Tobacco use causes preventable morbidity and mortality.1^–4 A number of studies have found that health professionals can substantially increase smoking cessation rates among their patients by brief or simple counselling.5^–7 Intervention by a health professional to encourage smoking cessation is cost-effective compared to other cessation therapies: the cost of nicotine replacement therapy alone has been estimated to cost about twice as much as physician counselling per year of life saved,8 9 while intensive cessation programmes can cost over four times as much as simple counselling.10 The costs of any successful cessation strategy are small compared to the economic burden of medical treatment and lost productivity associated with smoking-related morbidity.11

Although assisting tobacco users to quit and achieving long-term tobacco cessation can be difficult and costly, health professionals should advise their patients who use tobacco to quit. Previous studies have shown that patients who smoke are receptive to cessation counselling from a health professional and, for the most part, practising health professionals are willing to provide such advice.6 12 However, several barriers have been identified that reduce the effectiveness or willingness of health professionals to provide patient counselling, including time constraints during the consultation,13 health professionals’ lack of confidence in their ability to provide effective advice14 and the smoking status of the health professional.15 Formal training in tobacco cessation counselling and feedback from patients who receive the advice have been shown to improve the quality of counselling health professionals can provide.16 17

Despite the body of knowledge on health professionals’ role in tobacco cessation, few recent studies have collected information on tobacco use and training to provide cessation counselling among health professional students. A review published in 2007 found 66 articles published between 1976 and 2006 that focused on smoking behaviour among medical students.18 A key weakness in many surveys of tobacco use has been the lack of a standard definition for smoking status, despite a World Health Organization publication with clear guidelines on establishing many types of tobacco use prevalence.19 Furthermore, previous studies also used different sampling methods, questionnaires and data collection procedures, and very few are from low or middle-income countries.20^–22 The World Health Organization, US Centers for Disease Control and Prevention and the Canadian Public Health Association have attempted to overcome these limitations by developing and implementing the Global Health Professions Student Survey (GHPSS).23

METHODS

The GHPSS is part of the Global Tobacco Surveillance System, which collects data through four surveys: the Global Youth Tobacco Survey, the Global School Personnel Survey, the Global Adult Tobacco Survey and GHPSS. GHPSS is a school-based survey of third-year students pursuing advanced degrees in dentistry, medicine, pharmacy, and nursing. GHPSS uses standardised sampling, data collection and data processing procedures.23 Research coordinators from each country were identified by WHO and attended a training workshop to ensure that all GHPSS follow the standard protocols.

Sampling

The data reported in this study come from GHPSS conducted in 31 countries. GHPSS can be designed to be nationally representative of third-year students in the four target disciplines or representative of a subnational sampling frame such as a city or geographical region. Most countries conducted nationally representative surveys; however Brazil (Rio de Janeiro), Iraq (Kurdistan Region) and Bosnia and Herzegovina (Federation of Bosnia and Herzegovina and Republic of Srpska) conducted subnational surveys. For the remainder of this report, national and subnational sampling frames will be referred to as sites. Between 2005 and 2007, the GHPSS was conducted among third-year students in dental schools (18 sites in 17 countries), medical schools (29 sites in 28 countries), nursing schools (18 sites in 18 countries) and pharmacy schools (15 sites in 14 countries).

Countries conducting the GHPSS chose between two sampling options depending on the number of schools offering advanced degrees in the four target disciplines and the number of third-year students enrolled in these programmes. Countries with few schools and students conducted a census of schools and students. In countries with many schools, a sample of schools was drawn with probability proportional to enrolment of third-year students and the survey was conducted among a census of students in the selected schools. The GHPSS was conducted as a census of schools and students in most locations and disciplines. The exceptions, where a sample of schools was drawn and a census of students completed the survey, included the following countries with the discipline(s) noted in parentheses: Armenia (nursing), Bangladesh (medical), Bolivia (medical and nursing), Czech Republic (nursing), the Federation of Bosnia and Herzegovina (nursing), India (dental and medical), Indonesia (medical), Nepal (medical), Peru (medical and nursing), Philippines (pharmacy), Republic of Serbia (nursing) and Thailand (nursing).

Data collection

GHPSS follows an anonymous, self-administered format for data collection. All countries collected data using a questionnaire that covers demographics, prevalence of cigarette smoking and use of other tobacco products, exposure to secondhand smoke (SHS), desire to quit smoking and training received to provide patient counselling on cessation techniques. Research coordinators from each country adapted the GHPSS core questionnaire by adding questions about local forms of tobacco, translating it into local languages, back-translating to English to check for accuracy and compatibility with the core questionnaire and removing questions that are not relevant to the country. The GHPSS was conducted in schools during regular lectures and class sessions. Students recorded answers to the GHPSS questionnaire on a scannable answer sheet. Completed answer sheets were sent to the Centers for Disease Control and Prevention (CDC) for processing.

Data processing

After the answer sheets were scanned, all GHPSS data were processed by CDC, which is the coordinating centre for the Global Tobacco Surveillance System (GTSS). English translations of the adapted country questionnaires were checked for consistency with the core GHPSS questionnaires. A standard set of variables from core questions were created to facilitate cross-country comparisons such as those included in this article. SUDAAN, software developed for the analysis of multistage survey data, is used for analysis of the dataset, to calculate prevalence estimates and 95% confidence intervals.24

Although 80 total GHPSS have been conducted in dental, medical, nursing and pharmacy schools, it was not possible to report all indicators for each country. Some countries did not ask all the GHPSS core questions or altered the core question in a way that was incompatible with the standard indicator definitions. In these instances, cells are labelled with an “NA” (not asked) in the results tables. Some countries had few students eligible to participate in the GHPSS or very low prevalence of tobacco use. In some cases, estimates were not possible to obtain for indicators because of the small number of respondents. Throughout the presentation of the results, indicators with fewer than 10 eligible respondents are indicated with an asterisk in the results tables. Statistical differences are noted at the p<0.05 level.

RESULTS

Table 1 lists the sites that completed the GHPSS by discipline, year and country and includes response rates (school, student and overall) and number of completed interviews. The school response rate is calculated as the number of participating schools divided by the number of targeted schools. The student response rate is calculated as the number of participating students divided by the number of students enrolled in the class. The overall response rate is calculated as the product of the school response rate and the student response rate. For countries conducting the dental GHPSS, the school response rate was 100% in 15 of the 18 sites, the student response rate ranged from 62.4% to 100% and the overall response rate ranged from 51.7% to 100%; for the medical GHPSS, the school response rate was 100% in 24 of the 29 sites, the student response rate ranged from 62.6% to 100% and the overall response rate ranged from 62.5% to 98.5%; for the nursing GHPSS, the school response rate was 100% in 13 of the 18 sites and the student and overall response rate ranged from 68.2% to 99.3%; for the pharmacy GHPSS, the school response rate was 100% in 14 of the 15 sites and the student and overall response rate ranged from 71.8% to 100% (table 1).

Student characteristics

In almost all sites, dental programmes are of five years’ duration, medical programmes are six years, nursing programmes are four years and pharmacy programmes are five years. Over 60% of the students were females in 12 of the 18 dental sites compared to three sites with over 60% male students. Of the 29 medical sites, over 60% of the students were females in 12 sites compared to seven sites with over 60% male students. Over 70% of the students were females in 17 of the 18 nursing sites. Over 60% of the students were females in 14 of the 15 pharmacy sites. In 68 of the 80 sites, over 70% of the students were aged 20–24 years.

Prevalence

Current cigarette smoking

In all four disciplines, over 20% of the students currently smoked cigarettes in over half of the sites, including 13 of the 18 dental sites (table 2). Over 40% of the students currently smoked cigarettes in Albania (medical, nursing and pharmacy), Bolivia (medical), Federation of Bosnia and Herzegovina (dental and medical) and Russian Federation (medical and pharmacy); compared to less than 5% in Thailand (dental), Ghana (medical, nursing and pharmacy), Sri Lanka (medical and nursing), Uganda (medical and nursing), Republic of Korea (nursing), Myanmar (pharmacy) and Thailand (nursing and pharmacy). Male students were significantly more likely than female students to currently smoke cigarettes in 51 of the 77 sites for which a sex comparison could be performed, including 21 of 29 medical and 10 of 13 pharmacy sites.

Current use of tobacco products other than cigarettes

The percentage of students who reported currently using tobacco products other than manufactured cigarettes was greater than 20% for students in eight of the 80 sites compared to less than 5% in 33 of the 80 sites (table 2). Current other tobacco use was greater than 20% in all four disciplines in Lebanon and among dental, medical and pharmacy students in Syria. Male students had significantly higher prevalence of other tobacco use than females in 44 of the 77 sites; female students were significantly higher than male students in three sites; and there were no significant differences in the other 30 sites where sex comparisons could be performed.

Cigarette smoking compared to other tobacco use

The prevalence of current cigarette smoking was significantly higher than other tobacco use in 51 of the 80 sites, there was no difference in 23 sites, and other tobacco use was significantly higher than cigarette smoking in Syria (dental, medical, and pharmacy), Sri Lanka (nursing) and Lebanon (nursing and pharmacy).

Health professional roles and training

Over 80% of the students thought health professionals have a role in giving advice about smoking cessation to patients in 61 of the 76 sites; compared to less than 60% of the students in all four disciplines in Slovakia and pharmacy students in Iraq, Kurdistan (table 3). Over 80% of the students thought health professionals should get specific training on cessation techniques in 64 of the 80 sites; compared to less than 80% in the other 16 sites with the lowest levels in Czech Republic (61.0% and 66.5% in medical and nursing, respectively) and Iraq, Kurdistan (65.6% and 65.9% in nursing and pharmacy, respectively). Less than 40% of the students reported having ever received some kind of formal training in their professional school on cessation approaches to use with their patients in 72 of the 80 sites (ranging from 41.0% to 60.0% in the other eight sites). Over half of the students had received formal training in only three sites (Lithuania, dental; Brazil, Rio de Janeiro, nursing; and Iraq, Kurdistan, nursing). In 32 of the 80 sites, less than 20% of the students had received the training.

DISCUSSION

The tobacco control community should target cigarette smoking and use of other forms of tobacco among health professional students because this behaviour endangers their health and will reduce their ability to deliver effective anti-tobacco counselling when they start seeing patients.22 25 Findings from the GHPSS show that over 20% of students currently smoked cigarettes in 47 of 80 sites surveyed. Use of other forms of tobacco was less pronounced; but over 10% of students currently used other tobacco products in 29 of 80 sites. Cigarette smoking was significantly higher than other tobacco use in 52 of the 80 sites. Health professional educational institutions should help their students quit using tobacco by providing encouragement and information to students who are considering quitting and providing assistance to students who are motivated to quit.

Health professionals should be trained to provide effective, accurate and accessible advice to patients on all aspects of health.26 GHPSS data show that most health professional students recognise that they are role models in society, that they should receive training on counselling and treating patients to quit using tobacco, but that few have received formal training in smoking cessation techniques. In 61 of 76 sites, over 80% of the students thought health professionals have a role in advising patients about quitting the use of tobacco; in 64 of 80 sites, over 80% of the students thought health professional students should get specific training in cessation techniques; but in 73 of 80 sites less than 40% of the students reported they have received such training. Further, in 32 of the 80 sites, less than 20% of the students had received the training. Professional training should include courses detailing the harmful health effects of tobacco use and exposure to secondhand smoke, and training in counselling on tobacco cessation techniques.7 27 Curricula in each health professional field should include a distinct course or supplements to existing courses specifically relevant to the discipline on tobacco issues. If administrators are resistant to making changes in the core curricula, schools should be encouraged to incorporate tobacco-related modules within existing courses.

The GHPSS surveyed third-year students, so it is possible that students receive training on patient cessation techniques during the latter years of their programmes. To address this possibility, the GHPSS research coordinators from each country raised this question to school administrators or others with knowledge of curricula in the four target disciplines after the completion of the survey. They found that, in 25 of the 31 countries, there was no formal training at any time. Of the countries with training, the type of training included: problem-based learning (Argentina, but not in all schools), part of generic counselling curricula (Thailand), or curricula as part of community medicine or public health courses (Bosnia and Herzegovina, Iraq, Myanmar and Slovakia) (personal correspondence between authors and GHPSS research coordinators). This study did not make an effort to evaluate the adequacy of cessation training in the six countries reporting this type of instruction.

The majority of evaluation research conducted on tobacco-related curricula has been conducted in high-income countries. Relatively little information about the content of pedagogic materials and the process of teaching health professional students in low-income and middle-income countries about smoking prevention and cessation is accessible to the international tobacco control community. Peer-reviewed studies in international settings about educational materials and techniques to improve the capacity of health professionals to treat and counsel patients on cessation are necessary to focus limited resources on effective and efficient strategies to reduce the prevalence of tobacco use. Efforts should be made to assess and share the content of tobacco control components within the formal training curricula and continuing education courses for health professional students. Further research should be carried out to assess the impact of existing tobacco control-related materials and training provided in health professional faculties and schools in a variety of cultural and economic environments. The products from such research could form a compendium of “best practices” of patient counselling for training health professionals relevant to countries with a broad spectrum of health resources and infrastructures.

Limitations

The findings in this report are subject to at least four limitations. First, because GHPSS respondents are third-year health profession students who have not had substantial interaction with patients, survey results should not be extrapolated to account for practising health professionals in any of the countries. Second, the GHPSS did not survey students in all health professions whose members could provide patients with cessation counselling (for example, chiropractors, traditional healers, psychologists and counsellors). Third, because adult smoking rates across countries are not collected using a standardised and consistent methodology, comparison of the prevalence in this report with the prevalence in the general adult populations is not possible. Finally, a reliability study of the GHPSS core questionnaire was conducted in the United States in 2005 but not internationally.28 The study used two methodologies: the Question Appraisal System (QAS) and cognitive testing interviews. Results from the reliability were used in producing the final GHPSS core questionnaire.

CONCLUSION

Health professional schools, public health organisations and education officials should discourage tobacco use among health professionals and work together to design and implement programmes that train all health professionals in effective cessation counselling techniques. GHPSS has shown significant unmet need for cessation assistance among students as well as gaps in professional training to provide similar effective assistance to their future patients. GHPSS is helpful in evaluating the behaviour and attitudes regarding tobacco among health professional students, but additional research is necessary to improve the evidence base for effective tobacco-related curricula, especially materials that are appropriate for a range of cultural and economic settings. If the goal of the tobacco control community is to reduce substantially the use of tobacco products, then resources should be invested in improving the quality of education of health professionals with respect to tobacco control.