Smoking Behavior, Exposure to Second-Hand Smoke, and Attitudes Among Bulgarian and Foreign Medical Students

<b>Background:</b> Cardiovascular morbidity and mortality are alarmingly high in Bulgaria, partly due to behavioral risk factors such as smoking. <b>Purpose:</b> This study aimed to assess and compare smoking habits, second-hand smoke exposure, and attitudes of Bulgarian and foreign medical students to better understand smoking behavior in this population. <b>Methods:</b> A cross-sectional survey was conducted among 1063 medical students at the Medical University of Plovdiv (60.8% women; 53% Bulgarian). <b>Results:</b> More Bulgarian students were active smokers and ever-smokers than foreign students (24.7% vs. 14% and 29.3% vs. 18.8%, <i>p</i> < 0.001). Bulgarian women smoked nearly as much as Bulgarian men (24.1% vs. 25.6% for active smokers, <i>p</i> > 0.05), whereas foreign women smoked less than foreign men (15.7% vs. 23.7%, <i>p</i> = 0.034). Women more often replaced classic cigarettes with tobacco heating systems (THSs) than men (40.7% vs. 25.3%, <i>p</i> = 0.020). Nearly 85% of the respondents started smoking by the age of 19. Exposure to second-hand smoke among friends, among colleagues, and in the family was associated with a higher risk of being an ever-smoker (ORs ~8.9; 3.4 and 3.7, respectively). About 20% of students were unsure or disagreed that smoking fewer cigarettes, THSs, or e-cigarettes posed health risks. The majority (61.3%) of active smokers acknowledged negative health effects. <b>Conclusions:</b> These findings highlight a concerning smoking prevalence among Bulgarian medical students and emphasize the need to strengthen medical education and health policies with updated tobacco risk information and targeted prevention programs to reduce smoking and improve future physicians' cessation counseling skills. Smoking likely contributes significantly to Bulgaria's high cardiovascular morbidity.