|KIDS AND ADOLESCENTS
|Year : 2010 | Volume
| Issue : 5 | Page : 30-34
Linking India global health professions student survey data to the world health organization framework convention on tobacco control
DN Sinha1, G Singh1, PC Gupta2, M Pednekar2, CW Warrn3, S Asma3, J Lee3
1 School of Preventive Oncology, Patna, India
2 Healis - Sekhsaria Institute for Public Health, Navi Mumbai, India
3 Center for Disease Control, USA
|Date of Web Publication||9-Jul-2010|
D N Sinha
School of Preventive Oncology, Patna
The 2003 India Tobacco Control Act (ITCA) includes provisions designed to reduce tobacco consumption and protect citizens from exposure to secondhand smoke. India ratified the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) on February 27, 2005. The WHO FCTC is the world's first public health treaty that aims to promote and protect public health and reduce the devastating health and economic impact of tobacco. The Global Health Professions Student Survey (GHPSS) was developed to track tobacco use among third-year dental, medical, nursing, and pharmacy students across countries. Data from the dental (2005), medical (2006), nursing(2007), and pharmacy (2008) GHPSS conducted in India showed high prevalence of tobacco use and a general lack of training by health professionals in patient cessation counseling techniques. The Ministry of Health and Family Welfare could use this information to monitor and evaluate the existing tobacco control program effort in India as well as to develop and implement new tobacco control program initiatives.
Keywords: Tobacco use, second-hand smoke, health professional students, training
|How to cite this article:|
Sinha D N, Singh G, Gupta P C, Pednekar M, Warrn C W, Asma S, Lee J. Linking India global health professions student survey data to the world health organization framework convention on tobacco control. Indian J Cancer 2010;47:30-4
|How to cite this URL:|
Sinha D N, Singh G, Gupta P C, Pednekar M, Warrn C W, Asma S, Lee J. Linking India global health professions student survey data to the world health organization framework convention on tobacco control. Indian J Cancer [serial online] 2010 [cited 2013 Dec 8];47:30-4. Available from: http://www.indianjcancer.com/text.asp?2010/47/5/30/65177
Publication of the supplement was supported by the funds from the 14th World Conference on Tobacco or Health, March 8-12, 2009, Mumbai. The Guest Editors, Editors, Authors and others involved with the journal did not get any financial or non-financial benefit from the sponsors.
| » Introduction|| |
In 2003, the Indian Parliament passed the Indian Tobacco Control Act (ITCA 2003).  The ITCA 2003 provisions include prohibition of smoking in public places, direct and indirect advertisement of cigarettes and all other tobacco products, sale of tobacco products to minors (< 18 years), and sale of tobacco within 100 yards of any educational institution. In addition, the Indian Government is in the process of framing rules that will require including health warning labels on packages for cigarettes and other tobacco products and to specify the nicotine and tar contents of the products on the packages.
The World Health Organization Framework Convention on Tobacco Control (WHO FCTC), the world's first public health treaty on tobacco control, was adopted by the Fifty-sixth World Health Assembly in May 2003 and became international law on February 27, 2005.  India ratified the WHO FCTC on February 5, 2004. One important feature of the WHO FCTC (Article 20) was the call for countries to develop tobacco control surveillance systems.  The WHO, the US Centers for Disease Control and Prevention, and the Canadian Public Health Association developed the Global Tobacco Surveillance System (GTSS) to assist the WHO member states in establishing such a method.  The Global Health Professions Student Survey (GHPSS) is one of the components of GTSS. All countries conducting the GHPSS use a common survey methodology, similar field procedures for data collection, and similar data management and processing techniques.
The purpose of this article is to use data from the Indian GHPSS (dental 2005, medical 2006, nursing 2007, and pharmacy 2008), [Table 1] to assist in establishing baseline measures for monitoring provisions in the 2003 ITCA and relevant articles in the WHO FCTC.
The GHPSS is a school-based survey of third-year students pursuing advanced degrees in dentistry, medicine, nursing, and pharmacy. The GHPSS uses a core questionnaire that includes questions on demographics, prevalence of tobacco use, knowledge and attitudes about tobacco use, exposure to secondhand smoke (SHS), desire of smokers to stop smoking, perception of the health professional's role in patient counseling, and training received in counseling patients on smoking-cessation techniques. The questionnaire is self-administered in classrooms; and school, class, and student anonymity are maintained throughout the process.
The following data are presented in this report: lifetime cigarette use; initiation of smoking before the age of 16; current cigarette smoking; current use of tobacco products other than cigarettes; dependency on cigarettes among current smokers; desire of smokers to stop smoking, exposure to SHS at home; exposure to SHS in public places; perception of the health professional's role in patient counseling; and training received in counseling patients about smoking-cessation techniques.
| » Material and Methods|| |
The India Dental, Medical, Nursing, and Pharmacy GHPSS follows the same sample design that produced nationally representative, independent, cross-sectional estimates. A weighting factor is applied to each student record to adjust for non-response (by college and by student) and variation, in the probability of selection at the college level. All third-year students in the selected schools were eligible for participation in the survey. Self-administered surveys were conducted in the classrooms with school, class, and student anonymity maintained. SUDAAN [Release 7.5. Research Triangle Institute, Research Triangle Park, NC], a software package for statistical analysis of correlated data, was used to compute standard errors of the estimates and to produce 95% confidence intervals using a logit transformation.  Statistical differences were noted at the P < 0.05 level.
The sample frame consisted of 124 dental colleges obtained from the Dental College of India, for the academic year 2004 - 2005. The India Dental GHPSS sample included a target of 1,500 completed student interviews, from a total of 24 selected schools. A probability sample of 24 schools was selected from the 150 total, based on the enrollment of third-year students in each school. The school response rate was 100%, the student response rate was 93.1%, and 1,499 students completed the India Dental GHPSS.
During 2005, India had 170 medical schools recognized by the Indian Medical Council, which offered medical degrees. The India Medical GHPSS included a target of 1,200 completed student interviews from a total of 15 selected schools. A probability sample of 15 schools was selected from 170 schools, proportional to the enrollment of third-year students. The school response was 86.7% (13 of 15), the student rate was 89.1%, and 1,117 students completed the GHPSS.
India has 855 nursing schools offering the bachelor's degree and recognized by the Indian Nursing Council. A probability sample of 22 schools was selected from 855 schools, proportional to the enrollment of third-year students. The school response was 100%, the student response rate was 92.9%, and 1,082 students completed the GHPSS.
India has 225 Pharmacy schools offering bachelor's degree and recognized by Indian Pharmacy Council. A probability sample of 25 schools was selected proportional to the enrollment of third-year students. The school response was 100%, the student response rate was 84.8%, and 1,082 students completed the GHPSS.
| » Results|| |
Tobacco Use Prevalence
Dental (9.6%), medical (11.6%), and pharmacy (13.0%) students were significantly more likely to smoke cigarettes at present than nursing students (3.3%) [Table 2]. Among the dental, medical, nursing, and pharmacy students, males were significantly more likely than females to smoke cigarettes now. Across the four disciplines, for both males and females, there was no gender difference in current cigarette smoking.
Pharmacy students (10.6%) were significantly more likely than medical (3.7%), dental (5.4%), and nursing (4.5%) students to currently use other tobacco products [Table 2]. No statistical differences in the current use of other tobacco products were found between males and females among dental, medical, and pharmacy students, however, among nursing students, males were more likely to use other tobacco products than females. Medical students were significantly more likely to smoke cigarettes (11.6%) than use other tobacco products (5.4%).
College Policy and Enforcement
Dental (72.6%) and nursing (68.0%) students were significantly more likely than medical (40.8%) and pharmacy (48.8%) students to report that their college had official policies banning smoking in school buildings and clinics [Table 3]. However students from all faculties were as likely to smoke in college buildings.
Exposure to Secondhand Smoke
Dental (68.4%) and medical students (73.8%) were more likely than nursing (50.5%) and pharmacy (55.0%) students to be exposed to SHS in public places [Table 3].
Attitudes and Attempts to Quit
Among dental students, 82.5%, among medical students, 71.8%, and among pharmacy students, 63.6%, who currently smoked cigarettes, wanted to stop smoking [Table 3]. Similarly, 95.8% of dental students, 73.6% of medical students, and 87.8% of pharmacy students who currently used other tobacco products wanted to stop using those products now.
Responsibility to Counsel Patients about Smoking and Cessation
Dental students (97.2%) were significantly more likely than medical (73.8%), nursing (83.5%), and pharmacy (80.1%) students to believe that health professionals serve as role models for their patients and the public [Table 3]. Most of the dental (99.0%), medical (91.0%), nursing (89.8%), and pharmacy (83.9%) students thought health professionals should receive specific training on tobacco cessation techniques.
Medical (22.3%), nursing (37.6%), and pharmacy (29.0%) students were significantly more likely than dental students (10.5%) to have received learning cessation approaches to use on their patients.
| » Discussion|| |
The WHO FCTC and GHPSS envision the same broad goal: the development, implementation, and evaluation of effective tobacco control programs in all WHO member states. The ITCA 2003 has the same tobacco control goals. The GHPSS conducted in India provides data on several indicators (surveillance and monitoring, prevalence, exposure to secondhand smoke, medical school-based tobacco control,) that are needed to monitor provisions of the WHO FCTC and ITCA. The WHO FCTC calls for member states to use consistent methods and procedures in their surveillance efforts. The GHPSS follows this mandate by maintaining comparable sampling procedures, core questionnaire items, training in field procedures, and analysis of data across all survey sites. India has followed this example by conducting a national level survey of dental and medical students using the GHPSS methodology. The results from this effort can be used to establish a baseline for monitoring effective implementation and enforcement of national legislation and specific WHO FCTC Articles.
The data in this report show that dental, medical and pharmacy students had similar rates of current cigarette smoking (9.6, 11.6, and 13.0%, respectively), and similar rates of current use of other tobacco products among medical, dental, and nursing students (3.7, 5.4 and 4.5%, respectively). Elimination of tobacco use among health professionals should be the eventual goal of tobacco control, but achieving this objective among dental, medical, nursing, and pharmacy students presents challenges and requires careful planning by the Ministry of Health and Family Welfare and Health Professional Organizations at the central and state levels. Data from the GHPSS suggest that the first priority of the tobacco intervention program among medical, dental, nursing, and pharmacy students should focus on reducing cigarette smoking and use of other tobacco products among male and female students. These findings suggest that India can develop, implement, and evaluate a comprehensive tobacco control program that encompasses cigarette smoking and use of other tobacco products, as well as both genders. The Ministry of Health and Family Welfare can disseminate this report to all dental and medical schools throughout India requesting enforcement of all existing tobacco control policies.
The ITCA 2003 has provisions calling for a ban on smoking in public places, including hospital buildings and health and education institutions (1). The Ministry of Health and Family Welfare is now focusing on measures to ensure effective implementation and enforcement, prohibiting smoking in public places. Nearly 70% of the dental and medical students and 50% of the nursing and pharmacy students reported that they were exposed to SHS in public places a week before the survey; which demonstrates that although the legislation prohibiting smoking was in effect, implementation and enforcement had to be further strengthened at both the central and state levels.
Data from the GHPSS shows that dental and pharmacy colleges are more likely than medical and nursing colleges to have a policy banning smoking in school / college buildings and clinics, however, there is no statistical difference in ever smoking by students in dental, medical, nursing, and pharmacy school / college buildings This finding further suggests that effective enforcement of ITCA 2003 in dental, medical, nursing, and pharmacy school / college buildings, clinics, and in the entire campuses of medical / dental / nursing and pharmacy schools / colleges is needed, to raise awareness of the ban at institutional, health, and educational facilities and the importance of enforcing the ban.
The present study clearly shows that training to assist patients with cessation is insufficient (22.3% of medical and 10.5% of dental, 37.6% of nursing and 29.6% of pharmacy students learned cessation approaches to use with patients) and most of medical students and dental students want to receive specific training on cessation techniques. This information calls for the development, implementation, and evaluation of evidence-based programs to be used in schools and the need for the development of training materials and curriculum.
The majority of medical (82.5%), dental (73.8%), and pharmacy (63.6%) students who currently smoked stated that they wanted to stop smoking. This finding suggests a need to develop, pilot test, evaluate, and implement effective cessation programs to supplement the existing international knowledge base with proven strategies that work in India.  The Ministry of Health and Family Welfare has opened 18 tobacco cessation clinics throughout the country.  Faculties in the dental, medical, nursing, and pharmacy schools / colleges need to be trained by cessation experts in tobacco cessation clinics, and tobacco cessation clinics need to be initiated in all the dental, medical, nursing, and pharmacy schools and colleges of India, to provide cessation help to medical / dental students and others coming for similar help. Furthermore, those tobacco cessation clinics established in the medical / dental / nursing / pharmacy institutes can provide formal cessation training to students being trained in that institution.
| » Conclusion|| |
Passing the ITCA in 2003 and ratifying the WHO FCTC in 2005 were very important tobacco control measures for India. Effective enforcement of the provisions in the ITCA and meeting the obligations of the WHO FCTC will be a continuing challenge to the Indian Ministry of Health and Family Welfare. Such data collected in the GHPSS can assist in monitoring and evaluating both the provisions of ITCA and the Articles of WHO FCTC. Furthermore, the GHPSS results can also be used to identify new program efforts that are needed to lead India toward a more effective comprehensive tobacco control program. The synergy created by India's leadership in passing the 2003 ITCA, in ratifying the WHO FCTC, and in conducting surveys such as the dental, medical, nursing, and pharmacy GHPSS, offers India an excellent opportunity to develop, implement, and evaluate its tobacco control policy, so that the most effective tobacco control program can be implemented in India.
| » References|| |
|1.||Government of India. The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003, and rules framed there under. |
|2.||World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003. Available at http://www.who.int/tobacco/framework |
|3.||The Global Tobacco Surveillance System Collaborating Group. The global tobacco surveillance system (GTSS): purpose, production and potential. J Sch Health 2005;75:15-24. |
|4.||Shah BV, Barnwell BG, Bieler GS. Software for the Statistical Analysis of Correlated Data (SUDAAN): User′s Manual. Release 7.5, 1997 (software documentation). Research Triangle Park, NC: Research Triangle Institute; 1997. |
|5.||Reddy KS, Gupta PC, editors. Report on Tobacco Control in India. New Delhi: Ministry of Health and Family Welfare, Government of India; 2004. |
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[Table 1], [Table 2], [Table 3]
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