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  Table of Contents  
ORIGINAL ARTICLE
Year : 2012  |  Volume : 49  |  Issue : 4  |  Page : 425-430
 

Tobacco use and cessation counseling in India-data from the Global Health Professions Students Survey, 2005-09


1 Healis-Sekhsaria Institute for Public Health, Navi Mumbai, India
2 World Health Organization, Regional Office for South-East Asia, New Delhi, India
3 School of Preventive Oncology, Patna, India
4 US Centers for Disease Control and Prevention, Atlanta, USA

Date of Web Publication26-Feb-2013

Correspondence Address:
M S Pednekar
Healis-Sekhsaria Institute for Public Health, Navi Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.107751

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 » Abstract 

Context: Tobacco use by health professionals reflects the failure of healthcare systems in protecting not only beneficiaries of the system but also those involved in health care delivery. Aim: The aim of this study was to report findings from the Global Health Professions Students Survey (GHPSS) conducted in medical, dental, nursing and pharmacy schools in India. Settings and Design: A cross-sectional survey was conducted in Indian dental and medical schools (in 2009), nursing (in 2007), and pharmacy (in 2008) schools. Materials and Methods: Anonymous, self-administered GHPSS questionnaire covering demographics, tobacco use prevalence, secondhand smoke (SHS) exposure, desire to quit smoking and training received to provide cessation counseling to patients was used. Statistical Analysis: Proportions and prevalence were computed using SUDAAN and SPSS 15.0. Results: Current cigarette smoking and other tobacco use ranged from 3.4-13.4% and 4.5-11.6% respectively, in the four health professional schools, with the highest numbers for medical schools and males. Enforcement of smoking ban in medical schools was low (53%) compared to nursing (86.4%), pharmacy (85.5%), and dental (90.8%) schools. Ninety percent students thought health professionals have a role in giving smoking cessation advice to their patients. Three out of five current smokers wanted to quit. However, one out of two reported receiving help/advice to quit. Although all expressed the need, 29.1-54.8% students received cessation training in their schools. Conclusion: Tobacco control policy, cessation training and initiatives to help students quit smoking should be undertaken.


Keywords: Cessation training, health professionals, tobacco use


How to cite this article:
Surani N S, Pednekar M S, Sinha D N, Singh G, Warren C W, Asma S, Gupta P C, Singh P K. Tobacco use and cessation counseling in India-data from the Global Health Professions Students Survey, 2005-09. Indian J Cancer 2012;49:425-30

How to cite this URL:
Surani N S, Pednekar M S, Sinha D N, Singh G, Warren C W, Asma S, Gupta P C, Singh P K. Tobacco use and cessation counseling in India-data from the Global Health Professions Students Survey, 2005-09. Indian J Cancer [serial online] 2012 [cited 2020 Sep 28];49:425-30. Available from: http://www.indianjcancer.com/text.asp?2012/49/4/425/107751



 » Introduction Top


Tobacco use is described as the single most preventable cause of morbidity and mortality globally, with the World Bank predicting over 450 million tobacco deaths in the next 50 years, if the present scenario does not change. [1] Tobacco-related mortality in India is among the highest in the world, [2] with about 700,000 annual deaths attributable to smoking in the last decade and expected to increase to one million in the current decade. [3] The Global Adult Tobacco Survey (GATS) India revealed that more than one third (35%) of adults; 48% males and 20% females, use tobacco in some form or the other. [4] Tobacco control is a multisectoral issue that needs active collaboration of various health professions, departments/ministries, civil society and non-governmental organizations. [5] Although both smokers, [6] and smokeless tobacco users, [7] derive substantial benefits from cessation, few successfully give up tobacco use. In India, only 1.7% were former daily smokers with the highest percentage in Kerala (4.9%) and lowest in Punjab, Chandigarh, and West Bengal (0.2%). [4] In order to reduce tobacco-related deaths and disease, current users must quit, which requires special efforts to help them quit. Health professionals play a pivotal role in tobacco cessation and in motivating people not to initiate consumption of tobacco. Several studies have shown that tobacco cessation advice provided by health professionals' enhances the quit rate among their patients. [8] Despite the body of knowledge on health professionals' role in tobacco cessation, a recent review, [9] highlights the high prevalence of tobacco use among health professionals, although such trends may not be uniform across all countries. It also highlights a few weaknesses in these studies such as lack of standard definition for smoking status, different sampling methods, questionnaires and data collection procedures and lack of studies from many low or middle income countries. To overcome these limitations the World Health Organization, US Centers for Disease Control and Prevention, and the Canadian Public Health Association developed and implemented the Global Health Professions Student Survey (GHPSS) to collect data on tobacco use and cessation counselling among health-profession students, which is a part of the global tobacco surveillance system (GTSS). [10] We report findings from surveys conducted in India from the latest round of GHPSS.


 » Materials and Methods Top


GHPSS is a school based survey of third year students pursuing advanced degrees in dentistry, medicine, nursing, or pharmacy. GHPSS uses standardized sampling, data collection and data processing procedures.

Sampling

In India, a sample of schools (medical, dental, nursing and pharmacy) was drawn and a census of third year students completed the survey. In the present, a GHPSS study in schools in India, medical (2009) and dental (2009), nursing (in 2007) and pharmacy (in 2008) are included [Table 1]. Of the 170 medical schools recognized by the Indian medical council that offer medical degrees, 15 schools were sampled in surveys conducted in 2009. Similarly, of the 150 dental schools recognized by the dental council of India, 15 dental schools were sampled in 2009. For nursing, 22 schools were sampled in 2007 and 25 pharmacy schools were sampled in 2008.
Table 1: Response rates: Global health professions student survey-India

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For data collection, GHPSS used an anonymous, self-administered questionnaire covering demographics, prevalence of cigarette smoking and the 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 India 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 deleting questions not relevant to the country. The GHPSS was conducted in schools during regular lectures and class sessions 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, a software developed for the analysis of multistage survey data, was used for analysis of the dataset, to calculate prevalence estimates and 95% confidence intervals.


 » Results Top


Response rate

[Table 1] lists the number and response rates of schools and students by health professional course and the year in which the survey was conducted for each course. The school (student) response rate is calculated as the number of participating schools (students) divided by the number of targeted schools (students enrolled in the class). The school response rate and the student response rates are represented in [Table 1]. The proportion of females ranges from 33% in medical to 87.4% in nursing.

Tobacco use

Ever tobacco use


Comparison of the most recent year GHPSS data for medical, dental, nursing and pharmacy students reveals that prevalence of ever cigarette smokers was higher among medical students (40%) compared to pharmacy (26.3%), dental (22%) and nursing students (12.5%). Similarly, higher prevalence of ever users of other products among medical students (40.5%) compared to dental (28.4%), pharmacy (22.4%) and nursing students (18.7%) was also observed.

The prevalence of ever cigarette smokers was higher among male students compared to female students for all the four disciplines. Similarly, the prevalence of ever users of other products was also higher among male students compared to female students for all disciplines except dental.

Current tobacco use

Comparison of the GHPSS data for medical (2009), dental (2009), nursing (2007) and pharmacy (2008) students reveals highest prevalence of current use of tobacco in smoking or in other forms among medical students (13.4%, 11.6%) followed by pharmacy (13.0%, 10.6%), dental (6.5%, 8.6%) and nursing students (3.4%, 4.5%). The prevalence of current cigarette smokers was higher among male students compared to female students for all the four disciplines [Table 2]. Similarly, the prevalence of current users of other products was also higher among male students compared to female students for all disciplines except medical and pharmacy.
Table 2: Tobacco use among 3rd year Indian health professions students

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Initiation of smoking before 16 years of age

The highest proportion of ever cigarette smokers initiating smoking before 16 years of age was among nursing students (48.4%) followed by medical (34.20%), dental (23.3%) and pharmacy students (17.7%). There were no gender differentials except for nursing students where more females initiated smoking before 16 years age than male students [Table 2].

Addiction

About six out of ten current smokers in all the four health disciplines expressed a desire for a cigarette within 30 minutes of waking up [Table 2].

Exposure to secondhand smoke

The highest exposure to SHS at home as well as in public places was reported by medical students while the lowest was reported by nursing students [Table 3]. More males than females reported exposure to SHS at home except pharmacy students and in public places except medical students.
Table 3: Exposure to second-hand smoke among 3rd year Indian health professions students

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Existence and enforcement of a ban on smoking in schools

The lowest proportion of medical students reported existence of official smoking ban policy (48%) and its effective enforcement in their respective schools (53%) compared to nursing (68.1%, 86.4%), dental (67.6%, 90.8%) and pharmacy (48.8%, 85.5%) students [Table 4]. In addition, over 80% of students from all the four disciplines thought smoking should be banned in all enclosed public places (ranges from 86.6% in nursing to 93.7% in dental), tobacco sale to adolescents should be banned (ranges from 83.9% in nursing to 90.2% in medical) and there should be a complete ban on tobacco product advertisement (ranges from 79.9% in pharmacy to 84.8% in dental).
Table 4: Existence and enforcement of ban on smoking in Indian health professions schools

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Health professional roles and training

Around 90% of the students from all the four disciplines thought health professionals have a role in giving advice about smoking cessation to their patients. In contrast, only about 70% students thought that health professionals serve as role models to their patients [Table 5]. Even though most of the students from all four disciplines expressed the need for cessation training, very few (ranges from 29.1-54.8%) reported having ever received formal training in their professional school.
Table 5: Efforts of Indian health professions schools in providing knowledge, training and help to curb tobacco use

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 » Discussion Top


The study indicates that tobacco use is prevalent among health professional students in India. The issue of tobacco use amongst Indian health professional students is a major cause of concern, because it not only endangers their health, but will also reduce their ability to deliver effective anti-tobacco counseling when they start seeing patients. If health professionals are able to successfully restrain themselves from tobacco use, they will be in a better position to help their patients do the same. To do so, they need proper guidance and cessation support.

Most of the health professional students in the present study understand that the health care providers are role models and it is their moral obligation to provide advice to quit tobacco use to the patients attended by them. However, it is also noted from the present study that there is almost negligible formal training on tobacco cessation in health professional educational institutions. Similar findings are noted from several other countries in the South-East Asia Region and outside the region. [10],[11],[12],[13] However, there are countries with better training and cessation environment. Countries should learn from them and adopt the best practices. [10],[11],[12],[13]

Tobacco control efforts in India for many decades have not fully utilized the immense potential that health professionals have to offer in controlling tobacco related deaths that can be easily averted. Health care institutions are public places. Under tobacco control rules in India; they should implement smoke-free policies that would be exemplary for implementation of a smoke-free policy for other public places. Smoke-free policies in schools may help in reducing tobacco prevalence amongst its students. Therefore they should be extended to include not just a ban on smoking but a ban on using other tobacco products as well. Smoke-free policies in schools may be influenced by laws on smoke-free policies in public places. Strengthening these policies may be beneficial in the long run. It will be helpful to understand how some other countries in the Region and outside are handling the tobacco problem amongst their health professional students, and also in learning from other better performing countries like Thailand or Sri Lanka. Periodic GHPSS should be carried out to evaluate the change in the prevalence of tobacco use among Indian health professional students, implementation of a ban on use of tobacco in such schools, and provision of training in cessation techniques. Tobacco-one of the leading causes of death in the world, affects almost every part of the human body. Therefore, any health professional, be it from medicine, dentistry, nursing or pharmacy can contribute to tobacco control. A sensitized, responsible, and tobacco-free student, along with a formally devised curriculum for tobacco cessation and effective school policies can strengthen tobacco control efforts in India.


 » Acknowledgment Top


This work would not have been possible without the data collected for the Global Health Professions Students Survey (GHPSS) 2005-09 in India. We sincerely acknowledge the contributions of the World Health Organization, Regional Office for South-East Asia and the country office for India; Centers for Disease Control and Prevention (CDC); CDC Foundation, Association, Atlanta; Research Triangle Institute (RTI) International and Johns Hopkins Bloomberg School of Public Health (JHSPH) for their dedicated efforts in publishing the findings in this survey.

 
 » References Top

1.Jha P, Chaloupka FJ. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington DC: The World Bank 1999. Available from: http://www.usaid.gov/policy/ads/200/tobacco.pdf. [Last accessed on 2012 Aug 31].  Back to cited text no. 1
    
2.Murthy P, Saddichha S. Tobacco cessation services in India: Recent developments and the need for expansion. Indian J Cancer 2010;47:69-74.  Back to cited text no. 2
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3.Gajalakshmi V, Peto R, Kanaka TS, Jha P. Smoking and mortality from tuberculosis and other diseases in India: Retrospective study of 43000 adult male deaths and 35000 controls. Lancet 2003;362:507-15.  Back to cited text no. 3
[PUBMED]    
4.Global Adult Tobacco Survey India Report 2009-2010. Ministry of Health and Family Welfare, Government of India.  Back to cited text no. 4
    
5.Sinha DN, Singh G, Singh S. Report on India Global Health Professionals Survey (Medical), 2006. Ministry of Health and Family Welfare, Government of India. World Health Organization, India Office.  Back to cited text no. 5
    
6.US Department of Health and Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General, 1990;1-618.  Back to cited text no. 6
    
7.Gupta PC, Murti PR, Bhonsle RB, Mehta FS, Pindborg JJ. Effect of cessation of tobacco use on the incidence of oral mucosal lesions in a 10-years follow-up study of 12,212 users. Oral Dis 1995;1:54-8.  Back to cited text no. 7
[PUBMED]    
8.Gorin SS, Heck JE. Meta-analysis of the efficacy of tobacco counseling by health care providers. Cancer Epidemiol Biomarkers Prev 2004;13:2012-22.  Back to cited text no. 8
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9.Smith DR, Leggat PA. An international review of tobacco smoking in the medical profession: 1974-2004. BMC Public Health 2007;7:115.  Back to cited text no. 9
[PUBMED]    
10.The GTSS Collaborative Group. Tobacco use and cessation counselling: Global health professionals survey pilot study, 10 countries, 2005. Tob Control 2006;15:ii31-4.  Back to cited text no. 10
    
11.Warren CW, Sinha DN, Lee J, Lea V, Jones N, Asma S. Tobacco Use, exposure to secondhand smoke, and cessation counseling training among dental students around the world. J Dent Educ 2011;75:385-405.  Back to cited text no. 11
[PUBMED]    
12.Warren CW, Sinha DN, Lee J, Lea V, Jones NR. Tobacco use, exposure to secondhand smoke, and training on cessation counseling among nursing students: Cross-country data from the Global Health Professions Student Survey (GHPSS), 2005-2009. Int J Environ Res Public Health 2009;6:2534-49.  Back to cited text no. 12
[PUBMED]    
13.Warren CW, Sinha DN, Lee J, Lea V, Jones NR. Tobacco use, exposure to secondhand smoke, and cessation counseling among medical students: Cross-country data from the Global Health Professions Student Survey (GHPSS), 2005-2008. BMC Public Health 2011;11:72.  Back to cited text no. 13
[PUBMED]    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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