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Original article

Frequency of tobacco use and the attitudes of health professions students on tobacco use in Montenegro: global health professions student survey in Montenegro

Vilnerina Ramčilović1, Sabina Ćatić1, Enisa Kujundžić1

ABSTRACT

Introduction: Health professionals play a significant role in advising patients on the harmful effects of tobacco on human health and on the ways of abandoning this bad habit. However, tobacco consumption is also a challenge for health professionals themselves, as well as for medical students.

Aim: The objective of this study was to estimate the prevalence of smoking among students of health sciences in Montenegro, as well as to examine their attitudes related to tobacco control mechanisms.

Methods: This is a secondary analysis of the Global Health Professions Student Survey, which was conducted by the Ministry of Health of Montenegro, in the period between October 2010 and March 2011.

Results: In the 30 days preceding the survey, 25% of respondents had used tobacco. During the year preceding the survey, 38% smokers had consumed cigarettes on school premises. Of the respondents, 44.6% of smokers and 52.9% of non-smokers had been taught on the subject of the importance of providing educational material to patients, as a form of support to smoking cessation, but only 35% of smokers and 28% of non-smokers had received formal training on how to instruct patients to give up smoking. A total of 63.7% smokers and 81.7% non-smokers (p < 0.001) expressed the belief that health professionals who smoked cigarettes were less suited to advise patients on smoking cessation. There was a 70% lower probability that sixth year students would support the above stated attitude. Also, there was a 40% lower probability that the same attitude would be supported by students who felt that smoking in restaurants should not be banned in restaurants, and a 50% lower probability that this attitude would be supported by those students who believed that health workers do not need special training in smoking cessation techniques.

Conclusion: The study showed that it was necessary to improve the curricula at health sciences faculties and improve formal training on the harmful effects of tobacco on human health, as well as to improve the training for acquiring evidence-based smoking cessation skills, which would have an indirect effect of reducing tobacco use among students.


INTRODUCTION

Health experts worldwide have been drawing attention to the existing global epidemic of tobacco use in the form of cigarette and pipe smoking, tobacco chewing and sniffing, or passive smoking, i.e., passive smoke inhalation. Smoking cigarettes, although a socially acceptable habit, is, in fact, a behavior that puts a person’s health at risk [1], and, according to the estimate of the World Health Organization (WHO), leads to the death of around 8.7 million people every year [2]. Although significant progress has been achieved globally, regarding the decrease of the prevalence of tobacco product use, tobacco smoke remains one of the main causes of illness and premature death of the population [3]. Globally, the prevalence of smoking has been reduced from 22.7% to 17.5% [2]. Also, cigarette sales have been reduced globally, however, this is not satisfactory, since the tobacco industry has introduced new products, such as electronic cigarettes and tobacco heating devices, whose target group are primarily young people [2].

The first scientific proof of the harmful effects of smoking dates back to the middle of the last century, when a causal link was proven to exist between smoking and bronchial and lung carcinoma, myocardial infarction, and chronic obstructive pulmonary disease (COPD) [4]. Health workers can play a significant role in reducing this life-threatening habit [5], as they examine around 70% of smokers, per year [6]. Health professionals should play a leading role in smoking prevention in the community, both through the advice they offer, but also through modelling healthy behavior [7]. As health service providers, they play a key part in counselling smokers on smoking cessation, as well as in motivating people to refrain from taking up tobacco consumption [8]. Health workers should advise people suffering from carcinoma on the elevated risk linked to the continuation of smoking, as well as on the ways that they can stop smoking, and can also inform these patients on the existing treatments for smoking cessation that are covered by the patients’ medical insurance [9].

Young people are a part of the general population that is most susceptible to all forms of risky behaviors and to accepting new life challenges, since many youths do not have firmly established value systems or healthy lifestyle norms [10]. Those young people who do not recognize the health risks of the consumption of tobacco and its products are more likely to become smokers [11],[12]. Significant use of cigarettes in the period between adolescence and early adulthood is a strong predictor of smoking later in life [13]. It is of great importance that exposure to any form of tobacco products in youth should be avoided, as it has been proven that nicotine damages the normal development of the brain and influences brain function and cognition, attention and mood [14].

In 2004, within the project – Global Tobacco Surveillance System, the World Health Organization, the American Centers for Disease Control and Prevention, and the Canadian Public Health Association, developed the Global Health Professions Student Survey – GHPSS) [15]. This survey was implemented in more than 20 European countries [16]. The countries in the region – Serbia, Albania, Bosnia and Herzegovina, and Croatia, were the first European countries where this survey was carried out, in 2005 [16]. The purpose of the GHPSS was to obtain data on the prevalence of tobacco use amongst future health workers and to design programs that would reduce tobacco consumption amongst them [15].

According to the data of the Global Youth Tobacco Survey, the smoking prevalence in the age group 13 – 15 years, in the year 2018, was 7.1% (9.3% of boys and 4.0% of girls) [17]. The survey showed 9.9% of students (11.6% of boys and 8.1% of girls) to be current tobacco product users. Amongst them, 6.0% of students (6.7% of boys and 5.3% of girls) used cigarettes, while 2.2% of students (2.8% of boys and 1.7% of girls) used smokeless tobacco products [17].

The most frequent form of tobacco product consumption in Montenegro is smoking cigarettes [18], which should be observed in the context of the influence of the family, peer pressure, inadequate and incomplete health prevention and control of the implementation of the Law on Limiting the Use of Tobacco, in the sense of the availability and low prices of tobacco products.

The survey on the prevalence of tobacco use in the population of Montenegro indicates a high prevalence, since more than a third (35.4%) of adults (aged 15 to 64 years) reported that they actively smoked. In this population group, by 1% more women than men reported the use of tobacco products [19].

Paradoxically, students of health sciences continuously smoke cigarettes, despite a large body of information on the harmful effects of tobacco use which they have access to during their professional medical training [20],[21],[22]. Training students of health sciences to provide efficient, accurate, and available advice to patients on all aspects of health [23], including smoking, is an important task for health professionals [24], which can be deemed to reflect the state of public health in a country.

The purpose of the present study is to determine the prevalence of tobacco smoking amongst students of health sciences in Montenegro; to determine student attitudes towards smoking tobacco; as well as to analyze the relevance of the existing curriculum of undergraduate studies with regards to smoking control and prevention.

To this end, the survey carried out among health professions students in Montenegro had three specific goals:

  1. Determining the frequency/prevalence of smoking.
  2. Analyzing the relationship between smoking status and sociodemographic characteristics (sex, age, university study level/year of study) of the students; analyzing student attitudes towards bans and restrictions related to tobacco use; analyzing student attitudes on the role of health workers in smoking prevention; analyzing student attitudes towards undergraduate professional education.
  3. Investigating possible predictors of student attitudes on whether it is appropriate for health workers who smoke cigarettes and use other tobacco products to advise health service users, i.e., patients, on how to stop smoking.

MATERIALS AND METHODS

Study design and participants

This study is a secondary analysis of data obtained from the Survey on the use of tobacco products among health professions students in Montenegro [25], which was carried out in keeping with the methodology of the Global Health Professions Student Survey [15].

The Montenegro survey is a cross-sectional study, carried out between October 2010 and March 2011. The ethics committees of the Institute of Public Health of Montenegro and the Clinical Center of Montenegro approved all the necessary components of the survey (questionnaire, methodology, method of dissemination of the results obtained). All tertiary level medical education institutions (Faculty of Medicine, Faculty of Dental Medicine, and the Faculty of Pharmacy in Podgorica, Faculty of Applied Physiotherapy in Igalo, as well as the Nursing College in Berane) participated in the survey.

The survey included all respondents present in class on the day that the survey was carried out at their school and who volunteered to participate in the survey – a total of 822 respondents. Before the respondents took the survey, its purpose was explained to them as was the fact that the survey was anonymous, and that the data could be interpreted exclusively at the level of the entire sample of respondents. The respondents filled out the questionnaires on their own, with the option of asking the surveyors for clarifications, if needed. The data from each questionnaire were entered into a previously prepared database. The participation rate was 92% (as compared to the number of students at all the above-mentioned schools), and the response rate was 98%.

Instruments and variables

The standard GHPSS questionnaire was used as the research instrument [15]. It was translated and adapted to the particular characteristics of target groups in Montenegro. Before the survey was carried out, the questionnaire was piloted on a group of 20 students, in order to test the time necessary for completing the questionnaire, the clarity of the questions, as well as the level of precision of the provided answers. Testing and pretesting were monitored by specially trained coordinators from the Institute of Public Health of Montenegro.

The final version of the questionnaire consisted of 42 questions, divided into six segments. The first segment referred to the prevalence of the use of tobacco and other tobacco products amongst health professions students in Montenegro. The second part of the questionnaire included questions on exposure to tobacco smoke in the environment and the attitudes of the respondents on the ban on smoking in educational and health institutions. The third segment of the questionnaire referred to student attitudes on the policy prohibiting the sale of tobacco to minors (persons younger than 18 years), attitudes on the ban on advertising tobacco products, on banning smoking in public spaces and in workplaces, as well as attitudes on the role of health workers as models of behavior and patient counselors on smoking cessation. The questions in the fourth segment of the questionnaire related to student behavior, to self-assessment on smoking cessation, as well as to attitudes on health workers/counselors who smoke. The fifth segment of the questionnaire included questions on the attitudes related to the curriculum and undergraduate education on smoking and the importance of smoking cessation, as well questions on the knowledge of therapeutic methods included in the program for smoking cessation. The last, sixth segment of the questionnaire was composed of questions related to the respondent demographic data (age, sex, university study level/year of study). The survey, designed in such a way, provided the opportunity of additional (secondary) research of the connection between the risky behavior of health sciences students and their general characteristics and attitudes towards education, regulations, and the role of health workers in smoking prevention, from the point of view of their responsibility as future health service providers.

For the purpose of the survey, the classification of respondents as smokers was performed according to the existing WHO definition, which identifies persons using cigarettes for one or more days in the previous 30 days as smokers [26].

One dependent variable (smoking status) and 19 independent variables were used for the univariate regression model (Model 1). The univariate model was used to identify those attitudes and statements which significantly affect the smoking status. The following were the independent variables: sex; age intervals (18 – 24, 25 – 29, above 29 years of age); the university study level/year of study (from year 1 to year 6, degree candidates); attitudes on bans related to tobacco and tobacco products (attitudes on the ban on selling tobacco to adolescents and persons under the age of 18 years; attitudes on the ban on advertising tobacco products; attitudes on the ban on smoking in restaurants; attitudes on the ban on smoking in discos/bars/caffes; attitudes on the ban on smoking in all indoor public places); trying/experimenting with tobacco; attitudes on the role of health workers in smoking prevention (“Health workers should routinely advise their patients not to smoke.”; “Health workers should routinely advise their patients not to use other tobacco products.”; “Health workers should receive special training on smoking cessation techniques.”); the role of health workers in providing information or advice on smoking cessation to patients (“The possibility of smoking cessation increases if the health worker advises the patient to stop smoking.”); the perception of undergraduate training on the effects of tobacco and smoking cessation techniques (receiving formal training on how to help patients stop smoking; learning about the importance of providing educational material that would provide support in smoking cessation). Only those attitudes and statements which demonstrated a statistically significant difference, and which were tested in relation to both smokers and non-smokers were entered into the model.

In the second regression model, one dependent variable and 13 independent variables were presented. The dependent variable was the following: “Health workers who smoke are less suited to advise patients on how to stop smoking.” (Model 2). The logistic regression model was used to analyze possible predictors for the above stated dependent variable. The independent variables were as follows: sex; age intervals (18 – 24, 25 – 29, above 29 years of age); university study level/year of study (from year 1 to year 6, degree candidates); smoking status; attitudes on bans related to tobacco and tobacco products (attitudes on the ban on selling tobacco to adolescents and persons under the age of 18 years; attitudes on the ban on advertising tobacco products; attitudes on the ban on smoking in restaurants; attitudes on the ban on smoking in discos/bars/caffes; attitudes on the ban on smoking in all indoor public places); trying/experimenting with tobacco; attitudes on the role of health workers in smoking prevention (“Health workers should routinely advise their patients not to smoke.”; “Health workers should routinely advise their patients not to use other tobacco products.”; “Health workers should receive special training on smoking cessation techniques.”).

Statistical analysis

The basic methods of descriptive statistics were applied in presenting the data. The statistical χ2 test was applied in determining statistical significance of the difference between two student groups – smokers and non-smokers (non-smokers represented the reference category of the variable), in relation to sociodemographic characteristics, attitudes and statements on training during university education, as well as statistically significant differences in the use of other types of tobacco products, presented by sex, in students of health sciences in Montenegro who were smokers.

Univariate and multivariate logistic regression were used for assessing the odds ratio (OR), with a 95% confidence interval (CI) for assessing possible predictors for respondent attitudes on health workers who smoke cigarettes and their suitability to advise service users, i.e., patients on how to stop smoking. As dependent variables of the model, only attitudes that showed a statistically significant difference amongst respondents smokers and respondents non-smokers, were selected. The model describes potential predictors of respondents whose attitude was that health workers who smoke are less suited to advise patients on smoking cessation. The probability value of p < 0.05 was considered the threshold of statistical significance. The data were analyzed with SPSS software (SPSS Inc., Chicago, IL, USA).

RESULTS

Sociodemographic characteristics of the participants

The survey included 822 medical professions students enrolled at the University of Montenegro, of whom 71.90% (591) were female respondents. In the sample, 85.28% (701) students were between 18 and 24 years old. The prevalence of the participants who had used tobacco in the 30 days preceding the survey was 204 (24.8%), (Table 1). Of the 618 non-smokers, 313 (38.1%) had never experimented with tobacco, and a similar number of students, 305 (37.1%) of them, had tried tobacco but did not continue smoking.

Testing the difference in frequency of tobacco use against the age of the respondents showed no statistically significant difference (p = 0.84), although it was noted that the number of cigarette smokers in the sample rose with the age of the participants (Table 1).

Table 1. Prevalence of smokers and nonsmokers, by sex and age intervals among health professions students in Montenegro, 2011

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There was no statistically significant difference in tobacco use in relation to the sex of the respondents (p = 0.308), though the number of cigarette smokers was greater amongst the young men than the young women (Table 1).

In relation to the time when smoking was first experimented with, a statistically significant difference was noted amongst the sexes and age categories (p < 0.01). Almost every fifth student had tried smoking for the first time between the age of 16 and 17. The number of young men who had tried smoking for the first time at the age of 10 or earlier was twice greater than the number of girls who had done that, while there were more young women than young men who tried smoking cigarettes for the first time after the age of 18 years (Table 2).

Table 2. Age interval of smoking initiation among Montenegrin health professions students, by gender, 2011

0202

The prevalence of respondents who had used tobacco in the 30 days preceding the survey was 24.8%, whereby the young men (27.3%) had smoked cigarettes in that period more than the young women (23.9%).

The survey showed that 38.2% of the student smokers had smoked cigarettes on school premises in the year preceding the survey. There was no statistically significant difference amongst the sexes, although it is evident that the young women had smoked cigarettes on school premises at twice the percentage as the young men (p = 0.551).

Of the total number of participants, three fifths (61.9%) had experimented with cigarettes, i.e., had tried at least a few puffs of cigarette smoke (including the 305 respondents who were non-smokers at the time of the survey). Upon analyzing the sex structure of the participants in relation to experimenting with tobacco, the statistically significant difference becomes apparent (p < 0.05). Namely, more male students (68.4%) had tried smoking cigarettes, as compared to the female students (59.4%). Of the total number of students, 509 of them had tried smoking, i.e., had experimented with cigarettes, while two fifths of these (204 or 40.1%) continued to smoke cigarettes after that.

In the entire sample, the prevalence of respondents who stated that they used other tobacco products (pipe tobacco, cigars, cigarillos, chewing tobacco, and snuff) was 12.4%. Analysis of this variable, in relation to the sex of the participants, showed that there was no statistically significant difference (p = 0.084), with 15.6% male students and 11.2% female students consuming other tobacco products (Table 3).

Table 3. Use of tobacco products among health professions students, by sex, Montenegro, 2011

0203

Respondent attitudes on tobacco use regulations, the role of health professionals, and ducation/training received at health sciences faculties

The analysis showed that a little over four fifths (82.8%) of the smokers believed that it was necessary to ban the sale of tobacco to adolescents and persons under the age of 18 years. This attitude was also supported by most (92.4%) of the non-smokers (p < 0.001) (Table 4).

Table 4. Attitudes towards the ban on tobacco use among Montenegrin health professions students, according to their smoking status

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A little over two thirds (71.1%) of smokers felt that advertising tobacco products should be completely prohibited, while 82.2% of non-smokers was of the same opinion (p < 0.001) (Table 4).

As far as the attitude on banning smoking in restaurants was concerned, 59.8% of smokers and most (91.1%) non-smokers felt that smoking in them should be banned (p < 0.001) (Table 4).

It is interesting that only a little over a quarter (28.9%) of smokers, as compared to three quarters of non-smokers, i.e., 72.0% of them, believed that smoking should be banned in discos/bars/caffes, as well (p < 0.001) (Table 4).

Two fifths (41.7%) of the smokers stated that smoking should be banned in indoor public spaces, while 82.7% non-smokers had the same attitude (p < 0.001) (Table 4).

Three quarters (76.0%) of smokers felt that health workers have a part to play in offering advice or information on smoking cessation to their patients, and this opinion was shared by a majority (84.3%) of non-smokers (p < 0.01). Almost three quarters (73.5%) of smokers and most (91.1%) non-smokers were of the opinion that health professionals should receive special training on smoking cessation techniques (p < 0.001) (Table 5). Most (87.7%) smokers, as well as a majority (94.17%) of non-smokers felt that health workers should routinely advise their patients whoa are smokers to stop smoking (p < 0.005). Similarly, most (87.3%) smokers, as well as most (93.0%) non-smokers believed that health workers should routinely advise their patients who use other tobacco products to stop their consumption of these products (p < 0.005). It is interesting that two thirds (67.7%) of smokers thought that the probability of a patient ceasing to smoke increases if the patient receives advice to do so from a health worker, while 79.0% of non-smokers believed that such advice was effective (p < 0.01) (Table 5).

Table 5. The attitudes of health professions students in Montenegro, smokers and non-smokers, towards the role of health care workers in smoking control, 2010/2011

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The performed analysis also showed that there was no statistically significant difference between smokers and non-smokers in the belief that health workers should be role models for their patients as well as for the general public (p = 0.132). However, a little over three fifths (63.7%) of the smokers and 81.7% of the non-smokers felt that health workers who smoke are less suited to advise patients on smoking cessation (p < 0.001). An almost identical result was obtained with the analysis of the respondent attitudes on the suitability of health workers who use other tobacco products to advise patients to stop using these products (p < 0.001), (Table 5).

The analysis of student responses in relation to the training received during their university studies on the harmful effects of tobacco revealed that more than two fifths (44.6%) of smokers and around a half (52.9%) of the non-smokers stated that they had learned on the importance of providing educational material for patients, as a form of support in smoking cessation (p < 0.05), (Table 6). A little over a third (35.3%) of the smokers and a little over a quarter (28.0%) of the non-smokers stated that they had received formal training on the ways of helping patients with smoking cessation (p < 0.05). The responses of the smokers and non-smokers to the rest of the questions were not statistically significantly different. Around four fifths of the students had learned about the dangers of cigarette smoking during their university studies (82.5%) and had received information on nicotine substitute therapy with nicotine patches and nicotine chewing gum (83.9%). Less than two thirds of students stated that they had discussed the reasons why people smoked cigarettes (59.6%) and that they had learned about the importance of noting tobacco use as an integral part of patient history taking (61.2%). A little over two fifths (42.9%) of the students were informed on the use of antidepressants within the cigarette smoking cessation program (Table 6).

Table 6. The attitudes of health professions students in Montenegro, smokers and non-smokers, towards the education on the effects of tobacco use, which is being carried out at the faculties, 2010/2011

0206

Logistic regression models of respondent attitudes towards health care workers who are smokers

The univariate logistic regression model (Model 1) was used in this study, in order to identify attitudes which statistically significantly affect smoking status. The analysis of the identified variables, which relate to experimenting with tobacco, as well as to attitudes on the suitability of health workers who use tobacco and tobacco products and their influence on patients with regards to smoking cessation, showed the following results. Students who experimented with smoking had an almost 20 times greater chance (OR 19.9) of being smokers. Students who felt that “health workers who smoke are less suitable to advise patients on how to stop smoking”, had a twice lower likelihood of being smokers. Students who though that “health workers who use other tobacco products are less suited to advise patients on how to stop smoking”, had a 59% lower probability of being smokers (Table 7).

Table 7. The predictive value of the sociodemographic characteristics of health professions students regarding smoking status (reference value: Yes)*

0207

According to Model 2, in comparison with health professions students aged 18 – 24 years, respondents aged 25 – 29 years had a five times higher likelihood (OR 5.8) of supporting the attitude: “Health workers who smoke are less suitable to advise patients on how to stop smoking.”. Students who were on their sixth year of studies had a 70% lower likelihood of supporting the above stated statement (OR 0.3). Respondents whose opinion was that smoking should not be banned in restaurants had a 40% lower probability of supporting the attitude: “Health workers who smoke are less suitable to advise patients on how to stop smoking.” (OR 0.6). Also, those students who did not support the attitude: “Health workers should receive special training on smoking cessation techniques.”, had a 50% lower probability of supporting the above-mentioned attitude (OR 0.5), (Table 8). The entire model is statistically significant (p < 0.001). The model entirely explains between 8.3% (Cox & Snell) and 12.6% (Nagelkerke) of the variance in the smoking status, and precisely classifies 79.8% cases (98.6% of those who supported the stated attitude and 16.1% of those who negated it).

Table 8. The predictive value of the sociodemographic characteristics of health professions students regarding the attitude that “health care workers who smoke are less suited to advise patients to stop smoking” (reference value: No)*

0208

DISCUSSION

Smoking cigarettes is a global public health problem. The prevalence of tobacco use amongst health professions students varies in different parts of the world. In the year of our survey, it was above 40% in Albania (43.3%), Bosnia and Herzegovina (40.3%), and Bolivia (41.1%), while it was under 5% in Uganda (2.8%), Sri Lanka (4.1%) and Thailand (2.1%) [23]. Looking at the countries surrounding Montenegro, the prevalence of smoking in Serbia was 34.7%, it was 36.6% in Croatia, and 20.9% in Slovenia [23].

The fact that young men start smoking cigarettes earlier than young women, as well as the fact that the number of young men who smoke is double the number of young female smokers supports the view that certain societies are more tolerant towards men than towards women, whereby risky behavior is viewed as a part of the male identity [27]. This was, in fact, confirmed in certain studies, which showed that men who cultivate a traditional sense of masculinity more commonly engage in risky behavior, such as tobacco use, alcohol and drug abuse, risky sexual behavior and violence [28],[29],[30]. With the beginning of the fight for women emancipation, the prohibition of smoking was viewed as discrimination, and smoking became one of the symbols of the modern woman [31].

The prevalence of the use of tobacco products other than cigarettes amongst health professions students in Montenegro was, observing the year of the survey, 12.4%. In relation to the countries in the region, only Serbia had a higher prevalence, and it was 18%, while other countries had a lower prevalence than Montenegro, namely: Croatia (10.7%), Bosnia and Herzegovina (8.7%), Slovenia (5.6%), and Albania (1.5%). As compared to other countries worldwide, Nigeria had a leading prevalence of 27.7%, while Uganda had the lowest prevalence of 0.7% [23].

In Montenegro, in the recent years, with the formulation of new laws and regulations, a certain effort has been made to limit the use of tobacco and tobacco products. The adopted regulations formulate the ban on smoking in public institutions, especially in institutions involved in health and education [32]. Most non-smoking Montenegrin students had positive attitudes in relation to laws and regulations regulating tobacco sale, the ban on advertising tobacco, and providing smoke free zones. This opinion was shared also by health professions students in Croatia [33]. In relation to smoking prohibition in all public indoor spaces, research showed that most health professions students in Turkey, China, Riad (Saudi Arabia) supported this type of ban [34],[35],[36].

Almost two thirds of the respondents from Montenegro (62.7%) also felt that health workers should be role models both for their patients and for the general population. Similarly, 65% of the health professions students in Malta also believed that health workers should be role models in the society [37].

A study carried out in Canada amongst health sciences students, showed that it was considered a part of professional responsibility to equal one’s own healthy lifestyle with engagement in preventive consulting and with accepting the importance of this role [38]. Similarly, every eighth Montenegrin student, out of ten, felt that health workers have a role in providing advice and information on smoking cessation to their patients, while three quarters of them believed that the chances that a patient will stop smoking increase if they are given advice by a health worker to do so. It is believed that advice from a doctor to that effect, approximately doubles the probability that a patient will stop smoking [39]. However, health workers who consume tobacco may have reservations when it comes to advising patients on how to stop smoking [40].

Most students from Montenegro, i.e., more than 90% of them, felt that health workers should routinely advise their patients who smoke or use other tobacco products to stop using them. Also, a little over three quarters of the students believed that health workers who smoke, as well as those who use other tobacco products, are less suitable to advise patients on how to stop using them.

Several studies indicated the possible barriers which relate to the inability of health workers to provide preventive services [41], these being: lack of information (knowledge) on techniques related to smoking cessation [42], lack of confidence in their own counselling skills [43],[44], multiple simultaneous demands put before health care workers [42],[44],[45], lack of specialized services that deal with smoking cessation [45], as well as the fear of alienating those patients whom they may advise to stop smoking and who are not ready to do so [44]. The education and training of health workers could mitigate some of these barriers. In fact, research has shown that as little as several hours of training on the harmful effects of tobacco may significantly improve medical knowledge of students and doctors, as well as increase trust and the probability of offering preventive services [46],[47].

Most health professions students in Montenegro (86.74%) believed that health workers should receive special training in smoking cessation techniques, which is somewhat in keeping with the results of the study showing a situational analysis of the problem of smoking amongst students of health sciences, carried out according to the same methodology, in 48 countries worldwide [23]. The lowest rate supporting this attitude was in the Czech Republic (60.8%), while the highest was in Cambodia (99.1%) [23].

The efforts invested in helping patients stop the harmful habit of using tobacco stem primarily from doctors at the level of primary health care [48],[49],[50]. Research shows that medical students do not have the appropriate knowledge on smoking related diseases and that they do not receive training on smoking cessation techniques [51],[52]. In treating smoking addiction in patients, in addition to doctors, other profiles of health workers need to be included (e.g., medical nurses, dentists, pharmacists), which could help in the identification of new smokers, and thereby promote patient smoking cessation attempts [7].

The Framework Convention for Tobacco Control stresses the significance of the role of health workers (doctors, dentists, pharmacists, medical technicians) in the prevention of tobacco use and in smoking cessation, through short counselling or at least a simple piece of advice [40].

Through their studies at health sciences faculties in Montenegro, most students learned on the dangers of tobacco use. However, only one third of students received formal training on how to assist patients in smoking cessation. The results of the abovementioned data analysis obtained through research on the knowledge and attitudes of health professions students worldwide [23], showed that, in most countries, i.e., in 46 out of 48 countries, less than 40% of health professions students stated that they had received formal training related to this subject. However, in Nigeria, this percentage was somewhat higher 46.4%, as well as in Myanmar (43.7%) [23]. During their clinical internship, when taking the patient’s anamnesis, medical students usually inquire about smoking history, but they rarely advise on cigarette smoking cessation [40].

Around half of the health professions students in Montenegro included in the survey studied about the significance of providing educational materials to patients as a form of smoking cessation support, while around two fifths of them had the opportunity to discuss the reasons why people smoke and to discuss the harmful consequences of smoking on human health. The analysis of the knowledge on smoking cessation methods showed that four fifths of Montenegrin students had heard of nicotine replacement therapy, while a half of that number had heard of the use of antidepressants as a part of the smoking cessation program. Conversely, students in Spain were best informed on nicotine replacement products (96.3%), while students in Germany were less informed – 33.6% of them had heard of the use of antidepressants as one of the therapeutic methods used in patients to help with smoking cessation [51].

The results obtained in the present study indicate the deficiencies in the curricula of health sciences faculties. The study indicated the need for special content to be designed within the study programs of such faculties, which would, not only inform students on the health effects of tobacco use, but also enable them to obtain skills in counselling patients and assisting them in smoking cessation [53]. An overburdened core curriculum in most health sciences faculties limits the options for additional education and training, which is why the most basic strategy could relate to suggesting to the professors at these faculties to use every favorable opportunity to inform students on the toxic effects of the use of tobacco and tobacco products, which could be a profitable and efficient way of improving the students’ knowledge and understanding of this issue [54].

Health workers who smoke send an ambivalent message to patients whom they are, in fact, encouraging to stop smoking [15],[55]. There is a higher probability that health workers who smoke will have attitudes that prevent them from advising patients against smoking [56]. The results of the survey in Montenegro showed that it was less probable that a positive opinion on the attitude that health workers who smoke are less suitable to advise patients on smoking cessation would be held by those students who believed that smoking should be banned in restaurants as well as those who believed that health workers need special training in smoking cessation techniques, while it was more likely that this attitude would be supported by older students.

The analysis of a survey carried out amongst Pakistani health professions students, related to their perception on the role of health workers in tobacco control. The data showed that there was a higher probability that students would have a negative perception of the role of health workers in the control of tobacco if they were male and if the respondents had insufficient knowledge on smoke cessation techniques, as well as if the respondents were those who did not believe that tobacco and tobacco product advertising should be banned, nor that the use of tobacco in all public places [57] should be prohibited. The Montenegrin survey analyzed the perception of students related to the link between behavior and counselling, i.e., specifically the attitude on the suitability of health workers who smoke to counsel patients on cigarette smoking cessation. This survey may be useful for analyzing the curriculum for building the role of health professionals in smoking prevention and control.

Such results indicate that it is necessary to focus on the forming of healthy behavior amongst health professions students in order to cultivate generations of future health professionals who will foster a healthy lifestyle, and in this way promote counseling skills, in addition to being positive role models for patients and society. Reducing smoking amongst students of health sciences is potentially a very powerful strategy for decreasing smoking amongst future health professionals, which may have a significant impact on the reduction of tobacco consumption amongst healthcare service users, as well as the reduction of tobacco consumption in the general population [58].

However, promoting, improving, and maintaining health is not only the responsibility of the healthcare sector. Promoting non-smoking, as one of the forms of a healthy lifestyle, through the use of potentials of modern mass media, may be one of the most powerful instruments in the fight against tobacco advertising. There is enough evidence demonstrating the causeand-effect link between the efforts of tobacco companies advertising their products and the initiation and progressive use of tobacco amongst young people [26]. Research has shown that mass media campaigns are some of the most effective strategies in altering social norms, as well as in preventing smoking in young people [26]. Therefore, in addition to a comprehensive network of counseling youth centers in Montenegro, where smoking cessation programs are being carried out, it is also necessary to mobilize social networks, as a new and modern way of communicating and disseminating information with interesting messages, video clips, or short films on the harmful effects of tobacco use.

When interpreting the study carried out in Montenegro, certain limitations in methodology need to be taken into consideration. Although the survey included a large sample of the health professions student population, it was performed as a cross-sectional study, which made it impossible to determine cause-and-effect relationships or to generalize the results so that they could apply to all health workers. The second limitation relates to the fact that the data was obtained through a questionnaire filled out by the students themselves and based on self-reporting, which could consequently have led to the underestimation or overestimation of the obtained results. The third limitation lies in the fact that respondent attitudes were investigated but not their knowledge (for instance, on smoking effects or on interventions), which is necessary in order to work on decreasing smoking prevalence. The fourth limitation relates to the fact that the study did not consider the effects of other factors, such as the influence of the family or friends on the smoking status of the respondents. The fifth limitation is connected to the fact that the study did not investigate the differences in attitudes amongst the students of the faculties of medicine, dental medicine, and pharmacy, as well as students of applied physiotherapy and students at the nursing college. The study was carried out ten years ago, which is the sixth limitation, however, it is important that it represents a baseline study for new research, especially research on the attitudes on the use of electronic cigarettes amongst students of health sciences faculties, as well as in the population.

CONCLUSION

The research results showed that every fourth health professions student smoked cigarettes in the 30 days preceding the survey. There were more male than female cigarette smokers. The greatest number of cigarette smokers were third year students and degree candidates. In addition to laws and regulations and the role of health workers in smoking prevention, the weakest link in decreasing the use of tobacco amongst students, was their undergraduate education at health sciences faculties. The attitude that health workers who use tobacco are less suitable to advise patients on how to stop using tobacco, was supported by those respondents who also believed that it was not necessary to ban smoking in restaurants and those who felt that health workers did not need special training on smoking cessation techniques.

Bearing in mind the results of the research, and the increased use of electronic cigarettes, especially in the young population, it is necessary to carry out a similar survey, in order to determine whether smoking cigarettes and the consumption of other tobacco products has decreased, but also in order to establish the prevalence and frequency of the use of electronic cigarettes, both in the general population, and amongst health professions students. Bearing in mind the similarity of the results of the present study with the results from other European countries, it is necessary to design an efficient universal program of smoking control and prevention amongst students of health sciences, in keeping with the updated guidelines of the World Health Organization Framework Convention for Tobacco Control. It is important to improve the formal training and practice of evidence-based smoking cessation skills, to research reasons and develop media techniques for acquiring knowledge, in order to contribute to the effort of making health sciences faculties 100% smoke free. There are effective and efficient methods of smoking cessation, however, the most efficient measure is life without cigarette smoke, i.e., simply not beginning with this life-threatening habit.

  • Conflict of interest:
    None declared.

Informations

Volume 3 No 3

Volume 3 No 3

September 2022

Pages 277-299
  • Keywords:
    tobacco control, health workers, training
  • Received:
    15 June 2022
  • Revised:
    11 July 2022
  • Accepted:
    20 August 2022
  • Online first:
    25 September 2022
  • DOI:
Corresponding author

Vilnerina Ramčilović
Institute of Public Health of Montenegro, Podgorica, Montenegro
Džona Džeksona bb, Podgorica, Crna Gora
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


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REFERENCES

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48. Ferketich AK, Khan Y, Wewers ME. Are physicians asking about tobacco use and assisting with cessation? Results from the 2001-2004 national ambulatory medical care survey (NAMCS). Prev Med. 2006 Dec;43(6):472-6. doi: 10.1016/j.ypmed.2006.07.009. [CROSSREF]

49. Thorndike AN, Regan S, Rigotti NA. The treatment of smoking by US physicians during ambulatory visits: 1994 2003. Am J Public Health. 2007 Oct;97(10):1878-83. doi: 10.2105/AJPH.2006.092577. [CROSSREF]

50. Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA. 1998 Feb 25;279(8):604-8. doi: 10.1001/jama.279.8.604. [CROSSREF]

51. La Torre G, Saulle R, Unim B, Angelillo IF, Baldo V, Bergomi M, Cacciari P, Castaldi S, Del Corno G, Di Stanislao F, Panà A, Gregorio P, Grillo OC, Grossi P, La Rosa F, Nante N, Pavia M, Pelissero G, Quarto M, Ricciardi W, Romano G, Schioppa FS, Fallico R, Siliquini R, Triassi M, Vitale F, Boccia A. Knowledge, attitudes, and smoking behaviours among physicians specializing in public health: a multicentre study. Biomed Res Int. 2014;2014:516734. doi: 10.1155/2014/516734. [CROSSREF]

52. Dania MG, Ozoh OB, Bandele EO. Smoking habits, awareness of risks, and attitude towards tobacco control policies among medical students in Lagos, Nigeria. Ann Afr Med. 2015 Jan-Mar;14(1):1-7. doi: 10.4103/1596-3519.148701. [CROSSREF]

53. Richmond R, Zwar N, Taylor R, Hunnisett J, Hyslop F. Teaching about tobacco in medical schools: a worldwide study. Drug Alcohol Rev. 2009 Sep;28(5):484- 97. doi: 10.1111/j.1465-3362.2009.00105.x. [CROSSREF]

54. Grassi MC, Baraldo M, Chiamulera C, Culasso F, Raupach T, Ferketich AK, et al. Knowledge about health effects of cigarette smoking and quitting among Italian university students: the importance of teaching nicotine dependence and treatment in the medical curriculum. Biomed Res Int. 2014;2014:321657. doi: 10.1155/2014/321657. [CROSSREF]

55. Kawane H. Antismoking education for medical students. Chest. 1992 May;101(5):1480. doi: 10.1378/chest.101.5.1480-a. [CROSSREF]

56. Cummings KM, Giovino G, Sciandra R, Koenigsberg M, Emont SL. Physician advice to quit smoking: who gets it and who doesn't. Am J Prev Med. 1987 Mar-Apr;3(2):69-75. [CROSSREF]

57. Aslam SK, Zaheer S, Shafique K. Health professional students' perceptions regarding their role in tobacco control: findings from the Global Health Professional Students Survey, Pakistan, 2011. Subst Abuse Treat Prev Policy. 2014 Jun 23;9:25. doi: 10.1186/1747-597X-9-25. [CROSSREF]

58. Xinguang Chen, Xiaolan Tang, Bonita Stanton, Hanwu Li, Weiqing Chen. Cigarette smoking among medical students in China and modifiable risk factors for smoking prevention. Health Education. 2012; 112 (4): 333 – 34. doi:10.1108/09654281211237162. [CROSSREF]

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41. Springer CM, Tannert Niang KM, Matte TD, Miller N, Bassett MT, Frieden TR. Do medical students know enough about smoking to help their future patients? Assessment of New York City fourth-year medical students' knowledge of tobacco cessation and treatment for nicotine addiction. Acad Med. 2008 Oct;83(10):982-9. doi: 10.1097/ACM.0b013e3181850b68. [CROSSREF]

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44. Conroy MB, Majchrzak NE, Regan S, Silverman CB, Schneider LI, Rigotti NA. The association between patient-reported receipt of tobacco intervention at a primary care visit and smokers' satisfaction with their health care. Nicotine Tob Res. 2005 Apr;7 Suppl 1:S29-34. doi: 10.1080/14622200500078063. [CROSSREF]

45. Rigotti NA, Thorndike AN. Reducing the health burden of tobacco use: what's the doctor's role? Mayo Clin Proc. 2001 Feb;76(2):121-3. doi: 10.1016/S0025- 6196(11)63116-9. [CROSSREF]

46. Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, 2008. [HTTP]

47. Pederson LL, Blumenthal DS, Dever A, McGrady G. A web-based smoking cessation and prevention curriculum for medical students: why, how, what, and what next. Drug Alcohol Rev. 2006 Jan;25(1):39-47. doi: 10.1080/09595230500459503. [CROSSREF]

48. Ferketich AK, Khan Y, Wewers ME. Are physicians asking about tobacco use and assisting with cessation? Results from the 2001-2004 national ambulatory medical care survey (NAMCS). Prev Med. 2006 Dec;43(6):472-6. doi: 10.1016/j.ypmed.2006.07.009. [CROSSREF]

49. Thorndike AN, Regan S, Rigotti NA. The treatment of smoking by US physicians during ambulatory visits: 1994 2003. Am J Public Health. 2007 Oct;97(10):1878-83. doi: 10.2105/AJPH.2006.092577. [CROSSREF]

50. Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA. 1998 Feb 25;279(8):604-8. doi: 10.1001/jama.279.8.604. [CROSSREF]

51. La Torre G, Saulle R, Unim B, Angelillo IF, Baldo V, Bergomi M, Cacciari P, Castaldi S, Del Corno G, Di Stanislao F, Panà A, Gregorio P, Grillo OC, Grossi P, La Rosa F, Nante N, Pavia M, Pelissero G, Quarto M, Ricciardi W, Romano G, Schioppa FS, Fallico R, Siliquini R, Triassi M, Vitale F, Boccia A. Knowledge, attitudes, and smoking behaviours among physicians specializing in public health: a multicentre study. Biomed Res Int. 2014;2014:516734. doi: 10.1155/2014/516734. [CROSSREF]

52. Dania MG, Ozoh OB, Bandele EO. Smoking habits, awareness of risks, and attitude towards tobacco control policies among medical students in Lagos, Nigeria. Ann Afr Med. 2015 Jan-Mar;14(1):1-7. doi: 10.4103/1596-3519.148701. [CROSSREF]

53. Richmond R, Zwar N, Taylor R, Hunnisett J, Hyslop F. Teaching about tobacco in medical schools: a worldwide study. Drug Alcohol Rev. 2009 Sep;28(5):484- 97. doi: 10.1111/j.1465-3362.2009.00105.x. [CROSSREF]

54. Grassi MC, Baraldo M, Chiamulera C, Culasso F, Raupach T, Ferketich AK, et al. Knowledge about health effects of cigarette smoking and quitting among Italian university students: the importance of teaching nicotine dependence and treatment in the medical curriculum. Biomed Res Int. 2014;2014:321657. doi: 10.1155/2014/321657. [CROSSREF]

55. Kawane H. Antismoking education for medical students. Chest. 1992 May;101(5):1480. doi: 10.1378/chest.101.5.1480-a. [CROSSREF]

56. Cummings KM, Giovino G, Sciandra R, Koenigsberg M, Emont SL. Physician advice to quit smoking: who gets it and who doesn't. Am J Prev Med. 1987 Mar-Apr;3(2):69-75. [CROSSREF]

57. Aslam SK, Zaheer S, Shafique K. Health professional students' perceptions regarding their role in tobacco control: findings from the Global Health Professional Students Survey, Pakistan, 2011. Subst Abuse Treat Prev Policy. 2014 Jun 23;9:25. doi: 10.1186/1747-597X-9-25. [CROSSREF]

58. Xinguang Chen, Xiaolan Tang, Bonita Stanton, Hanwu Li, Weiqing Chen. Cigarette smoking among medical students in China and modifiable risk factors for smoking prevention. Health Education. 2012; 112 (4): 333 – 34. doi:10.1108/09654281211237162. [CROSSREF]


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