
costs, health effects and cost -effectiveness of tobacco control strategies in the
Republic of Moldova and a lower level of education. For women, however, the
situation is reversed: smoking prevalence is higher among women with a higher level
of education and higher socioeconomic status [National Scientific and Applied

13 Center for Preventive Medicine (Moldova) and ORC Macro. Moldova Demographic
and Health Survey 2005 ]
1.3.Social stigma
With the modernization of cigarette production compounded with the increased
life expectancies during the 1920s, adverse health effects began to become more
prevalent. In Germany, anti -smoking groups, often associated with anti -liquor
groups, first published advocacy against the consumption of tobacco in the
journal Der Tabakgegner (The Tobacco Opponent) in 1912 and 1932. In 1929, Fritz
Lickint of Dresden, Germany, published a paper containing formal statistical
evidence of a lung cancer –tobacco link. During the Great Depression , Adolf
Hitler condemned his earlier smoking habit as a waste of money, and later with
stronger asse rtions. This movement was further strengthened with Nazi reproductive
policy as women who smoked were viewed as unsuitable to be wives and mothers in
a German family .
The movement in Nazi Germany did reach across enemy lines during the
Second World War, as anti-smoking groups quickly lost popular support. By the end
of the Second World War, American cigarette manufacturers quickly reentered the
German black market. Illegal smuggling of tobacco became prevalent, and leaders of
the Nazi anti -smoking campaign were assassinated. As part of the Marshall Plan , the
United States shipped free tobacco to Germany; with 24,000 tons in 1948 and
69,000 tons in 1949. Per capita yearly cigarette consumption in post-war
Germany steadily rose from 460 in 1950 to 1,523 in 1963. By the end of the 20th
century, anti -smoking campaigns in Germany were unable to exceed the effectiveness
of the Nazi -era climax in the years 1939 –41 and German tobacco health research was
described by Robert N. Proctor as "muted" [ Colin White (September 1989).
In the UK and the USA, an increase in lung cancer rates, formerly "among the rarest
forms of disease", was noted by the 1930s, but its cause remained unknown and even
the credibility of this increase was sometimes disputed as la te as 1950. For example,
in Connecticut, reported age -adjusted incidence rates of lung cancer among males

14 increased 220% between 1935 –39 and 1950 -54. In the UK, the share of lung cancer
among all cancer deaths in men increased from 1.5% in 1920 to 19.7% in 1947.
Nevertheless, these increases were questioned as potentially caused by increased
reporting and improved methods of diagnosis. Although several carcinogens were
already known at the time (for example, benzo[a]pyrene was isolated from coal tar
and demonstrated to be a potent carcinogen in 1933), none were known to be
contained in adequate quantities in tobacco smoke. Richard Doll in 1950 published
research in the British Medical Journal showing a close link between smoking and
lung cancer . Four years later, in 1954 the British Doctors Study , a study of some 40
thousand doctors over 20 years, confirmed the suggestion , based on which the
government issued advice that smoking and lung cancer rates were related. Doll R,
Hill AB (June 26, 1954). In 1964 the United States Surgeon General 's Report on
Smoking and Health likewise began suggesting the relationship between smoking and
cancer, which confirmed its suggestions 20 years later in the 1980s. [ Berridge, V.
2007. ]
As scientific evidence mounted in the 1980s, tobacco companies
claimed contributory neglig ence as the adverse health effects were previously
unknown or lacked substantial credibility. Health authorities sided with these claims
up until 1998, from which they reversed their position. The Tobacco Master
Settlement Agreement , originally between the four largest US tobacco companies and
the Attorneys General of 46 states, restricted certain types of tobacco advertisement
and required payments for health compensation; which later amounted to the largest
civil settlement in United States history [ Milo Geyelin 1998). ]
From 1965 to 2006, rates of smoking in the United States have declined from
42% to 20.8%.[ VJ Rock, MPH, A Malarc her, PhD, JW Kahende, PhD, K Asman,
MSPH, C Husten, MD, R Caraballo, PhD (2007 -11-09). "Cigarette Smoking Among
Adults – United States, 2006" ]
A significant majority of those who quit were professional, affluent men.
Despite this decrease in the prevalence of consumption, the average number of

15 cigarettes consumed per person per day increased from 22 in 1954 to 30 in 1978. This
paradoxical event suggests that those who quit smoked less, while those who
continued to smoke moved to smoke more light cigarettes . This trend has been
paralleled by many industrialized nations as rates have either leveled -off or declined.
In the developing world , however, tobacco consumption continues to rise at 3.4% in
2002[ WHO/WPRO -Smoki ng Statistics" . World Health Organization Regional
Office for the Western Pacific. ]. In Africa, smoking is in most areas considered to be
modern, and many of the strong adverse opinions that prevail in the West receive
much less attention. Today Russia leads as the top consumer of tobacco followed
by Indonesia , Laos , Ukraine , Belarus , Greece , Jordan , and China [WHO REPORT on
the global TOBACCO epidemic 2008, pp. 267 –288]. The World Health Organization
has begun a program known as the Tobacco Free Initiative (TFI) in order to reduce
rates of consumption in the developing world.
In the early 1980s, organized international drug trafficking grew. However,
compounded with overproduction and tighter legal enforcement for the illegal
product, drug dealers decided to convert the p owder to "crack" – a solid, smoke -able
form of cocaine, that could be sold in smaller quantities, to more people. This trend
abated in the 1990s as increased police action coupled with a robust economy
deterred many potential candidates to forfeit or fail to take up the habit.
The most popular type of substance that is smoked is tobacco . There are many
different tobacco cultivars which are made into a wide variety of mixtures and
brands. Tobacco is often sold flavored, often with various fruit aromas, something
which is especially popular for use with water pipes, such as hookahs . The second
most common substance t hat is smoked is cannabis , made from the flowers or leaves
of Cannabis sativa or Cannabis indica . The substance is considered illegal in most
countries in the world and in those countries that tolerate public consumption, it is
usually only pseudo -legal. De spite this, a considerable percentage of the adult
population in many countries have tried it with smaller minorities doing it on a
regular basis. Since cannabis is illegal or only tolerated in most jurisdictions, there is

16 no industrial mass -production of cigarettes, meaning that the most common form of
smoking is with hand -rolled cigarettes (often called joints ) or with pipes. Water pipes
are also fairly common, and when us ed for cannabis are called bongs.
A few other recreational drugs are smoked by smaller minorities. Most of these
substances are controlled , and some are considerabl y more intoxicating than either
tobacco or cannabis. These include crack cocaine ,
heroin, metham phetamine and PCP. A small number of psychedelic drugs are also
smoked, including DMT , 5-Meo-DMT , and Salvia divinorum .
Even the most primitive form of smoking requires tools of some sort to perform. This
has resulted in a staggering variety of smoking tools and paraphernalia from all over
the world. Whether tobacco, cannabis, opium or herbs, some form of receptacle is
required along with a source of fire to light the mixture. The most common today is
by far the cigarette, consisting of a mild inhalant strain of tobacco in a tightly rolled
tube of paper, usually manufactured industrially and including a filter , or hand -rolled
with loose tobacco. Other popular smoking tools are various pipes and cigars.
A less common but increasingly popular alternative to smoking is vaporizers,
which use hot air convection to deliver the substance without combustion, thereby
decreasing health risk to the lungs. A portable vaporization alternative appeared in
2003 with the introduction of electronic cigarettes , battery -operated, cigarette -shaped
devices which produce an aerosol intended to mimic the smoke fr om burning
tobacco, delivering nicotine to the user without carbon monoxide and other harmful
substances released in tobacco smoke. Claims that electronic cigarettes are overall
less harmful to use than real cigarettes are, however, disputed, as is their l egal status
in many countries.
Other than actual smoking equipment, many other items are associated with
smoking; cigarette cases , cigar boxes , lighters , matchboxes , cigarette holders , cigar
holders , ashtrays ,silent butlers , pipe cleaners , tobacco cutters , match stands , pipe
tampers , cigarette companions and so on. Many of these have become

17 valuable collector items and particularly ornate and antique items can fetch high
prices at the finest auction houses.
Society and culture
Smoking has been accepted into culture, in various art forms, and has developed
many distinct, and often conflicting or mutually exclusive, meanings depending on
time, place and the practitioners of smoking. Pipe smoking , until recently one of the
most common forms of smoking, is today often associated with solemn
contemplation, old age and is often considered quaint and archaic. Cigarette smoking,
which did not begin to become widespread until the late 19th century, has more
associations of modernity and the faster pac e of the industrialized world. Cigars
have been, and still are, associated with masculinity , power and is an iconic image
associated with the stereotypical capitalist. In fact, so me evidence suggests that men
with higher than average testosterone levels are more likely to smoke. Smoking in
public has for a long time been something reserved for men and when done by
women has been associated with promiscuity . In Japan during the Edo period ,
prostitutes and their clients would often approach one another under the guise of
offering a smoke; th e same was true for 19th -century Europe [ Timon Screech,
"Tobacco in Edo Period Japan" in Smoke , pp. 92 -99]
The earliest depictions of smoking can be found on Classical Mayan pottery from
around the 9th century. The art was primarily religious in nature and depicted deities
or rulers smoking early forms of cigarettes. Soon after smoking was introduced
outside of the Americas it began appearing in painting in Europe and Asia. The
painters of the Dutch Golden Age were among the first to paint portraits of people
smoking and still lifes of pipes and tobacco. For southern European painters of the
17th century, a pipe was much too modern to include in the preferred motifs inspired
by mythology from Greek and Roman antiquity. At first smoking was considered
lowly and was associated with peasants. Many early paintings were of scenes set in
taverns or brothels. Later, as the Dutch Republic rose to considerable power and
wealth, smoking became more common amongst the affluent and portraits of elegant

18 gentlemen tastefully raising a pipe appeared. Smoking represented pleasure,
transience and the briefness of ea rthly life as it, quite literally, went up in smoke.
Smoking was also associated with representations of both the sense of smell and that
of taste.
In the 18th century smoking became far more sparse in painting as the elegant
practice of taking snuff became popular. Smoking a pipe was again relegated to
portraits of lowly commoners and country folk and the refined sniffing of shredded
tobacco followed by sneezing was rare in art. When smoking appeared it was often in
the exotic portraits influenced by Orientalism . Many proponents of post-colonial
theory controversially believe this portrayal was a means of projecting an image of
European superiority over its colonies and a perception of the male dominance of a
feminized Orient .
In the 19th century smoking was common as a symbol of simple pleasures; the
pipe smoking "noble savage", solemn contemplation by Classical Roman ruins,
scenes of an artists becoming one with nature while slowly toking a pipe. The newly
empowered middle class also found a new dimensio n of smoking as a harmless
pleasure enjoyed in smoking saloons and libraries. Smoking a cigarette or a cigar
would also become associated with the bohemian , someone who shunned the
conserva tive middle class values and displayed his contempt for conservatism. But
this was a pleasure that was to be confined to a male world; women smokers were
associated with prostitution and smoking was not considered an activity fit for proper
ladies. It was not until the start of the 20th century that smoking women would
appear in paintings and photos, giving a chic and charming impression.
Impressionists like Vincent van Gogh , who was a pipe smoker himself, would also
begin to associate smoking with gloom and fin-du-siècle fatalism.
Economics
Estimates claim that smokers cost the U.S. economy $97.6 billion a year in lost
productivity, and that an additional $96.7 billion is spent on public and private health
care combined [ Smith, Hilary. ,2008 This is over 1% of the gross domestic product .

19 A male smoker in the United States that smokes more than one pack a day can expect
an average increase of $19,000 just in medical expenses over the course of his
lifetime. A U.S. female smoker that also smokes more than a pack a day can expect
an average of $25,800 additional healthcare costs over her lifetime [ U.S. Department
of Treasury.
The staging -area camps were named after various brands of American cigarettes; the
assembly area camps were named after American cities. The names of cigarettes and
cities were chosen for two reasons: First, and primarily, for security. Referring to the
camps without an indication of their geographical location went a long way to
ensuring that the enemy would not know precisely where they were. Anybody
eavesdropping or listening to radio traffic would think that cigarettes were being
discussed or the camp w as stateside, especially regarding the city camps. Secondly,
there was a subtle psychological reason, the premise being that troops heading into
battle wouldn't mind staying at a place where cigarettes must be plentiful and troops
about to depart for comba t would be somehow comforted in places with familiar
names of cities back home (Camp Atlanta, Camp Baltimore, Camp New York, and
Camp Pittsburgh, among others). (I doubt if the GIs heading into Europe were taken
in by any of that cigarette and city mumbo -jumbo!) By war's end, however, all of the
cigarette and city camps were devoted to departees. Many processed liberated
American POWs (Prisoners of War) and some even held German POWs for a while.]
1.4. Health effects of smoking and regulation
Smoking is one of t he leading causes of preventable death globally. In the United
States about 500,000 deaths per year are attributed to smoking -related diseases and a
recent study estimated that as much as 1/3 of China's male population will have
significantly shortened life -spans due to smoking [ Leslie Iverson , "Why do We
Smoke?: The Physiology of Smoking" in Smoke , p. 320 ] Male and female smokers
lose an average of 13.2 and 14.5 years of life, respectively. At least half of all lifelong
smokers die earlier as a result of smoking [ Doll R, Peto R, Boreham J, S utherland I
(2004 ]. The risk of dying from lung cancer before age 85 is 22.1% for a male smoker

20 and 11.9% for a female current smoker, in the absence of competing causes of death.
The corresponding estimates for lifelong nonsmokers are a 1.1% probability of dying
from lung cancer before age 85 for a man of European descent, and a 0.8%
probability for a woman. Smoking one cigarette a day results in a risk of heart disease
that is halfway between that of a smoker and a non -smoker.
Among the diseases that can be caused by smoking are vascular stenosis , lung cancer,
heart attacks and chronic obstructive pulmonary disease . Smoking during pregnancy
may cause ADHD to a fetus [ Braun JM, Kahn RS, Froehlich T, Auinger P, Lanphear
BP (2006) ].
Many governments are trying to deter people from smoking with anti -smoking
campaigns in mass media stressing the harmful long -term effects of smoking. Passive
smoking , or secondhand smoking, which affects people in the immediate vicinity of
smokers, is a major reason for the enforcement of smoking bans . This is a law
enforced to stop individuals smoking in indoor public places, such as bars, pubs and
restaurants. The idea behind this is to discourage smoking by making it more
inconvenient, and to stop harmful smoke being present in enclosed public spaces. A
common concern among legislators is to discourage smoking among minors and
many states have passed laws against selling tobacco products to underage customers
(establishing a smoking age ). Many developing countries have not adopted anti –
smoking policies, leading some to cal l for anti -smoking campaigns and further
education to explain the negative effects of ETS (Environmental Tobacco Smoke) in
developing countries. Tobacco advertising is also sometimes regulated to make
smoking less appealing.
Despite the many bans, European countries still hold 18 of the top 20 spots,
and according to the ERC, a market research company, the heaviest smokers are from
Greece, averaging 3,000 cigarettes pe r person in 2007
[http://www.gadling.com/2008/05/12/which -country -smokes -the-most/ ]. Rates of
smoking have leveled off or declined in the developed world but continue to rise in
developing countries. Smoking rates in the United States have dropped by half from

21 1965 to 2006, falling from 42% to 20.8% in adults [ Cigarette Smoking Among
Adults – United States, 2006" .]
The effects of addiction on society vary considerably between different
substances that can be smoked and the indirect social problems that they caus e, in
great part because of the differences in legislation and the enforcement of narcotics
legislation around the world. Though nicotine is a highly addictive drug, its effects on
cognition are not as intense or noticeable as other drugs such as, cocaine,
amphetamines or any of the opiates (including heroin and morphine ).
Smoking is a risk factor in Alzheimer's disease . While smoking more than 15
cigarettes per day has been shown to worsen the symptoms of Crohn's
disease , smoking has been shown to actually lower the prevalence of ulcerative
colitis . [Lakatos PL, Szamosi T, Lakatos L ., 2007] .
1.5 What are Electronic Cigarettes?
There are many different shapes and sizes of e -cigarettes depending on the
manufacturer, but they all work in a similar way. All e -cigarettes will contain a
battery, an atomizer and a cartridge which is sometimes replac eable. The cartridge is
where the liquid nicotine is held in a solution of water and flavourings, and this liquid
is drawn up into a heating element when the patient sucks on the device. The liquid
then evaporates, sending some of it into your lungs and so me into the atmosphere
around you.
The cartridge, which holds the nicotine, also contains a number of other chemicals,
which help the liquid to evaporate. These include a number of flavours such as apple
and strawberry, which appeal to a younger market. There is also a compound called
propylene glycol in the cartridge. If someone handed you a can of aircraft de -icer
would you inhale it? Because Propylene glycol is the main component of both.
Are Electronic Cigarettes Safe?
The real answer is that we aren’t entirely sure yet. A new study by the American
Association for Cancer Research has shown that the vapour from e -cigarettes causes
a similar pattern of gene expression in bronchial cells t o tobacco smoke. That being

22 said, it is not yet known whether this change is carcinogenic as e -cigarettes have not
been on the market long enough. When discussing the safety of e -cigarettes we must
also take into account the danger of the cigarette itself. There have been a number of
instances where e -cigarettes have exploded and actually injured people. One elderly
woman was turned into a human fireball when her oxygen supply was ignited by the
e-cigarette after a hip operation.
What are the Regulations S urrounding Electronic Cigarettes?
Well, at the moment there aren’t any, which is causing the British Medical
Association (BMA) and World Health Association (WHO) a great deal of concern.
Whilst e -cigarettes can be used as an aid to quitting smoking there is no current
evidence to say that it is successful at this, or that it is completely without its own
risks.
The WHO have urged doctors to refrain from recommending them to their patients as
an aid for stopping smoking. Instead, the nicotine inhalator sho uld be offered, as it
has been fully regulated and is known to be safe. There is a worry that is doctors
condone the use of e -cigarettes they might be hit by a mass of clinical negligence
claims in the future, if it is decided that they are in fact harmful to our health.
The WHO have said that e -cigarettes are to be licensed and fully regulated from
2016, at which point, if they pass all of the regulations, they will be prescribed as a
genuine ai d to quitting smoking.
But is this enough? In a study of young people who use e -cigarettes in Cheshire and
Merseyside, 31% said that they had either never smoked before or didn’t like normal
cigarettes, where as e -cigarettes had nice flavours. This shows that the different
flavours and hype surrounding e -cigarettes is attracting people who would not
ordinarily have smoked. E -cigarettes have already been banned in Canada, Brazil and
Singapore for this reason.
The director of professional activities for the BMA, Dr Vivienne Nathanson, has said
that children were beginning to use e -cigarettes as a direct result of advertising

23 campaigns – something, which is banned for regular cigarettes. So again, this is
something that needs to be looked at.
Students at Linc oln University have created an app for the iPhone, which works with
e-cigarettes to help people to quit smoking. Although they know that e -cigarettes are
not yet regulated, they believe that their app would be used for good, helping people
to quit smoking by reducing the amount of nicotine they would inhale with each
cigarette.
The project is called ‘Relieve’ and would connect the electronic cigarette to an
iPhone via Bluetooth, so that the app could reduce the strength of nicotine the smoker
was getting. The app would also chart the smoker’s progress, showing them how
much longer they had to go before they would be free of nicotine: this type of
encouragement from a smoking cessation nurse has been shown to help people to
quite. The app also tells the user how much money they have saved, and how much
their risk of a heart attack had dropped!

24 Chapter 2
MATERIALS AND INVESTIGATION METHODS
Evaluation of attitudes and experiences related to the use of tobacco smoking among
international students from SUMPh “Nicolae Testemitanu” is performed in four
steps.
The first step of the research is planning and scheduling the work objectives and
tasks. At the secon d step we developed a questionnaire wi th 20 questions that explore
the tobacco consume of the students (attachment 1). The study group comprised 60
students from the Faculty of Medicine, second and fifth year of study.
The third step consists of processing the accumulated data.
At the last step we analyzed and interpreted the results, making the necessary
conclusions.
The questionnaire -based survey was performed from september to december
2014. Anonymous questionnaires were personally given to students during their
seminars and lectures with obligatory participation of students. The aims of the study
were explained to the present students, the anonymity was emphasized and they were
invited to participate in the survey. Despite of voluntariness all students presented
completed the questionnaires . Later the filled -out questionnaires were checked for
data integrity.
Subjects were students of the Faculty of Medicine. Fifty four (90%) participa nts
were males, 6 (10%) females. The average age of the respondents was 23.5 ± 1 .4
years.
The database is statistically accumulated and processed using Excel, and FoxPro
software. “Medline” and ,,Internet" systems in health promotion and disease
prevention were used as well.

25 Chapter 3
ASSESSMENT OF THE TOBACCO CONSUME OF INTERNATIONAL
STUDENTS FROM SUMPh ,,N. TESTEMITANU"
We took medical students as the focus of our survey as the attitudes and
practices towards tobacco use of these young health professio nals can influence
future poli cies and practice. If doctors and medical students are smoking then the
credibility of anti -smoking messages to the public is lost. Medical students are a
group that should be more aware than young people of the same age about the health
hazards associated with smoking
We received 60 completed questionnaires from 100 students; 90% (n = 52) were male
and 10 % (n = 6) female. The me an age of the respondents was 23,5 years (range 21–
32 years). Of the responden ts, 39% smok e as much as before, 23% reduced the
number of cigarettes, 23% not smoking at the moment, but smoked before and 15%
never smoked.

Fig.1 . Distribution of smoker and nonsmoker students.

Health consequences of smoking are not limited upon smokers. Conversely, exposure
to tobacco smoke – passive smoking – dramatically increases the risk of lung cancer
and heart disease among non -smokers, but also on the respiratory disease of children.
The query result shows a significantly higher number of passive smokers face of the
39%
23%23%15%q Yes, as much as before
q Yes, but I’ve reduced
the number of cigaretts
q Not smoking at the
moment, but smoked
before
q No, never smoked

26 active smokers, what may be denoted by the fact that an active smoker incumbent ten
or mor e passive smokers. From Figure 2 we see that the number of students who
smoke dail y is 45% and ocasionaly 40%.

Fig 2. How often do you smoke now?

Like smokers among the gene ral public, a high proportion ( 50%) of medical students
had also tried to quit smoking at least once in their lives but without success. Special
training is therefore required for all health professionals and medical students to
assist them in giving up smoking (Fig 3) .

45%
40%15%
q Daily
q Occasionaly smoking
q Don’t smoke
50142115
0 10 20 30 40 50 60q Yes, a lot of timesq Yes, onceq No, but I want to quitq No, and I don’t even want to quitq Didn’t smoked in the last 12 months

27 Fig 3. Have you tried to quit smoking in the past 12 months? (%).

A high proportion of current smokers smoke more than 15 cigarettes per day (fig4) .

Fig.4 . During the smoking days how many normal cigarettes do you consume?

A smoker was defined as someone who continued to smoke any amount of tobacco
either regularly or occasionally, a never smoker was one who had never smoked and
an ex-smoker was one who had smoked either occasionally or regularly in the past
but had now quit completely.

8%
33%
17%35%7%
1-5 cigarettes
6-10 cigarettes
11-25 cigarettes
16-20 cigarettes
21-25 cigarettes
11,62533,3
13,316,6
05101520253035
Between 1-5
minutesBetween 6-30
minutesBetween 31-60
minutesAfter an hour Don’t smoke

28 Fig 5. A t what interval after waking up you smoke a cigarette? (%)

The students were asked about the experie nces that students have had in relat ion to
smoking normal cigarettes containing tobacco. The results you can see in table nr.1.
Table 1
The experiences that students have had in relation to smoking normal cigarettes
containing tobacco (%)

1
2 3 4 5 6 7
Not at
all
true
for
me Is
very
true
in my
case
1. Often smoke without thinking about it 60 15 15 10
2. I feel that cigarettes control me 70 10 20
3. I usually want to smoke right after I wake up 40 20 40
4. Is it hard to ignore the urge to smoke? 50 25 25
5. The flavor of a cigarette is pleasant 10 10 80
6. I rely on smoking so I can control my hunger and
the amount of food I eat 26 20
7. I smoke without deciding that 10 35
8. Cigarettes keep me company, as a close friend 23 30
9. Sometimes I feel that cigarettes control my life 30
10. Most of the people whom I spend time with are
smokers 15 68
11. I would feel alone without cigarettes 45
13. Most of my friends and family smoke 5 45 25 20
14. Most of my relatives and acquaintances smoke 45 20 20
15. My smoking is out of control 65
16. I consider my self a heavy smoker 65
17. Even when I feel good, smoking helps me feel
better 80

29 Regular cigarette smoke contains around 7000 cancer -causing chemicals as a result of
the burning tobacco. E -cigarettes do not contain tobacco, which is why many people
think they are safe, but because of the nicotine in the cartridge they are still just as
addictive as regular cigarettes.

Fig 6. Have you ever tried electronic cigarette, even just a smoke?

The common misconception is that smoking shisheh/Nargilah is less harmful than
smoking cigarettes, because people assume that water purifies the smoke being
inhaled. In reality, smoking shisheh/Nargilah is an unhealthy habit. Many medical
studies indicate that Nargilah tobacco contains more than 500 different ch emical
elements, most of which cause lung cancer. The harmful effects of smoking Nargilah
are not limited to the effects of smoking the tobacco (which equals that of 55
cigarettes), because the Nargilah tobacco also contains added narcotics, increasing
the effect to that of over 102 cigarettes. We note also the harm caused by fruit
Shisheh, using fruit such as apple, cantaloupe, plums, etc., which has been treated
with adhesives? The danger is the result of the fruit being burned with coal, glycerin,
and ot her poisonous substance that causes bladder cancer. Although cigarette
smokers may be more exposed to lung cancer by inhaling deeply the cigarette smoke,
smokers of shisheh/Nargilah are more vulnerable to cancers of the mouth, chest
78%22%
Yes
No

30 diseases, and symptoms resulting from loss of oxygen, such as dizziness, inability to
focus, and lack of energy .
In our case 77% of the students use nargilah in the past 12 month.

Fig 7. Have you used the Nargilah in the past 12 months?

About 63% of the students consider that hookah it is much less damaging than
normal cigarettes and only 12% consider that it is more damaging than normal
cigarettes.

77%13%10%
Yes
No
I dont know/ I dont want
to answer
63
25
12
010203040506070
It is much less
damaging than
normal
cigarettesIt is less
damaging than
normal
cigarettesIt is just as
damaging as
normal
cigarettes It is a little
more damaging
than normal
cigarettesIt is more
damaging than
normal
cigarettes

31 Fig 8 What about the impact on health of others hookah use compared to smoking
normal cigarettes?

Health Professionals are role models in not smoking, or quitting smoking
People usually seek good role models to emulate in a particular behavioral or social
role. Therefore, with regards to health related issues, health professionals, especially
medical doctors should have re sponsibility for not only treating illness but also based
on their medical professional ethics to serve as role models for the community at
large. While smoking rates among physicians often reflect general population
smoking rates, in most countries doctor s smoke much less than the general
population. But despite knowledge of the negative health consequences of tobacco
use, cigarette smoking is still highly prevalent among physicians in some countries.
For example, in Italy, the group “Health Professionals against Smoking” recently
reported that 25.3% of the nation's doctors smoke; a rate that's close to that of the
general public. In Romania a recent study showed 50.1% of male and 38.6% of
female doctors were smokers. Amongst Japanese doctors 27.1% of men a nd 6.8% of
women are smokers. Although Sweden reported the lowest physician -smoking rate
(5%) of any country where data were available, it is noteworthy that chewing tobacco
use is on the rise. Among Swedish medical doctors, 16% of males and 5% of females
chew tobacco . In Mongolia, 5% of health professionals were smokers in 1990. But
there are still no data in Mongolia regarding usage of other tobacco products.
Regarding medical students, Smith and Leggat (2007) documented the prevalence of
smoking among me dical students, which varies widely amongst different countries
and also between males and females. Smoking rates among male students range
between 3% in the United State and 58% in Japan. Other relatively high prevalence
rates among male medical students were also reported in Greece (41%) and Spain
(42%). In Mongolia, there are still no data available regarding smoking among
medical students.
Reduction of health professionals smoking is critically important, they are health

32 educators who have a responsibil ity to be good role models. Therefore, the WHO
emphasized “Health professionals are encouraged to personally exhibit and promote a
tobacco -free lifestyle. The advice and treatment given by health professionals can be
a major factor in whether or not a pers on tries and su cceeds in quitting smoking.” . As
a result, getting doctors to quit smoking can have profound effects on tobacco
control.
Also, numerous studies have shown that non smokers are more likely to support a
non-smoking policy, which can become a motivator to reduce smoking prevalence
among health professionals.
Health professionals have role of providing smoking cessation treatment
Besides primary prevention from people choosing smoking, promotion of smoking
cessation plays a major role in the red uction of smoking prevalence. Therefore,
smoking cessation should be an essential part of a comprehensive tobacco control
policy. Benefits of quitting smoking are considerable positive on human body. The
study conducted by Taylor et al. (2002) found out th at if people quit smoking at 35
years old their life expectancy increases about 7 years, even if they quit at 65 years of
age their life expectancy st ill increases about 2 years .
Quitting smoking is a challenge for every person who is addicted nicotine. A study
illustrated that 70% of smokers say they would like to quit, but only 7.9% of them are
able to stop s moking without others’ help . Therefore Health Professionals have
important roles in preventing the increase number of smokers and also reducing the
prevalence of smoking by providing public education on smoking and smoking
cessation services.
Doctors’ advice
Advice and treatment provided by physicians have a more positive impact on
smoking cessation. Therefore, many international agencies such as the W orld Health
Organization, the American Academy of Family Physicians, the American Cancer
Society and International Union against Cancer (UICC) recommended that doctors
become more involve in tobacco control. An early meta -analysis showed the advice

33 of a ph ysician alone can improve the smoking cessation rate by 10.2 % [35].
Behavioral therapy
Behavioral therapy has been studied extensively, and cessation rates averaged 20%
for those willing to partici pate. For example, Lando et al. found that the cessation
rates with the American Lung Association and American Cancer Society programs
were 16% and 22%, respectively, after duration of one year. The key components to
an effective behavioral program are assessment of stages of change, id entification of
barriers to quitting, and development of cessation and relapse -prevention plans. Most
programs now combined this with pharmacotherapy. The combined use of nicotine
replacement, bupropion (Zyban), and social or behavioral support can increas e the
quit rate to 35 percent .
Pharmacotherapy
Drug therapy is the most attractive means of smoking cessation for many patients and
physicians. Since 1980, the clinical studies in the US and Europe have found that
chewing nicotine pills could increase the success rate of quitting smoking. These
studies have also shown that nicotine patches had similar effects as chewing nicotine
pills. After 1990, the growth of evidence -based studies and meta -analysis showed that
Nicotine Replacement Therapy (NRT), or bupro pion SR (Zyban) doubled the six –
month or one year success rate of smokers who wanted to quit smoking. Now,
pharmacotherapy is considered a cost -effective medical treatment for smoking.
Doctor -patient interaction
Doctors as health care providers are in a un ique position to help their patients to stop
smoking. In this regard, there should be an element of trust between doctors and their
patients whom they serve. This should foster patients’ satisfaction which is one of the
enablers to quitting smoking.
A stud y conducted by Anderson et al. (1993) showed that patients are more satisfied
when they believe that their doctors are partners in the exchange of information rather
than the doctors who control the relationship [38]. It implied that pateint’s positive
attitudes of their health related issues may derive from better doctor -patient

34 relationship.
Health professionals’ roles in public policies of tobacco control
Comprehensive tobacco programs aimed at controlling the use of tobacco efficiently
should not only c onsider legislation and pricing measures; but also prevention
measures through education and informational campaigns that raise awareness of the
effects of tobacco on health.
The WHO FCTC in its preamble especially emphasizes “the special contribution of
nongovernmental organizations and other members of civil society not affiliated with
the tobacco industry, including health professional bodies, women’s, youth,
environmental and consumer groups, and academic and health care institutions, to
tobacco control efforts nationally and internationally and the vital importance of their
participation in national and international tobacco control efforts” [20]. Therefore,
physicians have a special role to play in these considerations.
In addition, physicians should be leaders with regard to any issue affecting
health. Therefore, they will be able to address public policies regarding smoking
control, and they should have a responsibility to participate effectively in public
debate.

35 Conclusions
1. Cigarette smoking by youth and young adults has immediate adverse health
consequences, including addiction, and accelerates the development of chronic
diseases across the full life course.

2. Cigarette smoking is highly prevalent among male medical students in the Fac ulty
of Medicine. Contacts who smoke are the major risk factor for initiating the habit.

3. The results of surveys have demonstrated that international students from
SUMPh smoke daily more than 15 cigarettes per day.

4. Cigarettes and Nargilah smoking is very popular among international students
from SUMPh N.Testemitanu.

5. All possible efforts and strategies should be considered to control smoking among
medical studen ts from SUMPh . Medical and other health colleges should provide
educational programs and teach specific courses on tobacco control in order to
prepare and equip future health professionals with the knowledge and skills they
need to intervene with smoking effectively.

36 Recommendation

 Promoting tobacco -free university ;
 Promoting information on healthy lifestyle among future doctors.
 Eliminating availability of tobacco products and smoking oppor tunities for
students ;
 Increasing awareness and promoting th e image of a non -smoking university ;
 Minimiz ing social pressures on students to start and continue tobacco smoking.
 Adopting programs for the prevention of endangering behaviors;
 Promoting an antismoking culture among teachers, students, and their families ;
 Improving university environment and atmosphere, including t he student
perceptions of university ;
 Creating posi tive perceptions of the university role and academic mission among
students;
 Developing the abilities and social skills students need to res ist social pressures.

37
Bibliography

1. Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr, Doll R. Mortality from
smoking worldwide. Br Med Bull 1996; 52: 12–21.
2. MacKay J. The global tobacco epidemic: The next 25 years. Public Health
Rep1998; 113: 14–21.
3. Robert and Shiffman, Saul (2007). Fast Facts: Smoking Cessation . Health Press
Ltd. p. 28.
4. Ram P. Manohar, "Smoking and Ayurvedic Medicine in India" in Smoke , pp. 68 –
75.
5. Sander L. Gilman and Zhou Xun, "Introduction" in Smoke , p. 20 –21.
6. Cooper, William J, Liberty and Slavery: Southern Politics to 1860 , Univ of South
Carolina Press, 2001, p. 9.
7. Tanya Pollard, "The Pleasures and Perils of Smoking in Early Modern England"
inSmoke , p. 38.
8. Timon Screech, "Tobacco in Edo Period Japan" in Smoke , pp. 92 -99.
9. Sander Gilman and Zhou Xun, "Introduction" in Smoke , p. 15 -16.
10. Allen F. Roberts, "Smoking in Sub -Saharan Africa" in Smoke , pp. 53 –54.
11. Burns, Eric. The Smoke of the Gods: A Social History of Tobacco. Philadelphia:
Temple University Press, 2007.
12. Meijer B. Branski D. Kerem E. Ethnic differences in cigarette smoking among
adolescents: a comparison of Jews and Arabs in Jerusalem. Israel Medical
Association Jour nal: Imaj. 3(7):504 -7, 2001 Jul .
13. Tobacco or Health: A Global Status Report ,Centers for Disease Control and
Prevention (CDC) .
14. Israeli Ministry of Commerce and Industry .
15. Global Youth Tobacco Surv ey (GYTS). Factsheet, Ages 13 –15. Geneva, World
Health Organization and Centers for Disea se Control and Prevention, 2008 .

38 16. Warren WC et al. Tobacco Use, Exposure to Secondhand Smoke, and Training
on Cessation Counseling Among Nursing Students: CrossCountry Data from the
Global Health Professions Student Survey (GHPSS), 2005 –2009. International
Journal of Environmental Research and Public Health, 2009, 6(10):2534 –2549.
17. Lopez AD, Collishaw NE, Piha T. A Descriptive Model of the Cigarette
Epidemic in Developed Countries, Tobacco Control, 1994, 3:242 –247.
18. National Scientific and Applied Center for Preventive Medicine (Moldova) and
ORC Macro. Moldova Demographic and Health Survey 2005. Calverton,
Maryland, 2006.
19. Colin White (September 1989). "Research on Smoking and Lung Cancer: A
Landmark in the History of Chronic Disease Epidemiology" . The Yale Journal Of
Biology And Medicine 63 (1): 29 –46. PMC 2589239 .
20. Doll R, Hill AB (September 30, 1950). "Smoking and carcinoma of the lung.
Preliminary report" . British Medical Journal 2 (4682): 739 –48].
21. The mortality of doctors in relation to their smoking habits. A preliminary
report" . British Medical Journal 1 (4877): 1451 –55.doi:10.1136/bmj.1.4877.1451 .
Berridge, V. Marketing Health: Smoking and the Discourse of Public Health in
Britain, 1945 -2000 , Oxford: Oxford University Press, 2007.
22. Hilton, Matthew (2000 -05-04). Smoking in British Popular Culture, 1800 -2000:
Perfect Pleasures . Mancheste r University Press. pp. 229–241.
23. WHO/WPRO -Smoking Statistics" . World Health Organization Regional Office
for the Western Pacific. 2002 -05-28. Retrieved 2009 -01-01.].
24. WHO REPORT on the global TOBACCO epidemic 2008, pp. 267 –288].
25. Ivan Kalmar , "The Houkah in the Harem: On Smokin g and Orientalist Art"
in Smoke , pp. 218 –229.
26. Benno Tempel, "Symbol and File: Smoking in Art since the Seventeenth
Century" in Smoke , pp. 206 –217.
27. Noah Iserberg, "Cinematic Smoke: From Weimar to Hollywood" in Smoke , pp.
248–255.

39 28. Eugene Umberger, "In Praise of Lady Nicotine: A Bygone Era of Prose, Poetry…
and Presentation" in Smoke , pp. 236 –247.
29. Stephen Cottrell, "Smoking and All That Jazz" in Smoke, pp. 154 -59]. J. Edward
Chamberlin & Barry Chevannes, "Ganja in Jamaica" in Smoke, pp. 148 .
30. J. Edward Chamberlin & Barry Chevannes, "Ganja in Jamaica" in Smoke, pp.
144-53.
31. Leslie Iverson, "Why do We Smoke?: The Physiology of Smoking" in Smoke , p.
320
32. Doll R, Peto R, Boreham J, Sutherland I (2004). "Mortality in relation to
smoking: 50 years' observations on male British doctors" .
33. Braun JM, Kahn RS, Froehlich T, Auinger P, Lanphear BP (2006). "Exposures to
environmental toxicants and attention deficit hyperactivity disorder in U.S.
children" .Environ. Health Perspect. 114 (12): 1904 –9].
34. Lakatos PL, Szamosi T, Lakatos L (2007). "Smoking in inflammatory bowel
diseases: good, bad or ugly?". World J Gastroenterol. 13 (46): 6134 –9.
35. http://www.theweek.co.uk/health -science/58735/are -e-cigarettes -bad-for-you-
doctors -urge-new-controls
36. http://www.telegraph.co .uk/health/healthadvice/lifecoach/10951217/Life -coach –
are-e-cigarettes -safe.html
37. http://www.bbc.co.uk/news/uk -26958397
38. http://www.nature.com/news/e -cigarettes -affect -cells-1.15015
39. http://www.mirror.co.uk/news/uk -news/e -cigarettes -really -safer-alternative –
regular -3414860
40. http://www.nhs.uk/news/2013/06june/pages/e -cigarettes -and-vaping.aspx
41. http://www.newscientist.com/article/dn25739 -ecig-users -are-young -heavy –
smokers -trying -to-quit.html#.U8ZzxI1dWRM
42. http://www.ash.org.uk/files/documents/ASH_897.pdf
43. http://www.gizmag.com/relieve -app-e-cigarette/32880/

40 44. http://thelinc.co.uk/2014/06/lincoln -students -devise -e-cigarette -to-help-people –
quit-smoking/

41 Anexe 1
Dear students!
Please support us in carrying out a research that aims to assess the tobacco consume of international students from
SUMPh ,,N. Testemitanu". We ensure that your answers are confidential and will be used only in this study.

Thanks for your cooperation!!!

1. Age?
__ __
2. Se x?
 Male
 Female
3. Smoking?
 Yes, as much as before
 Yes, but I’ve reduced the number of cigaretts
 Not smoking at the moment, but smoked before
 No, never smoked
 Don’t know/ Don’t answer
4. How often do you smoke now?
 Daily
 Occasionaly smoking
 Don’t smoke
5. Have you ever regularelly smoked? (daily at least one mounth)
 Yes
 No
6. How often did you smoked in the past?
 Daily
 Smoked, but not daily
 Don’t smoke
7. Have you tried to quit smoking in the past 12 months?
 Yes, a lot of times
 Yes, once
 No, but I want to quit
 No, and I don’t even want to quit
 Didn’t smoked in the last 12 months
8. During the smoking days how many normal cigarattes do you consume?
 Less then a cigarette
 1-5 cigarettes
 6-10 cigarettes
 11-25 cigarettes
 16-20 cigarettes
 21-25 cigarett es
 26-30 cigarettes
 > 31 cigarettes
9. At what interval after waking up you smoke a cigarette?
 Between 1 -5 minutes

42  Between 6 -30 minutes
 Between 31 -60 minutes
 After an hour
 Don’t smoke
10. The following questions relate to the experiences you have had in r elation to smoking normal cigarettes containing
tobacco. Please note, on a scale from 1 -7, where 1 means "not at all true for me" and 7 means "is very true in my case",
the extent to which you agree with the following statements:
1
Not at all true
for me 2 3 4 5 6 7
Is very true in
my case
1. Often smoke without thinking about it
2. I feel that cigarettes control me
3. I usually want to smoke right after I wake up
4. Is it hard to ignore the urge to smoke?
5. The flavor of a cigarette is pleasant
6. I frequent smoke in order to concentrate
7. I rely on smoking so I can control my hunger and the
amount of food I eat
8. My life is full of things / issues that reminds me to
smoke
9. Smoke helps me to feel better in seconds
10. I smoke without deciding that
11. Cigarettes keep me company, as a close friend
12. There are specific scents and images that activates
my urge to smoke
13. Smoking helps me not to lose my focus
14. It happens frequently to light a cigarette without
realizing it
15. Most of the cigarattes I smoke daily have a good
taste
16. Sometimes I feel that cigarettes control my life
17. I often long for cigarettes
18. Most of the people whom I spend time with are
smokers
19. Weight control is one of the main reasons why I
smoke
20. Some cigarettes I smoke have awesome taste
21. I am even dependent of cigarettes
22. I feel that cigarettes are my best friends
23. Desire to smoke gets stronger if I abstain from it
24. Seeing someone smoking makes me also want to
25. It happens to take a cigarette from the pack without
realizing it
26. I would feel alone without cigarettes
27. Most of my friends and family smoke
28. Other smokers would consider me a heavy smoker
29. If I don’s smoke an hour the desire to smoke
becomes intolerable
30. Most of my relatives and acquaintances smoke
31. I smoke in the first 30 minutes after waking up
32. Smoke helps me think easier
33. If I feel sad, smoke helps me to feel better
34. Smoke helps me not to eat in excess
35. My smoking is out of control
36. I consider my self a heavy smoker
37. Even when I feel good, smoking helps me feel
better

43
11. Have you ever heard electronic cigarettes?
 Yes
 No
12. Where did you hear about electronic cigarettes??

Friends  Yes  No
Internet  Yes  No
TV  Yes  No
Newspapers  Yes  No
Pubs,clubs  Yes  No
Points of sale  Yes  No

13. Have you ever tried a electronic cigarette, even just a smoke?
 Yes
 No
14. If you have tried the electronic cigarette, which cartridge did you use??
 Which contained nicotine and wasnt flavor
 Which contained nicotine and was flavor
 Which didnt contain nicotine and wasnt flavor
 Which didnt contain nicotine and was flavor
 I dont know/I dont remember
15. If you used the electronic cigarette, what kind of device have you use?
 For single use electronic cigarette
 Reusable electronic cigarette
 I dont know/I dont remember
16. Have you ever tried to smoke the hookah?
 Yes
 No
 I dont know/ I dont want to answer
17. Have you used the hookah in the past 12 months?
 Yes
 No
 I dont know/ I dont want to answer
18. How often have you used the hookah in the last 12 months to inhale the tobacco or herbal / fruit dehydrated?

Never Between
1 and 3
times Between
4 and 9
times Between
10 and
19 times Between
20 and
29 times Everyda
y
A. I inhaled tobacco from hookah
B. I inhaled something other than tobacco
(eg. Plants, dried fruit) of hookah

19. What about the impact on health of others hookah use compared to smoking normal cigarettes?
 It is much less damaging than normal cigarettes
 It is less damaging than normal cigarettes
 It is just as damaging as normal cigarettes
 It is a little more damaging than normal cigarettes
 It is more damaging than normal cigarettes

44 Declaration

I hereby declare that the diploma thesis entitled " Evaluation of attitudes and
experiences related to the use of tobacco smoking among international students from
SUMPh “Nicolae Testemitanu " is written by me and has not been presented before at
another college or institution of higher education in the country or abroad. Also, I
declare that all sources used, including the Internet sources, are indicated in the
paper, considering the rules for avoiding plagiarism: – all text fragments are
reproduced exactly, even the proper trans lations from other languages are written in
quotes and have detailed reference source; – paraphrasing in own words of text
written by other authors has detailed reference; – summary of the ideas of other
authors has a detailed reference to the original tex t.

Date
Name and surname of student Amash Hassan
____________
(Original signature)