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ORIGINAL ARTICLE
Year : 2022 | Volume
: 14
| Issue : 1 | Page : 38-45
Evaluation of smoking prevalence, secondhand smoke exposure, attitudes of tobacco control, and smoking cessation knowledge among pharmacy and medical students in a private university, Malaysia
Aziz-ur Rahman1, Majory Mambali1, Fazlollah Keshavarzi1, Muhammad Ahsan Iftikhar Baig1, Enti Hariadha2, Muhmmad Junaid Farrukh1
1 Department of Clinical Pharmacy; Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur, Malaysia
2 Clinical Pharmacy Unit, School of Pharmacy, Management and Science University, Shah Alam, Selangor, Malaysia
Correspondence Address:
Dr. Aziz-ur Rahman
Department of Clinical Pharmacy; Faculty of Pharmaceutical Sciences, UCSI University Kuala Lumpur
Malaysia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpbs.jpbs_334_21
Abstract
Background: Tobacco use is one of the leading causes of premature morbidity and mortality globally, causing over eight million deaths per year. One of the best approaches to reduce smoking-related deaths is to encourage future health-care professionals in tobacco control programs. Objectives: To assess the smoking prevalence, secondhand smoke exposure, attitudes toward tobacco control, and smoking cessation knowledge and associated factors among pharmacy and medical students in a private university in Malaysia. Methodology: A cross-sectional study was conducted at two campuses of a private University in Malaysia, and the data were collected online using the Global Health Professionals Students Survey questionnaire and analyzed using IBM-SPSS Version 20. Results: The overall smoking prevalence was 1.6% (P = 0.009). The exposure to secondhand smoke was 21% and 39% at home and in public places, respectively. About 92% of respondents had a good attitude toward tobacco control, whereas 53.4% had good smoking cessation knowledge. However, only 39.4% of the respondents had received formal smoking cessation training. Logistic regression revealed that significant predictors toward tobacco control are the ban of tobacco sales to adolescents, ban on the advertising of tobacco products, ban of smoking in restaurants, and obtaining a specific training on cessation techniques. Conclusions: The prevalence of smoking among pharmacy and medical students was low, but exposure to secondhand smoke was higher. Most of the respondents had a positive attitude and good knowledge of smoking cessation. However, future training needs to be conducted among upcoming health-care professionals to act as a role model for community transformation.
Keywords: Prevalence, attitude, smoking cessation, secondhand smoke, health professional
Introduction 
Tobacco use is the most prevalent modifiable risk factor and one of the leading causes of premature morbidity and mortality globally, causing over eight million deaths per year.[1] About seven million of these deaths result from direct tobacco use, while the rest are caused by secondhand exposure to tobacco smoke. It is estimated that more than 80% of tobacco users worldwide live in developing nations where tobacco-related morbidity and mortality is high.[2],[3]
Tobacco use leads to severe health-related consequences such as cancer, pulmonary and cardiac diseases, and worsening existing chronic conditions. The earlier literature studies indicated that subjection to SHS is a danger to health that uniformly affects all age groups in the community.[4] The World Health Organization (WHO) targets reducing global tobacco use prevalence by 30% by 2025. Therefore, there is a need for all countries to enforce evidence-based tobacco control actions to reduce the prevalence of tobacco use.[2],[5]
In Malaysia, nearly 50% of adult males and one-third of adolescents aged between 13 and 15 years old are current smokers. At present, smoking kills nearly 20,000 Malaysians every year, and if the pattern of smoking does not change, the annual death rate may increase to 30,000 by 2021. To attain the WHO noncommunicable disease global target, Malaysia needs to decrease the smoking rate to at least 15% by 2025.[6],[7]
One of the best approaches to reduce the number of smoking-related deaths is to encourage health-care professionals such as medical and pharmacy personnel in tobacco use prevention and smoking cessation counseling.[5] Health-care professionals can encourage smokers to quit through giving advice, counseling, prescribing medicines for smoking cession, creating linkages to support groups, and making treatment follow-ups. The involvement of health-care professionals in smoking cessation promotion is more cost-effective than using other smoking cessation strategies.[8],[9] For successful smoking cessation, health professionals (HPs) must be knowledgeable, willing, and have a good attitude toward helping people quit smoking.[10]
The WHO, the US Centers for Disease Control and Prevention, and the Canadian Public Health Association have developed the Global HPs Students Survey (GHPSS). The survey collects data on tobacco use, knowledge, attitudes, cessation counseling, and training among health-care professional students in all WHO member states.[9] The introduction of the WHO framework convention on tobacco control stresses the role of HP bodies in tobacco control in the public health program and contribute actively to the reduction of tobacco consumption.[11]
Tobacco control improvements in curricula have not been adequately observed in teaching and the treatment of tobacco management in health-care professional programs remains insufficient among many countries.[12] The GHPSS results have generated valuable information about beliefs, attitudes, and behavior related to tobacco control among health-care professional students. The survey also provides a valuable source of information to develop tobacco control policies and intervention programs. However, GHPSS data have not been collected in many Malaysian universities, a country where around 5 million population engaged in tobacco usage, a practice that has led to an increase in cardiovascular and respiratory illnesses.[6],[7]
The future of health-care professionals' students should be assessed for their knowledge, attitudes, and perceived training related to tobacco management. If found lacking, adequate information regarding such health-care extended services, providing training, gives them greater opportunities to serve the public.[12] The current study explores the smoking prevalence and secondhand smoke exposure and assesses the attitudes toward tobacco control and the smoking cessation knowledge among third- and final-year pharmacy students and 3rd, 4th, and 5th-year medical students at a private university in Malaysia.
Methodology Study design
A cross-sectional study was designed to collect the data from two campuses of a private university in Malaysia, namely, Kuala Lumpur and Terengganu from May to August 2020. The participants included all the 3rd (n = 66) and 4th (n = 116) year pharmacy students: all 3rd (n = 50), 4th (n = 52), and 5th (n = 50) year students of medicine. Research approval was taken from the Faculty of Pharmaceutical Sciences and university ethical committee before distributing the questionnaire to the students.
Inclusion criteria
3rd and final-year pharmacy students3rd, 4th, and 5th-year medical students at the university.Exclusion criteria
1st and 2nd-year pharmacy and medical students at the universityAll students from other programs at the universityAll students from other universities.Data collection
The GHPSS pre-validated, self-administered questionnaire which is a part of the global tobacco surveillance system was used to collect data. There were no changes made in the adopted questionnaire. The contents in the adopted questionnaire were relevant to our study population; therefore, revalidation of the questionnaire was not required. In addition, based on the experts' opinions, the questionnaire can be used in its original form. A soft copy of the questionnaires was created in Google Forms and the link was distributed to both medical and pharmacy students via E-mail. The questionnaires were distributed to a total of 334 students.
Statistical analysis
The data were analyzed using (IBM®, SPPS® Inc., Chicago, Illinois, United States, windows version 20). Demographics of the students were summarized. The collected data were entered into SPSS and analyzed for descriptive and inferential statistics. Chi-square test was applied to compare the smoking cessation, SHS exposure, tobacco control attitudes, and smoking knowledge among the pharmacy and medical students. The key factors of interest and attitudes toward smoking cessation were also examined using regression analysis.
Results The overall response rate in this study was 74.6%. The difference in numbers of pharmacy and medicine students per program year was significant (P ≤ 0.001). Among the participants, 73 (29.3%) were male and 176 (70.7%) were female; there was no significant difference (P > 0.5). Whereas, the difference in the age between participants in the two programs was significant (P < 0.001). The majority of the student participants (n = 79, 84.9%) of medicine students' participants were Malaysians and there was a significant difference in nationality (P ≤ 0.001). The study demographic data are summarized in [Table 1].
Smoking prevalence and cessation intention
The overall prevalence of smoking in this study was 1.6% (n = 4) and it was higher among medicine students (n = 4, 4.3%) than pharmacy students (n = 0, 0%) with a significant statistical difference (P = 0.009). The overall smoking prevalence in the past year before the study was 4% (n = 6), this includes two (1.3%) among pharmacy students and four (4.3%) in medical students, and there was no statistical significance difference (P = 0.885). All the students who had smoked intended to quit and there was no significant difference between the participants from the two programs (P = 0.133) [Table 2].
Table 2: Prevalence of cigarette use, exposure to secondhand smoke, and attitudes toward tobacco control and knowledge of smoking cessationExposure to secondhand smoke
There was a significant difference in SHS exposure between the pharmacy and medicine students both at home (P = 0.047) and in public places (P = 0.037). The pharmacy student's exposure to SHS at home and in public places was 17.3% (n = 27) and 34% (n = 53), respectively, while that of medical students was 28% (n = 26) and 47.3% (n = 44), respectively. More than half (n = 163, 65.5%) of the respondents were aware of the university's smoking ban policy, while 58.6% (n = 146) were aware of the university policy regarding smoking enforcement. The difference in awareness of smoking enforcement policy between participants from the two programs was significant (P = 0.002) [Table 2].
Attitude toward tobacco control
Almost all the participants (n = 231, 92.8%) had a positive attitude, and only a few had negative attitudes (n = 18, 7.2%) toward tobacco control. Participants from the two programs had similar positive attitudes (pharmacy students, 92.3% (n = 144) and medicine students; 93.5% (n = 87) with no significant difference (P = 0.385). Both smokers and non-smokers had positive attitudes toward tobacco control (P = 0.854) [Table 3]a.
Knowledge toward smoking cessation
Over half of the participants (n = 133, 53.4%) had a high level of knowledge, while 46.6% (n = 116) had moderate-to-low levels of knowledge toward smoking cessation. Among the pharmacy students, 59.6% (n = 93) had a high level of knowledge, and 40.4% (n = 63) had a moderate-to-low level of knowledge. In contrast, the knowledge among students of medicine was high in 43% (n = 40) and medium to low in 57% (n = 53). The difference in the level of knowledge between the two programs (P = 0.28) and between the smokers and nonsmokers (P = 0.369) was not statistically significant [Table 3]b. The overall smoking and cessation prevalence, SHS exposure, attitudes, and knowledge of smoking cessation practices are summarized in [Table 2].
Regression analysis
Logistic regression analysis showed that the significant predictors of attitude toward tobacco control are the ban of tobacco sales to adolescents, a complete ban on the advertising of tobacco products, ban of smoking in restaurants, discos/bars/pubs and all enclosed public places, HPs obtaining specific training on cessation techniques, HPs serving as role models routinely providing advice to patients to stop smoking, and using other tobacco products. The standardized coefficient beta indicates that the smoking ban in discos, bars, and pubs has the greatest effect on total attitude toward tobacco control. The regression model indicates that the independent variables, when taken as a group, account for 44% (R2 = 0.440) of the variance of the total attitude score [Table ST1] and [Table ST2].
Predictors of smoking cessation knowledge include receiving information about the dangers of smoking, discussing the reasons for smoking in class, the importance of recording smoking inpatient medical history, receiving formal training in smoking cessation approaches, providing educational materials to support smoking cessation to patients who want to quit, use of nicotine replacement therapies, use of antidepressants in tobacco cessation programs, light cigarettes are less harmful to the health and smoking being an addictive disease. The strongest predictor according to the standardized R coefficient is the use of antidepressants in tobacco cessation programs. The regression model indicated that 36.6% (R2 = 0.366), of the variance of the total knowledge score, was accounted for by the independent variables [Table ST3] and [Table ST4].
Discussion Malaysia has a smoking prevalence of 22.8%, with close to 50% of the male population being current smokers. This practice leads to twenty thousand tobacco-related deaths annually.[7] Our study was conducted to determine the smoking prevalence, SHS exposure, attitudes, and knowledge of smoking cessation among pharmacy and medicine students at a private University in Malaysia.
The smoking prevalence of 1.6% among the pharmacy and medicine students in our study was similar to one study did in Malaysia (2.3%),[13] but was lower than other studies which have been conducted within the same country (14.7% and 34.5%).[14],[17] The current study reported smoking prevalence still lower compared to studies that did in the regions of China 9.8%,[18] Jordan 22.3%,[19] and Lebanon 14%–27%.[20] In European studies, the prevalence was higher than current study with 27.1%, 33%[23] in Greece, and 16.9%[24] in Kosovo. Studies in Africa reported a prevalence of 17.4% in Egypt[25] and 5% in Nigeria.[26] The reasons for low smoking prevalence in the current study may include the smoking ban policy in place at the university and student's awareness of the dangers of smoking (90% of respondents indicated they were taught in school). Besides, they may be social, cultural, and family traditions in which it is considered inappropriate for youths to smoke in front of elders in Malaysia.[14] The smoking ban policy creates a discouraging environment for smoking, reduces the peer pressure to start smoking, and prevents SHS exposure on university premises.
The prevalence of SHS exposure at home in our study was 21%; this prevalence was less when compared to similar studies conducted in and Greece (16%–33%)[22] and Nepal (31.6%).[27] On the other hand, the SHS exposure prevalence in public places in the current study was found to be 39%, lower than compared to similar studies which have been conducted in Malaysia (62%),[13] Lebanon (80%),[20] and Nepal (48.9%),[27] but higher than the prevalence in china (21.2%–31.9%).[28] Despite there being very few students found to be smoking in the current study, exposure to SHS is still considerably high. Therefore, there is a need to minimize student SHS exposure both at home and in public places.
About 65% of the students from our study were aware of the school smoking ban policy. However, a smaller number (58.6%) of the students thought that the ban was enforced. This scenario is similar to a study in Greece.[22] Other few studies[23],[25] found that < 50% of the participants were aware of the school smoking ban policy. However, an ineffectively implemented ban would encourage violations and lead to exposure to SHS on the university campus. There is a need for more student sensitization regarding the smoking ban policy at the university and more effort must be put into enforcement of the ban to discourage smoking and prevent SHS exposure. It may also be important to explore the factors associated with the perceived low smoking ban enforcement at the university. Greater benefits of university smoking ban policy are realized when firm enforcement is integrated with smoking cessation services, health promotion, and educational campaigns.[29],[30]
Almost all participants (92.8%) in our study had a good attitude toward tobacco control. This result was similar to results obtained in another Malaysian study (80%),[15],[16],[17] Nigeria (88%),[6] Greece (82%),[23] Saudi Arabia (81%),[31] and Iran.[32] The good attitude may be attributed to the students' awareness of the health hazards of cigarettes smoking and SHS exposure. The awareness was confirmed by our findings in this survey, which indicates that 90% of the students had been taught about the dangers of smoking. However, fewer people (70%) agreed with prohibiting smoking in bar/pubs/discos. The reason for this could be because the tobacco laws in Malaysia allow smoking in bars/pubs/discos.
Our study's respondents favored HPs obtaining specific training on cessation techniques, serving as role models, and habitually advising patients to stop smoking. These findings were similar to the results obtained from studies in Lebanon,[20] Malta,[21] Greece,[22] Kosovo,[24] Nigeria,[26] Saudi Arabia,[31] and India.[33] The reason for favoring specified cessation technique type of training for HPs may be because the students were familiar with the health burden associated with tobacco smoking. Evidence indicates that it is unusual for physicians who smoke to find out the patient's smoking history and offer counsel.[36] Physicians need to be role models in the fight against tobacco use to inspire the patients to quit smoking. Smoking cessation is a complex process because it is addictive and is associated with patient challenges such as failed attempts, beliefs, and misunderstandings, as well as social and lifestyle factors.[35] Health-care provider challenges include inadequate time, lack of training, and unmotivated patients.[34] There is a need for HPs to be trained appropriately to contribute effectively to smoking cessation programs.
Overall, about 53% of the respondents in our study had high knowledge regarding smoking cessation. Despite our study having more than 50% of the respondents with high knowledge, a smaller number (39%) had received prescribed smoking cessation teaching. More students need to be officially trained to participate effectively in helping patients quit smoking. Our study also indicates that more than 90% of the respondents were informed of the dangers of smoking through the curriculum. These findings were consistent with those found in Egypt (86%)[25] and Nigeria (93%),[26] but were higher when compared with the findings in Saudi Arabia,[31] Malaysia,[13],[14],[15],[16],[37],[39] and China[28] where fewer students reported having received an education.
Training HPs in smoking cessation enhances patient quit rates because it facilitates smoker identification and offering smoking cessation services. Training also enhances provider knowledge, competence, self-belief, and chances of making interventions.[36],[37],[38] Policies and strategies to lower smoking prevalence should be aimed at reducing existing as well as would be smokers.[40],[41] The majority of the students in our study were also aware that smoking is addictive and those light cigarettes are not harmful. Nonmisleading packing and advertising of cigarette are essential in lowering the misunderstanding that certain cigarettes are not as dangerous as ordinary cigarettes.[42]
The predictors of attitude toward smoking cessation in this study indicate that 44% (R = 0.44) of the total attitude score variance is accounted for by the independent variables. The standardized coefficient beta indicates that the smoking ban in discos, bars, and pubs has the greatest effect on total attitude toward tobacco control. Smoking in discos/bars/pubs is considered legal in Malaysia. The findings of smoking cessation knowledge predictors in our study indicate that 36.6% (R = 0.366) of the total knowledge score is accounted for by the independent variables. Low values for R squared in human behavior studies are commonly expected.[41],[43] According to the standardized R coefficient, the strongest predictor of smoking cessation knowledge is the use of antidepressants in tobacco cessation programs. Nicotine withdrawal can lead to depressive symptoms and antidepressants are often used to relieve such symptoms. In addition, some antidepressants may have a specific effect on neural pathways or receptors that underlie nicotine addiction. This is because antidepressant drugs have diverse mechanisms of action and pharmacological profiles, making them useful for people who want to stop smoking tobacco. The use of antidepressant such as bupropion increases the chance of stopping smoking by 52% to 77%.[44]
The current study findings may help arrange future training among the prospective health-care students to educate them with appropriate knowledge and skills in smoking cessation. The current study also revealed that there is the necessity of including knowledge and training about smoking cessation in the university educational curriculum. This initiative will ensure that future health-care students must play a pivotal role in health promotion and disease prevention management related to smoking-induced diseases. The study creates awareness and builds confidence among the future health-care professional students, so that they can offer smoking cessation services independently and support the public to quit smoking.
The study is not without limitations. The data obtained were based on self-reports from the students; some study participants may not report the truth. The sample size of this research was small and from just two geographical locations. However, the study data were collected with a rational approach and standard procedure was adopted at two sites. A larger sample size with other health programs in various universities may better generalize the study outcomes.
Conclusions The prevalence of smoking among pharmacy and medicine students in our study was low, but SHS exposure was higher. Whereas, just more than half of the study participants exhibited high knowledge and attitude toward smoking cessation. The study also reported that few respondents had received formal smoking cessation training. However, the current study results showed that future training needs to be conducted among pharmacy and medical students to enhance their knowledge and skills for smoking cessation to serve the public. The study also revealed that the necessity of inclusion into the educational curriculum about smoking cessation is needed to make future health-care professional students play a pivotal role in health promotion. Besides this, the study results also suggested the enforcement of the smoking ban policy to create and maintain a smoke-free environment at the University.
Acknowledgments
We sincerely thank our participants for joining this study and providing information about electronic cigarettes.
Financial support and sponsorship
The study was financed by the faculty of pharmaceutical sciences, UCSI university Malaysia, project-2019-in-FPS-026.
Conflicts of interest
There are no conflicts of interest.
References 
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