The present study provided, for the first time, an overview of ND among daily smoking Estonian physicians in Estonia who smoked daily. The aim of the study was to describe ND and to analyse the association between ND and smoking-related and background factors among daily smoking Estonian physicians.
According to the results of the present study, the mean FTND score of Estonian physicians who smoked daily was 2.8 (on a scale of 0 to 10). More than half of daily-smoking Estonian physicians had low ND levels (FTND score 0–3). This result is similar to physicians’ nicotine dependence in Germany in 2018 (22) and in Turkey or Greece from approximately 10 years ago (23, 24). Compared to the general population worldwide, Estonian physicians’ mean FTND score was similar to those in Germany and Norway (score 2.8 in 1990s) but lower than those in the USA (4.0 in the 1990s) and China (3.1 in 2013) (10, 25, 26). Unfortunately, there is no general population data for Estonia concerning nicotine dependence to add to the comparison.
The results of the fully adjusted logistic regression model showed that nicotine dependence was significantly associated with the age of smoking initiation. The earlier the initiation of smoking was, the higher the odds of having higher nicotine dependence. This result is in accordance with previous findings stating that people who initiate smoking at a younger age are more likely to become nicotine dependent (27, 28). Estonian physicians who smoked daily and who had at-least-moderate ND levels began smoking approximately three years earlier than those with low ND levels. Previous results from the smoking survey administered among Estonian physicians showed that in 2014, physicians started smoking at an earlier age than in 1982 or 2002. At the same time, an increasing number of non-smokers enter the profession (15), which creates a situation in which those who smoke have done so beginning at a younger age, while others in the profession will not start at all.
In the present study, after adjustments were made for all descriptive variables, the ND level was not significantly associated with the desire to quit or motives to quit. In crude models, compared to physicians who wished to quit smoking, the odds of having at-least-moderate ND levels were almost three times higher among physicians who did not wish to quit. Similar results were found in surveys conducted in the USA, the UK, Canada and Australia, where a lower level of ND was shown to be related to a higher probability of intentions to quit (29). In the current study, compared to physicians who stated personal health problems as the main motive to quit, the odds of having at-least-moderate ND levels were three times higher among those whose main motives were ‘other reasons’. This group included, for example, physicians who reported material or social pressure as the main motive to quit. On the one hand, this finding indicates that daily smokers with existing health problems might have already quit. On the other hand, the result could be accounted for by the notion that material reasons, although linked with nicotine dependence among the general population (30), might not be relevant among physicians. As the current study focused on nicotine dependence, motives to quit were not explored in detail here.
The present findings showed no association between ND level and the estimation of the harmfulness of smoking, the number of quit attempts or stress as a reason for relapse. However, some of these factors have been found to be related to ND in previous studies. For example, previous study data reports on the association between work-related stress and smoking intensity among public-sector employees (31) and between work-related stress and the use of addictive substances among physicians (22). These findings would allow us to hypothesize that ND is higher among physicians because the profession is considered to cause higher levels of stress. However, this association was not proven in the current study.
After adjustments were made for background factors, gender ceased to be significantly associated with ND level. The results of the crude models showed that men were almost twice as likely as women to have at-least-moderate ND levels. The results from other studies have similarly shown that men were more likely to have higher nicotine dependence (25, 32). The prevalence of daily smoking among men is higher than that among women in Estonia and in the Eastern European region in general (33), as well as among physicians (15).
In the current study, no association was found between ND level and age, ethnicity or medical specialty. The associations might not be evident due to the small sample size, as the prevalence of smoking among physicians was low. In the general population in other countries, ND has been shown to be significantly related to age. High ND has been shown to be more prevalent among 45- to 64-year-olds than among people in younger or older age groups (10) (32, 34). In the general population of Estonia, the prevalence of daily smoking among non-Estonians has consistently been higher than that among Estonians (35). Additionally, the prevalence of daily smoking among physicians of non-Estonian ethnicity was somewhat higher than among Estonians (data not shown). However, no indication of the finding that ND would be higher among ethnic minorities was found in the present study sample of physicians. Specifically, general practitioners in Australia tended to smoke less than specialist doctors (14). In Germany, the prevalence of smoking was lower among those in non-surgical specialties than among those in surgical specialties (22).
When the results of the current study are interpreted, some contextual factors should also be considered. Estonia has led a consistent tobacco policy that has resulted in, among other outcomes, smoking being restricted in hospitals. Several Estonian hospitals are smoke-free, and many hospitals actively promote smoking cessation among their staff and, in some cases, pay for cessation treatment. Moreover, according to the previous results, more than half of currently smoking Estonian physicians expressed a desire to quit (36). The results of the present study, however, indicate that smokers might still be facing difficulties to do so and therefore would benefit from cessation counselling specifically tailored to physicians’ needs.
The methodological limitations of the study are as follows. First, a possible self-representation bias of smokers could contribute to their underreporting of their smoking habits (21). Second, the response rate was just over 53%, and there is no information on non-respondents’ smoking habits. The prevalence of smoking might be underestimated, since non-respondents might systematically differ from the respondents. To compensate for non-response, data were weighted based on gender and age. Third, the small sample size, which is related to a low prevalence of smoking among physicians, should be considered. Fourth, respondents who answered ‘no’ when asked if they currently smoke every day were guided past the FTND questions. This approach limits the sample size to daily smokers only and leaves ND levels among occasional smokers unidentified. Despite these limitations, the smoking survey results for Estonian physicians provide an excellent opportunity to analyse smoking behaviour and nicotine dependence in a sample representing all Estonian physicians. Moreover, physicians comprise a homogenous group in terms of educational background, which can be considered a major strength in a study exploring health behaviour.