|Year : 2012 | Volume
| Issue : 4 | Page : 327-335
Involvement of health professionals in tobacco control in the South-East Asia Region
S Venkatesh1, DN Sinha2
1 Department of AIDS Control, Ministry of Health and Family Welfare, India
2 Tobacco Free Initiative, World Health Organization, Regional Office for South-East Asia, India
|Date of Web Publication||26-Feb-2013|
Department of AIDS Control, Ministry of Health and Family Welfare
Source of Support: None, Conflict of Interest: None
Tobacco use is widely entrenched in the South-East Asia (SEA) Region leading to high morbidity and mortality in this region. Several studies revealed that tobacco use is widespread among youth and school children. Exposure to second-hand smoke was reported as around 50% or more in three countries - Myanmar (59.5%), Bangladesh (51.3%), and Indonesia (49.6%). Health profession students encompassing medical, dental, nursing and pharmacy disciplines, and even qualified health professionals are no exception from tobacco use. While they are regarded as role models in tobacco cessation programs, their tobacco addiction will carry a negative impact in this endeavour. A mere inquiry about the smoking status of patients and a brief advice by doctors or dentists increases quit rates and prompts those who have not thought about quitting to consider doing so. Evidence from some randomized trials suggests that advice from motivated physicians to their smoking patients could be effective in facilitating cessation of smoking. However, the low detection rate of smokers by many physicians and the small proportion of smokers who routinely receive advice from their physicians to quit have been identified as a matter of concern. This paper describes the role and issues of involvement of health professionals in tobacco control. Data from a variety of sources is used to assess the status. Although there are some differences, tobacco use is widespread among the students and health professional students. Exposure to second hand smoke is also a matter of concern. Tobacco-related problems and tobacco control cut across a vast range of health disciplines. Building alliances among the health professional associations in a vertical way will help synergize efforts, and obtain better outcomes from use of existing resources. Health professional associations in some countries in the SEA region have already taken the initiative to form coalitions at the national level to advance the tobacco control agenda. In Thailand, a Thai Health Professional Alliance against Tobacco, with 17 allies from medical, nursing, traditional medicine, and other health professional organizations, is working in a concerted manner toward promoting tobacco control. Indian Dental Association intervention is another good example.
Keywords: Doctors, dentists, health professional students, nurses, pharmacists, smoking, tobacco use
|How to cite this article:|
Venkatesh S, Sinha D N. Involvement of health professionals in tobacco control in the South-East Asia Region. Indian J Cancer 2012;49:327-35
| » Introduction|| |
The use of tobacco products is one of the most important determinants of both individual and community health. It has emerged as the leading preventable cause of premature disease and death in the world.  In the 20 th century, the tobacco epidemic killed an estimated 100 million people worldwide. At the turn of this century, almost six million people would be dying from tobacco use each year, both from direct tobacco use and second-hand smoke. This number is expected to exceed eight million deaths by 2030, with approximately 70% of these deaths occurring in developing countries.  Tobacco use is an important modifiable risk factor for major non-communicable diseases (NCD) - cancer, cardiovascular diseases, chronic respiratory diseases and diabetes, and is responsible for 1 in 6 of all NCD deaths globally.  Containing this epidemic is among the most important public health priorities. Unless urgent action is taken now, it will kill more than one billion in the current century.
Data from several studies indicate that tobacco smokers have 2-3-fold higher relative risk of coronary heart disease (CHD), 1.5 times for stroke, 1.4 times for chronic obstructive pulmonary disease and 12-fold risks for lung cancer. The relative risks are 5-6 times higher in the younger age groups. The risks are similar for men and women. , The risks have been proven to decrease rapidly following quitting of smoking.  Even exposure to second-hand smoke increases the risk of developing and progression of atherosclerosis.  Tobacco smoke has synergistic action with other risk factors.
About 1.3 million tobacco attributable deaths occur every year in countries of the SEA region - Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste. Tobacco use is a growing public health menace in the region which is home to over 240 million smokers (about one quarter of all smokers in the world) besides a large number of smokeless tobacco users. Almost two-fifths of all tobacco cancer deaths in this region are linked with smoking. INTERHEART  , a case-control study, estimated the population attributable risk for smoking as risk factor for incident myocardial infarction as 37.4% among South-Asia countries (comprising Bangladesh, Nepal, India, and Sri Lanka) and 36% among other Asian countries (including Japan, Malaysia, Philippines, Singapore, and Thailand). The age and sex-standardized adult daily smoking prevalence in 2009 in the SEA Region is high varying from 29% in Indonesia and 28% in Nepal to 12% in India and 11% in Sri Lanka.  Maldives had a prevalence of 24%, Bangladesh 22%, Thailand 20%, and Myanmar 18%.
Tobacco surveys in the South-East Asia Region
Guided by the World Health Organization and the Centers for Disease Control and Prevention (CDC), and Canadian Public Health Association, many countries had taken the initiative to generate reliable data on tobacco use and key tobacco control measures at regular intervals for a better understanding and response with effective tobacco control intervention. To study current tobacco use prevalence among youth, Global Youth Tobacco Survey (GYTS) was conducted at the national level in Bangladesh (2007), Bhutan (2009), India (2009), Maldives (2007), Myanmar (2007), Nepal (2007), Sri Lanka (2007), Thailand (2009), and Timor-Leste (2009), and at the sub-national level (Java and Sumatra) in Indonesia (2009). 
There was a high overall response rate which ranged from 77.3% to 97.5%. The prevalence of current tobacco use among school students aged 13-15 years varied from 5.9% in Maldives to 56.5% in Timor-Leste. Among male students, tobacco use varied from 8.5% in the Maldives to 60.2% in Timor-Leste, and among female students, it varied from 3.4% in the Maldives to 53.4% in Timor-Leste. With the exception of Bangladesh, Sri Lanka and Timor-Leste, a higher percent of males used tobacco when compared to females. 
Among students aged 13-15 years, prevalence of current manufactured cigarette smoking varied from 1.2% in Sri Lanka to 24.6% in Timor-Leste. Among male students, current manufactured cigarette smoking varied from 1.6% in Sri Lanka to 41% in Indonesia (Java and Sumatra), while, among female students, it ranged from 0.9 % in Sri Lanka to 14.6% in Timor-Leste. Current use of tobacco other than manufactured cigarettes varied from 3.5% in the Maldives to 51.6% in Timor-Leste. Among male students, prevalence of smoking was more than 20% in three countries - Indonesia (41%), Timor Leste (38.2%) and Thailand (20.1%), while for use of tobacco other than manufactured cigarettes, prevalence was reported to be more than 10% in seven countries. Among female students, use of tobacco other than manufactured cigarettes varied from 2.7% in the Maldives to 50.1% in Timor-Leste and prevalence was reported to be over 5% in seven countries.
Global Adult Tobacco Survey (GATS), a household survey of persons age 15 and above, was conducted in Bangladesh (2009), India (2009-2010) and Thailand (2009) at the national level.  Among adults aged 15 and above, the prevalence of current tobacco use varied from 27.2% in Thailand to 43.3% in Bangladesh. Among both men and women prevalence was lowest in Thailand and highest in Bangladesh. In India, the prevalence of current tobacco use was 34.6%. In all three countries, current tobacco use considerably higher among men than among women, and current use of other tobacco products was higher than use of manufactured cigarettes. Prevalence of smoking among men was especially high, in terms of proportion and absolute numbers, in Bangladesh, India, Indonesia, Myanmar, and Thailand. It ranged from 24.3% (India) to 63.1% (Indonesia). The prevalence of smokeless tobacco use among men varied from 1.3% (Thailand) to 31.8% (Myanmar). Although women commonly used smokeless tobacco with prevalence ranging from 4.6% (Nepal) to 27.9% (Bangladesh), there was a rising trend in smoking among women, with prevalence varying from 0.4% (Sri Lanka) to 15% (Myanmar and Nepal). Tobacco use among youth, especially smoking, was quite high. Key factors that have contributed to the tobacco epidemic in the region include abundant tobacco production, weak enforcement of tobacco control measures, and easy accessibility and affordability of tobacco products. 
GATS showed that respondents said that health care providers asked smoking history in 59.1% cases in Thailand, 56.6% in Bangladesh, 53.2% cases in India, and 40.5% of cases in Indonesia. For cessation, pharmacotherapy was provided in 4% cases in India and 10.6% in Thailand, and counseling given in 14.9% in Bangladesh, 9.2% in India, and 5.8% in Thailand. These findings underscore the need for tobacco cessation help for health professionals in the form of formal training on cessation and tobacco control talks in various health professional meetings.
Thus, the findings from both GYTS and GATS point to the high current tobacco use other than manufactured cigarettes among youth and adults in the region. While smoking is the predominant practice among adult males, smokeless tobacco use is more common among females. It becomes, therefore, important for national tobacco control policies to address all tobacco products and not just limit to manufactured cigarettes. Youth interventions should be developed/strengthened to emphasize all tobacco products in the region. Reducing tobacco use is one of the best buys for preventing NCDs. Tobacco control interventions have high impact on burden of NCDs, and are highly feasible, directed toward whole population, these will be benefit the poor, and reduce inequities. Immediate action is called for in countries of the SEA region to achieve global goal by 2040 of a world essentially free from tobacco where less than 5% of the population use tobacco.
Health professional students surveys
While only a few studies had collected information on tobacco use, exposure to second-hand smoke, and training to provide cessation counseling among health professional students used different sampling methods, questionnaires, and data collection procedures, the WHO, U.S. 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 Professional Students Survey (GHPSS).  GHPSS includes school-based surveys of dental, medical, nursing, and pharmacy students in their third year. The surveys have revealed an alarming proportion of health professional students currently smoked cigarettes and used other tobacco products. Although the majority of students in nursing, medical and dental schools believed that should receive training to assist patients with tobacco cessation, only a small proportion of students have received such training. The surveys have also drawn attention to the significant unmet need for cessation assistance among health professional students as well as to gaps in their professional training to provide similar effective assistance to future patients.
In SEA region, the Nursing GHPSS conducted in Bangladesh, India, Sri Lanka, and Thailand, has shown significant unmet need for cessation assistance among nursing students as well as gaps in professional training to provide similar effective assistance to their future patients. In Bangladesh and Sri Lanka, the survey included a census of students and schools in all locations, while in India and Thailand; it covered a census of students in a sample of schools. The school and class response rates were 100% in all four countries, the student response and overall response rates ranged from 88.9% in Thailand to 93% in India. The number of students who participated in each survey varied from 443 in Sri Lanka to 1,594 in Thailand due to the number of schools and students in each sample design. Profile of the students surveyed showed that the percentage of nursing students who were females ranged from 87.4% in India to 93.8% in Thailand. The vast majority of the students were under 25 years of age, the proportion varied from 74.9% in Sri Lanka to 99.0% in India.
The proportion of nursing students who currently smoked cigarettes ranged from 1.1% in Thailand to 4.0% in Bangladesh. There was a significant gender difference in current smoking in all four countries, with males were significantly more likely to smoke than females. The proportion of nursing students currently using other tobacco products varied from 1.0% in Thailand to 8.1% in Bangladesh. Males were more likely than females to use other tobacco products; however, this difference was significant ( P < 0.05%) only in case of Bangladesh, India, and Sri Lanka and not significant ( P = 0.16%) in case of Thailand.
Over 60% of nursing students reported they were exposed to SHS in public places in 23 of the 39 sites. However, in 15 of the 39 sites over 60% of the students reported their schools have an official policy banning smoking in school buildings and clinics. Enforcement of the school policies is very high. Over 70% of nursing students recognize that they are role models in society (in 37 of 38 sites), over 90% think they should receive training on counseling and treating patients to quit using tobacco (30 of 39 sites), but less than 40% have received formal training in 28 of 39 sites. The school administrators informed that there was no formal training on patient cessation techniques at any time.
In a study of health care providers, dentists were found less active than other health professionals in counseling on smoking cessation.  In dental GHPSS, the student response rate varied from 96.1% for Thailand to 75.7% for Myanmar.  Current cigarette smoking was over 20% in Myanmar (34.4%) and Bangladesh (20.9%) and below 4% in Thailand (3.9%). Males had significantly higher smoking rates than females in all six countries. Use of other tobacco products ranged from 29.4% in Myanmar to less than 2% in Indonesia (1.2%) and Thailand (0.3%), males had a higher use rate than females in all sites except Bangladesh which showed no gender differential.
Exposure to second-hand smoke was reported as around 50% or more in three countries - Myanmar (59.5%), Bangladesh (51.3%), and Indonesia (49.6%). Exposure to SHS was more than 70% in Myanmar (86.4%) and Indonesia (82.3%). Over 88% of the students thought that dentists had a role in giving advice or information on smoking cessation to patients - highest being in Indonesia (98.7%) and lowest in Myanmar (88.8%). Except Myanmar (69.3%), over 80% in all countries thought that health professionals should get specific training on smoking cessation techniques. While 54.8% of students in India and 26.8% of those in Bangladesh had received formal training in smoking cessation approaches, there was a paucity of training in the five other countries with the reported proportion being less than 12%
In Medical GHPSS conducted in seven states  (Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Thailand), the overall student response rate varied from 89.1% in India to 63.8% in Thailand. Sri Lanka and Thailand sites had current smoking rates among medical students less than 5%. In all sites, males were 8-22 times more likely than females to smoke cigarettes except Thailand where current smoking rate among female students at 3% was higher compared to that of 1% among male students. Current cigarette smoking was over 20% in Bangladesh and Nepal and less than 5% in Sri Lanka and Thailand. Use of other tobacco products ranged from over 10% in Bangladesh, Myanmar, and Nepal to less than 10% in the other four sites. Males were more likely than females to use other tobacco products in all sites. Over 65% of the students who reported that they were current cigarette smokers expressed a desire to quit smoking cigarettes in all sites except Bangladesh where only 26.6% of the smokers wished to quit smoking.
Over 40% of the students reported that they had been exposed to SHS in their home in the past seven days in five sites. In case of Sri Lanka and Thailand, this proportion was less than 30%. The proportion of students reporting their schools have an official policy banning smoking in school buildings and clinics was 40% or more in six sites and 39.4% in Sri Lanka. Over 90% of the students thought health professionals have a role in giving advice about smoking cessation to patients in six sites. The lowest was in Bangladesh (71.1%). Over 90% thought that health professionals should get special training on cessation techniques in all sites except Bangladesh (87.8%). Less than 25% 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 all sites with the exception of Myanmar (43.7%).
In India, a very low prevalence of tobacco use among medical students was reported from Orissa (2009).  A study from Lucknow, of 250 undergraduate medical students in 2008 found a 28.8% current tobacco prevalence, with 37.5% reporting primary smokeless forms of tobacco use.  Similarly, in a cross-sectional survey in Kerala carried out in 2006 among 110 male faculty of medical schools, 229 physicians and 1130 medical students, 15.1% of the faculty, 13.1% of physicians and 14.1% of medical students reported current tobacco use.  When only males are considered, the proportion becomes much higher. While 42% of the faculty and physicians and 51% of the medical students had not made any quit attempt in the previous year, a third of the faculty and physicians and 16% of medical students had attempted to quit at least four times.
Medical students in India and Indonesia also have inadequate perceptions of harm from tobacco use. In a study of 1100 medical students in India reported in 2009, 33% viewed smoking five to 10 cigarettes per day as being relatively harmless. There was a similar perception among Indonesian medical students.23 In both countries, while students readily perceived a link between smoking and lung cancer, they were not aware of its relationship with many of the other well-established diseases associated with tobacco use.
Role of physicians
Health professionals, including physicians, nurses, midwives, dentists and pharmacists, have an important role to play in tobacco control through promotion of tobacco-free lifestyles and cultures. There is increasing recognition of tobacco dependence as a chronic disease, one typically requiring ongoing assessment and repeated intervention. Several studies in the west have shown that tobacco cessation advice provided by health professionals enhances the quit rate among their patients. ,,,,, On the occasion of the WHO World No Tobacco Day 2005 on the theme, 'health professionals and tobacco control', WHO, CDC, and World Medical Association together gave a clarion call for engaging health professionals in tobacco control.
At the individual level, health professionals, as part of their activities, can educate the population on the harms of tobacco use and exposure to second-hand smoke and provide advice and guidance and answer their questions. They can help tobacco users overcome their addiction by advising them that quitting tobacco is the best thing that can be done for one's own health. They can raise awareness about the immediate and long-term benefits of doing so and remind patients that stopping smoking at any age results in tremendous health benefits, and the earlier one quits, the better. Along with the counseling to quit smoking, they can offer their patients tobacco dependence treatments in the absence of contraindications. It takes health professionals less than three minutes to provide this brief assessment and advice to all their patients. An increasing array of options can be offered to enhance the effectiveness of advice and to assist people who want to quit - pharmacotherapies, including nicotine replacement therapy or bupropion, and behavioral counseling and support, either face-to-face or via telephone quit line services. Research has shown that simple advice from a physician significantly increases abstinence rates (by 30%) compared to no advice. Likewise, nursing-led interventions for smoking cessation increase by 50% the chances of successfully quitting. Cessation rates increase with repeated counseling by nurses. Interventions that use multiple providers are very effective: The more a person hears a consistent message from all health professionals, the more likely that he/she will be able to quit successfully.
A Cochrane review of 41 trials, published between 1972 and 2007 covering over 31,000 participants, confirmed that brief advice from physicians is effective in promoting smoking cessation.  A meta-analysis incorporating 28 trials and over 20,000 participants showed that a brief advice intervention is likely to increase the quit rate by one to three percentage points. Evidence from some randomized trials suggests that advice from motivated physicians to their smoking patients could be effective in facilitating cessation of smoking.  However, the low detection rate of smokers by many physicians and the small proportion of smokers who routinely receive advice from their physicians to quit has been identified as a matter of concern.  Even if the effectiveness of facilitating smoking cessation by physicians is small, were a large numbers of physicians to offer this advice, the net effect on reducing smoking rates could still be substantial.  Physicians should be encouraged to routinely identify all people who smoke and to provide smoking cessation advice. ,
At the community level, health professionals can help influence policy change for better tobacco control. They can be initiators or supporters of policy measures such as promoting smoke-free workplaces and extending the availability of tobacco cessation resources. At the provincial and national levels, health professionals can add their voice and their weight to tobacco control efforts like tax increase campaigns and involve themselves in promoting the WHO Framework Convention on Tobacco Control (WHO FCTC).
While health professionals are looked up to as role models by the general public, many among them are themselves addicted to tobacco. Tobacco use among health professionals is an important barrier to their providing tobacco cessation services.  Research has shown that health professionals who are smokers are less likely to promote smoking cessation or engage in tobacco control. Many of them have not received formal training in providing tobacco cessation. More efforts need to be made by health professional organizations and health professional schools to assist them in becoming the tobacco-free role models.
In a situation where the vast majority of the general populations are accessing health professionals annually, every smoker who does not receive advice in such contacts represents a 'missed opportunity'. While lifestyle advice may be offered during the health consultation, advice on smoking may still not be offered in a systematic manner. , Some primary care physicians feel that such advice need not be given at every consultation,  or that it may impact on a positive doctor-patient relationship.  However, there is growing evidence that tobacco users who receive clinician advice and assistance with quitting report greater satisfaction with their health care than those who do not. Thus, satisfaction may only be increased by provision of this advice. 
It has been suggested that questions about tobacco use should be included when monitoring vital signs and, at every encounter with a patient, the health professional must assess tobacco use and note it on the patient's chart. A brief simple advice given by physicians to their smoking patients offers immense potential benefit. Realizing this benefit requires that the health professionals are prepared to systematically identify their smoking patients and offer them advice as a matter of routine. Provision of follow-up, where possible, is likely to offer additional benefit. The national clinical practice guidelines should advocate the use of a brief intervention in which asking about tobacco use is followed by advice to quit. An assessment should be made of the smoker's willingness to make a quit attempt, and willing patients offered specific assistance and follow-up. Physicians are not only responsible for smoking cessation treatment, but also for anti-smoking campaigns. 
In a study on exposure to tobacco among pregnant women coordinated by the National Institutes of Health, USA,  one-third of all pregnant women in Orissa, India, were found to use tobacco, and 20% of women in Karnataka, India were exposed to tobacco smoke. An analysis of the National Household Survey in India  found no difference in tobacco use between pregnant and non-pregnant women, clearly demonstrating that reproductive health care programs were not paying attention to discouraging tobacco use in pregnancy. International research report behavioral interventions to have a relatively better outcome over pharmacotherapy in effecting tobacco cessation in this group. 
A cross-sectional survey in Kerala  assessed the tobacco cessation efforts by medical doctors practicing in public sector in Kerala, India where smoking among males in the general population was 28%  and that among practicing male doctors in the public sector was 14%.  Analysis of information on doctor's practices, skills and perceived need for training in tobacco cessation revealed that only a third of the doctors surveyed reported always asking patients about tobacco use, three-fourths advised all patients routinely to quit (irrespective of the smoking status of patients), and one-tenth offered useful information on how to quit. About 15% reported receiving information from medical representatives, and 32% found their training sufficient. A vast majority (80%) expressed interest in receiving training to help smokers quit. Majority of all doctors surveyed asked and advised patients most commonly to quit tobacco when these patients had lung, heart, mouth disease or cancer. Most doctors inquired about tobacco use from a minority of their patients, though many reported advising patients about quitting even without inquiring about their tobacco use status. The study revealed several missed opportunities to promote quitting at a time when patients are motivated to listen. In some developed countries, a mere inquiry about the smoking status of patients by doctors or dentists increases quit rates and prompts those who have not thought about quitting to consider doing so. ,,
Even simple health education can bring about change. In a prospective intervention study in India,  an over 36,000 tobacco users were examined in a baseline survey for oral cancer and pre-cancer, and annually thereafter. At each examination, they were provided health education about their tobacco habits. At the end of 10 years, 11% of men, and 37% of women had quit tobacco use compared with 2% and 10%, respectively, of the control cohort. In addition, a substantial number of tobacco users had reduced their smoking significantly. A significantly higher percentage of leukoplakia at baseline regressed in those who had quit or reduced smoking substantially.
A study in Bihar, India, showed that community-based mass approaches, with minimal sustained interventions, were more effective than clinic-centered individual interventions.  A WHO-supported tobacco cessation program among women in Bangladesh carried out through community-and clinic-based activities has demonstrated that a tobacco cessation program can be delivered by trained health workers at the grassroots levels.  In the project implemented Ekhlaspur Centre of Health, an NGO, was started in 2001. A follow-up of tobacco use status was carried out every 6 months and further counseling provided. The tobacco cessation intervention by community health workers was evaluated in 2006. A further follow-up carried out after 18 months showed that 25% of the 184 tobacco users had quit tobacco.
| » Conclusion|| |
Each and every health professional has a duty to implement the minimal intervention steps of asking about tobacco use, assessing willingness to quit, advising quitting and further referring and arranging for cessation services. He/she should incorporate assessments of exposure to tobacco smoke and provision of information about avoiding all exposure into the practice in a variety of health care settings (including maternal-child health clinics) and clientele. Health professionals can develop and disseminate science-based and practical materials about cessation. The cessation advice can be made relevant to the patient's current situation by linking it with the existing diagnosis or current lifestyle. While the possibility of lung cancer may be compelling for an older patient who has used tobacco for a long period of time, arguments like smoking can cause bad breath, or impair performance in sports might be more relevant for a young patient.
Health professionals can play an important role in preparing new generations of health professionals and effecting positive changes in their practice. Tobacco use initiation and maintenance involves the complex interplay of social, cultural, environmental, and personal factors. Health care professionals should recognize that effective prevention will need to address these issues comprehensively. They should be aware of their wider role in the context of tobacco control, and be inspired to play a role in advocacy against tobacco use. However, surveys have shown that tobacco control content, both theoretical and practical, in health professional schools is grossly inadequate. Health professionals' curricula lack, in general, appropriate content and practice on tobacco-related matters, from prevention to cessation and policy. Although some general aspects of harms to health might be covered, the full extent of the tobacco epidemic, the breadth and depth of the problem might be overlooked. Given that tobacco is one of the most significant causes of preventable illness and death in the world, health professional schools may need to reassess the time they dedicate to this issue.
Suggestions have been made for adoption of a standard undergraduate curriculum containing comprehensive tobacco prevention and cessation training to improve their effectiveness as role models.  All aspects of tobacco control, including the harmful health effects of tobacco use and exposure to second-hand smoke, and training in counseling on tobacco cessation techniques, need to be incorporated into the existing health professionals' curricula. Tobacco control can be taught as a separate matter or be a part of existing content. The health effects of tobacco can be incorporated in a variety of disciplines and students given an opportunity to gain practical skills in assessing tobacco use, cessation and advice as well as to learn about the policy aspects of tobacco control and their benefits to public health. Curricula should include a course or supplements to existing courses specifically relevant to tobacco issues. Where administrators are resistant to making changes in the core curricula, schools should be encouraged to incorporate tobacco-related modules within existing courses.
Training time is also an ideal opportunity to offer support to health professional students who are tobacco users and are trying to quit. Educational institutions training health professional students should help tobacco users among 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. These institutions should provide smoke-free work and study areas by banning smoking in their buildings and clinics. A smoke-free work environment has been shown to improve air quality, reduce health problems associated with exposure to tobacco smoke, support and encourage cessation attempts among smokers trying to quit, and receive high levels of public support from people who spend time in the area.  Also, the creation of such smoke-free areas by health education institutions sends a clear message to educators, students, patients, and clinicians about negative impact of tobacco. A wide range of health professionals need to be involved in providing tobacco cessation in primary health care. Trained doctors and dentists should take the responsibility to train other health professionals in providing tobacco cessation.
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 professionals. Further research should be carried out to assess the impact of existing tobacco control-related materials and training provided in training schools in a variety of cultural and economic environments. Peer-reviewed pilot studies in the countries of SEA region about educational materials and techniques to build the capacity of health professionals to treat and counsel patients on cessation will facilitate the application of limited resources to effective and efficient strategies to reduce the prevalence of tobacco use. The products from such research could form a compendium of "best practices" of patient counseling for training health professionals relevant to the countries in the SEA region with a broad spectrum of health resources and infrastructures. Thus, structural/institutional interventions like creating tobacco-free hospitals and providing insurance coverage for cessation services can be combined with practice-level strategies such as including tobacco cessation training in expected health professional's competency measures for fostering a positive environment for tobacco control in the national health system. 
As scientists, health professionals can create awareness and educate funding and research agencies about tobacco consumption's impact on all aspects of individual, community and social health, so that adequate funding resources for research in addressing this worldwide epidemic can be maintained or enhanced. They can urge for research on tobacco to be included in several other health fields, such as cancer clinical trials, maternal-child health program outcomes and cardiovascular disease studies.
Health professionals in positions of leadership can get involved in the policy-making process-supporting comprehensive tobacco control measures that go beyond the availability of cessation to include smoke-free workplaces; increased taxation and prices of tobacco products; campaigns to prevent youth from taking up tobacco and funding for tobacco control programs. This leadership position can be exerted at the community, national, or global level. Health professionals can take small steps to address at least one issue at their own workplace (for example, promoting smoke-free environments) and, depending on their position, tackle larger policy and political task as the opportunity arises.
Tobacco-related problems and tobacco control cut across a vast range of health disciplines. Building alliances among the health professional associations in a vertical way will help synergize efforts, and obtain better outcomes from use of existing resources. Health professional associations in some countries in the SEA region have already taken the initiative to form coalitions at the national level to advance the tobacco control agenda. In Thailand, a Thai Health Professional Alliance against Tobacco, with 17 allies from medical, nursing, traditional medicine and other health professional organizations, is working in a concerted manner toward promoting tobacco control.
Thus, adoption of a variety of strategic approaches  involving structural/institutional interventions such as creation of tobacco-free hospitals and provision of insurance coverage for cessation services, practice-level strategies such as inclusion of tobacco cessation training in expected competency measures as well as in continuing education of health professionals, and promoting collaboration and synergy between the professionals from different disciplines will foster a positive environment for tobacco control in the national health system.
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