"Empieza Con Nosotros" (It Begins with Us)
“Empieza con Nosotros” (It Begins With Us):
Tobacco Use and Visibility of Medical Students in Puebla, Mexico
Dr. Vania Smith-Oka, Advisor
Senior Honors Thesis
University of Notre Dame
Department of Anthropology
Glynn Family Honors Program
First and foremost, I would like to thank my wonderful advisor, Dr. Vania Smith-Oka, for her unwavering support in every step of the thesis process. From crafting original research questions to analyzing interview transcriptions, her mentorship, time, and expertise have made this project a reality. Secondly, I want to thank the students at UPAEP for offering their time and perspectives and for welcoming me into their lives - the medical students for elevating my research and Edson, Beto, and Angie for their constant friendship. I enjoyed meeting each and every person! I also would like to thank my host family in Puebla -- Maricela, Mar, and Chely -- for allowing me to return home after many months away; my time in Mexico was more than I could have asked for thanks to their hospitality and warmth. Lastly, I want to express sincere gratitude to the Glynn Family Honors Program and Kellogg Institute for their generous support of my field work. As always, thank you to my amazing family for everything!
Table of Contents
Setting: University Life in Puebla 9
Quantitative Results 17
Appendix A: Survey and Free List Questions (English) 54
Appendix B: Interview Questions (English) 55
Works Cited 56
Smoking is one of the leading causes of preventable death globally, and tobacco use claims about 5.4 million lives each year (Elamin et al. 2013). Although cigarette use has declined significantly over the past decade in high income countries like the United States, smoking rates have continued to persist in and negatively impact the health of low and middle income countries, such as Mexico (Elamin et al. 2013). In Mexico, the prevalence of smoking in the general population is about 15% but reaches over 25% within certain populations, depending on age, gender, region, and socioeconomic status. Men, specifically, have the highest smoking rates in the country, but tobacco use is especially elevated for adolescents (ages 15-18) in Mexico, with prevalence rates significantly greater than in other middle-income countries (Waters et al. 2010; Muller and Wehbe 2008).
Mexico is one of only 15 countries in the world with a heavy burden of tobacco-related illnesses (WHO 2017). In 2005, Mexico became a party of the World Health Organization’s Framework Convention on Tobacco Control and has since made significant efforts to create sustainable tobacco control programs and address the epidemic of tobacco use. It has been particularly successful in implementing health warnings regarding the dangers of tobacco use and offering cessation programs. Mexico has legislation mandating that 100% of the back, 100% of the sides, and 30% of the front of cigarette packages be covered in health warnings (see images below). These warnings are typically very graphic images of the health consequences (WHO 2015).
Figure 1: “By smoking, you multiply your risk of mouth cancer fivefold. By smoking, you stain your teeth and have high risk of mouth and lip cancer. This contains polonium 210. It is a radioactive, toxic, and carcinogenic substance. Stop smoking, it’s in your best interest.”
Figure 2: “Mouth Cancer. Smoking is the main cause of mouth cancer. It prevents you from eating, drinking liquids and you can expect an early death. This contains benzo pyrene. It is a toxic residue that causes tumors. Dare to stop smoking. Call us.”
Additionally, Mexico has raised the total taxes on cigarettes significantly since 2009, implementing tobacco specific taxes that, in addition to VAT and ad valorem rates, now comprise up to 69% the retail price of a standard cigarette pack. The tobacco specific tax is about seven pesos (around 40 cents, depending on the currency exchange rate) per pack of 20 cigarettes, and this increased economic barrier has since caused a noticeable decrease in sales (National Institute of Public Health 2012).
Smoking is officially prohibited indoors in primary and secondary schools, government facilities, and public hospitals. In other public spaces, isolated smoking areas can be found to protect non-smokers. In regards to advertising and tobacco product promotion, most forms of advertising are banned, yet still some media targeting exclusively adult audiences are permitted including magazines and personal communication by mail (Tobacco Control Laws). Each year, updated images and messaging are introduced to all forms of public tobacco control media, and measures are consistently being taken to protect people from the private interests of tobacco companies. In general, Mexico is certainly making admirable efforts to implement tobacco control measures that are both proven and recommended by international agencies, but despite significant progress in anti-tobacco programs in the country, there remain important and pressing health and social issues.
Health professionals and physicians play an especially important role in supporting national efforts to reduce tobacco use in Mexico. They are often seen as community role models and influencers for health policies, and cessation interventions from physicians have been proven to be both cost effective and impactful in the long term (Abdullah et al. 2014). “The potential role of health professionals in encouraging cessation is likely to be more limited in countries where smokers consult them less frequently,” yet lower income countries have fewer resources to invest in programs and services specific to tobacco cessation (Borland et al. 2012: 202). The focus is on general access to health services. Thus, much of the tobacco burden falls to the overall healthcare system which is charged with addressing and treating the tobacco-related illnesses of Mexican citizens, and if progress is to be made in the areas of service delivery, cessation counseling, and cultural change, physicians are situated in a position of power to help facilitate these changes.
As health experts, physicians can advise patients on cessation methods and encourage smokers to address addiction in a holistic manner, but these actions are inherently more difficult when physician behavior contradicts the messaging (Abdullah et al. 2014). Several studies have shown that tobacco use among health professionals in Mexico is higher than among the general Mexican population (Reynales-Shigematsu et al. 2007; Smith and Leggat 2007). Health professionals in these studies included physicians, nurses, and hospital or clinic administrative staff. Thus, spaces devoted to treatment of tobacco-related illnesses are often spaces where tobacco use is most prevalent. Previous research indicates that many physicians miss opportunities to counsel on tobacco cessation regardless of their personal consumption, and even in moments where the physicians offer advice, those who personally smoke have less confidence in their counsel and trust in the offered treatments (Muller and Wehbe 2008; Ponciano-Rodríguez 2010). There appears to be a disconnect between health education and health behavior, and high tobacco use within the health industry has important implications for the effectiveness and progress of tobacco control efforts. Medical education and health curriculum targeting aspiring physicians is absolutely critical to increasing the ability of health professionals to directly and positively advise and counsel patients.
A survey of global health professionals in 2006 concluded that, although nearly 33% of medical students smoke cigarettes regularly, 77.3% of Mexican health professionals perceive themselves as role models for health decision making. Furthermore, this research showed that 90% of health professionals understood and recognized the negative health consequences of smoking tobacco on personal health and the health of others (Reynales-Shigematsu et al. 2007). That is, the evidence suggests a gap in health practice and health theory. Additionally, in a study in Mexico City, 65% of physicians “acknowledged that it was their responsibility to encourage their patients to stop smoking” (Tapia-Conyer et al. 1997: 508). So, it becomes clear that the link between medical training of students, medical advice from health models, and personal health choices among health professionals can be strengthened, and this has the potential to improve national tobacco control efforts.
Despite general recognition of the persistently high tobacco use rates among Latin American populations and especially within the health field, public health researchers have done limited research on the aspects of culture promoting this striking health behavior (Reynales-Shigematsu et al. 2007). There is extensive literature on the high smoking rates among medical students and doctors in Asia, with a particular focus in the Middle East where similar trends of physician smoking are seen, but little has been done to truly explore the potential cultural factors -- family structures, religion, education status, university schedule, academic demands, and perceptions of doctors -- that have encouraged Mexican medical students to choose to smoke cigarettes despite access to scientific information and resources on the health consequences of tobacco use (Smith and Leggat 2007). The problem at hand is one concerning the disconnect between medical and public health education, personal health decision making, and the role of the doctor as a model for healthy living.
If health professionals are perceived as models of preached practices, cigarette use among medical students is a topic deeply connected to Mexico’s sustained efforts to reduce tobacco use. Thus, the principal research question guiding this thesis project is Why do health professionals in Mexico choose to smoke cigarettes despite having extensive scientific understanding about the long-term consequences? And consequently, through field work, data collection, and ethnography at a medical school in Puebla, Mexico, I attempt to gain insight into how these social and cultural influences on tobacco consumption might impact physician contributions to national tobacco control efforts -- in and out of the consult room. Answering these research questions is complex, but ultimately, this thesis will contribute to a critical body of knowledge addressing the role of the physician both in the community and in the hospital. If public health efforts -- like tobacco control policies in Mexico -- are to be impactful and sustainable, physician and health professional support is essential; better understanding the causes and consequences of future clinicians’ visible health behavior like cigarette use is just one aspect of strengthening health systems globally.
The bulk of this thesis project relies upon research and fieldwork at a medical school in Puebla, one of 32 states in Mexico. Puebla is uniquely positioned between the nation’s capital, Mexico City, and the port of Veracruz, making it a location for rapid growth and development (OECD 2013). Puebla de los Ángeles, formally known as Heróica Puebla de Zaragoza, is the state’s largest city and capital. It is the fourth largest city in the country with a population over 1.5 million (INEGI 2017). It is in this urban, fast paced region that one can find Universidad Popular Autónoma del Estado de Puebla (UPAEP), a private, Catholic university with approximately 13,000 undergraduate and graduate students. UPAEP’s striking red and white logo is posted in many places around the city, as its main campus sprawls across several city blocks and high school and graduate programs scattered throughout the state. Although its focus and recognition come from its 42 undergraduate programs, UPAEP also offers non-traditional services through its private hospital, nine high schools, and various technological programs. UPAEP has created a strong name for itself in the city, especially among the upper class Mexicans who can afford the relatively high cost of attending a private school.
Figure 3: The main quad of UPAEP’s central campus.
The main area of UPAEP’s urban campus consists of a grassy square surrounded by four tall academic buildings. Each of these buildings contains classrooms and several outdoor balconies where students often study, smoke, chat, and use their phones before and after classes. When I studied abroad at UPAEP in Fall 2016, these balconies were a great place to people watch and look for fellow classmates, and every so often, the mascot eagle (águila) would be released from a balcony to fly over the students heading to and from class. The main campus is truly a place of social interaction, and the consistent sunshine of Puebla made it especially easy to maximize time spent outside.
In addition to these four, squarely positioned buildings, UPAEP has several buildings, offices, and museums on the surrounding blocks, all marked by the university logo. Buildings are dotted with small and inviting cafes and taco stands where students grab a bite to eat. But while food and beverage are abundant in the immediate community, most of the social interactions that occur over food happen in the on-campus cafeteria. Below the administrative building on the main quad and to the right of the library, the cafeteria sits as a center for student life. A large open space with many small tables and red and white decorations, the room is noisy at most hours of the day, and even at less busy times, an intercom announcing food orders creates an environment ideal for passing time with friends and working on group projects.
The tables are typically filled with groups of two or three students, but occasionally, student groups push together multiple chairs and tables to establish larger seating arrangements. On particularly nice days, UPAEP students spill out of the indoor cafeteria space into the outdoor patio where larger round tables with bright red umbrellas offer a relaxed social scene. The outdoor patio is much more on display for passersby, so students here often congregate in bigger groups as friends head to and from class. Medical students, especially, are noticeable in their social groups due to their white uniforms, and it strikingly appears that medical students tend to socialize exclusively with their academic peers.
Figure 4: This is one entrance to the main cafeteria at UPAEP. I conducted the majority of my interviews at one of these tables. Typically students eat lunch and study here. Image courtesy of Angela Abarca.
Figure 5: This is an image of campus on the first week of Fall semester classes. Students are lining the balconies and surrounding the cafeteria, and medical students can be seen in their white uniforms.
Clusters of all-white lab coats dominate the entire campus, and cigarette smokers are plenty among both medical and non-medical groups. Signs prohibiting smoking on campus are scattered around the cafeteria and beyond. These signs can be found on poles or building walls and, interestingly, are situated at heights just beyond the eye’s gaze. Thus, it comes as no surprise that many of the social groups smoke cigarettes in front of or near these signs. Whether this behavior is intentional or accidental, the juxtaposition between practices of student smokers and ideal policies provided by the University is one of stark contrast that indicates a need to better understand the sociocultural factors influencing health behaviors explicitly prohibited by the administration.
Figure 6: These are images of no-smoking signs on UPAEP’s campus. The left hand sign is small but prominently located on an outdoor wall on central campus. Oftentimes students smoke directly underneath this sign. The right hand image is of signs in an academic classroom. They prohibit eating, drinking, and smoking. Images courtesy of Angela Abarca.
I first travelled to Puebla, Mexico when I spent the Fall semester of my junior year (2016) studying at Universidad Popular Autónoma del Estado de Puebla (UPAEP). From August to mid-December, I lived with a Mexican host family, completed clinical rotations at two public hospitals, and took a full load of classes in Spanish. It was during this time of participant observation that I became familiar with the university and medical culture of the area.
My time abroad was critical for creating a foundation of understanding that later enabled me to choose an appropriate methodological approach. I returned to Puebla and UPAEP, specifically, in summer 2017 to complete my fieldwork. For three weeks I lived with my same host family and spent each day on or near campus talking with medical students. I completed 31 semi-structured interviews with Mexican medical students studying at UPAEP during the summer session and collected additional survey information from the same participants through a Google Survey form.
Each day I would take the bus and arrive at UPAEP in the morning. I spent a short period of time reviewing my notes from the previous day and confirming I had enough printed materials. I often varied the arrival time to campus so as to avoid seeing the same group of medical students each day, and I tended to focus on the morning classes, since many medical students work at the hospitals in the afternoons. Students typically spend time between and after classes in one of the many cafes surrounding the borders of campus or in the cafeteria on the bottom floor of the main building. I focused on these social and relaxed locations as places to speak with UPAEP students.
Because medical students are required to wear an all-white uniform that I was already familiar with, I would simply approach students I identified as medical students, explain the project, and ask if they would be willing and able to participate. Sometimes students had class coming up and were unable to participate, but more commonly, students were happy to take a break from homework to learn more about my project. Interest in the project was often sparked by my accented Spanish and explanation of my previous study abroad. During this time, I made a clear effort to approach both male and female students and often approached the seventh medical student I saw. This randomization encouraged me to speak with students from a variety of social and academic groups.
When students were able to take time to speak with me, I would ask them to begin with a survey and free list on an iPad tablet. Free list elicitation is beneficial for collecting locally relevant terminology that illustrates psychological and cultural preeminence of items relating to smoking habits (Quinlan 2005). Occasionally, I approached multiple students simultaneously who were sitting in groups at a café or studying, and in these moments, one student would use the tablet and the others would use a printed copy of the same material. The survey collected demographic information focusing on their background, gender, smoking frequency, and medical education, but the heart of this survey manifested in the free list method. This method entails the participant creating a list of any length of all the reasons why a medical student might decide to smoke tobacco. This approach is designed to encourage the participant to think individually about trends as a whole and influences on group behavior versus personal behavior. The results can then be analyzed for saliency (Borgatti 2015). Often times, students wanted to discuss their answers with peers, but I would encourage them to complete the list with their own ideas. The lengths of these lists varied in size and content, and the responses hint at the complexity of this issue.
After completing the written portion on the tablet device, I would begin the short interview. These conversations typically lasted between 8 and 12 minutes, depending on the number of people in the conversation. During the interviews, I had two main foci: individual smoking habits and influences and the role of physicians as community examples of healthy habits. The first focus involved questions about how, why, and when a student began using tobacco or why the individual chose not to smoke. The second focus involved questions about the importance of role models, the role of physicians in society, and experiences with medical education. These interviews were truly a time to get to know the students and learn about the diverse experiences and relationships with smoking. The informality of the interview enabled candid conversation, and I found that the participants became more talkative in the presence of one or two peers. We were often gathered around a coffee or cafeteria table, sitting in chairs amongst a sea of other students preparing for the next class. The energy was high and the students very open to having honest discussion.
These conversations comprise the integral part of my research, and despite the occasional miscommunication, I was able to conduct all interviews entirely in Spanish. By speaking with all students in Spanish – even those who mentioned knowledge of English – I received much more natural and robust responses. There were certainly moments of hesitation on my behalf, but through rewording and rephrasing, we were able to address all questions. I was often limited in my ability to react and respond to answers immediately, and in this way, the interviews were much more structured than the original intent. However, through humility and humor, the students and I were able to talk through the answers to my main research questions.
Using the survey results, I was able to get a better understanding of the actual smoking habits of the specific student sample I interacted with. Further, this information painted a fuller image of the UPAEP demographic which could later contextualize the individual interviews. The saliency analysis of the free lists quantified the frequency and saliency, and thus importance, of various social and cultural influences on medical student health behavior. The analysis produced a list of themes and ideas that ultimately guided my analysis of the interviews. The interviews were transcribed from audio to written text, and I coded the conversations -- based on free list results -- in order to see how or if the conversations matched the data from the free lists. Ultimately, the methodology offered a balance of quantitative and qualitative information that guided the analysis and contributed to answering the research questions.
Over the course of my three weeks doing field research, I had the opportunity to interview and speak with 31 medical students. The participants were students at varying stages of their academic and professional careers, ranging from first to ninth semester (the latter is when they enter the internship year). The youngest student was 18 and the oldest was 24. Medical training in Mexico lasts six years in total: students take classes at a university for the first four years (about eight semesters), complete an internship in the fifth year, and work in a social service placement for the sixth year. The largest portion of students I interviewed (38.71%) were in their third year of university coursework, followed by students in their first year (25.81%). The participants were all taking summer courses at UPAEP, which is not a requirement for students. That is, summer school is often a way to get ahead in coursework or perhaps lighten the workload during the Fall or Spring semesters. In comparison to my experience studying at UPAEP during a Fall semester, there were significantly fewer students on and around campus while I was there in the summer, but still the cafeteria and patio areas were clustered with social groups.
Of the 31 students I spoke with, 15 (48.39%) were female and 16 (51.61%) were male. About half (48.39%) of the students were from the city of Puebla -- the location of the campus itself -- and the remaining portion (51.61%) of the sample were from one of many other cities in the country, including Oaxaca, Ometepec, and Tuxtla Gutierrez. Only two of the participants (6.45%) were not originally from Mexico. One male student was born in a southern state in the United States but moved with his Mexican-American parents back to the city of Puebla before entering high school; the other was a man born and raised in Panama who decided to pursue his medical career in Mexico after attending an international high school. When asked about a specific medical specialty, the students indicated a wide range of interests, spanning from pediatrics (19.35%) to surgery (12.90%) to internal medicine (16.13%).
When I asked about individual history with cigarette smoking, 71% indicated that they currently smoked cigarettes or had tried smoking at some point in the past. Only nine students (29%) said that they had never tried tobacco. In regards to more specific smoking behavior, 30% of students indicated that they smoked occasionally, 10% smoked daily, 6.7% smoked weekly, and 6.7% smoked monthly (see figure 7). Six students (20%) said that they had stopped smoking or were in the process of quitting. Based on these results, at the time of my research, over 50% of the participants were smoking cigarettes with some frequency, which is significantly higher than the 16.3% cigarette smoking rate for the general adult population of Mexico (WHO 2017).
Figure 7: This chart illustrates the participants’ responses to the question “How frequently do you smoke? (Select one option)”. The largest portion of students self-labelled as “occasionally” tobacco smokers. Only 26.7% of the students had never smoked.
The survey results for this specific sample of aspiring medical professionals support the findings of previous research studies indicating a higher smoking prevalence among Mexican medical professionals than among the general adult population of Mexico (Reynales-Shigematsu et al. 2007; Tapia-Conyer et al. 1997). Understanding the high rates of cigarette smoking among the very professional group that both assumes a social position with significant health behavior impact regarding smoking and carries much of the day-to-day responsibilities of cessation counseling and treatment of tobacco-related illnesses for the general public is critical to addressing the “high-burden” tobacco-use status assigned to Mexico (WHO 2017).
With a better of understanding of the smoking habits of the students I spoke with, I turned to the free list results for some insight into the causes of this specific health behavior. I used saliency analysis software in the form of an Excel plug-in -- FLAME -- to measure the salience of various terms and phrases suggested by the students. This approach depends upon the assumption that the reasons for tobacco use listed first or near the top are likely more important. These words came to mind quicker and thus can shed light on the social influences on smoking. The results of this saliency analysis -- which measures rank and frequency -- are pictured in the graph on the following page.
Figure 8: This graph demonstrates the saliency of the words found on the students’ free lists. Words with higher saliency are understood to be more important or socially valuable. Words such as “stress” (estrés), “anxiety” (ansiedad), “relaxation” (relajarse), and “de-stressing” (desestresarse) are among the most salient words.
The results of the FLAME saliency analysis push certain themes to the forefront. “Stress” (estrés) was the most salient reason offered, appearing in 28 of the 31 free lists (90.32% frequency). “Social” (social) was the second most salient item, occurring with a 38.71% frequency in 12 of the lists. This was followed closely by “pleasure” (gusto) with a 35.48% frequency and then by “anxiety” (ansiedad) at 29.03%. Of course, these are only the measurements for the specific words. Other items on the lists may have occurred less frequently but have similar meanings -- for example, “fun,” “conformity,” and “fashion” may all support the theme of “social.” However, before beginning the analysis, I was able to consolidate misspellings and conjugations into single items to better understand the frequency and ranks.
Overall, the saliency analysis from the free list methodology produced important results pointing to the most important and influential factors that might prompt a medical student to consume tobacco. When combined with the qualitative, semi-structured interviews, the free lists and surveys contribute to a fuller picture of the medical students at UPAEP and the kinds of health professionals working in Mexico.
I had the opportunity to interview all of the students who completed surveys and constructed free lists. These conversations varied greatly in length and covered topics from family health behavior and specific interests in healthcare to social life at a university. Despite this diversity, specific themes certainly emerged across all discussions that offered invaluable insight into the social and cultural influences on health behavior such as tobacco consumption. In this section, I will discuss the most important and salient themes from my interviews and incorporate student voices to illustrate the medical student and physician experience with smoking.
Before transcribing and coding the student interviews, I spent time sorting through the free list analysis and demographic survey information. From the quantitative data, I was able to recognize specific reasons or social pressures that heavily influence medical student behavior on a general level. The quantitative results then guided my analysis of interviews, as I compared the emerging themes of individual experiences with the salient themes of general experiences with smoking. I ultimately divided the themes for further discussion into the following sections: stress and anxiety in medical school, social influences and pressure, relaxation and de-stressing, and visible health behavior. These divisions are certainly not the only topics important to answering the research questions, and of course, they are not necessarily distinct in nature. There is much overlap throughout the topics, but when combined, these critical themes offer a holistic image of the medical student and health professional experience with smoking.
“Envuelto en estrés” (Wrapped in stress): Stress and Anxiety in Medical School
Medical education is widely understood as a cause for an immense amount of stress for students and health professionals (Lee et al. 2001; Wolf 1989). The physical and emotional demands of medical school can produce negative impacts on the well-being of students, specifically impacting personal relationships, mental wellbeing, and ability to perform in academic settings. Further, high quantities of stress have been shown to negatively impact health behavior, as coping mechanisms often result in decreased physical activity, hours of sleep, and quality of diet (Clark et al. 2016). The rigorous coursework and schedules associated with pursuing a career in the medical or health field often require a period of adjustment during which negative coping mechanisms are inhabited and integrated into the personal and social lives of students. Certain health habits (such as consumption of tobacco) are adopted with the purpose of masking negative moods and minimizing added tension, and in times of academic distress, positive health behaviors (like seat belt use and tooth brushing) are quick to deteriorate (Weidner et al. 2007). Behavioral and health adaptations to cope with the increased stress of medical education improve in effectiveness and health-impact as perceptions of student stress decrease over time, but the long term effects of stress coping techniques may have important consequences for medical counseling and quality of physician care (Wolf and Kissling 1984; Wolf 1994).
One of the primary sources of stress in the medical practice results from academic rigor in medical training (Familoni 2008). In Mexico, acquiring the medical degree to be a physician requires numerous years of medical education and maintaining high grades. The standard program to receive the Título de Médico Cirujano (Medical Surgeon Title, equivalent to Medical Doctor) takes six years to complete. Four of these years are classroom focused (two in basic sciences and two in clinical sciences), one year is a rotational internship, and the final year is required social service (van Zanten et al. 2012:587). The process of becoming a physician typically begins immediately after completion of high school, and although entrance exams are commonly required to gain acceptance to an accredited university -- public or private -- there are minimal additional requirements to assess interest in or fit for the medical field. As such, students studying medicine in Mexico are younger and, perhaps, less familiar with the material and rigor of coursework associated with the medical path (Bickel 2016).
The medical education path can potentially be extended beyond the year of social service by pursuing a specialty which can take between three and eight additional years. Entering a residency program does require taking the national residency examination, offered annually, and excellent performance is critical to entering a program of choice. There are far fewer spaces in residency programs than applicants; in 2003, nearly 21,000 physicians applied for only about 4,500 spots (Alonso and Mériyo-Azpiri 2004: 1475). Although there are no academic requirements to begin medical school, there are many throughout, and these have the potential to offer additional academic stressors to the already stressful environment of medical education.
The medical field is very competitive due to the sheer numbers of students pursuing careers as health professionals, and much of this competition is embodied in academic stress where high academic performance promotes greater success in the field. Placements for the rotational internship and the mandatory social service year are both determined in-part on the class rank, GPA, and exam scores of students, and many news sources around Mexico even publicize the results of these numerical measurements (Alonso and Mériyo-Azpiri 2004: 1475). Competition among peers for positions at better-resourced hospitals or urban places of care compounds with the pressure to perform well in classes to foster stress as a key characteristic of medical school. Stress in education was particularly important for the medical students at UPAEP, as estrés (stress) was the most salient item listed in the free lists, appearing in 24 of the lists with an average rank of 1.043.
One aspect of this stress manifests in the number of classes taken in a given semester. The nature of medical curriculum in Mexico is such that students often carry up to eight classes at a time in order to complete classes in the expected period. While studying at UPAEP and taking science courses within the department of medicine, I noticed that it is very common for students to carry a course load of seven to ten classes in one semester. This realization was startling, for in my experiences as a pre-medicine student at University of Notre Dame, simultaneously taking even five classes is more than enough to create a burdensome workload.
Many of the issues accompanied by high academic loads and stressful educational environments were captured when speaking with Maria, a fourth semester medical student. A participant who identifies as an occasional smoker, she first began smoking near the end of high school, initially intrigued by the social and political fuss surrounding tobacco use. Once her experiment developed into a normalized habit, it became increasingly difficult for her to stop; the pressures of entering medical school and the expectations to succeed academically compounded upon a heavy course load to make consumption of tobacco a coping mechanism. Unexpectedly, tobacco use could not be tossed to the side, and Maria beautifully described the cyclic nature of stress, anxiety, and tobacco use as an aspiring health professional in her observations about her classmates’ tobacco use, “I have seen them and they are classmates who take 8 classes or 7, and they feel very stressed...I have noticed that in medicine, there are more smokers than in other careers.”
Maria sees course load as a stressful -- but common -- aspect of medical training. Of course, her observation regarding the prevalence of tobacco use among students mirrors the documented data about health professionals in Mexico, so coursework is a welcomed explanation for this reality (Reynales-Shigematsu et al. 2007; Sansores et al. 1999). As she mentioned, many of her peers take more than seven classes in the same semester (she has taken up to ten) and the academic demand is a huge contributor to addiction and desire for experimentation.
Our conversation regarding the idea of academic stress as a contributor to smoking was interesting because she later offered her own academic coursework as a contrast to this self-justifying framework. Her peers take seven or eight classes at a time and smoke an entire pack a day as a response; the opportunity to draw connection between the two is not only obvious but also supported by the results from the free list methods I used with the participants. These results reveal the saliency of stress as an influence on tobacco use. However, Maria takes an equivalent amount of classes and with some effort, has slowly been able to reduce the frequency of her smoking. She mentioned, “You can be stressed, calm yourself down, and continue with your business, but I now see smoking as a waste of time.” That is, Maria questions the commonly used assertion of academic stress as the sole influence on smoking habits among health professionals. Her personal experience contrasts the rhetoric of a greater discussion and suggests stress as a superficial rationalization for otherwise harmful behavior. When she is stressed or anxious as a result of schoolwork, she has been able to find ways to move on without smoking as much, so, in this way, academic stress is perhaps a pathway for developing (and making permanent) potentially harmful coping mechanisms like tobacco use.
Taking many classes at the same time results in increased information to learn and memorize, and Monica, a female student in her second semester at UPAEP, adds to this understanding of academic stress when she stated, “We have so much pressure because there is so much pressure to study and to learn many things.” Another student identifying as an occasional smoker, Monica made it clear in our conversation that she does not identify as a regular smoker but understands the actions of her peer group. Her personal habits with tobacco use are tainted by health problems as she noted, “It relaxes me a little, but as I have asthma, there comes a time when time passes and my chest hurts, and I cannot breathe. So that’s why I don’t do it much.” Despite these hesitancies, she explained that while on campus with her classmates, she will suddenly crave a cigarette. The shared experience of smoking tobacco with a friend or peer draws Monica to ignore the known negative side effects.
In this way, Monica’s personal behavior and Maria’s discussion of medical student coping strategies for handling the immense pressure to study and learn indicate a sense of camaraderie between students who are experiencing similar stress and anxiety in an academic setting. If all students pursuing a medical career are dealing with demanding coursework and pressures to learn, then a mutual understanding of academic stress might serve as a common justification between peer groups for health behaviors that do not precisely align with the scientific and clinical information they are learning.
Academic stress is truly only one aspect of the stress experienced in medical training that may influence tobacco use in the medical field. The expectations of students to both perform and serve create extreme professional demands while the “social acceptability and recognition are not commensurate” (Familoni 2008: 6). That is, the professional expectations from the community receiving treatment or supporting future health professionals often exclude a sense of empathy for the human aspect of the students, and this can serve as a stressor. In a conversation with Leticia, a female medical student entering her rotating internship year of medical training, the impact of professional stress created by expectations became clear. She told me, “But there is not that empathy and that knowledge about what is behind all of this. For example: tight schedules, high demand on part of the hospital and on the part of the patients, expectations, challenges, goals that have to be met, and that cannot always be with the reality or the capacity of the force…” As someone straddling the structured academic classroom experience of her field and the hospital setting, Leticia provided wonderful insight into the complexities of being a healthcare provider in the community. She was truly a key informant for me during my fieldwork, as she was willing to really grapple with the social and health behavior of her peers. Her understanding of the way patients see doctors as role models for proper health behavior has been developed by her own experiences where patients often look to doctors for model behavior only to later lose trust or faith in their health expertise the moment they turn to a cigarette or sugary sweet. Simply said, Leticia has noticed a lack of empathy and understanding for the stressful work of medical professionals.
It is easy to turn to trained or aspiring health providers and judge their behaviors, but it is much harder to truly understand their professional stress and the sacrifices they endure in order to serve the greater community. High patient load, limited resources, demanding schedules, and difficult cases are only some of the struggles that medical students and professionals face in the field. They are expected to meet high standards set by both the hospitals and the patients, all the while maintaining model health behavior (Familoni 2008). Leticia is suggesting that patients have lost the ability to empathize with the professional stress placed on doctors to handle extraordinary work with perfect form -- lost the ability to see their human side -- ultimately creating more stress for the providers and contributing to health behavior that outwardly contradicts the level of expertise on health. Much of this stress, however, may stem from the visibility of medical students in comparison to other fields.
Francisco exposed this aspect of public visibility as a contributor to professional stress and expectations when he stated, “Honestly all students are exposed to stress, but in medicine, I do not know. In other words, in this university there are too many medical students.” Entering his third semester as a medical student, Francisco smokes at least one time per week (consuming multiple cigarettes in each sitting if time permits), and his time at UPAEP is significantly impacted by the culture of tobacco use among his immediate peer group. He, like most students, offered stress as the most pervasive reason for smoking behavior, but here he nuances the specific type of stress impacting aspiring medical professionals.
All students experience stress at some point throughout their university career, so why are medical students, especially, so likely to self-rationalize stress to explain health behavior? What makes their experiences with stress so different from the experiences of other kinds of students? This is a complicated matter marked by socioeconomic, historical, and political factors, but Francisco is suggesting that the number of medical students just might play a role. At UPAEP, medicine is one of the largest majors, with hundreds of students studying medicine per class and working at UPAEP’s private hospital Hospital Universitario Christus Muguerza (UPAEP 2012). Furthermore, students in this field are the most visible on campus, always sporting all white uniforms both on and off campus. On campus, a medical student might be more likely to be surrounded by a tobacco smoker simply due to the number of students, and this social presence within an academic and professional field makes access to tobacco -- in a socially acceptable manner -- much simpler.
In his interview, Francisco mentioned that smoking among medical students commonly begins with one or two students in the class and grows gradually until the social group of medical student smokers is much bigger. There seems to be a feedback loop that integrates stress from classwork, professional expectations, and social inclusion to create a system that encourages medical students to perceive tobacco as an acceptable form of handling stress.
Additionally, the sheer presence of so many medical students in uniform clothing forces certain shared health behaviors into the public eye where they can be scrutinized in greater detail. Despite tobacco use being a common health behavior among the young adult population in Mexico, medical students, specifically, are on display for people to watch and interpret (WHO 2015). Sociologist Erving Goffman’s performance-oriented approach to interpersonal communication resonates with the medical student’s visibility in the public eye. Medical professionals and students must strategically use their “front stage” interactions with non-medical professionals to assimilate into what people hope to see -- their uniform elevates normal behavior onto a stage for social performance. The value of their “impression management” depends on a group desire to avoid embarrassment, and in this case, embarrassment might result from not meeting the expectations for health experts’ behavior (Solomon et al. 2013: 197). The visibility of health behaviors like smoking cigarettes not only supports pre-existing stereotypes about doctors mentioned by students in interviews but also increases the stress of health professionals to meet community expectation.
The medical field is certainly a place of academic and professional stress, but still it is important to consider another type of stress that might distinguish it from other similarly stressful careers. Social stress fostered within the peer groups comprising the medical training environment plays a role in whether smoking tobacco is seen as an acceptable coping strategy for handling stress. Of course, tobacco use is not the only coping strategy used by medical students, but the very fact that it is a common and normalized technique suggests the presence of a social pressure to fit in among a peer group experiencing similar stresses in other aspects of life. Maria nuanced her discussion of academic stress with this concept of social pressure when discussing reasons for a high prevalence of tobacco use in her peer group, “Another reason would be stress, but sometimes a kid in middle school or high school smokes, what stress does he have? More than feeling accepted, feeling cool among the group.” Maria had already recognized the impact of stressors of schoolwork, work schedules, and exams on tobacco use, but here she calls into question the extent to which academic and professional stress form this health habit. She noticed that many high school students consistently smoke tobacco and that a seemingly high amount of medical student smokers picked up their habit prior to entering UPAEP. In this way, she questions the actual prevalence of stress as it pertains to academics and suggests a more social form of stress -- the pressure to be accepted and to fit into a group. Her thoughts resonated with the conversations I had with the other medical students, as many of the students who have tried tobacco first smoked a cigarette prior to finishing high school. Whether the habit was maintained in the transition to medical training or dropped quickly, health habits and ideas of social acceptability certainly are in the forefront of the high school experience.
While high school students can and do experience stress, the stresses in high school are often not the same ones discussed by UPAEP medical students in interviews. Rhetoric regarding stress typically revolved around university coursework, professional expectations, and the forceful gaze of the community eye, none of which are experienced (at least to the same extent) until a student begins a training at a university. Thus, the idea of stress in the context of academics and professionalism is perhaps an extension of a greater social stress that encourages experimentation and belonging to a group regardless of health knowledge. While career-specific stress may be the reason medical professionals can justify maintaining this behavior as they learn more about the negative health consequences, social stress is likely the initial reason for the experimental health habit.
Stress is an accepted reason for smoking tobacco as a medical professional. Peer groups understand the level of stress experienced by others, and doctors continue to have stress in the working environment with high patient load and tight work schedules. These shared experiences enable stress as a cause of smoking behavior to be the most popular storyline, but as Maria suggests, social stress is what leads to initial experimentation and ultimately encourages smoking as a go-to coping technique.
“Todo el mundo quiere experimentar” (The whole world wants to experiment): Social Influences and Pleasure
During our conversations about smoking and the ways that tobacco habits are introduced into the lives of students, several of the medical students mentioned experimentation with smoking cigarettes in high school. Whether this first taste of tobacco was the result of family exposure or peer pressure within a social group, many of these first experiences were tainted by negative physical outcomes related to tobacco. They mentioned chest pain, bad breath, sore throats, and headaches as some of the consequences of tobacco use that make smoking seem undesirable from a physical standpoint. However, despite these reactions, many students continued to experiment beyond just one try, nearly forcing themselves to integrate a specific health habit into their social routines. Ana, a second semester woman who self-defines as an occasional smoker, confessed to me that she truly did not enjoy smoking the first time that she tried it. She smokes occasionally to this day, but her smoking habits did not develop naturally. Rather, as she continued to experiment -- continued to socialize with her peers -- smoking became normalized to the point where perhaps the social outcomes from avoiding tobacco were perceived to be worse than her physical discomfort. She said, “And, well, truly at first I did not like it. After I continued going to parties, continued trying it, I ended up liking it and began to smoke actively.”
Ana’s honesty about her experiences with tobacco and its powerful infiltration into her life despite personal evidence of its negative health consequences were echoed by many others. She was not the only student to admit to smoking in spite of lived experiences that indicate negative physical reactions, and her allusion to addiction especially paralleled 21-year-old Martin’s story. A daily smoker, Martin was born in the United States into a Mexican family and has spent the majority of his academic career living in Puebla. As a fourth semester medical student, he, like Ana, smokes despite the initial distaste. After experimenting with cigarettes with his peer group in high school, he ignored his personal reaction to tobacco use in favor of the greater social benefits that accompany this health behavior. Spending time with his friends who smoke tobacco frequently encouraged him to transform what was initially an experiment into a routine and a habit. He told me, “At first I smoked but I did not like it. That is, it made [my throat] feel scratchy, and it was something that I did not like. After time was passing, I began to get together with more friends who, that is, they smoke a lot. Then, it went like that, give me one and it turns into a custom, no? A routine.”
Martin and Ana both propose social performance and participation as a key influence on their decision to smoke. Despite initial distaste, the pressure to conform and join in with the crowd is strong enough to pull behavior in a specific direction, and the habits that result from such experiences have long lasting impacts. As social conformity conflates with pleasure, substance addiction becomes painted in a light that is both self-justifying and socially acceptable. Tobacco is highly addictive, and the unfavorable reactions to the substances in cigarettes are often important mechanisms for deterring people from developing an addiction. Nicotine in small doses can create pleasant sensations that can distract from any unfavorable reactions, but ultimately, these positive emotional feelings encourage a person to smoke more in order to continue ignoring the negative physical feelings (American Cancer Society 2015). That is, if personal behavior reacts directly to the lived physical experiences, addiction can be avoided, but with the strong presence of social pressure redirecting behavior, addiction to nicotine is the natural result.
Maria really captured the essence of the existing conflict between behavior and evidence when she discussed her experiences in high school. It became very clear in many of the interviews that students see smoking as a health habit that is brought to UPAEP from a previous experience; the stressful environment of medical school may be conducive to smoking and tobacco use, but this specific health behavior is often developed prior to entering the medical field. She told me, “Ah no, in high school, the most important thing is to be accepted, more so than what can damage your body,” which paints the image of the high school student whose concerns about social inclusion are greater than concerns about long term physical health. We had been talking about the effectiveness of public health campaigns and speakers in primary and secondary schools. Several of the students had participated in tobacco and drug education lessons during scheduled school time, but these programs and outreach approaches had limited impact when overshadowed by social pressures to experiment with tobacco. This is an interesting point, especially in light of Ana and Martin’s descriptions of distaste, because it shows a ranking of priorities that are developed in the middle and high school environment. Short term benefits of acceptance are immense. The long term benefits of healthy behavior are not immediately threatening and perhaps cannot override an instant gratification mindset.
Social relationships, in general, are known to impact health behavior, either positively or negatively (Umberson and Montez 2010: 2). Whether social connections promote well balanced eating and an active lifestyle or normalize drug use and heavy alcohol consumption, the quantity and quality of the social relationships of a person are deeply connected to morbidity and mortality. Specifically, social ties affect health behavior because they control the range of health habits deemed acceptable and accessible. They may frame information about health behavior in a certain way or develop the norms that shape health perspectives (Umberson and Montez 2010: 3). In these ways, social relationships can guide personal priorities to situate a specific health behavior, like smoking, in a more valued position than a hypothetical long term consequence. It seems that the high school environment for many of the UPAEP medical students encouraged smoking as a form of social inclusion, pointing to the symbolic meaning of cigarette use within adolescent and student peer groups. Of course, symbolic meanings associated with health behaviors can be continued even after leaving the initial location (in this case, high school or social setting prior to medical school), but symbolic meanings find their strength in their very ability to create social cohesion across geographic distances (Umberson and Montez 2010: 3).
Strong and healthy social relationships that include normalizing and accepting positive health behavior can be greatly important for public health and tobacco control. Research indicates that learning about long term consequences of health behaviors is less effective in changing health behavior than focusing on the short term outcomes (Karen Gutierrez, Personal Communication, September 2017). People tend to evaluate health decisions using intertemporal trade-offs through which consideration of the short term and long term is a driving influence (Urminsky and Zauberman 2018). Evaluating short term benefits is guided by the quality and quantity of social connections and thus can be guided, transformed, and even altered through the culture within certain peer groups.
The important relationship between health behavior, socialization, and cohesion creates a particularly tempting pull toward health behavior that might also be damaging to long term health. Maria specifically pointed to experimentation as an idea that all medical students (and non-students) can relate to, regardless of health behavior, when she said, “The whole world wants to experiment, right?” This is a powerful statement for many reasons, primarily in its humanizing nature. Many of the students mentioned that they feel judged or harshly criticized for smoking while wearing a medical student uniform, especially as their health behavior mirrors the development of different health behaviors for others. Experimenting with actions and substances that are known to be harmful is a relatable experience due to the desire to participate in social surroundings; this may manifest as eating sugary foods, avoiding physical exercise, or consuming excessive amounts of alcohol. Truly, it is a human experience to act in direct contradiction to knowledge, but medical professionals, especially, work and learn in a social environment that particularly warps justifiable health behavior and its reception by the community.
Miguel, a second semester medical student, mentioned many of the same situations that introduce health behavior experimentation and tobacco use prior to entering the medical career. He started smoking at a very early age due to its normalization within his immediate family, and he originally tried a cigarette for fun, without even considering alternative reasons for tobacco avoidance. Unlike many other medical students I spoke with, Miguel was able to quit smoking, and his desire to drop the habit was particularly influenced by physical discomfort from the nicotine. In this way, his story contradicts many of the themes regarding social influence and pressure, yet he still spoke personally about the impact of medical socialization and peer pressure to experiment. He explained, “The same thing here, I mean it’s the same. They do not respect that the signals and signs symbolize what they should not do, right? Then, I also believe that there is a failure to take responsibility on the side of the students as well as on the part of some doctors.”
Here Miguel is pointing to some of the more concrete influences on socially guided health behaviors within the medical community. Students may have already started to smoke before UPAEP, but on campus, the particular health behavior becomes further ingrained by socially accepted policy negligence. The university campus has signs indicating that smoking is prohibited in certain areas of the property, yet it is very common to find both medical and non-medical students in front of the signs smoking cigarettes in groups. Social groups determine what is allowed or not allowed in regards to behavior, and by actively ignoring signs about tobacco use, the medical student community is enabling pre-established health behaviors to continue in a way that masks long-term consequences. The responsibility of social groups, though, does not exclusively fall on peers; older professionals and doctors also perpetuate this behavior. Miguel mentioned, “There are people who smoke, and we know that nicotine also causes reactions that can keep us awake, or several factors. I think that, on the part of the career, and some pressure, the doctors also make the students smoke…”
Miguel is indicating that social influences incorporate a wide range of factors, but in spite of recognized health outcomes, medical pressure is further encouraged by doctors themselves. In this case, “doctors” refers to his professors and clinical mentors, as the medical student classes are often taught by doctors. It is clear that the health behavior is not only deemed acceptable by social groups but left uninterrupted by older professionals in the same field. The prevalence of tobacco use among health professionals is deeply rooted, and the intergenerational acceptance only solidifies the social benefits deemed risk-worthy at a much earlier stage.
From both the free lists and the interviews, it became clear to me that a desire for relaxation was deeply embedded into medical student smoking habits. This motivating factor comes with little surprise, as stress induced health behaviors are often reactive coping mechanisms to environmental conditions (Rose et al. 1983). Relajarse (to relax one’s self) was the fifth most salient item for the 31 medical students, and this specific word -- only one of the many that connoted similar feelings of relaxation and de-stressing -- appeared in 16.13% of the lists for why medical students might smoke tobacco. Other words danced around this notion, adding desestresarse (to de-stress yourself), insomnio (insomnia), and sentirse mejor (to feel better) to the general understanding that wanting to release stress and relax goes hand in hand with a demanding academic curriculum or clinical schedule. As a student myself, this theme resonated with me, for students are often encouraged by friends, family, and university staff to seek an outlet for stress relief and relaxation. There seems to be an inherent desire and need to balance academic, social, and professional stress with other methods of relaxation, but what specifically about the medical school student experience in Mexico might present smoking tobacco as the best option? How does tobacco overcome other stress relieving actions as the preferred method?
The most pressing explanation centers on the academic pressure and stress felt by students. As I mentioned in earlier sections, the stress felt by aspiring health professionals is immense, especially as they often take more than eight classes simultaneously, complete extensive shifts in hospitals, and memorize exorbitant amounts of information, all the while serving as supposed community role models. Monica, whose story I introduced earlier, was able to address this topic of academic pressure when she said, “We have so much pressure because there is so much pressure to study and learn a lot of things, there is a moment when you want to relax a little, and well, I don’t know, the cigarette finishes as soon as, like, a minute? Less? Well, it’s only a short amount of time, like a rest, and yes, you do it and feel relaxed and return to your classes.” Monica is an occasional smoker herself and expressed an interest in pursuing a specialty in dermatology, a branch of medicine focused on skin disorders. For her, the relationship between her current tobacco use during medical school and concern for skin health is loaded with contradiction, but the immense pressure she feels is just enough to allow for self-rationalization. She told me, “there are times when you want to throw in the towel and say no. But, you make it to the end, and doctors are admirable for this, they are people and I see them as people.” As a medical student, she experiences and thus understands the struggles of medical education, specifically mentioning that she realizes all doctors han llorado (have cried) and han sufrido (have suffered). In this way, she is more than willing to push potential contradiction -- her own and others’ -- to the side, demonstrating that any means of relaxation is welcomed as a medical professional. And, her behavior is in line with research that shows stress inducing tasks directly elicit tobacco use (Rose et al. 1983). Monica sees smoking as a quick, accessible way to find relaxation, even within the very limited class change time period.
Interestingly, many smokers -- like Monica -- often report an increase in their consumption of tobacco during times of stress. Reported accounts of relaxation are common, even beyond the medical student community, and smoking has been described as a form of pleasure (Silverstein 1987). However, scientific research has suggested that while previous research does show that nicotine can increase the autonomic nervous system arousal and decrease emotional behavior, the true benefits come from the delay of uncomfortable withdrawal symptoms (Silverstein 1987: 946). Smoking even one cigarette between classes replenishes the body’s supply of nicotine, thus alleviating some of the potential withdrawal symptoms accompanying an addictive behavior. The alleviation is easily interpreted by the smoker as relaxation, which supports Monica’s articulation of taking a break between classes. Nicotine consumption to avoid withdrawal brings into question if students truly find the relaxation they seek when they smoke or if they are simply behaving in a necessary way to push off negative physical feelings.
Of course, when students in general are under time and academic pressure to perform, any method of finding relaxation is welcomed, but the specific pressures felt in medical school certainly combine with the socialization aspect of tobacco in peer groups to normalize the practice as both justifiable and rational. A sixth semester medical student, Gerardo, was able to connect the socialization and relaxation aspects of smoking when he told me, “Sometimes I feel like they smoke because they crave it, because they see one person smoking and all the rest are smoking.” Not only does Gerardo note the addictive nature of nicotine that ultimately leads to feelings of relaxation and de-stressing, but he also illustrates how the sheer presence of cigarettes in the immediate student environment enables a stress-coping mechanism like this to become commonplace. Smoking can be a “vehicle to belonging” or feeling included in a social group, and this form of connection over a common behavior can bring equality, even in a field marked by a strict hierarchy throughout the schooling process (Thrasher and Bentley 2006: 580).
Gerardo previously was a smoker and has since dropped the habit, but still, he understands how the academic pressures can present any escape as positive. The desire to relax is shared within the medical community, making this outlet a communal and unifying experience. And, when school pressures and work demands seem to be beyond individual control, perhaps controlling the social experience through tobacco use is a concrete sense of relief. Indeed, a “desire for the fleeting escape” that is offered through cigarettes can be seen as empowering students to take control over their psychological states (Thrasher and Bentley 2006: 581). The decision to smoke, though sometimes impulsive or made through physical necessity, is a deliberate act, one that serves both as a socializing force and as a source of individual autonomy.
James Thrasher describes cigarette smoking as a “temporary transition to relaxation” or to more long term leisurely activities (2006: 582). This notion of unified travel between psychological states of academic stress, relaxation and leisure, and professionalism is powerful, and the temporal nature of cigarette use is certainly a key element in medical student tobacco use. Exercise or art making could be more positive outlets, but when time is a concern, cigarettes offer great opportunity for quick relaxation. Monica’s quote at the start of this section alludes to the brief moment it takes to finish a cigarette as a factor in tobacco use, and this value of time in seeking relaxation is further strengthened by Leticia’s statement that, “For the tiredness, too, the tiredness makes you hungry, and for this, they also smoke, and you relax but also remain awake and feel less hungry.” Throughout her eight semesters as a medical student, Leticia has felt firsthand the physiological effects of stress and workload. Students must stay up late to study and work the necessary amount, and with this increase in time awake, there seems to be an increase in appetite. Leticia’s discussion of cigarettes as a means of reducing appetite and maintaining alertness is critical for understanding the reasoning behind smoking. Nicotine brings a sense of relief while also helping students study more, eat less, and better manage their schedules. The sense of control and empowerment that can result from these effects is immeasurable.
Monica challenges the storyline of stress relief through smoking in medical school, as she comments on the health behavior of medical students before and during the university. She told me, “I think that here they don’t come and start to smoke, I think that they were already smoking before, but here, for the same pressure, they see it as a kind of release.” The pressure that Monica had mentioned earlier in the conversation is determined as a reason for turning to cigarettes, but many of the students began smoking before even entering medical school. The stress and anxiety that has “bi-directional relations” with tobacco use is understandable and justifiable within the university or professional context, but what sort of stress levels exist in high school or even before (Gonzalez et al. 2008: 138)? The anxiety and stress taken on by students is at play when making the decision to smoke, as even the fear of potential anxiety and future stress is shown to be correlated to habitual use (Gonzalez et al. 2008). The fact that many of the students I spoke with began smoking prior to entering this world of stress and pressure pushes against the perception of cigarettes solely as a means of relaxation and poses even more questions of addiction and health habit formation.
The rhetoric around relaxation and de-stressing in regards to tobacco use was generally very positive. Students see cigarettes as both a unifying force among peer groups and an activity that can directly benefit both the stress levels and academic performance in a timely manner. Nicotine can suppress hunger, sustain alertness in long shifts, and affect the emotional state of medical students under pressure; all of these characteristics or outcomes offer a sense of control and empowerment that can be seen as relief. The positivity surrounding this specific health behavior was very evident, but as the association between relaxation and smoking continues to go uninterrupted by incoherent university tobacco policies and positive social reinforcement, tobacco use will certainly persist as an accepted relaxation technique (Thrasher and Bentley 2006). Smokers consistently connect cigarettes with relaxing, and efforts to negate this relationship may be greatly beneficial in disrupting the cultural notions around tobacco.
I was initially intrigued by tobacco consumption among medical students and health professionals because both the scent and sight of cigarettes juxtaposed against a clinical lab coat were visually jarring. I rarely see physicians in the United States smoking around the hospitals or in between classes, but through my fieldwork in Puebla and conversations with students, I slowly began to grapple with this very notion of behavior visibility. Why is the image of a medical student smoking so memorable? Why is this particular health behavior so complicated by the presence of an all-white uniform or a nearby emergency room sign? Why am I more impacted by seeing a physician smoking in public than discovering they drink excessive amounts of alcohol at home? Health behavior encompasses both the beliefs and actions people hold in regards to physical and emotional wellbeing, and the active component truly makes it a social performance. Enacting certain health behaviors in the public eye evokes specific reactions, judgments, and assumptions from others, and physicians and medical students feel the pressures of this performance significantly more than different professions.
The patient-provider relationship is pivotal for reducing health risk and proactively providing treatment, and in the context of tobacco control efforts, the relationship is critical to offering appropriate counseling and cessation services (Frank et al. 2000; Puhl et al. 2013). This relationship is impacted by many aspects of the patients’ and providers’ appearance, personality, and cleanliness. Research has shown that patients often prefer to adhere to guidelines from physicians dressed in white lab coats or those who disclose their personal health habits (Rehman et al. 2005). Much of the foundation of trust and respect, however, is developed within moments of interacting or seeing a health provider because an image can be immediately compared to a person’s pre-constructed expectation for doctors in general. People have ideas about what is appropriate behavior in and out of the consult room, and “thin slices of behavior” -- often lasting less than even five minutes -- are the basis for making interpersonal judgments. Even when taken out of context, patients are known to make assumptions about intelligence level, personality, and motivation from a few simple words or actions (Mast 2007: 316). Verbal and nonverbal communication is wide reaching, and health behavior like smoking cigarettes falls into the nonverbal category shaping community perceptions of physicians or medical students.
Personal health behaviors of physicians have often been associated with perceptions of “decreased credibility” (Puhl et al 2013: 1416), and the expectation to live and perform a certain way was certainly on the minds of many of the UPAEP students I spoke with. The understanding that medical students must behave in a particular way to conform to societal expectations was relevant even to non-smoker Silvia, a fifth semester student, who was very cognizant of her visibility in the community as a future physician. She told me that, regarding medical staff, “the stereotype continues and that’s why this stereotype is so rigorous, that’s why we are very offended. If they do not see me fixed up, they are like ‘it’s the doctor, why is she not all fixed up?’” Silvia’s experiences with negative reception of doctors not living in the assumedly appropriate or correct way suggests a certain level of confidence of community members -- potential patients -- who feel empowered to make critiques on physician behavior. Of course, her experiences may be nuanced by her femininity in a traditionally patriarchal society -- there was a clear focus on beauty and makeup for the women that differed from expectations for men. But, regardless, the white uniform immediately announces to the public eye that someone is a health professional, immediately declares a certain level of scientific knowledge. Thus, the white uniform projects ideas of good, bad, and unacceptable, and Silvia strengthens this by saying, “the stereotype is so strict that when they see something out of place, it is for them to judge.” The importance of visibility in the community lies at the heart of the visible cue created by medical professionals engaging in an otherwise very common health behavior. Smoking, especially in attire that draws attention and sends a distinct message, is visible in a way that health behaviors like sleep and water intake are not. And, as Mary Douglas discusses, smoking as a means of stirring distrust within a community is a matter of “territorial definition” -- smoking is not necessarily “profane” by itself, but rather, its proximity to places and people of healing and health introduces ideas of impurity that prompt judgment and stereotypes (Douglas 2001: 181).
Pedro, a 20 year old male medical student, spoke about the visibility of physicians in the community in a way that paralleled Sylvia’s experiences. He, too, is not a tobacco smoker but is still aware of the expectations that non-medical professionals have of doctors in regards to personal health behavior. Many of his friends smoke regularly between classes and during long shifts at the hospitals, and through watching them contest the theme of visibility in a professional sphere, Pedro has become aware of a sort of incongruence that plagues the clinic consult rooms. When I asked about the responsibility physicians have to be role models of behaviors they promote, he told me, “yes...because otherwise there would be a huge incongruence, right? Because if you are promoting health and your image does not appear to be healthy, you are contradicting yourself and there is not collaboration between you and the patient.” Just as “unconscious nonverbal behavior” has the potential to negatively impact patient functioning, incongruence between physical appearance and verbal communication is also able to damage a physician-patient relationship (Mast 2007: 315). Physicians have an intimate role in smoking cessation and accompanying people while they struggle with addiction. There is a special level of trust and vulnerability that fosters faith in physician advice, and as Pedro describes, contradiction to expectation can prevent progress.
The importance of image was salient across my conversations, and some examples surrounding non-smoking health behavior were offered to drive this point home. In the same conversation Pedro mentioned the issues a patient -- or anyone -- might have if they saw empty alcohol bottles on a doctor’s desk or if they notice empty cigarette packages on the ground. Of course, these scenarios seem highly unlikely, especially given the professionalism surrounding the medical field, yet they highlight the value that is placed on visibility. Patients, it seems like, expect physicians to model the behavior they promote, to serve as an example of how to live a healthy life, even if it is simply a facade for harmful health behavior that happens behind closed doors.
The most common parallel scenario, however, revolved around obesity. Over half of my interviews included some discussion of the problems that arise when an obese physician encourages weight loss, and the issues many of the medical students had with taking nutritional advice from an overweight doctor reveal the power of visibility. Obesity does not necessarily reflect a person’s current lifestyle or health behavior, yet it is a noticeable and highly visible marker of potential health problems. Additionally, it is a topic that continues to leave room for jokes and harassment; weight is so tightly bound to notions of beauty -- especially in the US -- that obesity fits nicely into a category of superficial qualities that prompt unapologetic, public ridicule. Potentially, patients look to see their future healthier selves when creating a relationship or consulting a physician, and being overweight strongly connotes both an undesirable physical appearance and moral compass.
There exists a Cartesian dualism that separates mind from body and individual from society which encourages people to separate health behavior or status from the sociocultural context (O’Connor and Van Esterik 2008:7). By seeing physicians as overweight or smokers or drinkers -- rather than people engaging with the social world -- patients box physicians into a moral and emotional categorization that perhaps does not reflect their ability to offer health advice. Silvia sees physicians as “models to follow” and compares physicians who smoke publicly to “doctors who ask you to lose weight but are obese.” She did not explicitly say why obese physicians are less reliable in offering weight loss advice, but the assumptions she makes about professionals in her own field are clear. People with great access to information and knowledge on health should behave in a particular way that reflects high health standards.
Indeed, health agencies and public discourse promote “individual responsibility” when discussing health behaviors (O’Connor and Van Esterik 2008: 8). Eating less, exercising more, and avoiding tobacco are associated with ideas of goodness and discipline, but this approach to health is problematic in that it “cherry-picks science,” adding to pre-existing pressure on physicians (O’Connor and Van Esterik 2008: 8). Fernando, an occasional smoker, echoed Silvia’s scenario when he compared smokers leading cessation counseling to “a nutritionist who gives a nutrition plan to someone trying to lose weight but the nutritionist is fat.” Fernando is a high intensity athlete and was even carrying two gym bags and a protein powder beverage when we spoke. His passion for athletics and value on his physical health was obvious, yet he struggled to make the connection between his personal incongruence as a smoker and athlete and the incongruence of an obese person and nutritionist. The stereotypes that pressure physicians to behave and look and engage with health in a rigid way are perpetuated and internalized even among professional peer groups, and it was interesting to be with students as they teased out these ideas. Unhealthy or obese patients are known to be vulnerable to bias and discrimination from their physicians, but interestingly, physicians seem to also be vulnerable to these same negative experiences (Puhl et al. 2013).
Despite a physician’s appearance or personality, doctors are still typically revered as experts in clinical science and medicine. In times of bad health, community members must turn to those with formal backgrounds in medical training for counsel, and as 20 year old Rosa phrased it, “they are giving us their trust.” Patients place a high level of trust in physicians, especially when their personal wellbeing is at stake, and it reasons well that there are expectations for professionals -- in and out of the consult room -- in such esteemed positions. Healthcare is innately intimate, but assumptions about how medical professionals should act and behave in public often blur the fact that doctors are still humans.
This idea was powerful to explore in my conversations because I realized I hold doctors to above-human standards of willpower and self-control. Rosa is not currently a smoker herself but through friendship and university socialization, has come to understand why tobacco consumption might be such a common behavior within a community of students and professionals holding great knowledge of the consequences. After all, they work and learn in highly stressful environments. When asked about her opinion on physicians as role models she told me, “doctors do not stop being people, we do not stop feeling, living, or getting sick. And neither do we stop enjoying the things of life.” Doctors practice medicine professionally, but they are still people. They are still vulnerable to the same temptations, social pressures, and coping mechanisms that lawyers, businessmen, or engineers face. Rosa’s sentiment on the visibility and stereotypes of doctors who smoke cigarettes is a constant balancing act between a firm belief in the power physicians have to influence community health and the realization that doctors are people too. Health education is an excellent way to create positive changes in public health behavior but even at the level of expertise, it does not exempt people or physicians from responding to and engaging with the world around them.
This study has shown the immense complexity underlying health behavior and the decision to smoke cigarettes among Mexican medical students -- future health professionals who will soon be at the forefront of national tobacco control efforts. While I was initially interested in this project because of the visual paradox created by medical experts executing health behavior so widely known to have negative physical consequences, my interest was sustained throughout the project by the stressors, concerns, and pressures felt by the medical students I interacted with. Tobacco use is a health behavior with positive and negative consequences, similar to drinking alcohol, consuming sugary or fatty foods, and sleeping minimally; but, when contextualized by the high stress culture of medical school and perpetuated by social pressures prominent in University and professional life, smoking emerges as a dynamic health trend with immeasurable importance for progressing global public health efforts.
Of the students I spoke with, the vast majority (73.3%) had tried smoking at least once. That is, only about a quarter of the medical students had made the conscious and explicit decision to disregard tobacco use as a social norm or a necessary experiment. This reality points to the important theme of overwhelming stress in medical school. While many students had tried smoking prior to entering the university, the stress and pressure of an unbearable class load and narrow focus on academic achievement through grades presented cigarettes as a coping behavior that easily fits into their schedules. The academic stress of school performance and rapid information memorization, the professional stress of long hospital shifts and urgent decision making, and the social stress of fitting in with professional and student peer groups all contribute to the persistence of tobacco use within the medical field. This theme of stress is further developed by the theme of relaxation and de-stressing which goes hand-in-hand with the social and professional expectations for medical students. Relaxation is a necessary yet difficult pursuit when time is a luxury as it is for health professionals, and because cigarettes can be justified through the concrete benefits regarding de-stressing, they are still deemed as acceptable.
Further, the social experimentation that spans high school and university life continues to add to the smoking physician image that is attached to widely acknowledged stereotypes. The immediate social benefits of inclusion and acceptance outweigh the extensive scientific knowledge clinicians have. This normalization, though, is truly only visible and deemed of interest because of the visibility of health leaders in the community. Physicians -- and medical students -- must meet patients’ preconceived expectations for appropriate and healthy behavior, and as a result, their inability to live up to above-human ideas of willpower and self-control might stir distrust within communities. Before medical students are physicians and before physicians are health leaders, they are people. This is critical to understanding their relationship to smoking.
Given the themes that emerged from interviews and quantitative data analysis, what does this research mean for tobacco use in Mexico and the role of doctors in national public health efforts? Mexico has been making admirable strides in reducing the general population’s rate of tobacco consumption, and as it works to relieve the heavy tobacco burden it faces, the country needs to focus on supporting the physicians who are interacting with and influencing the very populations these policies address. Physician influence in smoking cessation is an important variable in tobacco control that cannot be overstated. As community leaders and influencers, they are uniquely positioned to both effectively model positive health behavior and advise patients on cessation strategies, but in order for physicians to truly harness the power of this social position, health policies should also incorporate and consider the lived realities of health professionals who face immense stressors socially, academically, and professionally.
Perhaps reducing the academic course load of medical students or breaking up the focus on grades might ease the stress felt by medical students. Perhaps implementing stronger tobacco cessation counseling courses into physician and medical student education might better equip health professionals to promote cessation regardless of their personal health behavior. Or, perhaps working toward a greater humanized understanding of physicians through public campaigns and media might alleviate some of the observed pressures to present facades of perfection and model behavior. The effectiveness of small measures like these at both the university and national level is an area of research that could further this project’s findings to develop holistic health policies that consider both the patient and physician relationship with smoking, stress, and socialization.
Additionally, it would be valuable for future research to explore alternative coping mechanisms and stress relievers that could gain traction within the medical field without tainting their social images as community health role models. Smoking is still seen as a normalized and easily justifiable means of socializing, seeking relaxation, and meeting the demands of a clinical job, but it is likely not the only means of reaching these goals. Exploring healthy, timely, and socially acceptable methods of coping with the stressors and pressures of medical school and, later, physician life is critical to contributing to Mexico’s progress in this area.
Healthcare and access to necessary health services is a human right. In Mexico, this means that improving access to accurate and holistic cessation counselling as a means of strengthening individual and population physical and emotional wellbeing is critical. Physicians are a key component of granting this right to all people, and as social and cultural factors continue to outweigh the advanced medical knowledge obtained by health professionals, we need to hone in on the specific aspects of the medical field that promote negative health behavior.
Gender: M F
City of origin:
Specialty of interest:
Do you currently smoke cigarettes or have you ever smoked cigarettes? Yes No
How frequently? (Please choose one)
I have never smoked
I have stopped smoking
Please make a list of all the reasons why any medical student would smoke cigarettes (the list can be as long as you want).
Appendix B: Interview Questions (English)
Questions Regarding Smoking Habits
- Could you please tell me more about your smoking habits? (Where, how often, with whom, etc)
- When did you begin smoking?
- How old were you when you first smoked a cigarette and how did you begin?
- Why did you smoke for the first time or why do you not smoke?
- Does anyone in your family smoke cigarettes?
- In what way has this person had an effect on your decisions?
- Are there other things or people that have affected your smoking habits?
- Typically, where do you smoke cigarettes? (ie: in bars, outside of school, in your house)
- With whom?
- For medical students, are there differences in smoking habits between genders?
- Has there ever been a time when you decided to stop smoking?
- Could you tell me more about this decision?
- What did you do and why?
Questions Regarding Medicine and Doctors
- Why did you choose to study medicine? Why are you interested in medicine and being a doctor?
- How do you understand the role of doctors in society?
- Do you think that doctors have to act like “health models” in society?
- Do you think that patients perceive doctors as “models”?
- Do you think it is important for your patients to see you as healthy? If so, in which ways?
- Do you think that your advice/counsel to patients is affected by your own lifestyle habits?
- In your medical classes, which are the most emphasized themes? (public health, cancer, laboratories, etc)
- Do you learn about smoking in the context of public health or are your classes primarily science and laboratory based?
- Do you learn how to speak with patients or how to give advice?
- Have you learned about smoking in your classes?
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 The Popular Autonomous University of the State of Puebla
 Free-List Analysis under Microsoft Excel
 During my time in Puebla, I noticed that women in Mexico are particularly focused on physical appearance via their use of makeup, perfume, and fashionable clothing. Mexican women tend to strive to meet societal standards of beauty through lush eyelashes, perfectly groomed eyebrows, and manicured nails. I was particularly aware of the beauty habits of my female peers as even during difficult exam weeks or early morning classes, the women were often expected to be seen as ‘put together’ in a female specific manner.
 While female physicians often focused on makeup and nail polish, the men tended to focus on their hair and clothing. Many of the male medical students consistently wore hair gel and tightly fitting dress pants along with their uniform, suggesting a similar emphasis on looking put together as a social performance.