Abstract
Background
Globally, undergraduate students exhibit a higher tendency towards tobacco and other substance use. Although there are almost 50,000 undergraduate medical students studying in Bangladesh currently, evidence regarding the prevalence of tobacco & other substance use among them is very limited, let alone the predictors.
Aim
This research aims to investigate the prevalence of tobacco or other substance use among medical students in Bangladesh and to investigate the factors associated with tobacco or other substance use.
Methods
This cross-sectional study was conducted between May 2023 and August 2024 in sixteen medical colleges in Bangladesh. A total of 1,129 medical students were selected by convenience sampling, and data were collected using an online self-reported semi-structured questionnaire. Descriptive statistics, chi-square test, t-test, and multiple logistic regression model were used to report the study findings.
Results
The mean age of the students was 22.3 (± 2) years, with slightly higher female preponderance (52.3%). Out of 1129 medical students, tobacco or other substance use was prevalent in 154 (13.6%) students. The students most commonly used tobacco products (54.5%) followed by non-medical use of sedatives (26%) and cough syrup (18.8%). The odds of using tobacco or other substances increased with age and academic year. Male students (AOR: 1.41, 95%CI: [1.26, 1.59], p < 0.001), living at an off campus housing without family (AOR: 2.25, 95% CI: [1.02, 4.94], p = 0.043) and living in a medical college hostel (AOR: 2.1, 95% CI: [1.20, 3.67], p = 0.009), having tobacco or other substance use in family (AOR: 3.97, 95% CI: [2.64, 5.98], p < 0.001), and not willingly admitted to medical college (AOR:3.61, 95%CI: [2.20, 5.90], p < 0.001) were significant predictors of tobacco or other substance use.
Conclusion
This study observed a high prevalence of tobacco or other substance use among medical students. Therefore, the factors associated with their tobacco or other substance use related behavior should be mitigated, and necessary provisions should be made available to help with the cessation of such use among the current users.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12889-025-25955-4.
Keywords: Medical student, Substance use, Tobacco use, Bangladesh
Background
Tobacco, alcohol, and other illicit substance use have become a global public health concern in recent times [1]. Nearly 1.3 billion people around the globe use tobacco, and it is responsible for more than 7 million deaths every year [2]. Globally, the mean age of smoking tobacco use initiation is 19·2 years [3] and undergraduate students are found to be regular users of tobacco products [4, 5]. A study conducted among the medical students from six south-east Asian countries (Malaysia, India, Pakistan, Nepal, and Bangladesh) has shown that the prevalence of tobacco use among Bangladeshi students is the second highest (17.4%) among those countries [6].
Alcohol use disorders were the most common of all substance use disorders worldwide in 2016, with an estimated 100.4 million cases in over 2 billion alcohol users [7, 8]. According to a report by the United Nations Office on Drugs and Crime (UNODC), approximately 275 million people used illicit substances worldwide in 2020, and by 2030, this number is expected to increase by 11% [9]. This instrument of human devastation, substance use, has stretched its claws to every corner of the globe, particularly in South Asian countries like Bangladesh [10]. As per a recent report, Bangladesh has approximately 7.5 million substance users [11]. The most alarming issue is that 33% of the users begin abusing substances between the ages of 15 and 19, and about 80% of them are young individuals (aged 16 to 35); it is also reported that 50% of users are educated individuals [12]. It has been reported that of all the drug abusers, the highest prevalence is among undergraduates [13]. This higher prevalence of substance use in undergraduates may be explained by the transition from adolescence to adulthood [14]. Students from all walks of life with different customs, cultures, norms, and beliefs come together in a university to continue their undergraduate studies. Some of the students may have to live in hostels or dormitories without their parents or guardians around, which may influence their personality and practice [15]. The lack of supervision, along with the influence of peers, combined with the vulnerability the young undergraduates experience, may lead them towards tobacco and substance use [16]. Moreover, the urge to try something new, failure in relationships, poverty, poor subjective health status, and availability of substances have also been documented as the reasons behind substance use initiation [17, 18]. Furthermore, the widespread availability of substances has remained an important factor [19]; since medical students have convenient access to different substances (e.g., opioids, sedatives, etc.).
The prevalence of substance use among medical students varies globally, with alcohol being the most common (24%), followed by tobacco (17.2%) [20]. Prevalence tends to increase with medical training years and is higher among men. Studies conducted in Nepal, Romania, Saudi Arabia, New Zealand, Brazil, India, Greece, France, and Germany highlight variations in substance use, revealing responsible factors like gender, academic year, GPA, mental health, family history, and social influences [21–29].
Although there are almost 50,000 medical students in Bangladesh [30], there is limited evidence regarding the prevalence of tobacco products and substance use among them, let al.one the predictors of the uses. It has been recognized that substance use among physicians starts early in their lives [31] and can have major effects on their ability to work as doctors in the future [32]. Therefore, the aim of this study is to investigate the prevalence of tobacco or other substance abuse (TOSU) in medical students and factors that are responsible for it, so that effective measures can be taken to isolate the factors associated with tobacco or other substance use and take necessary action to mitigate the extent of such use.
Materials and Methods
Study design, setting, and participants
This cross-sectional study was conducted in Bangladesh between May 2023 and August 2024. The research enrolled 1129 medical students conveniently selected from sixteen medical colleges (supplementary file 1) across Bangladesh. In order to be eligible for the study, participants were required to satisfy the following criteria: (1) permanent residents of Bangladesh, (2) currently enrolled in a medical college, and (3) willing to provide consent to participate in this study.
Pilot study
Prior to the start of the survey, a pilot study was carried out (on 5% of the sample) to ensure the questionnaire’s validity, reliability, and cultural and linguistic suitability. The survey questionnaire was then modified based on the comments obtained from the pilot study. Some questions were updated based on face validity to improve the clarity and accuracy of the phrasing. The survey’s content validity was established through the evaluation of two medical college teachers who conducted an independent review. The reliability and internal consistency of the questionnaire were determined using Cronbach’s alpha coefficient (0.79).
Operational Definitions
Alcohol, cannabis, non-prescription sedatives, non-prescription cough syrup (codeine, dextromethorphan, etc.), opioids (i.e., morphine, pethidine, heroin, fentanyl, etc.), amphetamine (i.e., yaba, methamphetamine, ecstasy, etc.), and cocaine, which are commonly available in Bangladesh [33] are considered as ‘substance’ in this study. Tobacco or other substance use will be defined as ‘using on at least two occasions in the previous month’ and responding positively to the question of whether he or she consumes that particular substance at present. The operational definition of substance use applied in our study was adopted from prior research conducted among university students in Bangladesh [34], a population that closely resembles our study sample.
Instrument and Measurement
The data collection process involved the utilization of a semi-structured and self-reported questionnaire, which was accompanied by an electronic informed consent form. The questionnaire (supplementary file 2) comprised two sections, namely background characteristics and tobacco or other substance use. The background characteristics section had 13 questions which included age, gender, marital status, curriculum, type of medical college (government, non-government), medical college location, academic year, division of residence, medical college location, academic year, current residence ( house with family, off campus housing without family - mess/single stay, medical college hostel), region of residence (urban, semi-urban, rural), monthly family income (in Bangladeshi Taka, BDT), parents’ companionship status, parent’s highest educational level, monthly family income (in BDT), willingly admitted to medical college or not, and tobacco or other substance use in first degree relative.
The tobacco or other substance use section had two questions. Two questions - use (yes, no) and availability (easy, moderate, difficult) were asked for each of the following: tobacco, alcohol, cannabis, non-prescription sedatives, non-prescription cough syrup (containing codeine, dextromethorphan, etc.), opioids (i.e., morphine, pethidine, heroin, fentanyl, etc.), amphetamine (i.e., yaba, methamphetamine, ecstasy, etc.), and cocaine. If a participant were using tobacco and/or any of the mentioned substances, he/she had to answer the following six more questions: Introducer to tobacco and/or substance, monthly expense behind tobacco or substance use (in BDT), source of fund, approached by anyone for tobacco and/or other substance use cessation, reasons behind first using tobacco and/or other substance, and reasons behind continuing tobacco and/or other substance use. If a participant was not using tobacco and/or any of the mentioned substances, they had to answer one more question: reasons behind not using tobacco or other substances.
The full questionnaire was then entered into Google Forms for online distribution without any item randomization and validated for usability and technical functionality. The form contained 28 questions spread across four pages. The mandatory items were denoted by a red asterisk, and a corresponding non-response option was provided. Participants had the opportunity to review and modify their responses, if deemed necessary, by utilizing the back button. To avoid duplicate entries, the survey was not presented again after the user had completed it.
Data collection
One research assistant for each of the eight divisions was recruited through social media advertisement and online interview. After recruitment, they received training and thorough information about the project, and after that, they were deployed for data collection. Potential participants were reached through convenience sampling by the research assistants. After confirming that the participants satisfied the eligibility requirements, a link to a closed web-based survey made with Google Forms containing an electronic informed consent form was delivered through Facebook message, email, or SMS. There was no other form of promotion or advertising for the survey. Of the 1200 eligible participants who agreed to participate, 1129 participants completed the entire questionnaire (completion rate: 94.08%), and incomplete questionnaires were excluded from the analysis.
Statistical analysis
We used Stata (version 16; StataCorp, College Station, TX, USA) for the data analysis. A histogram, a normal Q-Q plot, and the Kolmogorov-Smirnov test were used to check for normality in continuous data. For quantitative variables, the arithmetic mean and standard deviation were reported as measures of center and variability, respectively. In the case of categorical variables, frequencies and percentages were reported. Pearson’s Chi-square test and t-test were used to examine the relationship between tobacco or other substance use and independent variables such as socio-demographics. Logistic regression models were fitted using important variables, considering the literature review and bivariate analysis. The lowest values of the Akaike Information Criterion and the Bayesian Information Criterion (BIC) were considered while considering the model selection. The variance inflation factor (VIF) was used to measure the presence of multicollinearity (VIF < 5 for all).
Ethics
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board (Ethics Committee) of North South University (Approval number: 2023/OR-NSUIIRB/0403). All participants and/or their legal guardians provided informed written consent. No minors were included in our study.
Results
Background characteristics of the study participants
The study included a total of 1129 medical students from all eight divisions of Bangladesh, and their background characteristics are presented in Table 1. The mean age of the students was 22.3 ± 2 years, with slightly higher female preponderance (52.3%). The majority of the students were from government medical colleges (71.7%), and there was an almost equal distribution of academic years, with a slightly higher participation from third-year students (23.9%). The majority of the students were staying at medical college hostels (70.7%) and are urban residents (57.9%). Of the total respondents, nearly one-third of the students had a monthly family income between 10,000 and 30,000 BDT, and one-third of the students had a monthly family income between 30,000 and 50,000 BDT. The majority of the students’ parents were still married during the time of data collection (93.4%), and most had completed at least a higher secondary education (45.8%). Additionally, 73.0% of the students reported that their families did not have a history of tobacco or other substance use (TOSU), while 27.0% reported a history of TOSU. Finally, 85.0% of the students reported that they willingly admitted themselves to the medical college.
Table 1.
Background characteristics of the study participants (N = 1129)
| Variables | Frequency (%) | |
|---|---|---|
| Age (in years), mean (SD) | 22.3 | (2.0) |
| Gender | ||
| Male | 539 | (47.7%) |
| Female | 590 | (52.3%) |
| Medical college location (division wise) | ||
| Dhaka | 192 | (17.0%) |
| Chattogram | 145 | (12.8%) |
| Rajshahi | 101 | (8.9%) |
| Khulna | 194 | (17.2%) |
| Barisal | 174 | (15.4%) |
| Sylhet | 105 | (9.3%) |
| Mymensingh | 109 | (9.7%) |
| Rangpur | 109 | (9.7%) |
| Type of Medical | ||
| Government | 810 | (71.7%) |
| Private | 319 | (28.3%) |
| Academic year | ||
| 1st | 206 | (18.2%) |
| 2nd | 108 | (9.6%) |
| 3rd | 270 | (23.9%) |
| 4th | 212 | (18.8%) |
| 5th | 206 | (18.2%) |
| Internship | 127 | (11.2%) |
| Current residence | ||
| House with family | 251 | (22.2%) |
| Off campus housing without family | 80 | (7.1%) |
| Medical college hostel | 798 | (70.7%) |
| Region of Residence | ||
| Urban | 654 | (57.9%) |
| Semi-urban | 232 | (20.5%) |
| Rural | 243 | (21.5%) |
| Monthly Family Income (in BDT) | ||
| <10,000 | 106 | (9.4%) |
| 10,000–30,000 | 354 | (31.4%) |
| 30,000–50,000 | 359 | (31.8%) |
| >50,000 | 310 | (27.5%) |
| Marital status | ||
| Unmarried | 1,046 | (92.6%) |
| Ever Married | 83 | (7.4%) |
| Parents’ companionship status | ||
| Married | 1,054 | (93.4%) |
| Divorced/separated/widowed | 75 | (6.6%) |
| Parents’ highest educational level | ||
| No formal education | 22 | (1.9%) |
| Primary school | 143 | (12.7%) |
| Secondary school | 181 | (16.0%) |
| Higher secondary | 517 | (45.8%) |
| Graduation | 243 | (21.5%) |
| Post-graduation | 23 | (2.0%) |
| Tobacco or other Substance Use in first degree relative | ||
| No | 824 | (73.0%) |
| Yes | 305 | (27.0%) |
| Willingly admitted to medical college or not | ||
| No | 169 | (15.0%) |
| Yes | 960 | (85.0%) |
Data are presented as n (%) unless otherwise mentioned
BDT Bangladeshi taka (1 USD = 120 BDT), SD Standard deviation
Tobacco or other substance use
Out of 1129 medical students, tobacco or other substance use (TOSU) was prevalent in 154 (13.64%) (Fig. 1).
Fig. 1.
Prevalence of tobacco or other substance use among the medical students of Bangladesh (N = 1129)
The students most commonly used tobacco products (54.5%) followed by non-prescription use of sedatives (26%) and cough syrup (18.8%) (Fig. 2).
Fig. 2.
Tobacco or other commonly used substances among the users (n = 154)
Most of the students were introduced to TOSU by their friends (by non-medical friends: 44.8%; by medical friends: 31.8%). Nearly two-thirds of the students who used TOSU spent less than 1000 BDT, and for most of them, the source of this money was from their families (48.1%). One-third of the students have never been approached by anyone for TOSU cessation, and among the rest, friends (26.6%) and family members (17.5%) commonly approached them for cessation of use (Table 2).
Table 2.
Tobacco or other substance use related variables among the users (n = 154)
| Variables | N (%) | |
|---|---|---|
| Introducer to tobacco or substance | ||
| Non-medical Friends | 69 | (44.8%) |
| Medical Friends | 49 | (31.8%) |
| Family Members | 18 | (11.7%) |
| Medical Seniors | 13 | (8.4%) |
| Non-medical Seniors | 4 | (2.6%) |
| Drug Pusher | 1 | (0.6%) |
| Monthly expense behind tobacco or substance use | ||
| < 500 BDT | 66 | (42.9%) |
| 500–1000 BDT | 29 | (18.8%) |
| 1000–2000 BDT | 26 | (16.9%) |
| > 2000 BDT | 33 | (21.4%) |
| Source of Fund | ||
| Family | 74 | (48.1%) |
| Tuitions | 61 | (39.6%) |
| Friends | 36 | (23.4%) |
| Side business | 9 | (5.8%) |
| Medical Seniors | 9 | (5.8%) |
| Drug selling | 5 | (3.2%) |
| Criminal work | 3 | (1.9%) |
| Approached by anyone for tobacco or other substance use cessation | ||
| Hasn’t been approached by anyone | 55 | (35.7%) |
| By Friends | 41 | (26.6%) |
| By Family | 27 | (17.5%) |
| By Spouse/Partner | 18 | (11.7%) |
| By Seniors | 9 | (5.8%) |
| By Teachers | 3 | (1.9%) |
| By Institution | 1 | (0.6%) |
BDT Bangladeshi taka (1 USD = 120 BDT)
Reasons behind tobacco or other substance use and non-use
Most of the students first started using tobacco or other substances out of curiosity (70.8%); however, they continue using tobacco or other substances mostly due to enjoyment (36.4%) (Fig. 3).
Fig. 3.
The reasons behind first use and continuing use among the tobacco and/or other substance users (n = 154)
Among the students who never used or have stopped using tobacco or other substances, religious ethics (68.3%) and moral ethics (63.8%) were the two most cited reasons, followed by family reasons (39.8%) (Fig. 4).
Fig. 4.
The reasons behind not using tobacco or other substances among non-users (n = 975)
Availability of tobacco or other substances
Cough syrup (64.2%), tobacco (56.3%), and sedatives (44.5%) were the most easily available among the medical students. On the other hand, amphetamine (73.3%), opiates and opioids (71%), and cannabis (65.6%) were the most difficult obtain (Fig. 5).
Fig. 5.
Availability of tobacco or other substance (N = 1129)
Factors associated with tobacco or other substance use
The use of tobacco or other substance use increased significantly with increasing age (mean age of the users: 23.6 years vs. mean age of the non-users: 22.1 years; p < 0.001) and academic year (1st year: 4.9%, 2nd year: 17.6%, 3rd year: 9.3%, 4th year: 10.4%, 5th year: 21.8%. Internship: 26%; p < 0.001). Nearly one-fifth of the male students used tobacco or other substances (23.4%), which is significantly (p < 0.001) higher than female students (4.7%). The students studying in non-government medical colleges (18.1%) had a significantly higher (p = 0.005) prevalence of TOSU compared to government (11.9%) medical colleges. The students staying in an off campus housing without family had a significantly higher prevalence of TOSU (26.3%, p = 0.001), followed by those residing in medical college hostels (13.8%). The students whose parents were divorced/separated/widowed had a significantly higher (25.3%) prevalence of TOSU compared to the students whose parents were still married (12.8%). The students who had TOSU in the family were significantly (p < 0.001) more prone to TOSU (28.9%) compared to those without (8%). Tobacco or other substance use was significantly higher in medical student who were admitted into medical college against their will (27.8% vs. 11.1%, p < 0.001) (Table 3).
Table 3.
Bivariate relationship between tobacco or substance use and baseline characteristics of the study population (N = 1129)
| Variables | Tobacco or other substance use | p-value | |||
|---|---|---|---|---|---|
| No (n = 975, 86.36%) | Yes (n = 154, 13.64%) | ||||
| Age (in years), mean (SD) | 22.1 | (1.9) | 23.6 | (2.1) | < 0.001 |
| Gender | < 0.001 | ||||
| Male | 413 | (76.6%) | 126 | (23.4%) | |
| Female | 562 | (95.3%) | 28 | (4.7%) | |
| Location of medical college (division wise) | 0.076 | ||||
| Dhaka | 155 | (80.7%) | 37 | (19.3%) | |
| Chattogram | 129 | (89.0%) | 16 | (11.0%) | |
| Rajshahi | 90 | (89.1%) | 11 | (10.9%) | |
| Khulna | 173 | (89.2%) | 21 | (10.8%) | |
| Barisal | 157 | (90.2%) | 17 | (9.8%) | |
| Sylhet | 91 | (86.7%) | 14 | (13.3%) | |
| Mymensingh | 90 | (82.6%) | 19 | (17.4%) | |
| Rangpur | 90 | (82.6%) | 19 | (17.4%) | |
| Type of Medical | 0.005 | ||||
| Government | 714 | (88.1%) | 96 | (11.9%) | |
| Non-government | 261 | (81.9%) | 58 | (18.1%) | |
| Academic year | < 0.001 | ||||
| 1st | 196 | (95.1%) | 10 | (4.9%) | |
| 2nd | 89 | (82.4%) | 19 | (17.6%) | |
| 3rd | 245 | (90.7%) | 25 | (9.3%) | |
| 4th | 190 | (89.6%) | 22 | (10.4%) | |
| 5th | 161 | (78.2%) | 45 | (21.8%) | |
| Internship | 94 | (74.0%) | 33 | (26.0%) | |
| Current residence | 0.001 | ||||
| House with family | 228 | (90.8%) | 23 | (9.2%) | |
| Off-campus housing without family | 59 | (73.8%) | 21 | (26.3%) | |
| Medical college hostel | 688 | (86.2%) | 110 | (13.8%) | |
| Region of Residence | 0.003 | ||||
| Urban | 562 | (85.9%) | 92 | (14.1%) | |
| Semi-urban | 189 | (81.5%) | 43 | (18.5%) | |
| Rural | 224 | (92.2%) | 19 | (7.8%) | |
| Monthly Family Income (in BDT) | 0.16 | ||||
| <10,000 | 97 | (91.5%) | 9 | (8.5%) | |
| 10,000–30,000 | 307 | (86.7%) | 47 | (13.3%) | |
| 30,000–50,000 | 313 | (87.2%) | 46 | (12.8%) | |
| >50,000 | 258 | (83.2%) | 52 | (16.8%) | |
| Marital status | 0.22 | ||||
| Unmarried | 907 | (86.7%) | 139 | (13.3%) | |
| Ever Married | 68 | (81.9%) | 15 | (18.1%) | |
| Parents’ companionship status | 0.002 | ||||
| Married | 919 | (87.2%) | 135 | (12.8%) | |
| Divorced/separated/widowed | 56 | (74.7%) | 19 | (25.3%) | |
| Parents’ highest educational level | 0.35 | ||||
| No formal education | 19 | (86.4%) | 3 | (13.6%) | |
| Primary school | 127 | (88.8%) | 16 | (11.2%) | |
| Secondary school | 160 | (88.4%) | 21 | (11.6%) | |
| Higher secondary | 450 | (87.0%) | 67 | (13.0%) | |
| Graduation | 201 | (82.7%) | 42 | (17.3%) | |
| Post-graduation | 18 | (78.3%) | 5 | (21.7%) | |
| Tobacco or other Substance Use in first degree relative | < 0.001 | ||||
| No | 758 | (92.0%) | 66 | (8.0%) | |
| Yes | 217 | (71.1%) | 88 | (28.9%) | |
| Willingly admitted to medical college | < 0.001 | ||||
| No | 122 | (72.2%) | 47 | (27.8%) | |
| Yes | 853 | (88.9%) | 107 | (11.1%) | |
Data are presented as n (%) unless otherwise mentioned
BDT Bangladeshi taka (1 USD = 120 BDT), SD Standard deviation
Multiple logistic regression revealed that with each year of increase in age, the likelihood of using tobacco or other substances increased by 41% (AOR: 1.41, 95%CI: [1.26, 1.59], p < 0.001). Male students were at 6.88 times higher odds of using tobacco or other substances than female students (AOR: 6.88, 95% CI: [4.15,11.40], p < 0.001). Students who were living at an off-campus housing without family (AOR: 2.25, 95% CI: [1.02, 4.94], p = 0.043) and a medical college hostel (AOR: 2.1, 95% CI: [1.20, 3.67], p = 0.009) were almost two times more at risk of using tobacco or other substances than those who were living with their families. Parental divorce or separation or widowhood increased the chance of using tobacco or other substances 2.81 times compared to those whose parents were still married (AOR: 2.81, 95% CI: [1.42, 5.53], p = 0.003). Finally, students who had TOSU in the family (AOR: 3.97, 95% CI: [2.64, 5.98], p < 0.001) and students who were admitted to medical college against their will (AOR:3.61, 95%CI: [2.20, 5.90], p < 0.001) were at 3.97- and 3.61-times higher odds of using tobacco or other substances, respectively (Table 4).
Table 4.
Multiple logistic regression for factors associated with tobacco or substance use among medical students (N = 1129)
| Variables | AOR | 95% CI | p-value |
|---|---|---|---|
| Age | 1.41 | [1.26, 1.59] | < 0.001 |
| Gender | |||
| Female | Reference | ||
| Male | 6.88 | [4.15,11.40] | < 0.001 |
| Division | |||
| Dhaka | Reference | ||
| Chattogram | 0.62 | [0.29, 1.32] | 0.213 |
| Rajshahi | 0.54 | [0.22, 1.30] | 0.167 |
| Khulna | 0.51 | [0.26, 1.01] | 0.054 |
| Barisal | 1.49 | [0.68, 3.24] | 0.317 |
| Sylhet | 0.43 | [0.20, 0.92] | 0.029 |
| Mymensingh | 2.33 | [1.07, 5.06] | 0.032 |
| Rangpur | 0.52 | [0.25, 1.08] | 0.081 |
| Type of Medical College | |||
| Government | Reference | ||
| Non-government | 1.79 | [1.13, 2.83] | 0.013 |
| Current Residence | |||
| House with family | Reference | ||
| Off campus housing without family | 2.25 | [1.02, 4.94] | 0.043 |
| Medical College Hostel | 2.10 | [1.20, 3.67] | 0.009 |
| Region of Residence | |||
| Urban | Reference | ||
| Semi-urban | 1.07 | [0.66, 1.74] | 0.792 |
| Rural | 0.35 | [0.19, 0.63] | 0.001 |
| Parents’ companionship status | |||
| Married | Reference | ||
| Divorced/Separated/Widowed | 2.81 | [1.42, 5.53] | 0.003 |
| Tobacco or other Substance Use in first degree relative | |||
| No | Reference | ||
| Yes | 3.97 | [2.64, 5.98] | < 0.001 |
| Willingly admitted to medical college or not | |||
| Yes | Reference | ||
| No | 3.61 | [2.20, 5.90] | < 0.001 |
AOR Adjusted odds ratio, CI Confidence interval
Table 5 further elucidates gender-specific predictors of tobacco or other substance use among medical students. For both male and female students, increasing age significantly raises the odds of substance use, with adjusted odds ratios (AOR) of 1.373 (95% CI: 1.208–1.560) for males and 1.441 (95% CI: 1.143–1.817) for females, corroborating the age effect noted in the combined analysis of Table 4. Parental companionship disruption (divorced/separated/widowed) emerged as a significant risk factor for female students (AOR 4.335; 95% CI: 1.292–14.55), although its effect did not reach significance in males, highlighting potential gender differences in familial influences. Family history of substance use strongly predicted use for both genders, with a notably higher risk among females (AOR 5.289 vs. 3.823 in males), consistent with Table 4’s demonstrated importance of familial substance use. Similarly, unwilling admission to medical college was associated with substantially higher odds of substance use in both males (AOR 2.891) and females (AOR 5.445), with females again showing a stronger effect.
Table 5.
Multiple logistic regression for the predictors of tobacco or other substance use in terms of gender
| Variables | Male Students | Female Students | ||
|---|---|---|---|---|
| AOR | 95%CI | AOR | 95%CI | |
| Age (in years) | 1.373 | [1.208,1.560] | 1.441 | [1.143,1.817] |
| Parents’ companionship status | ||||
| Married | Reference | |||
| Divorced/Separated/Widowed | 4.335 | [1.292,14.55] | ||
| Tobacco or other Substance Use in first degree relative | ||||
| No | Reference | Reference | ||
| Yes | 3.823 | [2.397,6.097] | 5.289 | [2.280,12.27] |
| Willingly admitted to medical college or not | ||||
| Yes | Reference | Reference | ||
| No | 2.891 | [1.593,5.248] | 5.445 | [2.349,12.62] |
| Location of medical college (division wise) | ||||
| Dhaka | Reference | |||
| Chattogram | 0.698 | [0.296,1.645] | ||
| Rajshahi | 0.892 | [0.344,2.313] | ||
| Khulna | 0.52 | [0.247,1.097] | ||
| Barisal | 1.237 | [0.486,3.147] | ||
| Sylhet | 0.533 | [0.226,1.256] | ||
| Mymensingh | 2.647 | [1.081,6.482] | ||
| Rangpur | 0.72 | [0.326,1.592] | ||
| Current Residence | ||||
| House with family | Reference | [1,1] | ||
| Off-campus housing without family | 2.973 | [1.248,7.082] | ||
| Medical College Hostel | 2.52 | [1.305,4.866] | ||
| Region of Residence | ||||
| Rural | Reference | |||
| Urban | 3.203 | [1.667,6.153] | ||
| Semi-urban | 3.792 | [1.842,7.805] | ||
AOR Adjusted odds ratio, CI Confidence interval
Discussion
This study investigates the prevalence of tobacco and other substance use (TOSU) among medical students in Bangladesh and explores the factors associated with this behavior. Additionally, it examines the reasons behind the use or non-use of tobacco and other substances (TOS), identifies the first introducer to TOS, sources of funding for TOSU, availability of TOS, and whether users have been approached for cessation.
The overall prevalence of TOSU in Bangladeshi medical students is 13.64%, which is quite similar to the findings of Arora et al. (20.43%) in India [35]. Interestingly, the prevalence in our study is lower than that of Bangladesh’s non-medical university students, according to the studies conducted by Roby et al. (33.5%), and Sujan et al. (54.9%) [34, 36]. This finding is consistent with the study done by Chatterjee et al. in Kolkata where smoking among medical students (14.9%) is much lower than that among non-medical students (40.7%) [37]. This may be associated with the awareness of the health issues related to TOSU in medical students. From our research data, we can see that tobacco is most commonly used among medical students in India and Egypt [38]. The second and third most commonly consumed other substance was non-prescription use of cough syrup and sedatives, respectively, whereas the second and third most commonly consumed substances by Indian medical students were alcohol and cannabis [35]. But in Nepal, the picture is quite different; here, alcohol (59.6%) is used the most [39] like in many developed countries [40, 41].
There is a male predominance in the user group, and they were 6.88 times more likely to use tobacco or other substances compared to their female counterparts. These findings are consistent with the results from India, Nepal, and Egypt [35, 38, 39, 42]. The observed gender differences likely reflect common socio-cultural factors across the region, including patriarchal social structures that restrict women’s social mobility and access to tobacco or other substances. Stigma and stronger societal disapproval also limit women’s disclosure resulting in consistently lower reported prevalence among females [43]. Furthermore, the stronger association of disrupted parental companionship, TOSU in first-degree relatives, and unwilling medical admission with substance use among female students, evident in our study, supports studies indicating that females may be more vulnerable to psychosocial stressors as triggers for substance use [44].
The students studying in non-government medical colleges had a significantly higher likelihood of TOSU (AOR: 1.79, 95% CI: [1.13, 2.83], p = 0.013) compared to government medical colleges. This finding can be explained by the association between financial burden and depression, which may predispose to TOSU [45]. Only 4.9% of the first-year students used tobacco or other substances, while 21.8% and 26% of final-year students and intern doctors used them accordingly. Similar results were found in the study of Arora et al. and Kushwaha et al., which suggest that the increasing curve is mostly due to increasing academic pressure and workloads [35, 39].
Another interesting outcome of our study was that the companionship status of the parents also played a significant role. Parental divorce or separation or widowhood increased the chance of using tobacco or other substances 2.81 times compared to those whose parents were still married (AOR: 2.81, 95% CI: [1.42, 5.53], p = 0.003). Students with a first-degree relative who had a history of tobacco or other substance use had 3.97 times higher odds of TOSU compared to those without such a family history. A similar association was found in a study by Khan et al. [46]. Individuals who grow up in a family where there is a TOSU are at significantly higher risk of developing SUDs due to genetic and environmental factors [47–49]. The students who are unwilling to be admitted to the medical college use tobacco or other substances 3.61 times more than the willingly admitted students. This may be due to the increasing level of depression, frustration, and lack of interest in medical science. Also, heavy academic pressure may play a role. The students who are living without parents are found to have a significantly higher prevalence of TOSU, which is a matter of concern. Similar findings have been shown in studies in different medical schools in India [50]. Since a large number of students in medical schools in Bangladesh are living in hostels away from their families, these places might require targeted intervention and alternative entertainment with direct monitoring to control the use of substances and tobacco.
Looking closely at the users, most of the participants first used tobacco or other substances out of curiosity (70.8%) and then continued taking them for enjoyment (36.4%). They are influenced mainly by non-medical seniors (44.8%) and medical friends (31.8%). These findings are quite similar to the findings of Seid et al. [49]. Another important piece of information is that most users (35.7%) are not even approached by their family and friends to counsel them to change this behavior. Family and friends opposed them about 17.5% and 26.6% accordingly. There should be a significant role the institutions to prevent TOSU, but in our country, it is way too little to be mentioned (0.6%).
Regarding availability, most of the students (64.2%) think that cough syrups are the easiest other substance to get; as it is an over-the-counter (OTC) drug, it can be managed from any drug store, even without a prescription [51]. Over half the students (56.3%) consider tobacco to be easily available since they are present in almost all the shops and stalls in the country. Amphetamine is the hardest to get (73.3%), according to the non-users of TOS. In investigating what motivates individuals who do not use TOS to refrain from taking them, most of the students do so due to their religious ethics (68.3%), moral ethics (63.8%), and family reasons (39.8%). Future awareness programs may consider incorporating themes related to religion and moral values, as these were among the most frequently cited reasons for abstaining from substance use. Also, family can play a great role. These findings are consistent with a study in Ethiopia where the majority of the students refrained from TOSU due to religious bounding (39%), family supervision (36.8%), and other causes (8.8%) [49].
The notably low rate (0.6%) of institutional intervention for student substance use highlights a significant gap in campus-based prevention in Bangladesh. Studies demonstrate that proactive university-led programs like educational campaigns, counseling, and screening effectively reduce substance use among students, emphasizing the need for stronger institutional engagement and policy action [52].
Although this study is one of the pioneering studies to shed light on the current scenario of tobacco or other substance use among the medical students of Bangladesh, it has some limitations. Due to the study’s cross-sectional design, we can’t imply causality for our demonstrated associations. However, we attempted to adjust for the confounders by presenting an adjusted odds ratio from a multiple logistic regression model. Also, sampling bias may have been introduced due to the use of a convenience sampling method for participant selection. To mitigate that, we sampled 1129 participants spanning sixteen medical colleges from all eight divisions of Bangladesh to make the sampling frame more representative and the findings more generalizable. The chosen operational definition for ‘tobacco or other substance use’ may influence the estimated prevalence of tobacco and other substance use. For instance, broader definitions tend to yield higher prevalence estimates, while narrower criteria may underreport actual use. Using a definition that has been applied in comparable settings [34] ensures both methodological consistency and comparability of findings within the local context. There was no direct measurement of mental health variables, such as depression or anxiety, which may mediate the association between independent variables (i.e., unwilling admission to medical college) and TOSU. Due to potential stigma and social desirability, underreporting of substance use is likely. Additionally, the absence of standardized instruments to assess the severity and patterns of use limits the depth of behavioral characterization. Nevertheless, the survey’s content validity was established through the evaluation of two medical college teachers who conducted an independent review. The reliability and internal consistency of the questionnaire were determined using Cronbach’s alpha coefficient (0.79). Future longitudinal studies with in-depth qualitative explorations of all possible covariates are needed to understand the extent of the problem.
Conclusion
The current study revealed that tobacco or other substance use is prevalent in nearly one in seven medical students in Bangladesh. This finding highlights the need for targeted interventions, particularly directed towards at-risk young individuals. To accomplish this, innovative, motivational programs and counseling approaches should be developed, and the university should enforce strict regulations to control tobacco and other substance use on campus, along with accessible cessation services. The researcher conducting this investigation suggests implementing comprehensive and strategic awareness programs based on religious and moral values to safeguard young people. Additionally, strengthening family and peer support systems through engagement programs can counteract peer pressure and familial risk exposure.
Supplementary Information
Acknowledgements
We would like to thank Mr. Jahidul Islam from Shaheed M. Monsur Ali Medical College, Sirajganj, Bangladesh for extending his help in the data collection.
Authors’ contributions
Study conception and design: MAI, SR, ABS; data collection: MD, AnS, RAC, NJI, SRS & MMI; analysis and interpretation of results: MAI, RY and NN; draft manuscript preparation: MAI, SR, GDP, AkS, MTH & ABS. All authors reviewed the results and approved the final version of the manuscript.
Funding
No fund was received for conducting this study.
Data availability
The dataset used and/or analysed during the current study are available from the corresponding author Dr. Mohammad Azmain Iktidar on reasonable request, at sazmain@gmail.com.
Declarations
Ethics approval and consent to participate
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board (Ethics Committee) of North South University (Approval number: 2023/OR-NSUIIRB/0403). Before interviewing each subject, the participants were clearly briefed about the aims and procedures of the research. The participants provided informed consent via electronic form to participate in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Azaz Bin Sharif and M. Tasdik Hasan are joint senior authors.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The dataset used and/or analysed during the current study are available from the corresponding author Dr. Mohammad Azmain Iktidar on reasonable request, at sazmain@gmail.com.