Cross-Sectional Survey: Prevalence, environmental exposure of tobacco use among Health Professional Students Rajalakshmi* Ramachandhra** Jeeva*** Abstract

Background: Tobacco is the worlds major preventable killer. The universal world is in a state of tobacco epidemic, with larger population of tobacco users, emerging day by day. According to WHO, tobacco is the second major cause of death in the world. It is currently responsible for the death of one in ten adults worldwide. It has been predictable that the death tolls will reach, to 10 million by 2020, out of which 70 per cent will occur in the developing countries. The health professionals take part in considerable roles in tobacco control, their attitude and practice toward tobacco use can influence the health of the society. The present study aimed to assess Prevalence, exposure to environmental tobacco use, Attitudes, and Curriculum/Training of the Health professional students. Method: A cross sectional survey conducted among nursing and pharmacy students. The study used questionnaire from Global Health Professional Survey (GHPS) which was developed by the World Health Organization, US Center for Disease Control and the Canadian Public Health Association (2008).Descriptive research design was adapted and it was conducted in selected Nursing and Pharmacy Colleges at Bangalore. One Hundred and forty one subjects, Nursing (n=62) and Pharmacy (n=79) college students were selected through purposive sampling method. The self administered questionnaire was distributed and data were collected for socio demographic characteristics and Prevalence of tobacco use, exposure to environmental tobacco use, Attitude, and curriculum/ Training. The collected data were systematically coded, computed and analyzed using Statistical Software Package for Social Sciences (SPSS) 21.0. Analyses of the data were done by authors in accordance with the specified objectives. Results: Smoking prevalence among health professional students is relatively low; however, majority believed that health-care providers serve as role models for their patients and the public. *Clinical Instructor, **Principal ***Lecturer, College of Nursing, NIMHANS, Bangalore29 Introduction The World Health Organization (WHO) has estimated that five million deaths occur annually due to tobacco use and this number of deaths is expected to reach more than eight million by the year 2030 1,2. About 80% of this number will be in developing countries.1 However; the exact magnitude of the problem of smoking in developing countries is not well defined. India is no exclusion to this global scenario owing to the expanding prevalence of tobacco usage in India. This increase in tobacco usage could be attributed to increased economic growth witnessed in India over the past few decades. It has been estimated that 26.2% and 3.6% of Indian males and females respectively are smokers (GATS India, 2010; Tobacco Atlas, 2012). Also there is growing concern over increasing exposure to secondhand smoke (GATS India,
1

2010; Tobacco Atlas, 2012).20 Smoking also has an environmental impact due to second hand (passive) smoking.3The impact of smoking is not restricted on the smokers, but it can stretch to affect the non-smokers as well. Smoking prevalence rises sharply during adulthood. This means that there is an induction of smoking even after high school4. A significant barrier for tobacco cessation and effective prevention is lack of knowledge of the health effects of tobacco use. Inferior quality of knowledge towards risks of smoking has been shown to be associated with smoking commencement among school and college students.[5,6] Health professionals play a pivotal role in tobacco cessation and in motivating people not to initiate consumption. Several studies have shown that tobacco cessation advice provided by health professionals' enhances the quit rate among their patients.7 The prevalence, morbidity and the mortality associated with tobacco usage is on the rise18,19,20, average age at which most of the people in the first tried smoking were 20.144.29 years and when they started smoking regularly was 22.304.88 years. This is higher than that reported by investigators in GATS India 20108. Health Professional School students is a group of society expected to have quite conscious approach to addictive substance use, the rate of current smoking (38.2%) among them higher than that in the general population 15.There is substantiation that smoking cessation interventions are effective when conveyed by non-physician health professional groups: nurses9, dentists 10, dental hygienists 11, and pharmacists 12; so, it is relevant to have information on their habits and attitudes towards smoking, especially concerning their role to give help to smokers who wish to quit.Health professional who continues to smoke sends inconsistent message to patients, whom he/she counsels, and need to acquire knowledge about smoking related diseases and specific skills in smoking cessation techniques 13, 14. Interestingly the current smokers prevalence is higher among many other Health Professional School students than the Strictly Medical School students, thus more attention needs to be given to them in prevention and controlling tobacco smoking15. Since students in healthcare profession are future professionals, basic information about tobacco smoking among healthcare professional student population would be important since their approach and credibility as future treatment providers may be influenced by their own smoking habits. HealthCare professional student population would be essential since their approach and credibility as future treatment providers may be influenced by their own smoking habits 16. In a study carried out among health profession students 86.6%99.8% believed health professionals should advise patients about smoking cessation however only 5.2%36.6% among pharmacy students had received formal training in tobacco cessation counseling. Among these students 71.7% 99.0% believed that health professionals should be trained in cessation techniques 17. Methodology: Study design used for the present study was descriptive design, cross sectional survey in approach. The researcher selected one Pharmacy and one Nursing college based on her convenience contains 3 rd year students, all of them were included in the survey. Both Pharmacy and nursing college containing 3 rd year students were included in the sampling frame. The GHPSS was conducted by censes approach during regular class sessions, with preplanned
2

intimation.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 the GHPSS. The GHPSS is a school-based survey of 3rd year students pursuing advanced degrees in dentistry, medicine, pharmacy, and nursing. The GHPSS uses a core questionnaire on 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 counseling on cessation techniques. All the subjects were selected for the present study as per the inclusion criteria . Hence for the present study, 141 study subjects (Nursing -n1=62 Pharmacy -n2=79) were selected.Data collection was done in the month of January 2014 by the investigator at each site followed the permission from concerned authorities. The students were briefed about the purpose of the research and were invited to participate in the survey. The students were informed that their participation in the survey was anonymous, voluntary and was not compulsory. Assurance was given about anonymity and confidentiality of the information to be provided. The present GHPSS was conducted in colleges during regular lectures and class sessions. Anonymous, self-administered data collection procedures were used. Primary data were collected systematically coded, computed and analyzed using descriptive statistics (frequency & percentage), using Software Packages for Social Sciences (SPSS) 21.0 and windows 7 version. Analyses of the data were done in accordance with the study objectives. Results: Profile of the sociodemographic showed (Table1) majority 79 percent of the health professional students coming under the age group of 19 to 24 years, 75 percent of the students were females, 63 percent of the students belongs to the Christian religion. Profile of Prevalence showed(Table2) that majority20(n1=4,n2=16) 14% subjects were ever smokers or tried smoking in the life ,17(n1-1,n2= 16)5% first tried their smoking in their age between 16-17 years,12 (n1=4,n2=11)11% of the study subjects are reported that they are currently using (during past 30 days) the tobacco by smoking. out of them 4% used all 30 days .Majority Seven (n1=2,n2=5)5% of the study subjects using smokeless tobacco products like chewing tobacco and snuff along with cigarette smoking. Profile of the Environmental exposure and Policy showed (Table3) majority15 (n1=6, n2=14)14% of them were expressed that they have exposed to the environmental tobacco in the living area. Majority 110(n1=46, n2=64)78% expressed that their college enforced policy to band the tobacco use

Table1
Responses 15 to 18 years Age 19 to 24 years 25 to 29 years Female Gender Male Hindu Muslim Religion: Christian others Nursing % Pharmacy % Total Percentage

1 61 0 60 2 10 1 51 0

1 43 0 43 1 7 1 36 0

21 50 8 46 33 20 15 38 6

15

22

16 79 6 75 25 21 11 63 4

35 111 6 8

33 106 23 14 11 27 4 35 30 16 89 6

Table 2
Nursing (n1=62) f 1.Ever tried or experimented with cigarette smoking Yes No Age10 or younger 2. Age at when first tried a cigarette Age 11-15 Age 16-17 Age18-19 Not smoked 1 or 2 days 3. No. of days smoked in the past 30 days . 3 to 5 days 10 to 29 days All 30 days 4 58 2 0 1 1 58 4 0 0 0 % 3 41 1 0 1 1 41 3 0 0 0 Pharmacy (n2=79) f 16 63 1 5 6 4 68 1 2 3 5 % 11 45 0.5 4 4 3 48 1 1 3 4 TOTAL (N=141) f 20 121 3 5 7 5 126 5 2 3 5 % 14 86 3 4 5 4 89 4 1 2 4

2.Prevalence parameters

Responses

3.ENVIRONMENT EXPOSURE &POLICY ENFORCEMENT

Nursing (n1=62)

Pharmacy (n2=79)

TOTAL (N=141)

1. How many days have people smoked where you live, in your presence? (Past 7 Not days) 38 smoked

27

50

35

88 62

1-2 days 9 3-4 days 9 5-6 days 0 all days 7 6

6 6 0 4

8 3 4 14

6 2 3 10

17 12 12 8 4 3

20 14

2.How many days have people smoked in your presence, in places other than where Not 33 you live? (Past 7 days ) smoked

23

36

26

69 49

1-2 days 15 3-4 days 7 5-6 days 6 all days 7 1

11 5 4 1

23 2 1 17

16 1 1 12

38 27 9 7 6 5

18 13

Discussion Most of the health professional students were young female adults, from Christian community. The prevalence among nursing students is relatively less than the pharmacy students. This could be because of majority of the students in nursing profession are females, more over the Indian
5

females are not having the habit of smoking much in their culture. The study results congruent with the findings of Maha Meqla AlKawari et al 2009, Balajoke et al 2009 and World Health Organization 2008 & 2010 respectively for Pharmacy and Nursing.(9.4%, 13% and 5.5% , 4.4%). Exposure to the environmental smoking or second hand smoking were less among our study subjects this could be because many of the students are staying in the hostel environment so less likely they are exposing to the smoking environment ,further our government of India implemented .Among our study subjects14% of them were expressed that they have exposed to the environmental tobacco in the living area and 78% of the study subjects expressed that their college enforced policy to band the tobacco use . This could be because of the Indian government rule against the tobacco use. Vanphanom sychareun et al 2014 found that only 7.3% of the respondents including nursing and pharmacy exposed to second hand smoke(SHS).WHO 2007 found in their study, enforced policy to ban smoking in school buildings and clinics was reported by 37.3% of nursing students, and 29.1% of pharmacy students . The study conducted with small sample size thus the generalization of these findings was limited. Due to the time limitation convenient sample was applied and used for the selection of the colleges. Similar study could be replicated on large sample. Prospective longitudinal studies can be conducted. Comparative study may be conducted at various course levels. Conclusions: Smoking prevalence among health professional students is relatively low; however, majority believed that health-care providers serve as role models for their patients and the public. The Ministry of Public Health, the Ministry of Education, and educational institutions should work together with other interested partners in developing, testing, and implementing successful cessation counseling training programs for health professionals. References: 1.World Health Organization (WHO) (2009). "WHO Report on the Global Tobacco Epidemic, 2009: Implementing smoke-free environments." from http://www.who.int/tobacco/mpower/en/. 2.Gajalakshmi V, Asma S, Warren CW (2004). Tobacco Survey Among Youth in South India. Asian Pac. J. Cancer Prev. 5:273-278. 3.El-Ansari W (2002). Passive smoking in children: Facts and public health implications. East Mediterr. Health J. 8(1):74-87. 4.Torabi MR, Yang J, Li J (2002). Comparison of tobacco use knowledge, attitude and practice among college students in China and the United States. Health Prom. Int. 17(3):247-253. Awe 5. Singh G, Sinha DN, Sarma PS, Thankappan KR. Prevalence and correlates of tobacco use among 10-12 year old school students in Patna District, Bihar, India. Indian Pediatr 2005;42:80510. 24. 6.Perry CL, Stigler MH, Arora M, Reddy KS. Preventing tobacco use among young people in India: Project MYTRI. Am J Public Health 2009;99:899-906.
6

7.Gorin SS, Heck JE. Meta analysis of the efficacy of tobacco counseling by health care providers. Cancer Epidemiol Biomarkers Prev 2004;13:2012 22. 8. Almas Binnal et.al .Insights into Smoking and its Cessation among Current Smokers in India .Asian Pacific J Cancer Prev, 14 (5), 2811-2818 9. Rice VH, & Stead L. Nursing intervention and smoking cessation: Meta-analysis update. Heart Lung 2006;35:147- 63. DOI: 10.1016/j.hrtlng.2006.01.001 approach. 10.Gorin SS, & Heck JE. Meta-analysis of the efficacy of tobacco counseling by health care providers. Cancer Epi- demiol Biomarkers 2004;13:2012-22. 11. Binnie VI, McHugh S, Jenkins W, Borland W, & Macpherson LM. A randomized controlled trial of a smoking cessation intervention delivered by dental hy- gienists: A feasibility study. BMC Oral Health 2007;7:5. DOI: 10.1186/1472-6831-7-5 12. Sinclair HK, Bond CM, & Stead LF. Community phar- macy personnel interventions for smoking cessation. Cochrane Database Syst Rev 2004;(1):CD003698. DOI: 10.1002/14651858.CD003698 13.Chatkin J, Chatkin G. Learning about smoking during medical school: are we still missing opportunities? Int J Tuberc Lung Dis 2009;13:429-37. 14.GTSS Collaborative Group. Tobacco use and cessation counselling: Global Health Professionals Survey Pilot Study, 10 countries, 2005. Tob Control 2006;15(Suppl. 2):ii31-4. DOI: 10.1136/tc.2006.015701 15.Margherita Ferrante et .al. Prevalence of smoking habits, attitudes, knowledge and beliefs among Health Professional School students: a cross-sectional study. Ann Ist Super Sanit 2013 | Vol. 49, No. 2: 143-149 16.Patka AA, Hill K, Batra V, Vergare MJ, Leone FT: A Comparison of Smoking Habits among Medical and Nursing Students. CHEST 2003, 124(4):1415-1420. Retrieved [cited 2007 June]. 17.Department of Health and Human Services, Centers for Disease Control and Prevention: Tobacco use and cessation counselingGlobal health professionals survey pilot study. Morbidity And Mortality Weekly Report 2005, 54(20):505-509. 18.World Health Organisation. WHO Report on the Global Tobacco Epidemic 2009: Implementing Smoke-free Environments. Geneva: WHO. (2009) 19.World Health Organisation. Economics of tobacco toolkit: assessment of the economic costs of smoking. Geneva: WHO. (2011) 20.Tobacco use. Global Adult Tobacco Survey: India Report 2009-2010. Ministry of Health and Family Welfare,Government of India. (2010)
7

21.Margherita Ferrante et .al. Prevalence of smoking habits, attitudes, knowledge and beliefs among Health Professional School students: a cross-sectional study. Ann Ist Super Sanit 2013 | Vol. 49, No. 2: 143-149 22.World Health Organization 2010.Tobacco Use, Exposure to Secondhand Smoke, and Cessation Counseling Among Health Professions Students: Sudan Data from the Global Health Professions Student Survey (GHPSS), 2007 23.Vanphanom Sychareun V, Hansana V, Choummanivong M, et al. Cross-sectional survey: smoking among medical, pharmacy, dental and nursing students, University of Health Sciences, Lao PDR BMJ Open 2013;3:e003042. doi:10.1136/bmjopen-2013-003042