Tobacco and Alcohol Use Among 1996 Medical School Graduates | JAMA | JAMA Network
[Skip to Navigation]
Sign In
October 7, 1998

Tobacco and Alcohol Use Among 1996 Medical School Graduates

Author Affiliations

Not Available

Not Available

JAMA. 1998;280(13):1192-1195. doi:10.1001/jama.280.13.1192-JMS1007-4-1

In this era of prevention and health promotion, the health-related behaviors of medical professionals have drawn considerable attention and are a common focus of research. Today's physicians not only serve as providers of care for their patients, but also are expected to model the advice they impart.1,2 Addiction to chemical substances is a problem that may afflict any person, and it has long been a concern among physicians. Brewster2 found reference in the literature to concerns of physician addiction to alcohol, cocaine, and morphine as early as 1869. Multiple cross-sectional studies have since tracked the use of tobacco and alcohol among medical students and physicians. Although tobacco use among medical students and physicians has decreased steadily over the past 50 years, the patterns of alcohol intake in this group have remained relatively stable.3 The purpose of this study is to assess the prevalence of tobacco use and the patterns of alcohol consumption among 1996 graduating medical students using a cross-sectional survey.


A questionnaire was developed to assess social and health-related habits and experiences of fourth-year medical students. The questionnaire included sections from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System Questionnaire. Topics addressed included overall general health status and practices, social and professional relationships, and demographics.

This instrument was placed in the campus mailbox of all graduating medical students at 8 US medical schools (4 public and 4 private), with 2 schools in each of the 4 regions commonly designated by the Association of American Medical Colleges for geographic categorization. A randomization scheme was not used. Questionnaires required less than 10 minutes to complete and were returned individually in unmarked, stamped envelopes provided to students. No incentive was offered for participation in the study and no individual follow-up was possible. Data were collected between April and June of 1996. Statistical analyses were conducted using SPSS (version 6.1, SPSS, Inc).


A total of 1001 questionnaires were placed and 548 were returned (55%), with individual schools' response rates ranging from 44% to 69%. Of the returned questionnaires, 61% were from students at public universities and 39% from students at private institutions. The sample included a greater proportion of males (56%) than females (44%), and more whites (73%) than other racial groups (27%) (Table 1). Respondents' ages ranged from 23 to 47, with a median age of 26 years (mean, 27.5).

Demographics of Students and Bivariate Analysis of Responses
Demographics of Students and Bivariate Analysis of Responses

Among graduating students, 2% reported currently being smokers, and 13% reported ever having been smokers. Differences in tobacco use as a function of age and gender were not statistically significant, with the exception of a history of previous smoking, which was more common with increasing age.

Frequent alcohol use (3 or more days a week) was reported by 18% of students, and 21% of students reported at least one episode of binge drinking (5 or more drinks in one sitting) in the past 30 days. Male students were significantly more likely than female students to exhibit both of these behaviors (P=.03 and P<.01). Frequent alcohol use was most common in whites and blacks and among older students. Eighteen percent of respondents consumed more than 2 drinks at each drinking session, and male students were more likely to report this drinking behavior than were female students (P=.01). White students were much more likely than any of the other racial groups to report binge drinking, and age groups did not significantly differ regarding binge drinking.

Eighteen percent of women and 11% of men (P=.02) believed that their alcohol intake increased in medical school. Asians and the "25 and younger" age category were the racial and age groups most likely to report an increase in alcohol intake during medical school.


Results from this survey suggest an important decline in the prevalence of tobacco use among medical students. The 2% prevalence of smoking in this sample is the lowest rate reported in the literature among a large sample of medical students and is indicative of a continued acknowledgment by medical professionals of the dangers of tobacco use.4 Although 20% of the students in the oldest age group reported ever having smoked, this was true of only 8% in the youngest age group. Considering that few individuals begin smoking after age 18, this is an important marker for a much decreased use of tobacco among medical students.5

The preventive care beliefs and practices of health professionals are noted by the general public and may influence patient behaviors.1 For this reason, the decline in physician smoking in recent years has important repercussions for the nation's health. The 1979 Surgeon General's report on smoking and health concluded that between 10% and 25% of smokers who are advised to quit by their physician may quit smoking or reduce the amount they smoke.6 Several subsequent studies demonstrated a relationship between physician advice concerning tobacco consumption and the subsequent use of tobacco by patients.7-9

Although the prevalence of tobacco consumption by physicians has declined over the past half century, the patterns of physician alcohol intake have remained stable or shown a slight increase.10 In general, younger physicians consume alcohol with the same frequency and in the same amounts as their age-related peers.11,12 But as physicians age, their alcohol intake tends to increase, in contrast to the intake of the general population, which tends to decrease with age.10 Estimates of physician impairment due to alcoholism are as high as 10%, comparable to the estimated 12% in the general population.13,14 Seven studies conducted among medical students between 1977 and 1990 found that over this time period, the prevalence of alcohol abuse ranged from 7% to 17%.15-21 Among this study's sample of 1996 senior medical students, 21% reported an episode of binge drinking within the last 30 days, and 18% averaged more than 2 drinks per drinking session. Binge drinking and heavy alcohol consumption are possible markers for alcohol abuse.

The patterns of alcohol intake for this sample of medical students are similar to those for the age-related general population. Men tended to drink more often and more heavily than their female peers and were significantly more likely to have engaged in an episode of binge drinking within the last 30 days. Interestingly, women were more likely than their male peers to report an increase in alcohol intake while in medical school, which supports the hypothesis of Flaherty and Richman22 that there is a gender convergence in the drinking patterns among medical students that results from the occupational hazards of medical school. These findings may indicate the unique pressures placed on female medical students compared with their male counterparts. Possible examples of these gender-specific pressures include cultural expectations of women regarding child-rearing and domestic responsibilities and the deemphasis of a woman's career compared with that of her male colleagues. Additionally, women in the medical field must compete in a profession still largely dominated by men.23

Results from this study must be viewed in light of the limitations of a self-report survey design. These include recall bias, reporting errors, and nonresponse bias. Though self-reported alcohol consumption has generally been shown to be a valid measurement, it is possible that underreporting of both alcohol and tobacco use may have occurred because of the negative associations with use of these substances.24,25 This study had a 45% nonresponse rate, introducing a nonresponder bias of unknown quantity into the results. Data collection for this study occurred toward the end of the last year of medical school, which may have artificially inflated the results of the alcohol intake questions, especially those related to binge drinking. Finally, this questionnaire was not distributed in a strictly random fashion and its reliability and validity were never completely assessed.

Despite these limitations in the study's comparability with other studies, it provides key information on a large, geographically distributed sample of medical students whose demographics are similar to the enrollment of all US medical students with regard to gender, age, race, and enrollment patterns.26 Based on published studies concerning the validity of substance use questionnaires24,25 and given the educational level and medical background of the study sample, there is a high likelihood that the results are a true representation of actual substance intake.

Najem  GRPassannante  MRCFoster  JD Health risk factors and health promoting behavior of medical, dental and nursing students.  J Clin Epidemiol. 1995;48841- 849Google ScholarCrossref
Brewster  JM Prevalence of alcohol and other drug problems among physicians.  JAMA. 1991;2551913- 1920Google ScholarCrossref
Flaherty  JARichman  JA Use and addiction among medical students, residents, and physicians.  Psychiatr Clin North Am. 1993;16189- 197Google Scholar
Baldwin  DCHughes  PHConard  SEStorr  CLSheehan  DV Substance use among senior medical students: a survey of 23 medical schools.  JAMA. 1991;2652074- 2078Google ScholarCrossref
Elders  MJPerry  CLEriksen  MPGiovino  GA The report of the surgeon general: preventing tobacco use among young people.  Am J Public Health. 1994;84543- 547Google ScholarCrossref
Not Available, Smoking and Health: A Report of the Surgeon General. US Dept of Health, Education, and Welfare, publication (PHS) 79-500661979;
Pederson  LL Compliance with physician advice to quit smoking: a review of the literature.  Prev Med. 1982;1171- 84Google ScholarCrossref
Stewart  PJRosser  WW The impact of routine advice on smoking cessation from family physicians.  Can Med Assoc J. 1982;1261051- 1054Google Scholar
Jamrozik  KVessey  MFowler  GWald  NParker  GVan Vunakis  H Controlled trial of three different anti-smoking interventions in general practice.  BMJ. 1984;2881499- 1502Google ScholarCrossref
Hilton  MEClark  WB Changes in American drinking patterns and problems, 1967-1984.  J Stud Alcohol. 1987;48515- 522Google Scholar
Wyshak  GLamb  GALawrence  RSCurran  WJ A profile of health-promoting behaviors of physicians and lawyers.  N Engl J Med. 1980;303104- 107Google ScholarCrossref
McAuliffe  WERohman  MBreer  PWyshak  GSantangelo  SMagnuson  E Alcohol use and abuse in random samples of physicians and medical students.  Am J Public Health. 1991;81177- 182Google ScholarCrossref
Brewster  JM Prevalence of alcohol and other drug problems among physicians.  JAMA. 1986;2551913- 1920Google ScholarCrossref
Moore  RDMead  LPearson  TA Useful predictors of alcohol abuse in physicians.  Am J Med. 1990;88332- 336Google ScholarCrossref
Thomas  RBLuber  SASmith  JA A survey of alcohol and drug use in medical school.  Dis Nerv Syst. 1977;3841- 43Google Scholar
McAuliffe  WERohman  MWechsler  H Alcohol, substance use, and other risk-factors of impairment in a sample of physicians-in-training.  Adv Alcohol Subst Abuse. 1984;467- 87Google ScholarCrossref
Clark  DCEckenfels  EJDaugherty  SRFawcett  J Alcohol use patterns through medical school.  JAMA. 1987;2572921- 2926Google ScholarCrossref
Forney  MARipley  WKForney  PD A profile and prediction study of problem drinking among first-year medical students.  Int J Addict. 1988;23767- 779Google Scholar
Conard  SHughes  PBaldwin  DCAchenbach  KESheehan  DV Substance use by fourth-year students at 13 US medical schools.  J Med Educ. 1988;63747- 758Google Scholar
Clark  DCDaugherty  SR A norm-referenced longitudinal study of medical student drinking patterns.  J Subst Abuse. 1990;215- 37Google ScholarCrossref
Kuzel  AJSchwartz  RHLuxenberg  MGLewis  DCKyriazi  NC A survey of drinking patterns during medical school.  South Med J. 1991;849- 12Google ScholarCrossref
Flaherty  JARichman  JA Risk factors for substance use in medical students.  Presented at the Annual Meeting of the American Psychiatric Association New Orleans, La 1991
Richman  JA Occupational stress, psychological vulnerability and alcohol-related problems over time in future physicians.  Alcohol Clin Exp Res. 1992;16166- 171Google ScholarCrossref
Hilton  ME A comparison of a prospective diary and two summary recall techniques for recording alcohol consumption.  Br J Addict. 1989;841085- 1092Google ScholarCrossref
Midanik  L Perspectives on the validity of self-reported alcohol use.  Br J Addict. 1989;841419- 1423Google ScholarCrossref
Not Available, Association of American Medical Colleges 1996 Medical School Graduation Questionnaire Survey Results: All Schools Summary. Association of American Medical Colleges, Section for Educational Research Washington, DC1996;