Health Professionals Survey on Tobacco Use and Cessation Counseling -- Lebanon 2005

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1 Health Professionals Survey on Tobacco Use and Cessation Counseling -- Lebanon 2005 Georges Saade (1) Charles W Warren (2) Nathan R Jones (2) Ali Mokdad (3) Samira Asma (2) (1) Non Communicable Disease Program World Health Organization, Beirut Office Glass Bld. 4 th Floor, Museum Square Beirut, Lebanon. (2) Office on Smoking and Health Centers for Disease Control and Prevention 4770 Buford Highway, NE MS K 50 Atlanta, Georgia USA (3) Division of Adult and Community Health Centers for Disease Control and Prevention 4770 Buford Highway, NE MS K 50 Atlanta, Georgia USA 1

2 Abstract Background. The global burden of disease estimates a doubling in the number of deaths every year attributable to tobacco use, from 5 million in 2005, to over 10 million in By providing brief and simple advice to patients regarding smoking cessation, health professionals can serve an important role in reducing tobacco use. The purpose of this paper is to describe tobacco use and attitudes towards providing patient counseling regarding smoking cessation among 3rd-year students pursuing advanced health professional degrees in Lebanon. Methods. The Global Health Professionals Survey (GHPS) produces nationally representative estimates for 3 rd year students in dental, medical, nursing, and pharmacy schools. In the Lebanese GHPS, the school response rate was 100% for all 4 disciplines and the student response rate ranged from 64.0% (dental) to 71.9% (pharmacy). The GHPS was conducted during regular lectures and class sessions using a self-administered questionnaire. Results. Current cigarette use ranged from 14.8% for pharmacy students to 31.6% for dental students. Current use of Narguileh ranged from 20.6% for medical students to 44.9% for nursing students. About 8 in 10 students in all 4 disciplines were exposed to secondhand smoke in public places. More than 8 in 10 students in medical, nursing, and pharmacy schools believed that health professionals have a role in giving advice or information on smoking cessation to their patients. More than 9 in 10 students in all 4 disciplines believed that health professionals should receive training on smoking cessation techniques. However, the amount of training ranged from 19.8% for pharmacy students to 43.7% for nursing students. Conclusions. The Ministry of Health, Ministry of Education, health profession schools, public health organizations, and educational institutions should discourage tobacco use among health professionals and work together to develop and implement programs that train all health professionals in effective patient cessation-counseling techniques. 2

3 INTRODUCTION Health professionals are generally considered to be role models in communities and can contribute to tobacco control efforts by either not smoking or quitting smoking; counseling their patients not to smoke; providing smoking cessation counseling and treatment; or being community advocates for tobacco control (1). Thus, one strategy to reduce the number of smoking-related deaths is to encourage health professionals to become involved in tobacco-use prevention and cessation counseling. There have been a few studies that collected information from health professional students in various countries about their tobacco use and training as cessation counselors; however, these studies did not use a consistent survey methodology or questionnaire (2-7). In response, the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention, and the Canadian Public Health Association developed and implemented the Global Health Professionals Survey (GHPS) to collect data on tobacco use and training in cessation counseling among health professional students in WHO member states (8). This report includes data from the GHPS conducted in Lebanon in 2005 among 3rdyear students in 4 health profession disciplines (i.e., dentistry, medicine, nursing, and pharmacy). METHODS GHPS is part of the Global Tobacco Surveillance System (GTSS), which collects data through 3 surveys: the GHPS, the Global Youth Tobacco Survey, and the Global School Personnel Survey (8). The GHPS is a school-based study of 3 rd year students pursuing advanced degrees in dentistry, medicine, nursing, or pharmacy. The survey uses a core questionnaire on demographics, prevalence of cigarette smoking and use of Narguileh, knowledge and attitudes about tobacco use, exposure to secondhand smoke (SHS), desire to 3

4 quit smoking, and training received in counseling patients on smoking cessation techniques. The GHPS was conducted in schools during regular class sessions using an anonymous, selfadministered format for data collection. The GHPS questionnaire was translated in Arabic and back-translated to check for accuracy. The GHPS uses a standardized methodology for selecting schools and students, a consistent data collection process, and uniform data-processing procedures. For the Lebanese GHPS, a census of schools and students was selected which included 3 dental schools, 6 medical schools, 9 nursing schools, and 4 pharmacy schools. The school response rates were 100% in all 4 disciplines, and the student response rates were: dental, 64.0% of 71 students; medical, 69.0% of 243 students; nursing, 68.3% of 343 students; and pharmacy, 71.9% of 171 students. SUDAAN, a software package developed for statistical analysis of correlated data, was used to compute standard errors of the estimates and produce 95% confidence intervals which are shown as lower and upper bounds (9). Statistical differences noted are at the p< 0.05 level. RESULTS Student Characteristics Over 7 in 10 nursing and pharmacy students were females compared to 67.2% of dental students, and 44.5% of medical students. For the dental, nursing, and pharmacy students, over 9 in 10 were aged For the medical students, 75.5% were aged and 21.2% were Prevalence Almost 7 in 10 dental students had ever smoked cigarettes, compared to 6 in 10 medical and nursing students, and over 5 in 10 pharmacy students (Table 1). Male students were significantly more likely than female students to have ever smoked in medical, nursing, 4

5 and pharmacy schools. Over 7 in 10 nursing students had ever used Narguileh, compared to 6 in 10 dental and medical students, and over 5 in 10 pharmacy students. Male nursing students (80.1%) were significantly more likely than female nursing students (66.8%) to have ever used Narguileh. Current cigarette smoking ranged from 14.8% for pharmacy students to 31.6% for dental students (Table 1). For medical, nursing and pharmacy students, males were significantly more likely than females to currently smoke cigarettes. Current use of Narguileh ranged from 20.6% for medical students to 44.9% for nursing students. Male nursing students (54.3%) were significantly more likely than female nursing students (41.6%) to currently use Narguileh. Current cigarette smoking was significantly higher than current use of Narguileh for male and female medical students. Current use of Narguileh was significantly higher than current cigarette smoking for female nursing and pharmacy students. Exposure to Secondhand Smoke (SHS) About 8 in 10 students in all 4 disciplines were exposed to SHS in public places (Table 2). About than 7 in 10 students in all 4 disciplines supported the idea of banning smoking in restaurants, whereas 4 in 10 students supported banning smoking in discos, bars, or pubs; a rate significantly lower than that for restaurants. Fewer students in nursing schools (36.5%) than in dental (50.6%), medical (51.5%), or pharmacy (48.8%) schools reported that their schools had a ban on smoking in school buildings or clinics. Students attending dental schools (28.8%) were the least likely to report high enforcement of the ban than students in medical, nursing, or pharmacy schools (61.0%, 63.2%, and 64.0%, respectively). Role Model and Training More than 8 in 10 students in medical, nursing, and pharmacy schools believed that health professionals have a role in giving advice or information on smoking cessation to their patients (Table 3). Dental students (71.8%) were significantly less likely than students in the 5

6 other 3 disciplines to believe health professionals have such a role. More than 9 in 10 students in all 4 disciplines believed that health professionals should receive training on smoking-cessation techniques. However, the percentage of students who received training ranged from 19.8% for pharmacy students to 43.7% for nursing students. DISCUSSION Health professionals who use tobacco send an inconsistent message to patients whom they counsel to quit smoking. Findings from the GHPS conducted in Lebanon show that tobacco use among health professional students is high. Current cigarette smoking ranged from 14.8% for pharmacy students to 31.6% for dental students; while current use of Narguileh ranged from 20.6% for medical students to 44.9% for nursing students. Current cigarette smoking and current Narguileh use among female students in dental and nursing schools was as high or higher than the smoking rate for adult females in Lebanon (30.6%) (10). Current cigarette smoking and current Narguileh use among male students in nursing schools was as high or higher than the smoking rate for adult males in Lebanon (42.3%) (10). These results suggest that Lebanon s tobacco control program needs to be broad and include cigarette smoking and Narguileh use for both males and females. On February 3, 1993 the Lebanon Ministry of Interior issued a decree (Number 1/213) which stated that smoking in hospitals, infirmaries, pharmacies, elevators, theaters, health clubs, public transport, and all educational institutions should be prohibited (11). In Lebanon, a decree issued by a Minister is not legally binding on institutions or individuals; so enforcement of the decree is up to the institutions. Data from the GHPS shows that over 8 in 10 students in all 4 disciplines report exposure to SHS in public places. The data also indicate that half of the dental and medical students report their schools have an official policy banning smoking in school buildings; but enforcement in the dental schools is very low 6

7 (28.8%) compared to the medical schools (61.0%). Less than half of the students in nursing and pharmacy schools reported that their schools have a policy; but where the policy exists, enforcement is high (over 60%). These findings suggest the Ministry of Health, Ministry of Education, and all educational institutions should work together in support of a national law that, after being passed by Parliament, would be implemented and have strong enforcement provisions. GHPS data from Lebanon show that less than 20% of pharmacy students, about 3 in 10 dental and medical students, and 4 in 10 nursing students received formal training in patient tobacco-cessation counseling, even though more than 90% of the same students wanted this type of training to be included in their formal curricula. The GHPS findings suggest that the Ministry of Health, Ministry of Education, and all academic institutions in Lebanon should work together in developing, testing, and implementing successful patient cessation-counseling training programs for health professionals. The students recognize their responsibility to provide patients with tobacco-cessation counseling and want to be properly trained to do so; however, to date, the majority of students have not received this training. CONCLUSIONS All health profession schools, public health organizations, and education officials should discourage tobacco use among health professionals and work together with the Ministry of Health, Ministry of Education, and all education institutions to strengthen the national tobacco control action plan in Lebanon, with especial emphasis on training all health professionals in effective patient cessation-counseling techniques. Lebanon ratified the WHO Framework Convention on Tobacco Control (WHO FCTC) on December 7, 2005 (12). As a party to the WHO FCTC, Lebanon has an obligation to develop and implement a national action plan to curb tobacco consumption. The GHPS data can serve as part of the 7

8 evidence base for monitoring and evaluating progress toward meeting the objectives of the WHO FCTC as well as meeting the overall objectives of the tobacco control program in Lebanon. Acknowledgement The GHPS team would like to thank all those who contributed in writing this report, the field coordinator Miss Simone Abou Jaoude and the ten administrators who applied GHPS in Lebanon. 8

9 References 1. The American Cancer Society and the International Union Against Cancer. Engaging Doctors in Tobacco Control. Tobacco Control Strategy Planning, Companion Guide #2. July 22, Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services; Lancaster T, Stread L, Silagy C, et al. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ. 2000;321: Gupta PC, Ray CS. Smokeless tobacco and health in India and South Asia. Respirology. 2003;8: Naskar NN, Bhattacharya SK. A study on drug abuse among the undergraduate medical students in Calcutta. J Indian Med Assoc. 1999;97: Mammas IN, Bertsias GK, Linardakis M, Tzanakis NE, Labadarios DN, Kafatos AG. Cigarette smoking, alcohol consumption, and serum lipid profile among medical students in Greece. Eur J Public Health. 2003;13: Vakeflliu Y, Argjiri D, Poposhi I, Agron S, Melani AS. Tobacco smoking habits, beliefs, and attitudes among medical students in Tirana, Albania. Prev Med. 2002;34: Global Tobacco Surveillance System Collaborative Group. Tobacco use and cessation counseling Global Health Professionals Survey, pilot study, 10 countries, Tobacco Control. 2006;15(suppl 2):ii31-ii 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; Mackay J, Eriksen M, Shafey O. The tobacco Atlas (2 nd Edition). The American Cancer Society; Ministry of Interior Decree Number 1/213. February 3, All Tobacco Legislation in Lebanon is deposited at the Ministry of Finance, 1/ World Health Organization (WHO). WHO Framework Convention on Tobacco Control. Geneva, Switzerland: WHO; Available at: 9

10 Table 1 Prevalence of Tobacco Use among Third-Year Dental, Medical, Nursing, and Pharmacy Students by Gender, Lebanon GHPS, 2005 Lifetime Use Current Use Cigarettes Narguileh Cigarettes Narguileh Dental Total 67.4 ( ) 65.4 ( ) 31.6 ( ) 37.3 ( ) Male 66.9 ( ) 65.5 ( ) 34.8 ( ) 30.6 ( ) Female 67.6 ( ) 65.3 ( ) 30.0 ( ) 40.5 ( ) Medical Total 63.0 ( ) 65.2 ( ) 27.4 ( ) 20.6 ( ) Male 71.0 ( ) 69.3 ( ) 35.9 ( ) 22.0 ( ) Female 52.2 ( ) 60.0 ( ) 27.4 ( ) 18.6 ( ) Nursing Total 64.3 ( ) 70.2 ( ) 26.9 ( ) 44.9 ( ) Male 81.4 ( ) 80.1 ( ) 43.0 ( ) 54.3 ( ) Female 58.7 ( ) 66.8 ( ) 21.5 ( ) 41.6 ( ) Pharmacy Total 55.2 ( ) 55.4 ( ) 14.8 ( ) 21.5 ( ) Male 73.7 ( ) 62.9 ( ) 23.8 ( ) 21.8 ( ) Female 49.6 ( ) 53.1 ( ) 12.0 ( ) 21.4 ( ) 10

11 Table 2: Exposure to Secondhand Smoke (SHS) in public places, attitudes toward banning SHS, and school policy and enforcement regarding SHS, Third-Year Dental, Medical, Nursing, and Pharmacy, Lebanon GHPS, 2005 Exposed to smoke in public places during the past week Dental 77.0 ( ) Medical 80.7 ( ) Nursing 83.0 ( ) Thought smoking should be banned in restaurants Thought smoking should be banned in discos, bars, or pubs Percentage of colleges with an official policy banning smoking in college buildings and clinics Of colleges that had an official policy banning smoking in school buildings and clinics, percentage that enforced it 61.7 ( ) 41.3 ( ) 50.6 ( ) 28.8 ( ) 69.6 ( ) 46.7 ( ) 51.5 ( ) 61.0 ( ) 68.5 ( ) 43.5 ( ) 36.5 ( ) 63.2 ( ) Pharmacy 81.6 ( ) 66.8 ( ) 47.9 ( ( ) 64.0 ( ) 11

12 Table 3: Percentage of Third-Year Dental, Medical, Nursing, and Pharmacy Students Who Reported That Health Professionals have a Responsibility to Counsel Patients about Smoking and Cessation, Lebanon GHPS, 2005 Dental Medical Nursing Pharmacy Percentage who thought health professionals have a role in giving advice or information about smoking cessation to patients Percentage who thought health professionals should get specific training on cessation techniques Percentage who learned cessation approaches to use with patients 71.8 ( ) 95.2 ( ) 32.9 ( ) 89.9 ( ) 93.8 ( ) 29.1 ( ) 85.4 ( ) 96.4 ( ) 43.7 ( ) 86.1 ( ) 97.1 ( ) 19.8 ( ) 12

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