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DOI: 10.1055/s-0042-1742447
Smoking Prevalence, Attitude, and Cessation Training among Nursing Students in Bhubaneswar, India—A Cross-sectional Study
Abstract
Introduction The smoking habit of health professionals including nursing students may prevent them from providing cessation advice and counseling to their patients as one cannot persuade others to quit if he/she is smoking himself/herself.
Objective The study aimed to assess the smoking prevalence, attitude, and tobacco cessation training among nursing students.
Materials and Methods During January to April 2019, we conducted a cross-sectional study among 432 third-year nursing students of eight graduate nursing colleges of Bhubaneswar using the Global Health Professional Student Survey (GHPSS) questionnaire.
Results Overall, 38 (8.8%) were current smokers. Majority of participants agreed that health professionals should receive specific training on smoking cessation techniques (91%), serve as role models for their patients and the public (94%), advise their patients to quit tobacco (96.1%). Current smokers were more likely to be males (adjusted OR [aOR]: 6.53, 95% confidence interval or CI: 2.61–16.36), those not supporting a smoking ban in discos/bars/pubs (aOR: 2.82, 95% CI: 1.13–7.05), those lacking knowledge about dangers of smoking (aOR: 2.48, 95% CI: 1.10–5.60), and those not discussing the reasons of smoking (aOR: 2.49, 95% CI: 1.05–5.93).
Conclusion Sincere efforts must be undertaken in the nursing colleges to design and implement strategies to discourage tobacco use among nursing students and adequately train them on tobacco cessation techniques.
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Introduction
Tobacco use is one of the most important preventable causes of premature mortality and morbidity. Direct tobacco smoking kills more than 7 million people every year worldwide and an additional 1.2 million die from the effects of second-hand smoke.[1] In the 20th century, tobacco is estimated to have killed 100 million people and in the current century, it is expected to kill approximately 1 billion people, mostly in the low- and middle-income countries (LMICs).[2] Globally, almost 1.3 billion people are currently smokers and more than 80% of smokers live in LMICs.[1] [2] Smoked tobacco in the form of cigarettes or bidi accounts for around 97% of all tobacco sales worldwide and results in a higher incidence and variety of diseases compared with smokeless tobacco.[2]
According to World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), population-based surveys are needed to be conducted among adults, youth, school personnel, and student health professionals to monitor the global tobacco epidemic.[3] WHO FCTC has emphasized the importance of the role played by health professionals in the cessation and prevention of tobacco use by giving simple advice and counseling.[4] [5] [6] [7] It is essential for health care facilities and educational institutes to assume greater responsibility by promoting smoke-free facilities and practices among their staff and patients.[8] However, the smoking habit of health professionals may prevent them from providing cessation advice and counseling to their patients as one cannot persuade others to quit if they are smoking themselves.[9] [10] In the implementation of tobacco cessation strategies, there are barriers like lack of knowledge about dangers of tobacco use, absence of adequate training, competing demands, lack of familiarity with appropriate therapies, and reimbursement for providing treatment.[6] [11] [12] Moreover, nursing students' perceptions about tobacco cessation and their efficiency in providing appropriate interventions may negatively impact nurses' role in tobacco cessation.[13]
To our knowledge, studies regarding tobacco use among nursing students in India are scarce. In light of the above, the present study was performed with the following objectives: (1) to assess the tobacco consumption behavior, prevalence of current smoking, and associated factors; (2) to assess the attitudes and beliefs toward tobacco control and educational training received on tobacco control among nursing students.
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Materials and Methods
This cross-sectional study was performed involving eight graduate nursing colleges at Bhubaneswar, the capital city of Odisha, located in the eastern region of India. The survey was conducted between January to April 2019 during regular class sessions. All the third-year B.Sc. nursing students studying in the nursing colleges, i.e., overall 465 students were considered for the study. Students not willing to participate and those absent on the day of the survey were excluded from the study. Twenty-eight students were absent on the day of the survey and the rest 437 students were included as study participants as all of them agreed to participate in the study.
The tool used in this survey was the Global Health Professional Student Survey (GHPSS) questionnaire which was developed by WHO, Centres for Disease Control and Prevention (CDC), and the Canadian Public Health Association (CPHA).[14] The students were asked to complete an anonymous, self-administered GHPSS questionnaire which was composed of 59 questions including information regarding socio-demographic characteristics, smoking habits, other tobacco use, intention to quit, exposure to second-hand smoke, attitudes and beliefs toward tobacco control activities, and educational training received concerning smoking and smoking cessation. The outcome measure was “being a current smoker” who used smoked tobacco on at least one day during the last 30 days before the survey.
Statistical Analysis
All the data were scrutinized and analyzed with SPSS version 21.0 software and expressed as frequency, percentages, odds ratio, and 95% confidence intervals (CIs). Chi-square tests were performed to evaluate differences for the categorical variables. Variables with a p-value <0.15 in bivariate analyses were introduced in the final multivariate logistic regression model to identify possible factors associated with tobacco smoking status. The goodness of fit of the model was assessed by the model χ 2 statistic and Hosmer–Lemeshow test. The level of significance was set at p <0.05.
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Ethics Statement
The study was approved by the Institute Ethics Committee of Kalinga Institute of Medical Sciences, KIIT Deemed to be University, Bhubaneswar, India (Ref. No: KIMS/KIIT/IEC/01/2018, Date: March 01, 2019). The procedures used in this study adhere to the tenets of the Declaration of Helsinki of 1964 as revised in 2013. Also, permission was sought from respective college authorities. Before participation in the study, all the students were informed about the aims of the study and asked to provide written informed consent.
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Results
Study Participants and Smoking Status
The study sample consisted of 437 third-year nursing students, out of which responses of five students were not considered due to incompleteness of data and thus data of 432 students were considered for final analysis. The response rate was 100% as all 437 students responded by filling the questionnaires. Among the total population, 388 (89.8%) were females and 44 (10.2%) males. Majority of the respondents (264, 61.1%) were ≤20 years old, while 168 (38.9%) were >20 years old. The mean age of the participants was 20.4 ± 1.1 years. Concerning smoking status, 38 (8.8%) were current smokers (smoking cigarettes or bidi daily or occasionally within the past month). Most of the students first tried using tobacco (cigarette: 66.7%, bidi: 47.9%, and smokeless tobacco: 60%) at the age between 16 and 20 years. More than half of the students were using tobacco within 30 minutes after waking up. Nearly three-fourths of the current tobacco users had the intention to quit it. More than half of the nursing students reported that they were exposed to secondhand smoke during the past 7 days in living places (221 [51.2%] and other places (262 [60.6%]). Details of the tobacco consumption behavior of nursing students are given in [Table 1].
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Attitudes and Beliefs toward Tobacco Control
[Table 2] summarizes the findings regarding the students' attitudes toward tobacco control by their smoking status. Fifty-seven (13.2%) of the students reported that there was no policy that forbids smoking in school buildings and clinics and 151 (35.0%) stated that the policy was not enforced. Compared with non-smokers, a higher proportion of smokers believed that the policy existed and was enforced in the campus, but these differences were statistically not significant. With regard to their beliefs toward tobacco control policies, non-smokers were more positive toward banning smoking in restaurants [333 (84.5%) vs. 26 (68.4%), p <0.05), in bars/discos/pubs [319 (81%) vs. 21 (55.3%), p <0.05)]. Also, a higher percentage of nonsmokers were in favor of a complete ban of tobacco advertisements [330 (83.8%) vs. 26 (68.4%), p <0.05)]. Majority of the participants agreed that health professionals should receive specific training on smoking cessation techniques (393, 91%), should serve as role models for their patients and the public (406, 94%), should advise their patients to quit tobacco (415, 96.1%), and nursing professionals have a role in providing advice about tobacco cessation (412, 95.4%).
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Educational Training on Smoking and Smoking Cessation
[Table 3] depicts nursing students' educational training on tobacco control by their smoking status. The differences in responses to questions like “were you taught about dangers of smoking,” “did you discuss the reasons why people smoke,” and “have you heard of using antidepressants in tobacco cessation” between smokers and nonsmokers were statistically significant whereas no statistically significant differences were identified in the responses for other questions indicating similar levels of training and understanding.
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Factors Associated with Current Smoking Status
[Table 4] presents the multivariate logistic regression model showing the possible factors associated with the current smoking status of nursing students. After adjustment of confounders, variables like male gender (adjusted OR: 6.53, 95% CI: 2.61–16.36), not supporting a smoking ban in discos/bars/pubs (adjusted OR: 2.82, 95% CI: 1.13–7.05), lack of knowledge about dangers of smoking (adjusted OR: 2.48, 95% CI: 1.10–5.60), and not discussing the reasons of smoking (adjusted OR: 2.49, 95% CI: 1.05–5.93) had shown significant associations with the current smoking status of nursing students.
Abbreviations: CI, confidence interval; OR, odds ratio; R, reference category.
Note: Model χ2 statistic = 40.451 (p <0.001) and Hosmer-Lemeshow p-value = 0.773 show that the model fits and support the existence of the relationship between independent variables and the dependent variable. The classification table reports that 91.5% of the cases can be expected to be classified correctly by the model.
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Discussion
The present study shows a prevalence of current smokers of 8.8%, higher than the country figure of 3.4% reported in a study conducted in 2007.[15] and this may be attributed to stress, peer influence, and curiosity. Given the rise of prevalence of smoking among Indian nursing students and the key role of these health professional students as future behavioral models and counselors, more attention should be focused on smoking cessation training of nursing students. More than 80% of the respondents had tried their first tobacco use before reaching the age of 20 years, indicating the importance of initiating interventional measures during adolescence. Nearly 70% of the students currently using tobacco reported that they want to quit, which is comparable with the national figure.[15] Thus, it can be inferred that with timely intervention, many students can be saved from falling prey to tobacco. Our study revealed that more than half of the respondents were exposed to secondhand smoke in living places and public places, which is higher than the national figures.[15] This indicates ineffective implementation of the smoking ban in the region. Also, nearly 75% of the students were of the view that policy banning smoking was not enforced on school premises, again indicating complacency in implementation despite the policy existed. In our study, concerning attitudes and beliefs, nonsmokers appeared to be more active than smokers in smoking cessation counseling. This is consistent with the results of previous literature.[16] [17] [18]
Compared with the results reported in earlier studies,[15] [19] [20] our study showed that a higher proportion of nursing students had received any formal training in smoking cessation approaches. In this study, we observed that 91% of students thought that health professionals should get specific training on cessation techniques. Similar findings have been reported in other GHPSS studies.[15] [20] [21] As nurses are the largest group of health care professionals and spend more time with the patients, they can adequately contribute to health promotional activities. They can effectively counsel their patients about smoking cessation techniques and persuade them to stop tobacco use.[13] Thus, it is imperative to put more emphasis on smoking cessation techniques in the nursing curriculum and there should be sincere efforts to train 100% of nurses on tobacco cessation approaches. There is evidence that nurses who had received training were more likely to perform tobacco control interventions than untrained nurses.[22] Also, nursing students' knowledge of intervention methods for tobacco cessation such as nicotine replacement therapies and the use of antidepressants could be further improved by improving the content of the current nursing curriculum on tobacco cessation. Sarna et al reported in their study that nurses in Asian countries may not be adequately trained to help tobacco users to quit as the curriculum does not offer appropriate training related to tobacco cessation interventions.[6]
In agreement with our findings, males were more likely to smoke than females in previous studies.[16] [23] [24] Our study revealed that compared with nonsmokers, smokers were more unlikely to support the fact “smoking should be banned in discos/bars/pubs.” This is consistent with the result reported in an earlier study.[20] Similarly, Brar et al in their study conducted on medical students observed that more nonsmokers were supportive of banning smoking in discos/bars/pubs.[24] In our study, students who were taught about the dangers of smoking appeared to have a lower probability to be a smoker. Also, those who discussed the reasons why people smoke were less likely to be smokers. This is supported by the findings of a previous study.[20] This indicates that knowledge about smoking and its dangers might prevent nursing students from being a smoker.
In interpreting our results, the main limitations of the study should be addressed. First, the design of our study was cross-sectional and thus causality of association cannot be established. Second, there is a risk of underreporting and recall bias due to self-reported data. Also, the population split in the study was leaning more toward female students than males and this might lead to bias in the findings of the study. However, the study provides relevant information regarding tobacco consumption behavior, attitudes, and educational training of nursing students. The multicentric nature of the study increases the generalizability of the findings of our study. Furthermore, as the survey was anonymous and completely voluntary, it can be assumed that smoking status was reliably captured. Further research in diverse geographical settings is needed to establish the findings of our study.
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Conclusion
The prevalence of current smoking among nursing students studying in nursing colleges of Bhubaneswar is 8.8%. The study findings indicate that smoking prevalence among the nursing students might be reduced by helping students develop a positive attitude toward smoking ban in discos/bars/pubs, teaching them about the dangers of smoking, and discussing the reasons of smoking during their school training.
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Conflict of Interest
None declared.
Source(s) of Support in the Form of Grants, Equipment, Drugs, or all of These
None.
Authorship Statement
The manuscript has been read and approved by all the authors, that the requirements for authorship have been met, and that each author believes that the manuscript represents honest work.
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References
- 1 World Health Organization. Tobacco. 2020 . Accessed 3 March, 2021 at: https://www.who.int/news-room/fact-sheets/detail/tobacco
- 2 Jha P, MacLennan M, Chaloupka FJ. et al. Global hazards of tobacco and the benefits of smoking cessation and tobacco taxes. In: Gelband H, Jha P, Sankaranarayanan R, Horton S. eds. Cancer: Disease Control Priorities. 3rd ed.. Washington, DC: The World Bank; 2015
- 3 Warren CW, Lee J, Lea V. et al. Evolution of the Global Tobacco Surveillance System (GTSS) 1998-2008. Glob Health Promot Educ 2009; 16 (Suppl. 02) 4-37
- 4 Carr AB, Ebbert J. Interventions for tobacco cessation in the dental setting. (Review) Cochrane Database Syst Rev 2012; (06) CD005084
- 5 Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2013; (05) CD000165
- 6 Sarna L, Danao LL, Chan SSC. et al. Tobacco control curricula content in baccalaureate nursing programs in four Asian nations. Nurs Outlook 2006; 54 (06) 334-344
- 7 Aina BA, Onajole AT, Lawal BMO, Oyerinde OO. Promoting cessation and a tobacco free future: willingness of pharmacy students at the University of Lagos, Nigeria. Tob Induc Dis 2009; 5: 13
- 8 Vardavas CI, Bouloukaki I, Linardakis MK, Tzilepi P, Tzanakis N, Kafatos AG. Smoke-free hospitals in Greece: personnel perceptions, compliance and smoking habit. Tob Induc Dis 2009; 5 (01) 8
- 9 Smith DR, Leggat PA. An international review of tobacco smoking among medical students. J Postgrad Med 2007; 53 (01) 55-62
- 10 Smith DR, Leggat PA. An international review of tobacco smoking among dental students in 19 countries. Int Dent J 2007; 57 (06) 452-458
- 11 Braun BL, Fowles JB, Solberg LI, Kind EA, Lando H, Pine D. Smoking-related attitudes and clinical practices of medical personnel in Minnesota. Am J Prev Med 2004; 27 (04) 316-322
- 12 Zillich AJ, Aquilino ML, Farris KB. Knowledge and attitudes about smoking cessation among pharmacy technicians. J Am Pharm Assoc (2003) 2004; 44 (05) 578-582
- 13 Lenz BK. Beliefs, knowledge, and self-efficacy of nursing students regarding tobacco cessation. Am J Prev Med 2008; 35 (Suppl. 06) S494-S500
- 14 Warren CW. GTSS Collaborative Group. Tobacco use and cessation counselling: Global Health Professionals Survey Pilot Study, 10 countries, 2005. Tob Control 2006; 15 (Suppl. 02) ii31-ii34
- 15 Surani NS, Pednekar MS, Sinha DN. et al. Tobacco use and cessation counseling in India-data from the Global Health Professions Students Survey, 2005-09. Indian J Cancer 2012; 49 (04) 425-430
- 16 Ferrante M, Saulle R, Ledda C. et al. Prevalence of smoking habits, attitudes, knowledge and beliefs among Health Professional School students: a cross-sectional study. Ann Ist Super Sanita 2013; 49 (02) 143-149
- 17 Vogt F, Hall S, Marteau TM. General practitioners' beliefs about effectiveness and intentions to prescribe smoking cessation medications: qualitative and quantitative studies. BMC Public Health 2006; 6: 277
- 18 Gunes G, Karaoglu L, Genc MF, Pehlivan E, Egri M. University hospital physicians' attitudes and practices for smoking cessation counseling in Malatya, Turkey. Patient Educ Couns 2005; 56 (02) 147-153
- 19 Warren CW, Jones NR, Chauvin J, Peruga A. GTSS Collaborative Group. Tobacco use and cessation counselling: cross-country. Data from the Global Health Professions Student Survey (GHPSS), 2005-7. Tob Control 2008; 17 (04) 238-247
- 20 Patelarou E, Vardavas CI, Ntzilepi P. et al. Nursing education and beliefs towards tobacco cessation and control: a cross- sectional national survey (GHPSS) among nursing students in Greece. Tob Induc Dis 2011; 9: 4
- 21 Saade G, Warren CW, Jones NR, Mokdad A. Tobacco use and cessation counseling among health professional students: Lebanon Global Health Professions Student Survey. J Med Liban 2009; 57 (04) 243-247
- 22 Heath J, Crowell NA. Factors influencing intentions to integrate tobacco education among advanced practice nursing faculty. J Prof Nurs 2007; 23 (04) 189-200
- 23 Gualano MR, Siliquini R, Manzoli L. et al. Tobacco use prevalence, knowledge and attitudes, and tobacco cessation training among medical students: results of a pilot study of Global Health Professions Students Survey (GHPSS) in Italy. J Public Health (Bangkok) 2012; 20: 89-94
- 24 Brar M, Chaudhary N, Ramakrishnan TS, Randhawa A. A study of prevalence of tobacco use and related factors among medical students as per the Global Health Professions Student Survey protocol. Int J Res Med Sci 2020; 8: 2243-2247
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References
- 1 World Health Organization. Tobacco. 2020 . Accessed 3 March, 2021 at: https://www.who.int/news-room/fact-sheets/detail/tobacco
- 2 Jha P, MacLennan M, Chaloupka FJ. et al. Global hazards of tobacco and the benefits of smoking cessation and tobacco taxes. In: Gelband H, Jha P, Sankaranarayanan R, Horton S. eds. Cancer: Disease Control Priorities. 3rd ed.. Washington, DC: The World Bank; 2015
- 3 Warren CW, Lee J, Lea V. et al. Evolution of the Global Tobacco Surveillance System (GTSS) 1998-2008. Glob Health Promot Educ 2009; 16 (Suppl. 02) 4-37
- 4 Carr AB, Ebbert J. Interventions for tobacco cessation in the dental setting. (Review) Cochrane Database Syst Rev 2012; (06) CD005084
- 5 Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2013; (05) CD000165
- 6 Sarna L, Danao LL, Chan SSC. et al. Tobacco control curricula content in baccalaureate nursing programs in four Asian nations. Nurs Outlook 2006; 54 (06) 334-344
- 7 Aina BA, Onajole AT, Lawal BMO, Oyerinde OO. Promoting cessation and a tobacco free future: willingness of pharmacy students at the University of Lagos, Nigeria. Tob Induc Dis 2009; 5: 13
- 8 Vardavas CI, Bouloukaki I, Linardakis MK, Tzilepi P, Tzanakis N, Kafatos AG. Smoke-free hospitals in Greece: personnel perceptions, compliance and smoking habit. Tob Induc Dis 2009; 5 (01) 8
- 9 Smith DR, Leggat PA. An international review of tobacco smoking among medical students. J Postgrad Med 2007; 53 (01) 55-62
- 10 Smith DR, Leggat PA. An international review of tobacco smoking among dental students in 19 countries. Int Dent J 2007; 57 (06) 452-458
- 11 Braun BL, Fowles JB, Solberg LI, Kind EA, Lando H, Pine D. Smoking-related attitudes and clinical practices of medical personnel in Minnesota. Am J Prev Med 2004; 27 (04) 316-322
- 12 Zillich AJ, Aquilino ML, Farris KB. Knowledge and attitudes about smoking cessation among pharmacy technicians. J Am Pharm Assoc (2003) 2004; 44 (05) 578-582
- 13 Lenz BK. Beliefs, knowledge, and self-efficacy of nursing students regarding tobacco cessation. Am J Prev Med 2008; 35 (Suppl. 06) S494-S500
- 14 Warren CW. GTSS Collaborative Group. Tobacco use and cessation counselling: Global Health Professionals Survey Pilot Study, 10 countries, 2005. Tob Control 2006; 15 (Suppl. 02) ii31-ii34
- 15 Surani NS, Pednekar MS, Sinha DN. et al. Tobacco use and cessation counseling in India-data from the Global Health Professions Students Survey, 2005-09. Indian J Cancer 2012; 49 (04) 425-430
- 16 Ferrante M, Saulle R, Ledda C. et al. Prevalence of smoking habits, attitudes, knowledge and beliefs among Health Professional School students: a cross-sectional study. Ann Ist Super Sanita 2013; 49 (02) 143-149
- 17 Vogt F, Hall S, Marteau TM. General practitioners' beliefs about effectiveness and intentions to prescribe smoking cessation medications: qualitative and quantitative studies. BMC Public Health 2006; 6: 277
- 18 Gunes G, Karaoglu L, Genc MF, Pehlivan E, Egri M. University hospital physicians' attitudes and practices for smoking cessation counseling in Malatya, Turkey. Patient Educ Couns 2005; 56 (02) 147-153
- 19 Warren CW, Jones NR, Chauvin J, Peruga A. GTSS Collaborative Group. Tobacco use and cessation counselling: cross-country. Data from the Global Health Professions Student Survey (GHPSS), 2005-7. Tob Control 2008; 17 (04) 238-247
- 20 Patelarou E, Vardavas CI, Ntzilepi P. et al. Nursing education and beliefs towards tobacco cessation and control: a cross- sectional national survey (GHPSS) among nursing students in Greece. Tob Induc Dis 2011; 9: 4
- 21 Saade G, Warren CW, Jones NR, Mokdad A. Tobacco use and cessation counseling among health professional students: Lebanon Global Health Professions Student Survey. J Med Liban 2009; 57 (04) 243-247
- 22 Heath J, Crowell NA. Factors influencing intentions to integrate tobacco education among advanced practice nursing faculty. J Prof Nurs 2007; 23 (04) 189-200
- 23 Gualano MR, Siliquini R, Manzoli L. et al. Tobacco use prevalence, knowledge and attitudes, and tobacco cessation training among medical students: results of a pilot study of Global Health Professions Students Survey (GHPSS) in Italy. J Public Health (Bangkok) 2012; 20: 89-94
- 24 Brar M, Chaudhary N, Ramakrishnan TS, Randhawa A. A study of prevalence of tobacco use and related factors among medical students as per the Global Health Professions Student Survey protocol. Int J Res Med Sci 2020; 8: 2243-2247