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Awareness, Attitude and Use of Tobacco among Medical Students in Chennai

Background Health professionals have an important role to play in the fight against tobacco. As individuals, health professionals can help educate the population; as community members, they can support anti-smoking policies; and, at a societal level, they can influence national and global tobacco control efforts. The objectives of the study was to estimate the prevalence of tobacco use among medical students in Chennai and to measure the extent of attitude toward, behavior around and knowledge of tobacco use among medical students. Methods This cross-sectional study was conducted among 400 medical students from 4 randomly selected medical colleges, comprised of 1 government and 3 private medical colleges in and around Chennai, India. The Global Health Professional Students Survey (GHPSS), a standardized college-based tool, was administered to students in the four medical colleges. Results The proportion of students who ever tried cigarette smoking was found to be 10.9% (males, 23.5% and females, 1.8%). The prevalence of exposure to tobacco smoke at home was found to be 34.2%. A majority of students agreed that smoking should be banned. The proportion of students who wanted to quit smoking cigarettes and who ever tried to stop smoking were 29.8% and 34.6% respectively. Only 23.6% of the students said they have received formal training in smoking cessation techniques. Conclusion As indicated by the majority of the medical students queried, there is a need for formal training in smoking cessation techniques, and this training should be included in the medical curriculum, such that students can instruct or counsel their patients.


INTRODUCTION
Tobacco use is the single largest preventable cause of death and disability worldwide. Nearly 80% of these deaths occur in low-and middle-income countries [1]. Tobacco is one of the major causes of death and disease in India, accounting for nearly 900,000 deaths every year. About 53% of all deaths in India are caused by NCDs, for which tobac- products are available at very low prices [2]. Tobacco-related mortality in India is among the highest in the world [3]. Smoking among health care personnel, such as medical students, is an important public health issue. More effective measures to reduce tobacco smoking among medical students are needed worldwide [4]. Health professionals, while recognizing smoking as the leading preventable cause of death and disability, are not aware of their fundamental role in helping people quit smoking [5,6]. In some countries, the prevalence of smoking is higher among health professionals than among the general population [7,8].
Teaching about the effects of the use of tobacco and its related diseases is essential for undergraduate medical students, especially to counter the deadly effects of the same.
Physicians occupy a key position in this regard, as they are uniquely placed to lead smoking cessation programs in the community [9]. In most developed countries where tobacco use has decreased, doctors often have set an example by being the first group to quit tobacco use [10]. Health professionals have an important role to play in the fight against tobacco. As individuals, health professionals can help educate the population; as community members, they can support anti-smoking policies; and at a societal level, they can influence national and global tobacco control efforts [11].
To date, very few studies had been conducted in India to understand the magnitude of knowledge of smoking as a public health problem among medical students. Medical students are better placed to understand and practice the latest developments in healthcare. Therefore, it is important to understand the factors affecting tobacco use among medical students and to know whether medical students perceive tobacco use as a public health problem. Hence, this study was undertaken to estimate the prevalence of tobacco use among medical students in Chennai and to measure the extent of attitude toward, behavior around and knowledge of tobacco usage among medical students.  [13]. This tool was administered in colleges during regular class sessions. The questionnaire was pre-tested in a pilot study to assess the feasibility of adopting the questionnaire, and it was adopted without modification.

MATERIALS AND METHODS
The protocol was submitted to the institution ethics committee and approval was obtained.
After obtaining the permission of heads of the in- The proportion of students who ever tried cigarette smoking was found to be 10.9% (males, 23.5%; females, 1.8%).
The prevalence of current cigarette smoking among students was found to be 4.8% (males, 11.5%; females, 0%). The proportion of cigarette smoking on college premises during the past year was found to be 1.9%. The proportion of students  Should tobacco sales to adolescents be banned? Should there be a complete ban of the advertising of tobacco products? Should smoking be banned in restaurants? Should smoking be banned in discos/ bars/pubs? Should smoking in all enclosed public places be banned? Should health professionals get specific training on cessation techniques? Do health professionals serve as role models for their patients and the public? Shouldhealth professionals routinely advise their patients who smoke to quit smoking? Should health professionals routinely advise their patients who use other tobacco products to quit using these products? Do health professionals have a role in giving advice or information about smoking cessation to patients? Are a patient's chances of quitting smoking increased if a health professional advises him or her to quit? Do you feel that health professionals who smoke are less likely to advise patients to stop smoking? (n = 479) During college, were you taught, in any of your classes, about the dangers of smoking? During college, did you discuss, in any of your classes, the reasons why people smoke? During college, did you learn that it is important to record tobacco use history as part of a patient's general medical history? During college, did you ever receive any formal training in smoking cessation approaches to use with patients? During college, did you learn that it is important to provide educational materials to support smoking cessation to patients who want to quit smoking? Have you ever heard of using nicotine replacement therapies in tobacco cessation programs (such as nicotine patch or gum)? Have you ever heard of using antidepressants in tobacco cessation programs (such as bupropion or zyban)?  The difference in attitudes between males and females was significant (p = 0.007). The proportion of students who said health professionals who smoke are less likely to advise patients to stop smoking was 70.6% (Table 2).
Among the students who tried smoking/smokeless tobacco (n = 52), 29.8% and 34.6% wanted to quit smoking cigarettes and tried to stop smoking, respectively. The proportion of students who stopped smoking cigarettes and re-ceived help or advice to stop smoking cigarettes were 13.5% and 59.6%, respectively. The proportion of students who wanted to stop using smokeless tobacco was 44.4% (Table   3). In the present study, the distribution of cigarette smoking on college premises during the past year was 1.9%. In contrast, studies by AlKawari et al. [25] and Surani et al. [18] found that one-third of students smoked on college premises/property and 17.1% smoked in college buildings during the past year, respectively.
In the present study, the prevalence of smokeless tobacco ever used was found to be 1.9% and the prevalence of current smokeless tobacco use was found to be 1.0%. In contrast, a study by Joge et al. [26] reported the prevalence of smokeless tobacco was 5.8%, Selokar et al. [14] reported 10% and Surani et al. [18], 11.6%. In the present study, 2.5% of males and none of the females were current smokeless tobacco users, whereas Surani et al. [18] reported that 13.7% of males and 7.5% of females were current smokeless tobacco users. In our study, about 0.6% had used smokeless tobacco on college premises during the past year, whereas Surani et al. [18] found that 34.2% used smokeless tobacco on campus during the past year.

Exposure to environmental tobacco smoke
In our study, approximately one-third of the students had exposure to smoke at home. Nearly half of the male students and one-fourth of the female students had exposure to smoke at home. Similar findings was reported by AlKawari et al. [25], where 27.9% were exposed to smoke at home. In contrast, Sinha et al. [20] and Tacettin Inandi et al. [27] reported that upward of fifty percent of the students had exposure to smoke at home.
In the present study, approximately half of the participants had exposure to smoke at public places (58.5% among male students and 44.4% among female students). Similar findings were reported by AlKawari et al. [25] and Inandi et al. [27]. In contrast, studies by Sinha et al. [20] and Saade et al. [28] reported that two-thirds of the students were exposed to smoke at public places.
The study findings revealed that more medical students were exposed to environmental tobacco smoke than to active smoking among both males and females. This indicates the need for health education of families and the community about the health hazards of passive smoking.
Of the students in the study, 79.1% reported that their college has an official policy banning smoking in college buildings and clinics. A similar finding was reported by Inandi et al. [27], with 88.2% of students reporting that their college had an official policy banning smoking on col-lege premises. In contrast, studies by Sinha et al. [20] in 2005-2011 and Saade et al. [28] found that only half the students reported that their college had an official policy banning smoking in college premises.
In the present study, two-thirds of the students said an official smoking ban in college buildings and clinics has been enforced. A slightly higher percentage of students reported a smoking ban was enforced in the studies done by Inandi et al. [27] with 87.2% and AlKawari et al. [25] with 88.1%. Surani et al. [18] found that a slightly lower number of students (53%) reported that there was official smoking ban enforcement in their medical school.

Attitude towards smoking and sale of tobacco products
In the present study, more than 90% of the students favored banning the sale of tobacco products to adolescents, banning the advertisement of tobacco products, and banning smoking in restaurants and in public places. Similar findings were reported by Sychareun et al. [29], Mehrotra et al. [30], and AlKawari et al. [25]. In the present study, nearly three-fourths of the students reported that smoking should be banned in discos/bars/pubs. Sychareun et al. [29] and Mehrotra et al. [30] reported that 70.5% and 66.9%, respectively, of students indicated smoking should be banned in discos/bars/pubs.
In our study, even though more than 90% of the students supported bans of tobacco products in public places and restaurants, sales to adolescents and advertisements of tobacco products, only three-fourths of the students believed that tobacco products should be banned in discos, bars and pubs; this finding was supported by other published studies [29,30]. In the present study, approximately three-fourths of the students reported that health professionals should serve as a role model for their patients. Similar findings were reported by Sinha et al. [20], where 73.8% of medical students believed that health professionals served as role models for their patients and the public. Thankappan et al. [31] reported that a slightly higher proportion (89%) of medical students believe that health professionals serve as role models for their patients and the public. In the present study, 95.2% of the students reported that health professionals should get specific training in smoking cessation.

Behavior/cessation of smoking and smokeless tobacco
In the present study, one-third of students had ever tried to stop smoking. In contrast, the study done by other investigators found that more than 50% of medical students had tried to quit smoking [21,27]. In the present study, 59.6% of smokers ever received help/advice to stop smoking cigarettes. Similarly, studies conducted by other investigators found that more than half of smokers ever received help or advice to stop smoking cigarettes [18,27]. In our study, more than 70% of students reported health professionals who smoke are less likely to advise patients to stop smoking. Adeel Khan et al. [33] found that a slightly higher proportion of students (77.5%) reported that health professionals who smoke are less likely to advise patients to stop smoking.

Training/curriculum on smoking and tobacco use
In the present study, more than 90% of students reported they were taught about the dangers of smoking. In contrast, Adeel Khan et al. [33] reported that only 43.7% of students were taught about the dangers of smoking. In addition, in the present study, more than 90% of students were taught that it is important to record tobacco use as a part of a patient's history. Similarly, Adeel Khan et al. [33] found that 88.9% of students were taught the importance of recording tobacco usage history.
In our study, one-fourth of students received formal training in smoking cessation for patients. In contrast, Adeel Khan et al. [33] found that 34.2% of students received formal training in smoking cessation. In the present study, nearly three-fourths of the students are taught that it is important to provide educational materials on smoking to patients. In contrast, Adeel Khan et al. [33] found that 58.5% of students were taught the importance of providing educational materials on smoking to patients.
In the present study, more than three-fourths of students have heard of using nicotine replacement therapies in tobacco cessation programs. Lam et al. [15] found a slightly higher proportion (90.8%) in their study. In contrast, Jradi [24] reported that only 18.4% have heard of nicotine replace-ment products. In the current study, more than half of the students are aware of the use of antidepressants in tobacco cessation programs. Jradi [24] found that a slightly higher proportion (63%) of students were aware of the use of antidepressants in tobacco cessation programs.

CONCLUSION
In our study, less than 5% of medical students were current smokers, but upward of one-third to one-half were exposed to environmental tobacco smoke at home and in public places. This indicates that a health awareness campaign for the prevention and control of smoking at home and public places must be intensified. As indicated by the majority of the participants, medical students need to receive formal training in smoking cessation techniques and this training must be included in the medical curriculum so that students can instruct or counsel patients.