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Knowledge, attitudes and preventive efforts of Malaysian medical students regarding exposure to environmental tobacco and cigarette smoking
Journal of Adolescence 1999, 22, 627±634 Article No. jado.1999.0258, available online at http://www.idealibrary.com on
Knowledge, attitudes and preventive efforts of Malaysian medical students regarding exposure to environmental tobacco and cigarette smoking ANN STIRLING FRISCH, MARGOT KURTZ
AND
KHADIJAH SHAMSUDDIN
A longitudinal study was conducted to determine changes in knowledge, attitudes and preventive efforts of Malaysian medical students concerning cigarette smoking and environmental exposure to tobacco smoke from their first pre-clinical year in medical school until their final clinical year. There were significant improvements in knowledge about cigarette smoking and in knowledge, attitudes and efforts concerning environmental exposure to tobacco smoke. Overall attitudes concerning cigarette smoking did not change over this period. The same pattern was found for male nonsmokers. Women improved on all five scales; male smokers improved on none over the 3-year period. Male non-smokers had better scores on these scales than male smokers in both beginning and ending years. Women excelled in comparison to male non-smokers on smoking attitudes in the pre-clinical year and on all scales except preventive efforts in the final clinical year. Although medical students experienced no changes in the amount of pressures not to smoke from family and friends, there was a significant increase in the amount of prohibition on smoking from their teachers. Male non-smokers alone accounted for this increase. Women experienced more pressure than men not to smoke from their teachers in both years, but the male smokers and non-smokers did not differ in teacher pressure for either year. # 1999 The Association for Professionals in Services for Adolescents
Introduction Research suggests that physicians and nurses are significant role models and educators for appropriate health care behavior (National Clearinghouse for Smoking and Health, 1976a; US Public Health Service, 1991; Nelson et al., 1994); and that smoking by health-care providers hinders their ability to educate on the topic (Noll, 1969a, b; Levitt and DeWitt, 1970; National Clearinghouse for Smoking and Health, 1976b; Elkind, 1980; Kottke et al., 1985; Dalton and Swenson, 1986, Nelson et al., 1994). At the University of Malaya, smoking among male medical students declined from 25.2% in 1972 to 17% in 1987 (Wong and Chen, 1989). This compares to 44% of males in a 1990 study of Malay engineering students (Kurtz et al., 1990) and 40?9% of males in the general population of Malaysia according to a 1985 survey (Ministry of Health, Malaysia, 1986). Declines in smoking among Malaysian medical students are mirrored in the U.K. and the U.S.A. (Coe and Cohen, 1980; Elkind, 1982; Maynard et al., 1986; Conard et al., 1988; Baldwin et al., 1991; Nelson et al., 1994). The declining rate of smoking for all physicians, registered nurses and licensed practical nurses has been attributed to both an increase in smoking cessation and increase in the number of non-smokers joining the health-care fields (Nelson et al., 1994). Reprint requests and correspondence should be addressed to Dr Ann Stirling Frisch, University of Wisconsin, 800 Algoma, Oshkosh, Wisconsin 54901, U.S.A. (E-mail: [email protected]). 0140-1971/99/050627+08 $3000/0
# 1999 The Association for Professionals in Services for Adolescents
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A. S. Frisch et al.
Researchers have found that physicians and nurses quit smoking for many of the same reasons as the general public: personal health concerns, cost and pressure from family (Feldman and Richard, 1986; Centers for Disease Control, 1990). In addition, the desire to be an educational role model for patients and children is also mentioned as a reason for smoking cessation (Feldman and Richard, 1986; Nelson et al., 1994). Interaction with patients with smoking-related problems may have impact on the smoking cessation rates for health-care providers (Nelson et al., 1994). Researchers note that physicians and nurses who smoke can less effectively convey the message about the adverse health impacts of smoking (Dawley et al., 1981; Nelson et al., 1994). Studies have shown that smokers are six times more likely to quit smoking permanently if their physicians help in the cessation process (Friend, 1989). However, in their study of physicians at a teaching hospital in Lagos, Nigeria, Bandele and Osadiaye (1987) found that fewer physicians gave anti-smoking advice to all patients (30%) than to patients with smoking-related diseases (44%). Twenty-three per cent gave advice only if asked. In a 1987 study of the educational efforts of British physicians to improve patient health lifestyles, only 39?7% of the 17,610 patient respondents who smoked reported ``definitely'' or ``probably'' receiving advice about smoking cessation (Wallace et al., 1987). A 1979 study of Malaysian military physicians (Supramaniam, 1980) revealed that 50% of these physicians were smokers; 50?5% of the total sample would advise their patients to stop smoking regardless of their medical condition; 57?5% would advise stopping if the patient's illness was smoking-related. A decade later, Wong and Chen (1989) reported that while virtually all the students would advise against smoking if the patient had a related health problem, only 30% would advise against smoking if there were no health problem and the patient didn't raise the question. Slightly more smokers than non-smokers agreed with exsmokers in an intermediate position. In terms of setting a good example by not smoking, 97% of non-smokers and 78% of smokers agreed. Ninety-three per cent of non-smokers and 70% of smokers held the opinion that physicians should play a more active role against smoking. In light of this research, a study was designed which would track longitudinally the changes in knowledge, attitudes and preventive efforts of Malaysian medical students concerning cigarette smoking and environmental exposure to tobacco during their 6 years of medical school.
Materials and method The data in this study were collected from 148 first pre-clinical year medical students at the Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM) in Kuala Lumpur during the 1991±1992 school year. The first year students had completed their first year of medical school following 1 year of university education. This same group was surveyed in the 1993± 1994 school year. Of the 146 students still enrolled, 104 completed the follow-up survey. These clinical year students were completing their final rotations in surgery, medicine, community health, pediatrics or obstetrics and gynecology. Students completed a self-administered questionnaire requesting information about student smoking behaviors, family pressure not to smoke and knowledge, attitudes and preventive efforts concerning the cigarette smoking and the risks of exposure to environmental tobacco. Three scales were created with the available data. A knowledge scale was created to measure the student's knowledge about exposure to environmental
Malaysian medical students and smoking
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tobacco. Nine questions were drawn from the research literature concerning the health risks associated with exposure to environmental tobacco, with regard to lung cancer, lower birthweight and respiratory illnesses. Ten statements such as ``I worry about breathing other people's smoke'' and ``Smoking should not be permitted at school and colleges'' were included in an attitude scale. A third scale rated their current preventive efforts to protect people from exposure to environmental tobacco. Included among the 22 statements were ``I ask people not to smoke near me'' and ``I ask people not to blow smoke in my face''. The three scales were scored on a scale of 1±5 with 1 = strongly agree to 5 = strongly disagree, so a lower scorer was considered ``better'' in terms of pro-health knowledge, attitudes and preventive efforts. For each component a composite score was computed as the average of the individual item scores. An additional effort question, where the students rated their perceptions of their responsibilities to discuss with patients the problem of environmental tobacco, was examined separately. The questionnaire was pre-tested on medical students who did not participate in the study to assess administration time and obtain feedback on wording and language level. Although the students were bi-lingual English±Malay, some parenthetical comments were added to clarify the meaning of some questions. The questionnaire took about 20 min to complete. Students were assured that their participation was voluntary and that all responses were anonymous. t-Tests were performed to test for differences between students' scores on the knowledge, attitude and preventive efforts concerning cigarette smoking and environmental exposure to tobacco smoke by gender, smoking status and pressure not to smoke. Pearson correlation coefficients were utilized to determine the relationship between students' knowledge and preventive efforts scores.
Results Reliability analyses of the composite knowledge, attitudes and preventive efforts scales were conducted to determine the internal reliability of the composite scales. The reliability coefficients (Cronbach's alpha) were: knowledge 0?69, attitudes 0?84 and preventive efforts 0?91 for environmental exposure and knowledge 0?75 and attitudes 0?77 for cigarette smoking. Ninety-five per cent of the pre-clinical year students' questionnaires (148 of 154) were returned. The pre-clinical year class consisted of 35?8% women (n=53) and 64?2% men (n=95). There were 78% Malay students (n=116) and 22% others. The final clinical year class consisted of 146 students of which 77% (n=104) returned the follow-up questionnaires. Thirty per cent of the members of the final clinical year were women (n=37), 60% were men (n=67); 75% (n=78) Malay and 25% other (n=26). The rate of return by gender was 64% women, 74% men; and by ethnicity: 70% Malay, 76% others. There was a difference between men and women in the number of smokers. There were 13 (8?8%) current smokers in the pre-clinical year and 11 (10?6%) smokers in the final clinical year Ð all were male; and there were no female smokers in either year. Similarly, there were 30 (20%) ever smokers (current non-smoker, but had smoked at one time) in the earlier period and 32 (31%) in the later period Ð all male. There was a difference among medical students in the number of smokers by race (Malay or other) in the pre-clinical year (p50?049), but not in the clinical year class. The opposite
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was true for the number of ever-smokers, where there was a difference in the final clinical year (p = 0?014). There were no differences in the two classes by ethnicity, number of smokers or ever-smokers, in the education of the students' father or mother. A statistically significant difference between the classes in their self-reported health status was noted. Compared to the pre-clinical class, the final year class reported better health (p = 0?000). This was true for females (p = 0?006) and male non-smokers (p = 0?000) as well as smokers (p = 0?007). There were no differences in health status between smokers and non-smokers in either time period, but women had better self-reported health than men in the clinical year (p = 0?001).
Knowledge, attitudes and preventive efforts
Although there was no change in students' scores on the item ``smoking during pregnancy is harmful to the fetus'', there was an improvement in students' score on the more specific knowledge question ``infants and children have more respiratory illness if their parents smoke'' (p50?007). There were significant improvements in the students' scores on three preventive efforts items: ``I teach children about the hazards of cigarette smoke'' (p50?000), ``I ask people not to smoke in front of children'' (p50?000) and ``I tell pregnant women that smoking is harmful to their baby'' (p50?000). The improvements in scores were consistent for women and male non-smokers (all p50?05). Smokers' scores did not improve on the knowledge question (effects on respiratory illness), nor on teaching children about hazards, but they did improve on the latter two preventive efforts items.
Environmental attitudes
Students' attitudes about whether a person should try to prevent others from smoking were similar in the two time periods. There was also no change in their attitude that smoking should not be permitted at schools and colleges, about smoking being prohibited in healthcare facilities and a ban on advertising of cigarettes. (Their attitudes overall were strongly pro-health in both years.) However, their attitudes about their own preferences changed significantly: they felt more strongly during their clinical year that a smoke-free environment would make them more productive (p50?001) and that they would choose a non-smoking area if offered (p50?003). On these two items, the pattern was consistent for men and women and non-smokers (all p50?05). Not surprisingly, there was no difference for smokers from one time period to the next on either of these items.
Personal attitudes
Selected items on the attitudes scale, i.e. preference that a spouse, son or daughter not smoke, the obligation of health professionals to set a good example by not smoking and the responsibility of people in the health professions to inform non-smokers about the hazards of cigarette smoking, did not change from the pre-clinical to final clinical year.
Pressures not to smoke
Among family members and friends, there were no reported changes in pressures not to smoke while students were in medical school. However, for the total population and for male non-smokers, there were significant increases in reported pressure from teachers (p = 0?008 and p=0?007, respectively). Nonetheless, women reported significantly more pressure from teachers than men in both pre-clinical (p=0?000) and clinical years (p=0?006). There was
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no difference between male non-smokers and smokers in the amount of pressure experienced from teachers in either year.
Overall scores
While attitudes about cigarette smoking did not change from the pre-clinical to final clinical year, knowledge about cigarette smoking did improve, as well as knowledge, attitudes and preventive efforts concerning exposure to environmental tobacco smoke (all p50?05). This pattern held for male non-smokers (p=0?000, p=0?000, p=0?006 and p=0?002, respectively). Women improved on all five scales: cigarette smoking knowledge (p=0?000) and attitudes (p=0?003); and environmental tobacco smoke knowledge (p=0?000), attitudes (p=0?001) and preventive efforts (p=0?001). Male smokers improved on none. When these scales were examined in terms of amount of teacher pressure not to smoke, those who felt strong pressures not to smoke improved on all scales except attitudes about cigarette smoking (all p50?02). There were no changes from pre-clinical to final clinical year on these scales for those who felt little pressure not to smoke. Women excelled over men only in attitudes about cigarette smoking during the preclinical year (p=0?003) and on both knowledge and attitude scales during their final clinical year (p50?05). On the preventive efforts scale, there was no difference during the final clinical year. Male non-smokers scored better than smokers did on every scale at each time period (p50?05).
Links between knowledge, attitudes and preventive efforts
Examining the data for the relationships between knowledge and attitudes, we found a systematic and substantial correlation for the total group in both the pre-clinical and final clinical years. When sorted by gender, smoking status and teacher pressure, we found that there were systematic links between knowledge and attitudes and preventive efforts for the total sample, for male non-smokers and those who experienced pressure from their teachers not to smoke. This was not the case for women, smokers and those who did not experience pressure from their teachers not to smoke.
Discussion In the total sample, knowledge about cigarette smoking improved but attitudes did not. This same pattern was found for male non-smokers and students whose teachers pressured them not to smoke. Women, however, improved on both scales; smokers and those whose teachers did not pressure them not to smoke improved on neither scale. Kurtz et al. (1990) found that attitudes about cigarette smoking did not change following a lecture on health risks associated with cigarette smoking among Malaysian engineering students, although knowledge scores did improve. Frisch et al. (1992) found that non-smokers scored better than smokers, never-smokers better than ever-smokers and women better than men on both knowledge and attitudes about cigarette smoking. A similar pattern was found by comparing medical students whose brothers were non-smokers compared to smokers, and where male friends were non-smokers compared to smokers. In relation to exposure to environmental tobacco, the clinical group showed improvements in environmental exposure knowledge, attitudes and preventive efforts in the total group, in women and in male non-smokers, through not in smokers. Those who
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reported teacher pressures not to smoke also improved on all three scales. Those who reported little or no pressure improved on none of the scales. In the pre-clinical year, women's knowledge about environmental exposure to tobacco smoke is linked to attitudes about environmental exposure to tobacco smoke as well as to attitudes about smoking. In the final clinical year, the links are between both knowledge scales (cigarette smoking and environmental exposure) and attitudes about environmental exposure to tobacco smoke. Male non-smokers (the only group to receive both increased teacher pressure and higher preventive efforts scores from the pre-clinical to final clinical year) and those who received strong pressures from teachers not to smoke have consistent links between knowledge, attitudes and preventive efforts. There are no correlations between knowledge, attitudes and preventive efforts for smokers in either year. A previous study with the same medical students (Frisch et al., 1995) showed that men's and non-smokers' (but not women's and smokers') scores on environmental exposure to tobacco smoke were linked to pressures from brothers and friends not to smoke. The exception to that was that attitudes were not related to pressure from brothers not to smoke. Teacher pressures were linked to attitudes and preventive efforts for the total sample and only to preventive efforts for non-smokers in that study. Although women seem to have better scores, there are fewer correlations between knowledge and preventive efforts than for male non-smokers. The low rate of smoking by medical students is certainly an indicator of more pro-health attitudes and efforts among medical students. A close examination of the data indicates that even smokers may be helpful in promoting healthful attitudes. Frisch et al. (1995) found that Malaysian medical student smokers' attitudes were positively correlated with pressure not to smoke from friends but not from other family members or teachers. Smokers in that same study had inconsistent pressures from family and friends, whereas that was not the case with non-smokers, men and women. Smokers' knowledge (of exposure to environmental tobacco smoke) in the 1995 study was also linked to efforts to inform non-smokers about the hazards of environmental smoke. The better the smokers' attitudes, the better their preventive efforts. In the present study, there were also some encouraging data to support the value of teacher pressure not to smoke. Although smokers had the poorest record for correlation between knowledge, attitudes and practice at both time periods, those with little or no teacher pressure not to smoke had links between attitudes and knowledge about environmental exposure to tobacco smoke. Those who received strong pressure not to smoke had substantial and consistent links between knowledge, attitudes and preventive efforts.
Acknowledgements This paper was funded in part by the University of Wisconsin-Oshkosh Faculty Development Board Grant # R252 for which the authors express their appreciation. The authors thank the faculty of the Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM) for their assistance in conducting this study. Thanks also to the student group leaders who were responsible for the collection of questionnaires. In addition, the authors gratefully acknowledge Dr Jay Kurtz, Professor of Mathematics at Michigan State University, Encik
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Mohd Zul Mohd Yusoff, computer programmer at the Universiti Pertanian Malaysia, for assistance on SPSS-X programming and Annett Smith, Graduate Assistant, College of Education and Human Service, University of Wisconsin-Oshkosh. Dr Frisch is Professor, Department of Human Services and Professional Leadership at the University of Wisconsin-Oshkosh. Dr Kurtz is Professor, Department of Family Medicine, at Michigan State University. Dr Khadijah is a physician and Professor at Universiti Kebangsaan Malaysia in Kuala Lumpur.
References Baldwin, D. C., Hughes, P. H., Concard, S. C., Storr, C. L. and Sheehan, D. V. (1991). Substance abuse among senior medical students. Journal of the American Medical Association, 265, 2074±2078. Bandele, E. O. and Osadiaye, J. A. (1987). Attitudes and smoking habits of physicians at the Lagos University Teaching Hospital. Journal of the National Medical Association, 79, 430±432. Centers for Disease Control. (1990). Tobacco Use in 1986: methods and basic tabulations from adult use of tobacco survey. Rockville, MD: Office on Smoking and Health. US Department of Health and Human Service Publication OM 90-2004. Coe, R. M. and Cohen, J. D. (1980). Cigarette smoking among medical students. American Journal of Public Health, 70, 1697±171. Conard, S., Hughes, P., Baldwin, D. C. Jr., Achenbach, K. E. and Sheehan, D. V. (1988). Substance use by four-year students at 13 US medical schools. Journal of Medical Education, 63, 741±761. Dalton, J. A. and Swenson, I. (1986). Nurses and smoking: role modeling and counseling behaviors. Oncology Nursing, 13, 45±48. Dawley, H. H., Carrol, S. F. and Morrison, J. E. (1981). The discouragement of smoking in a hospital setting: the importance of modeled behavior. International Journal of Addiction, 16, 905±910. Elkind, A. (1980). Nurses smoking behavior: review and implications. International Journal of Nursing Studies, 17, 261±269. Elkind, A. (1982). Changes in the smoking behavior, knowledge and opinion of medical students 1972±1981. Social Science and Medicine, 16, 2137±2143. Feldman, B. M. and Richard, E. (1986). Prevalence of nurse smokers and variables identified with successful and unsuccessful smoking cessation. Research in Nurse Health, 9, 131±138. Friend, T. (1989). Doctors to help patients stop smoking. Lansing State Journal, May 5, Section C, p. 5. Frisch, A. S., Kurtz, M. and Shamsuddin, K. (1992). Family patterns and smoking knowledge and attitudes among Malaysian medical students. Malaysian Journal of Family Studies, 3, 11±22. Frisch, A. S., Shamsuddin, K. and Kurtz, M. (1995). Family factors and knowledge, attitudes and efforts concerning exposure to environmental tobacco among Malaysian medical students. Journal of Asian and African Studies, 29, 68±79. Kottke, T. E., Hill, C., Heitzig, C., Brekke, M., Blake, S., Arneson, S. and Caspersen, C. (1985). Smokefree hospitals. Minnesota Medicine 68, 53±55. Kurtz, M. E., Johnson, S. M., Ross-Lee, B. and Srinivasan, N. (1990). Knowledge and attitudes regarding smoking: a health education experiment with Malay college students. Medical Journal of Malaysia, 45, 319±32. Levitt, E. E. and DeWitt, K. N. (1970). A survey of smoking behavior and attitudes of Indiana physicians. Journal of the Indiana State Medical Association, 63, 336±339. Maynard, L., Goldberg, R., Ockene, J., Levy, B., Howe, J. III and Dalen, J. (1986). Behaviors and attitudes among medical students concerning cigarette smoking and alcohol consumption. Journal of Medical Education, 61, 921±922. Ministry of Health, Malaysia (1986). National Health and Morbidity Survey (Smoking). Kuala Lumpur, MOH. National Clearinghouse for Smoking and Health. (1976a). Adult Use of Tobacco Ð1975. Rockville, MD: US Dept of Health, Education and Welfare, p. 23.
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National Clearinghouse for Smoking and Health. (1976b). Survey of Health Professionals: smoking and HealthÐ1975. Rockville, MD: US Dept of Health, Education and Welfare. Nelson, D. E., Giovino, G. A., Emont, S. L., Brackbill, R., Cameron, L. L., Peddicord, J. and Mowery, P. D. (1994). Trends in cigarette smoking among US physicians and nurses. Journal of the American Medical Association, 271, 1273±1275. Noll, C. E. (1969a). Health Professionals and the Problems of Smoking and Health, Report 3: physicians' behavior, beliefs and attitudes towards smoking and health, report on NORC survey 401. Chicago, IL: University of Chicago, National Opinion Research Center. Noll, C. E. (1969b). Health Professionals and the Problems of Smoking and Healh, Report 5. Nurses' behavior, beliefs and attitudes toward smoking and health, report on NORC survey 4001. Chicago, IL: University of Chicago, National Opinion Research Center. Supramaniam, V. (1980). Habits and attitudes of Malaysian military doctors towards smoking. Medical Journal of Malaysia, 3, 205±210. US Public Health Service. (1991). Healthy People 2000. National health promotion and disease prevention objectives: full report, with commentary. Washington DC: US Department of Health and Human Services, Public Health Service. US Dept of Health and Human Services Publication PHS 91-50212. Wallace, P. G., Brennan, P. J. and Haines, A. P. (1987). Practice observed: are general practitioners doing enough to promote healthy lifestyle? Findings on the medical research council's general practice research framework study on lifestyle and health. British Medical Journal, 294, 940±942. Wong, M. L. and Chen, P. C. Y. (1989). Smoking behavior, knowledge and opinion of medical students. Medical Journal of Malaysia, 44, 317±323.
Knowledge, attitudes and preventive efforts of Malaysian medical students regarding exposure to environmental tobacco and cigarette smoking ANN STIRLING FRISCH, MARGOT KURTZ
AND
KHADIJAH SHAMSUDDIN
A longitudinal study was conducted to determine changes in knowledge, attitudes and preventive efforts of Malaysian medical students concerning cigarette smoking and environmental exposure to tobacco smoke from their first pre-clinical year in medical school until their final clinical year. There were significant improvements in knowledge about cigarette smoking and in knowledge, attitudes and efforts concerning environmental exposure to tobacco smoke. Overall attitudes concerning cigarette smoking did not change over this period. The same pattern was found for male nonsmokers. Women improved on all five scales; male smokers improved on none over the 3-year period. Male non-smokers had better scores on these scales than male smokers in both beginning and ending years. Women excelled in comparison to male non-smokers on smoking attitudes in the pre-clinical year and on all scales except preventive efforts in the final clinical year. Although medical students experienced no changes in the amount of pressures not to smoke from family and friends, there was a significant increase in the amount of prohibition on smoking from their teachers. Male non-smokers alone accounted for this increase. Women experienced more pressure than men not to smoke from their teachers in both years, but the male smokers and non-smokers did not differ in teacher pressure for either year. # 1999 The Association for Professionals in Services for Adolescents
Introduction Research suggests that physicians and nurses are significant role models and educators for appropriate health care behavior (National Clearinghouse for Smoking and Health, 1976a; US Public Health Service, 1991; Nelson et al., 1994); and that smoking by health-care providers hinders their ability to educate on the topic (Noll, 1969a, b; Levitt and DeWitt, 1970; National Clearinghouse for Smoking and Health, 1976b; Elkind, 1980; Kottke et al., 1985; Dalton and Swenson, 1986, Nelson et al., 1994). At the University of Malaya, smoking among male medical students declined from 25.2% in 1972 to 17% in 1987 (Wong and Chen, 1989). This compares to 44% of males in a 1990 study of Malay engineering students (Kurtz et al., 1990) and 40?9% of males in the general population of Malaysia according to a 1985 survey (Ministry of Health, Malaysia, 1986). Declines in smoking among Malaysian medical students are mirrored in the U.K. and the U.S.A. (Coe and Cohen, 1980; Elkind, 1982; Maynard et al., 1986; Conard et al., 1988; Baldwin et al., 1991; Nelson et al., 1994). The declining rate of smoking for all physicians, registered nurses and licensed practical nurses has been attributed to both an increase in smoking cessation and increase in the number of non-smokers joining the health-care fields (Nelson et al., 1994). Reprint requests and correspondence should be addressed to Dr Ann Stirling Frisch, University of Wisconsin, 800 Algoma, Oshkosh, Wisconsin 54901, U.S.A. (E-mail: [email protected]). 0140-1971/99/050627+08 $3000/0
# 1999 The Association for Professionals in Services for Adolescents
628
A. S. Frisch et al.
Researchers have found that physicians and nurses quit smoking for many of the same reasons as the general public: personal health concerns, cost and pressure from family (Feldman and Richard, 1986; Centers for Disease Control, 1990). In addition, the desire to be an educational role model for patients and children is also mentioned as a reason for smoking cessation (Feldman and Richard, 1986; Nelson et al., 1994). Interaction with patients with smoking-related problems may have impact on the smoking cessation rates for health-care providers (Nelson et al., 1994). Researchers note that physicians and nurses who smoke can less effectively convey the message about the adverse health impacts of smoking (Dawley et al., 1981; Nelson et al., 1994). Studies have shown that smokers are six times more likely to quit smoking permanently if their physicians help in the cessation process (Friend, 1989). However, in their study of physicians at a teaching hospital in Lagos, Nigeria, Bandele and Osadiaye (1987) found that fewer physicians gave anti-smoking advice to all patients (30%) than to patients with smoking-related diseases (44%). Twenty-three per cent gave advice only if asked. In a 1987 study of the educational efforts of British physicians to improve patient health lifestyles, only 39?7% of the 17,610 patient respondents who smoked reported ``definitely'' or ``probably'' receiving advice about smoking cessation (Wallace et al., 1987). A 1979 study of Malaysian military physicians (Supramaniam, 1980) revealed that 50% of these physicians were smokers; 50?5% of the total sample would advise their patients to stop smoking regardless of their medical condition; 57?5% would advise stopping if the patient's illness was smoking-related. A decade later, Wong and Chen (1989) reported that while virtually all the students would advise against smoking if the patient had a related health problem, only 30% would advise against smoking if there were no health problem and the patient didn't raise the question. Slightly more smokers than non-smokers agreed with exsmokers in an intermediate position. In terms of setting a good example by not smoking, 97% of non-smokers and 78% of smokers agreed. Ninety-three per cent of non-smokers and 70% of smokers held the opinion that physicians should play a more active role against smoking. In light of this research, a study was designed which would track longitudinally the changes in knowledge, attitudes and preventive efforts of Malaysian medical students concerning cigarette smoking and environmental exposure to tobacco during their 6 years of medical school.
Materials and method The data in this study were collected from 148 first pre-clinical year medical students at the Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM) in Kuala Lumpur during the 1991±1992 school year. The first year students had completed their first year of medical school following 1 year of university education. This same group was surveyed in the 1993± 1994 school year. Of the 146 students still enrolled, 104 completed the follow-up survey. These clinical year students were completing their final rotations in surgery, medicine, community health, pediatrics or obstetrics and gynecology. Students completed a self-administered questionnaire requesting information about student smoking behaviors, family pressure not to smoke and knowledge, attitudes and preventive efforts concerning the cigarette smoking and the risks of exposure to environmental tobacco. Three scales were created with the available data. A knowledge scale was created to measure the student's knowledge about exposure to environmental
Malaysian medical students and smoking
629
tobacco. Nine questions were drawn from the research literature concerning the health risks associated with exposure to environmental tobacco, with regard to lung cancer, lower birthweight and respiratory illnesses. Ten statements such as ``I worry about breathing other people's smoke'' and ``Smoking should not be permitted at school and colleges'' were included in an attitude scale. A third scale rated their current preventive efforts to protect people from exposure to environmental tobacco. Included among the 22 statements were ``I ask people not to smoke near me'' and ``I ask people not to blow smoke in my face''. The three scales were scored on a scale of 1±5 with 1 = strongly agree to 5 = strongly disagree, so a lower scorer was considered ``better'' in terms of pro-health knowledge, attitudes and preventive efforts. For each component a composite score was computed as the average of the individual item scores. An additional effort question, where the students rated their perceptions of their responsibilities to discuss with patients the problem of environmental tobacco, was examined separately. The questionnaire was pre-tested on medical students who did not participate in the study to assess administration time and obtain feedback on wording and language level. Although the students were bi-lingual English±Malay, some parenthetical comments were added to clarify the meaning of some questions. The questionnaire took about 20 min to complete. Students were assured that their participation was voluntary and that all responses were anonymous. t-Tests were performed to test for differences between students' scores on the knowledge, attitude and preventive efforts concerning cigarette smoking and environmental exposure to tobacco smoke by gender, smoking status and pressure not to smoke. Pearson correlation coefficients were utilized to determine the relationship between students' knowledge and preventive efforts scores.
Results Reliability analyses of the composite knowledge, attitudes and preventive efforts scales were conducted to determine the internal reliability of the composite scales. The reliability coefficients (Cronbach's alpha) were: knowledge 0?69, attitudes 0?84 and preventive efforts 0?91 for environmental exposure and knowledge 0?75 and attitudes 0?77 for cigarette smoking. Ninety-five per cent of the pre-clinical year students' questionnaires (148 of 154) were returned. The pre-clinical year class consisted of 35?8% women (n=53) and 64?2% men (n=95). There were 78% Malay students (n=116) and 22% others. The final clinical year class consisted of 146 students of which 77% (n=104) returned the follow-up questionnaires. Thirty per cent of the members of the final clinical year were women (n=37), 60% were men (n=67); 75% (n=78) Malay and 25% other (n=26). The rate of return by gender was 64% women, 74% men; and by ethnicity: 70% Malay, 76% others. There was a difference between men and women in the number of smokers. There were 13 (8?8%) current smokers in the pre-clinical year and 11 (10?6%) smokers in the final clinical year Ð all were male; and there were no female smokers in either year. Similarly, there were 30 (20%) ever smokers (current non-smoker, but had smoked at one time) in the earlier period and 32 (31%) in the later period Ð all male. There was a difference among medical students in the number of smokers by race (Malay or other) in the pre-clinical year (p50?049), but not in the clinical year class. The opposite
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was true for the number of ever-smokers, where there was a difference in the final clinical year (p = 0?014). There were no differences in the two classes by ethnicity, number of smokers or ever-smokers, in the education of the students' father or mother. A statistically significant difference between the classes in their self-reported health status was noted. Compared to the pre-clinical class, the final year class reported better health (p = 0?000). This was true for females (p = 0?006) and male non-smokers (p = 0?000) as well as smokers (p = 0?007). There were no differences in health status between smokers and non-smokers in either time period, but women had better self-reported health than men in the clinical year (p = 0?001).
Knowledge, attitudes and preventive efforts
Although there was no change in students' scores on the item ``smoking during pregnancy is harmful to the fetus'', there was an improvement in students' score on the more specific knowledge question ``infants and children have more respiratory illness if their parents smoke'' (p50?007). There were significant improvements in the students' scores on three preventive efforts items: ``I teach children about the hazards of cigarette smoke'' (p50?000), ``I ask people not to smoke in front of children'' (p50?000) and ``I tell pregnant women that smoking is harmful to their baby'' (p50?000). The improvements in scores were consistent for women and male non-smokers (all p50?05). Smokers' scores did not improve on the knowledge question (effects on respiratory illness), nor on teaching children about hazards, but they did improve on the latter two preventive efforts items.
Environmental attitudes
Students' attitudes about whether a person should try to prevent others from smoking were similar in the two time periods. There was also no change in their attitude that smoking should not be permitted at schools and colleges, about smoking being prohibited in healthcare facilities and a ban on advertising of cigarettes. (Their attitudes overall were strongly pro-health in both years.) However, their attitudes about their own preferences changed significantly: they felt more strongly during their clinical year that a smoke-free environment would make them more productive (p50?001) and that they would choose a non-smoking area if offered (p50?003). On these two items, the pattern was consistent for men and women and non-smokers (all p50?05). Not surprisingly, there was no difference for smokers from one time period to the next on either of these items.
Personal attitudes
Selected items on the attitudes scale, i.e. preference that a spouse, son or daughter not smoke, the obligation of health professionals to set a good example by not smoking and the responsibility of people in the health professions to inform non-smokers about the hazards of cigarette smoking, did not change from the pre-clinical to final clinical year.
Pressures not to smoke
Among family members and friends, there were no reported changes in pressures not to smoke while students were in medical school. However, for the total population and for male non-smokers, there were significant increases in reported pressure from teachers (p = 0?008 and p=0?007, respectively). Nonetheless, women reported significantly more pressure from teachers than men in both pre-clinical (p=0?000) and clinical years (p=0?006). There was
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no difference between male non-smokers and smokers in the amount of pressure experienced from teachers in either year.
Overall scores
While attitudes about cigarette smoking did not change from the pre-clinical to final clinical year, knowledge about cigarette smoking did improve, as well as knowledge, attitudes and preventive efforts concerning exposure to environmental tobacco smoke (all p50?05). This pattern held for male non-smokers (p=0?000, p=0?000, p=0?006 and p=0?002, respectively). Women improved on all five scales: cigarette smoking knowledge (p=0?000) and attitudes (p=0?003); and environmental tobacco smoke knowledge (p=0?000), attitudes (p=0?001) and preventive efforts (p=0?001). Male smokers improved on none. When these scales were examined in terms of amount of teacher pressure not to smoke, those who felt strong pressures not to smoke improved on all scales except attitudes about cigarette smoking (all p50?02). There were no changes from pre-clinical to final clinical year on these scales for those who felt little pressure not to smoke. Women excelled over men only in attitudes about cigarette smoking during the preclinical year (p=0?003) and on both knowledge and attitude scales during their final clinical year (p50?05). On the preventive efforts scale, there was no difference during the final clinical year. Male non-smokers scored better than smokers did on every scale at each time period (p50?05).
Links between knowledge, attitudes and preventive efforts
Examining the data for the relationships between knowledge and attitudes, we found a systematic and substantial correlation for the total group in both the pre-clinical and final clinical years. When sorted by gender, smoking status and teacher pressure, we found that there were systematic links between knowledge and attitudes and preventive efforts for the total sample, for male non-smokers and those who experienced pressure from their teachers not to smoke. This was not the case for women, smokers and those who did not experience pressure from their teachers not to smoke.
Discussion In the total sample, knowledge about cigarette smoking improved but attitudes did not. This same pattern was found for male non-smokers and students whose teachers pressured them not to smoke. Women, however, improved on both scales; smokers and those whose teachers did not pressure them not to smoke improved on neither scale. Kurtz et al. (1990) found that attitudes about cigarette smoking did not change following a lecture on health risks associated with cigarette smoking among Malaysian engineering students, although knowledge scores did improve. Frisch et al. (1992) found that non-smokers scored better than smokers, never-smokers better than ever-smokers and women better than men on both knowledge and attitudes about cigarette smoking. A similar pattern was found by comparing medical students whose brothers were non-smokers compared to smokers, and where male friends were non-smokers compared to smokers. In relation to exposure to environmental tobacco, the clinical group showed improvements in environmental exposure knowledge, attitudes and preventive efforts in the total group, in women and in male non-smokers, through not in smokers. Those who
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reported teacher pressures not to smoke also improved on all three scales. Those who reported little or no pressure improved on none of the scales. In the pre-clinical year, women's knowledge about environmental exposure to tobacco smoke is linked to attitudes about environmental exposure to tobacco smoke as well as to attitudes about smoking. In the final clinical year, the links are between both knowledge scales (cigarette smoking and environmental exposure) and attitudes about environmental exposure to tobacco smoke. Male non-smokers (the only group to receive both increased teacher pressure and higher preventive efforts scores from the pre-clinical to final clinical year) and those who received strong pressures from teachers not to smoke have consistent links between knowledge, attitudes and preventive efforts. There are no correlations between knowledge, attitudes and preventive efforts for smokers in either year. A previous study with the same medical students (Frisch et al., 1995) showed that men's and non-smokers' (but not women's and smokers') scores on environmental exposure to tobacco smoke were linked to pressures from brothers and friends not to smoke. The exception to that was that attitudes were not related to pressure from brothers not to smoke. Teacher pressures were linked to attitudes and preventive efforts for the total sample and only to preventive efforts for non-smokers in that study. Although women seem to have better scores, there are fewer correlations between knowledge and preventive efforts than for male non-smokers. The low rate of smoking by medical students is certainly an indicator of more pro-health attitudes and efforts among medical students. A close examination of the data indicates that even smokers may be helpful in promoting healthful attitudes. Frisch et al. (1995) found that Malaysian medical student smokers' attitudes were positively correlated with pressure not to smoke from friends but not from other family members or teachers. Smokers in that same study had inconsistent pressures from family and friends, whereas that was not the case with non-smokers, men and women. Smokers' knowledge (of exposure to environmental tobacco smoke) in the 1995 study was also linked to efforts to inform non-smokers about the hazards of environmental smoke. The better the smokers' attitudes, the better their preventive efforts. In the present study, there were also some encouraging data to support the value of teacher pressure not to smoke. Although smokers had the poorest record for correlation between knowledge, attitudes and practice at both time periods, those with little or no teacher pressure not to smoke had links between attitudes and knowledge about environmental exposure to tobacco smoke. Those who received strong pressure not to smoke had substantial and consistent links between knowledge, attitudes and preventive efforts.
Acknowledgements This paper was funded in part by the University of Wisconsin-Oshkosh Faculty Development Board Grant # R252 for which the authors express their appreciation. The authors thank the faculty of the Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM) for their assistance in conducting this study. Thanks also to the student group leaders who were responsible for the collection of questionnaires. In addition, the authors gratefully acknowledge Dr Jay Kurtz, Professor of Mathematics at Michigan State University, Encik
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Mohd Zul Mohd Yusoff, computer programmer at the Universiti Pertanian Malaysia, for assistance on SPSS-X programming and Annett Smith, Graduate Assistant, College of Education and Human Service, University of Wisconsin-Oshkosh. Dr Frisch is Professor, Department of Human Services and Professional Leadership at the University of Wisconsin-Oshkosh. Dr Kurtz is Professor, Department of Family Medicine, at Michigan State University. Dr Khadijah is a physician and Professor at Universiti Kebangsaan Malaysia in Kuala Lumpur.
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