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Prevalence of smoking and environmental tobacco smoke exposure, and attitudes and beliefs towards tobacco control among Hong Kong medical students
Public Health 123 (2009) 42–46
Contents lists available at ScienceDirect
Public Health journal homepage: www.elsevierhealth.com/journals/pubh
Original Research
Prevalence of smoking and environmental tobacco smoke exposure, and attitudes and beliefs towards tobacco control among Hong Kong medical students T.S. Lam a, b, L.A. Tse a, c, *, I.T. Yu c, S. Griffiths a a b c
School of Public Health, The Chinese University of Hong Kong, Hong Kong SAR, China Centre for Health Protection, Department of Health, Hong Kong SAR, China Department of Community and Family Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
a r t i c l e i n f o
s u m m a r y
Article history: Received 10 December 2007 Received in revised form 2 July 2008 Accepted 28 July 2008 Available online 17 December 2008
Objectives: To investigate the prevalence of active smoking and environmental tobacco smoke (ETS) exposure among medical students in Hong Kong, and their attitudes and beliefs towards tobacco control.
Keywords: Tobacco Public health Attitude Health professional
Study design: A cross-sectional survey with a self-administrated questionnaire. Methods: All medical students from a university in Hong Kong were invited to participate in this survey and completed structured questionnaires. Descriptive data analyses were performed. Result: In total, 313 medical students participated in this study (response rate 44.7%). Only 7.2% [95% confidence interval (CI) 4.3–10.1] reported having ever smoked and 0.7% (95% CI 0–1.6%) were current smokers. ETS exposure at home was reported by 19.3% (95% CI 14.9–23.8) of students, but the proportion of ETS exposure in public places was much higher (61.6%, 95% CI 56.2–67.1%). More than 85% of students had positive attitudes towards tobacco control, but 30.8% (95% CI 25.6–36.0) disagreed with banning smoking in disco/bars/pubs. Although the majority (93.1%, 95% CI 90.3–96.0) of students thought that health professionals should receive specific training for counselling on smoking cessation, only 38.0% (95% CI 32.5–43.5) reported having received any formal training in this area. Conclusions: This study suggests that a specific professional training programme, including counselling on smoking cessation and actions on legislation and tobacco tax policy, should be built into the undergraduate medical curriculum. Ó 2008 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction China has 20% of the world’s population, and smokes 30% of the world’s cigarettes.1 Data from the Hong Kong Census and Statistics Department showed that 14% (793,300) and 4.5% (260,100) of the local population aged 15 years were current and ex-smokers, respectively, in 2005.2 The prevalence of daily cigarette smokers in Hong Kong has decreased by 40% since 1982 (23.3%).2 This trend mirrors that of the USA a decade ago.3,4 Cigarette smoking is not popular among Hong Kong medical students, but their attitudes towards smoking control are variable. According to the results from a survey in 1989, the prevalence of daily smokers among 250 medical students was 0.4%, and approximately 30% of the respondents disagreed with the banning
* Corresponding author. 4/F School of Public Health, Prince of Wales Hospital, Shatin, N.T., Hong Kong SAR, China. Tel.: þ852 2252 8791; fax: þ852 2606 3500. E-mail address: [email protected] (L.A. Tse).
of cigarette advertising and increasing the price of tobacco products.5 However, this survey was limited to two of the five classes of medical students at the University of Hong Kong, and thus raised concern about the representativeness of the study subjects. The World Health Organization (WHO), the US Centers for Disease Control and Prevention, and the Canadian Public Health Association developed the Global Health Professionals Survey (GHPS) to collect data on tobacco use and cessation counselling among health professional students in all WHO member states.6 The GHPS is a school-based survey of third-year students pursuing advanced degrees in dentistry, medicine, nursing and pharmacy. The GHPS adopts a core questionnaire to collect information on demographic data, prevalence of cigarette smoking and the use of other tobacco (e.g. cigars or pipes), knowledge and attitudes about tobacco use, exposure to second-hand tobacco smoke, attitude of willingness to stop smoking, and training received regarding patient counselling on smoking cessation techniques. The GHPS pilot study consisted of 16 surveys conducted in 10 countries in four health professional disciplines (dentistry, medicine, nursing and
0033-3506/$ – see front matter Ó 2008 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2008.07.016
T.S. Lam et al. / Public Health 123 (2009) 42–46
pharmacy) during the first quarter of 2005.6 However, the GHPS did not include students from China or Hong Kong. The aim of this study was to investigate the prevalence of active smoking and environmental tobacco smoke (ETS) exposure among medical students in Hong Kong, and their attitudes and beliefs towards tobacco control as a supplement to the 2005 GHPS study.
43
prevalence to enable comparisons between the claimed similarities and differences. Third-year students were singled out in the data analysis for the purpose of valid comparison with the GHPS data, as the GHPS pilot study was conducted among third-year students alone. Results
Methods This was a cross-sectional study conducted in a classroom setting. A standard self-administered questionnaire derived from the GHPS was used, designed for health professionals by the WHO and Canadian Public Health Association. All 687 medical students from the first year to the fifth year (130, 134, 133, 140 and 150, respectively) studying at one university in Hong Kong in December 2006 were invited to participate in the study. There are two medical schools in Hong Kong, with a total of approximately 1500 undergraduate medical students each year. Ethical approval was received from the university before the start of the fieldwork. In order to include as many students as possible in each class, the questionnaires were distributed to the students prior to a group lecture that the majority of students would attend. Students were reassured that their participation was voluntary and the questionnaires were anonymous. Multiple choice questions were used to enhance the response rate. The adapted questionnaire included information on demographics, prevalence of cigarette smoking and other tobacco use, ETS exposure, attitudes towards tobacco use, desire for smoking cessation, and training received regarding counselling on smoking cessation techniques while studying at the medical school. ‘Current smokers’ were defined as those who used any tobacco products (e.g. cigarette, cigar and/or pipe) on a daily basis at the time of the enquiry (including students who did not smoke on certain days because of illness or other reasons which prevented them from doing so). ‘Ex-smokers’ were defined as those who had previously had a daily smoking habit for a continuous period of 6 months, but who had given up smoking at the time of the enquiry. ‘Ever smokers’ included both current and ex-smokers. ETS exposure meant that the students perceived inhaling second-hand smoke from smoker(s) nearby during the past 7 days. Descriptive data analysis was performed using Statistical Package for the Social Sciences Version 13.0. Chi-squared test was used for categorical data to compare the differences in proportion. The significance level was set at P < 0.05. Ninety-five percent confidence intervals (95% CI) were calculated for frequency/
In total, 687 questionnaires were distributed; 313 were returned, giving an overall response rate of 44.7%. Response rates by year of study were 31.5%, 31.4%, 49.3%, 61.4% and 48.7%, respectively, from first year to fifth year. Eight questionnaires were excluded from the data analyses due to missing gender and/or year of study. Among all 305 respondents with complete information, 91.5% were aged 19–24 years and 60.7% were female. Distribution of gender was similar (P ¼ 0.34) among students across different study years. Table 1 shows the prevalence of smoking habits and ETS exposure among Hong Kong medical students in 2006. Among all medical students, 11.8% (95% CI 8.2–15.4) reported having ever tried or experimented with cigarette smoking (including one or two puffs). The prevalence of ever smoking was 7.2% (95% CI 4.3–10.1) and that of current smoking was 0.7% (95% CI 0–1.6); very few students (0.3%) had ever used tobacco products other than cigarettes, such as cigars or pipes. The prevalence of ever smoking cigarettes on university premises was 1.2% (95% CI 0–2.6), and 1.3% (95% CI 0–2.7) reported ever smoking inside university buildings during the past year. More third-year students were ever or current smokers compared with average levels for all students, but this difference was not statistically significant. In general, male students were more likely to smoke than female students, although more female third-year students had ever tried cigarette smoking (Table 1). No third-year students had smoked on the campus premises or in the buildings. Smoking has been banned on all university campuses in Hong Kong since 2007. During the past 7 days, 19.3% (95% CI 14.9–23.8) of the participants reported ETS exposure at home, but the proportion reporting ETS exposure in public places was three times higher (61.6%, 95% CI 56.2–67.1). Table 2 summarizes the patterns of students’ attitudes, beliefs and training received at university regarding tobacco control. More than 85% of the respondents agreed with the statements: ‘tobacco sales to adolescents should be banned’; there should be ‘a complete ban of the advertising of tobacco products’; ‘ban smoking in restaurants and in all enclosed public places’; and ‘believe health
Table 1 Prevalence (%) of active smoking and environmental tobacco smoke (ETS) exposure among Hong Kong medical students by gender, 2006 All students
Smoking status Ever tried or experimented with cigarette smoking, even one or two puffs
Third-year students
Female (n ¼ 185) % (95% CI) [n]
Male (n ¼ 120) % (95% CI) [n]
Total (n ¼ 305) % (95% CI) [n]
Female (n ¼ 34) % (95% CI) [n]
Male (n ¼ 33) % (95% CI) [n]
Total (n ¼ 67) % (95% CI) [n]
10.8 (6.4–15.3) [20]
13.3 (7.2–19.5) [16]
11.8 (8.2–15.4) [36]
17.6 (4.1–31.1) [6]
12.1 (0.4–23.9) [4]
14.9 (6.2–3.7) [10]
Daily smoking habits Ever Current Former
6.0 (2.5–9.4) [11] 0.5 (0–1.6) [1] 5.4 (2.1–8.7) [10]
9.2 (3.9–14.4) [11] 0.8 (0–2.5) [1] 8.4 (3.3–13.5) [10]
7.2 (4.3–10.1) [22] 0.7 (0–1.6) [2] 6.6 (3.8–9.4) [20]
8.8 (0–18.9) [3] 0 8.8 (0–18.9) [3]
9.1 (0–19.4) [3] 3.0 (0–9.2) [1] 6.1 (0–14.7) [2]
9.0 (0–16.0) [6] 1.5 (0–4.5) [1] 7.5 (1.0–13.9) [5]
Place of smoking on campus University premises Inside university building
1.1 (0–2.6) [2] 1.1 (0–2.7) [2]
2.5 (0–5.4) [3] 1.7 (0–4.1) [2]
1.2 (0.2–3.1) [5] 1.3 (0–2.7) [4]
0 0
0 0
0 0
11.8 (0.4-23.2) [4] 76.5 (61.4-91.5) [26]
24.2 (8.8–39.7) [8] 42.4 (24.6–60.2) [14]
17.9 (8.5–27.3) [12] 59.7 (47.6–71.8) [40]
Sources of ETS exposure Home Place other than home
20 (14.2–25.8) [37] 65.4 (58.5–72.3) [121]
18.3 (11.3–25.4) [22] 55.8 (46.8–64.9) [67]
19.3 (14.9–23.8) [59] 61.6 (56.2–67.1) [188]
98.5 (95.5–100) [66] 16.4 (7.3–25.5) [11] 98.5 (95.5–100) [66]
professionals should obtain specific training on cessation techniques, serve as role models for their patients and the public, and give advice or information about smoking cessation to patients’. However, 30.8% (95% CI 25.6–36.0%) of the students disagreed with banning smoking in disco/bars/pubs. About two-thirds of the students believed that health professionals who smoke or use other tobacco products were less likely to advise patients to stop smoking. Although the patterns of the attitudes and beliefs towards tobacco control in the third-year students were generally similar to the students in other years of study, more third-year students thought that smoking should be banned in disco/bars/ pubs. There were no significant differences in the attitudes, beliefs and training regarding tobacco control between male and female students. Although 92.5% (95% CI 89.5–95.4) of the respondents reported that they had received training regarding the hazards of smoking, and 90.8% (95% CI 87.5–94.1) had heard of nicotine replacement products during their medical school training, only 38.0% (95% CI 32.5–43.5) had received formal training regarding counselling for smoking cessation. In fact, 93.1% (95% CI 90.3–96.0) of the respondents believed that health professionals should be given specific training about smoking cessation techniques. Third-year students had similar positive attitudes and beliefs towards tobacco control, but a lower proportion (16.4%, 95% CI 7.3–25.5) were in favour of receiving formal training regarding smoking cessation techniques compared with medical students in other years of study. Discussion
97.1 (91.1–100) [33] 11.8 (0.4–23.2) [4] 97.1 (91.1–100) [33] * P < 0.05 for comparison between males and females.
Curriculum/training Received knowledge about hazards of smoking Received formal training regarding smoking cessation approaches Ever heard of nicotine replacement products
93.5 (89.9–97.1) [173] 39.1 (32.0–46.3) [72] 91.4 (87.3–95.4) [169]
90.8 (85.6–96.1) [109] 36.1 (27.4–44.9) [43] 89.9 (84.4–95.4) [107]
92.5 (89.5–95.4) [282] 38.0 (32.5–43.5) [115] 90.8 (87.5–94.1) [276]
100.0 [33] 21.2 (6.5–35.9) [7] 100.0 [33]
74.2 (63.4–85.1) [49] 75.4 (64.6–86.1) [49] 70.6(54.5–86.7) [24] 75.8(60.3–91.2) [25] Beliefs Health professionals who smoke are less likely to advise patients to smoke Health professionals who use other tobacco products were less likely to advise to stop smoking
77.2 (71.0–83.3) [142] 74.9 (68.5–81.2) [137]
78.2 (70.6–85.7) [93] 75.6 (67.8–83.5) [90]
77.6 (72.8–82.3) [235] 75.2 (70.3–80.1) [227]
78.1 (63.0–93.3) [25] 75.0 (59.1–90.9) [24]
100 [67] 100 [34] 93.3 (88.8–97.9) [112] 93.0 (89.3–96.7) [172]
93.1 (90.3–96.0) [284]
100 [33]
95.5 (90.4–100) [64] 97.1(91.1–100) [33] 84.2 (77.5–90.8) [101] 91.9 (87.9–95.9) [170]
88.9 (85.3–92.4) [271]
93.9 (85.3–100) [31]
88.1 83.6 98.5 80.6 95.5 97.0 90.9 (80.6–100) [30] 75.8 (60.3–91.2) [25] 97.0 (90.8–100) [32] 81.8 (67.9–95.7) [27] 93.9 (85.3–100) [31] 100.0 [33] 85.3 (72.8–97.8) [29] 91.2 (81.1–100) [31] 100.0 [34] 79.4 (65.1–93.7) [27] 97.0(90.8–100) [32] 94.1(85.8–100) [32] (86.8–93.5) [274] (81.9–90.0) [261] (94.3–98.5) [294] (64.0–74.4) [211] (87.5–94.1) [274] (90.3–96.0) [284]
Attitudes Tobacco sales to adolescents should be banned A complete ban of the advertising of tobacco products* Ban smoking in restaurants Ban smoking in discos/bars/pubs Ban smoking in all enclosed public places Believe health professionals should obtain specific training on cessation techniques Believe health professionals serve as role models for their patients and the public* Believe health professionals should give advice or information about smoking cessation to patients
90.8 89.2 97.3 68.1 91.9 94.1
(86.5–95.0) [167] (84.7–93.7) [165] (94.9–99.7) [180] (61.3–74.9) [126] (87.9–95.8) [169] (90.6–97.5) [174]
89.2 80.7 95 70.8 89.2 91.7
(83.5–94.8) [107] (73.5–87.9) [96] (91.0–99.0) [114] (62.6–79.1) [85] (83.5–94.8) [107] (86.7–96.7) [110]
90.1 85.9 96.4 69.2 90.1 93.1
Male (n ¼ 33) % (95% CI) [n] Third-year students
Female (n ¼ 34) % (95% CI) [n] Total (n ¼ 305) % (95% CI) [n] Male (n ¼ 120) % (95% CI) [n] Female (n ¼ 185) % (95% CI) [n]
All students
Table 2 Attitudes, beliefs and training regarding tobacco control among Hong Kong medical students by gender, 2006 (%)
(80.1–96.0) [59] (74.5–92.7) [56] (95.5–100) [66] (70.9–90.3) [54] (90.3–100) [63] (92.8–100) [65]
T.S. Lam et al. / Public Health 123 (2009) 42–46
Total (n ¼ 67) % (95% CI) [n]
44
This study found that the prevalence of tobacco smoking among Hong Kong medical students is low, but the prevalence of ETS exposure in public places is high. Although most students showed positive attitudes towards tobacco control, and perceived that health professionals should be given specific training regarding cessation techniques, only 38% (95% CI 32.5–43.5%) of students had received any formal training in counselling for smoking cessation. Third-year students had a slightly higher prevalence of ever (9%) and current (1.5%) smoking than the students in other study years. Nevertheless, such figures were only in the lowest range compared with the third-year medical students in other countries included in the GHPS pilot study in 2005 (Fig. 1).6 In the GHPS pilot study, the majority (range 71.7–99.0%) of third-year students from several disciplines/professions (medical, nursing, dental and pharmacy) believed that health professionals should be trained to provide smoking cessation counselling.6 Highly positive attitudes were also observed in Hong Kong’s third-year medical students (97.1%). Data from the GHPS pilot study showed that the proportion of third-year students who had received formal training in tobacco cessation counselling was low, with wide variation between disciplines and countries ranging from 5.2% among medical students in Argentina to 36.6% among pharmacy students in the Philippines. Formal training received at medical schools included classroom lectures, special seminars, clinical practicum and other problem-based learning opportunities.6 Similar experiences were recorded in Hong Kong, where the majority of third-year medical students perceived a need for specific training about smoking cessation approaches, but only a few (16.4%, 95% CI 7.3–25.5%) had received formal training in this area (Table 2). Overall, relatively little has been done regarding smoking cessation in Asia. As populations are becoming increasingly aware of the harmfulness of smoking, there is a need to address smoking cessation; this needs to be taught in medical and allied health schools. To the best of the authors’ knowledge, very little postgraduate training in smoking
T.S. Lam et al. / Public Health 123 (2009) 42–46
45
45
80 70
40
95 CI
95 CI
35
Prevalence ( )
Prevalence (
)
60 50 40 30 20
30 25 20 15 10
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g
K
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A
H
U
ia
an
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a
in
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A
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tia
oa
Cr
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tin a A
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Figure 1. Comparison of current smoking prevalence between third-year medical students in Hong Kong and other areas by gender.6
cessation is formally provided in Hong Kong. There is an urgent need to enhance specific training in smoking cessation counselling, building it into the medical curriculum. The action checklist for medical students suggested by the Tobacco Control Research Centre provides a very good reference for Hong Kong medical students.7 Compared with the survey of local medical students in 1989,5 15% more students in the present survey showed positive attitudes towards a ban on advertising of tobacco products. Moreover, the moderate to high prevalence of ETS exposure at home and in public places presents an urgent need for tobacco control in the general population. Selection bias may not be totally excluded because the response rate of this study was not high (44.7%). Age and gender distributions of the participants did not differ significantly from the target population (all 687 medical students currently studying at the university from first to fifth year). Therefore, it was considered that these results were largely representative. Nevertheless, it is still possible that the attitudes and beliefs regarding tobacco control of the respondents are more positive than those of the non-respondents, which would mean that the proportions of positive attitudes and beliefs regarding tobacco control in the current sample were overestimated. Under-reporting of smoking habits was possible because medical students may be more sensitized than the general population to reporting their smoking behaviour, and deny smoking habits more frequently.8 Misclassifications on ETS exposure and attitudes toward tobacco control were possible, but were likely to be non-differential given the similar training background of these students. While it was gratifying to see relatively high levels of support for most tobacco control measures, 30% of Hong Kong medical students did not support a smoking ban in discos, bars and pubs. Medical students are tomorrow’s doctors. Their attitudes and beliefs towards tobacco control will influence their patients’ or the public’s health behaviours in their future medical practices. Brief and consistent advice from a health professional to stop smoking has been identified as a major factor in whether or not a person tries and succeeds to quit smoking.9 There is evidence that comprehensive tobacco control programmes including mass media
campaigns can be effective in changing smoking behaviour.10 The authors believe that the effect size of smoking cessation could be larger if joint efforts were made by the media, medical professionals, smokers and their families. In conclusion, this cross-sectional study revealed a low prevalence of tobacco smoking but a high prevalence of ETS exposure among Hong Kong medical students. Most of the students have positive attitudes towards tobacco control. Although most of the students thought that health professionals should be given specific training in smoking cessation counselling, only one-third had received formal training in this area. This study suggests an urgent need for a specific professional training programme for counselling on smoking cessation, which should be built into the curriculum. Meanwhile, other aspects of training on tobacco control, especially regarding legislation and tobacco tax policy, is also strongly recommended and should be built formally into the undergraduate medical curriculum, since it is clear that the medical model is inadequate for dealing with the tobacco epidemic. These newly developed curricula and materials could be shared with Mainland China. Ethical approval Research Committee of the Chinese University of Hong Kong. Funding None declared. Competing interests None declared. References 1. Peto R, Chen ZM, Boreham J. Tobaccodthe growing epidemic. Nat Med 1999;5:15–7. 2. Department of health. Tobacco control office: Hong Kong smoking prevalence. Available from: http://www.tco.gov.hk/tc_chi/infostation/infostation_sta_01. html [accessed 29.11.07].
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3. Millar S. Hong Kong human ecology programme. The biosocial survey in Hong Kong. Canberra: Central Printery: Australian National University; 1979. 4. Mackay JM, Barnes GT. Effects of strong government measures against tobacco in Hong Kong. BMJ 1986;292:1435–7. 5. Cheng KK, Lam TH, Ratanasiri A. Smoking among medical students in Hong Kong. Asia Pac J Public Health 1989;3:306–9. 6. GTSS Collaborative Group. Tobacco use and cessation counseling: global health professionals survey pilot study, 10 countries, 2005. Tob Control 2006; 15(Suppl. II):II31–4.
7. Tobacco Resource Control Centre, British Medical Association. Doctors and tobacco medicine’s big challenge. Available from: http://www.doctorsandtobacco. org/resources/files/3-1.pdf [accessed 26.06.08]. 8. Xiang H, Wang Z, Stallones L, Yu S, Gimbel HW, Yang P. Cigarette smoking among medical college students in Wuhan, People’s Republic of China. Prev Med 1999;29:210–5. 9. Zapka JG, Fletcher KE, Ma YS, Pbert L. Physicians and smoking cessation development of survey measures. Eval Health Prof 1997;20:407–27. 10. Bala M, Strzeszynski L, Cahill K. Mass media interventions for smoking cessation in adults. Cochrane Database Syst Rev 2008;1. CD004704.
Contents lists available at ScienceDirect
Public Health journal homepage: www.elsevierhealth.com/journals/pubh
Original Research
Prevalence of smoking and environmental tobacco smoke exposure, and attitudes and beliefs towards tobacco control among Hong Kong medical students T.S. Lam a, b, L.A. Tse a, c, *, I.T. Yu c, S. Griffiths a a b c
School of Public Health, The Chinese University of Hong Kong, Hong Kong SAR, China Centre for Health Protection, Department of Health, Hong Kong SAR, China Department of Community and Family Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
a r t i c l e i n f o
s u m m a r y
Article history: Received 10 December 2007 Received in revised form 2 July 2008 Accepted 28 July 2008 Available online 17 December 2008
Objectives: To investigate the prevalence of active smoking and environmental tobacco smoke (ETS) exposure among medical students in Hong Kong, and their attitudes and beliefs towards tobacco control.
Keywords: Tobacco Public health Attitude Health professional
Study design: A cross-sectional survey with a self-administrated questionnaire. Methods: All medical students from a university in Hong Kong were invited to participate in this survey and completed structured questionnaires. Descriptive data analyses were performed. Result: In total, 313 medical students participated in this study (response rate 44.7%). Only 7.2% [95% confidence interval (CI) 4.3–10.1] reported having ever smoked and 0.7% (95% CI 0–1.6%) were current smokers. ETS exposure at home was reported by 19.3% (95% CI 14.9–23.8) of students, but the proportion of ETS exposure in public places was much higher (61.6%, 95% CI 56.2–67.1%). More than 85% of students had positive attitudes towards tobacco control, but 30.8% (95% CI 25.6–36.0) disagreed with banning smoking in disco/bars/pubs. Although the majority (93.1%, 95% CI 90.3–96.0) of students thought that health professionals should receive specific training for counselling on smoking cessation, only 38.0% (95% CI 32.5–43.5) reported having received any formal training in this area. Conclusions: This study suggests that a specific professional training programme, including counselling on smoking cessation and actions on legislation and tobacco tax policy, should be built into the undergraduate medical curriculum. Ó 2008 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction China has 20% of the world’s population, and smokes 30% of the world’s cigarettes.1 Data from the Hong Kong Census and Statistics Department showed that 14% (793,300) and 4.5% (260,100) of the local population aged 15 years were current and ex-smokers, respectively, in 2005.2 The prevalence of daily cigarette smokers in Hong Kong has decreased by 40% since 1982 (23.3%).2 This trend mirrors that of the USA a decade ago.3,4 Cigarette smoking is not popular among Hong Kong medical students, but their attitudes towards smoking control are variable. According to the results from a survey in 1989, the prevalence of daily smokers among 250 medical students was 0.4%, and approximately 30% of the respondents disagreed with the banning
* Corresponding author. 4/F School of Public Health, Prince of Wales Hospital, Shatin, N.T., Hong Kong SAR, China. Tel.: þ852 2252 8791; fax: þ852 2606 3500. E-mail address: [email protected] (L.A. Tse).
of cigarette advertising and increasing the price of tobacco products.5 However, this survey was limited to two of the five classes of medical students at the University of Hong Kong, and thus raised concern about the representativeness of the study subjects. The World Health Organization (WHO), the US Centers for Disease Control and Prevention, and the Canadian Public Health Association developed the Global Health Professionals Survey (GHPS) to collect data on tobacco use and cessation counselling among health professional students in all WHO member states.6 The GHPS is a school-based survey of third-year students pursuing advanced degrees in dentistry, medicine, nursing and pharmacy. The GHPS adopts a core questionnaire to collect information on demographic data, prevalence of cigarette smoking and the use of other tobacco (e.g. cigars or pipes), knowledge and attitudes about tobacco use, exposure to second-hand tobacco smoke, attitude of willingness to stop smoking, and training received regarding patient counselling on smoking cessation techniques. The GHPS pilot study consisted of 16 surveys conducted in 10 countries in four health professional disciplines (dentistry, medicine, nursing and
0033-3506/$ – see front matter Ó 2008 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2008.07.016
T.S. Lam et al. / Public Health 123 (2009) 42–46
pharmacy) during the first quarter of 2005.6 However, the GHPS did not include students from China or Hong Kong. The aim of this study was to investigate the prevalence of active smoking and environmental tobacco smoke (ETS) exposure among medical students in Hong Kong, and their attitudes and beliefs towards tobacco control as a supplement to the 2005 GHPS study.
43
prevalence to enable comparisons between the claimed similarities and differences. Third-year students were singled out in the data analysis for the purpose of valid comparison with the GHPS data, as the GHPS pilot study was conducted among third-year students alone. Results
Methods This was a cross-sectional study conducted in a classroom setting. A standard self-administered questionnaire derived from the GHPS was used, designed for health professionals by the WHO and Canadian Public Health Association. All 687 medical students from the first year to the fifth year (130, 134, 133, 140 and 150, respectively) studying at one university in Hong Kong in December 2006 were invited to participate in the study. There are two medical schools in Hong Kong, with a total of approximately 1500 undergraduate medical students each year. Ethical approval was received from the university before the start of the fieldwork. In order to include as many students as possible in each class, the questionnaires were distributed to the students prior to a group lecture that the majority of students would attend. Students were reassured that their participation was voluntary and the questionnaires were anonymous. Multiple choice questions were used to enhance the response rate. The adapted questionnaire included information on demographics, prevalence of cigarette smoking and other tobacco use, ETS exposure, attitudes towards tobacco use, desire for smoking cessation, and training received regarding counselling on smoking cessation techniques while studying at the medical school. ‘Current smokers’ were defined as those who used any tobacco products (e.g. cigarette, cigar and/or pipe) on a daily basis at the time of the enquiry (including students who did not smoke on certain days because of illness or other reasons which prevented them from doing so). ‘Ex-smokers’ were defined as those who had previously had a daily smoking habit for a continuous period of 6 months, but who had given up smoking at the time of the enquiry. ‘Ever smokers’ included both current and ex-smokers. ETS exposure meant that the students perceived inhaling second-hand smoke from smoker(s) nearby during the past 7 days. Descriptive data analysis was performed using Statistical Package for the Social Sciences Version 13.0. Chi-squared test was used for categorical data to compare the differences in proportion. The significance level was set at P < 0.05. Ninety-five percent confidence intervals (95% CI) were calculated for frequency/
In total, 687 questionnaires were distributed; 313 were returned, giving an overall response rate of 44.7%. Response rates by year of study were 31.5%, 31.4%, 49.3%, 61.4% and 48.7%, respectively, from first year to fifth year. Eight questionnaires were excluded from the data analyses due to missing gender and/or year of study. Among all 305 respondents with complete information, 91.5% were aged 19–24 years and 60.7% were female. Distribution of gender was similar (P ¼ 0.34) among students across different study years. Table 1 shows the prevalence of smoking habits and ETS exposure among Hong Kong medical students in 2006. Among all medical students, 11.8% (95% CI 8.2–15.4) reported having ever tried or experimented with cigarette smoking (including one or two puffs). The prevalence of ever smoking was 7.2% (95% CI 4.3–10.1) and that of current smoking was 0.7% (95% CI 0–1.6); very few students (0.3%) had ever used tobacco products other than cigarettes, such as cigars or pipes. The prevalence of ever smoking cigarettes on university premises was 1.2% (95% CI 0–2.6), and 1.3% (95% CI 0–2.7) reported ever smoking inside university buildings during the past year. More third-year students were ever or current smokers compared with average levels for all students, but this difference was not statistically significant. In general, male students were more likely to smoke than female students, although more female third-year students had ever tried cigarette smoking (Table 1). No third-year students had smoked on the campus premises or in the buildings. Smoking has been banned on all university campuses in Hong Kong since 2007. During the past 7 days, 19.3% (95% CI 14.9–23.8) of the participants reported ETS exposure at home, but the proportion reporting ETS exposure in public places was three times higher (61.6%, 95% CI 56.2–67.1). Table 2 summarizes the patterns of students’ attitudes, beliefs and training received at university regarding tobacco control. More than 85% of the respondents agreed with the statements: ‘tobacco sales to adolescents should be banned’; there should be ‘a complete ban of the advertising of tobacco products’; ‘ban smoking in restaurants and in all enclosed public places’; and ‘believe health
Table 1 Prevalence (%) of active smoking and environmental tobacco smoke (ETS) exposure among Hong Kong medical students by gender, 2006 All students
Smoking status Ever tried or experimented with cigarette smoking, even one or two puffs
Third-year students
Female (n ¼ 185) % (95% CI) [n]
Male (n ¼ 120) % (95% CI) [n]
Total (n ¼ 305) % (95% CI) [n]
Female (n ¼ 34) % (95% CI) [n]
Male (n ¼ 33) % (95% CI) [n]
Total (n ¼ 67) % (95% CI) [n]
10.8 (6.4–15.3) [20]
13.3 (7.2–19.5) [16]
11.8 (8.2–15.4) [36]
17.6 (4.1–31.1) [6]
12.1 (0.4–23.9) [4]
14.9 (6.2–3.7) [10]
Daily smoking habits Ever Current Former
6.0 (2.5–9.4) [11] 0.5 (0–1.6) [1] 5.4 (2.1–8.7) [10]
9.2 (3.9–14.4) [11] 0.8 (0–2.5) [1] 8.4 (3.3–13.5) [10]
7.2 (4.3–10.1) [22] 0.7 (0–1.6) [2] 6.6 (3.8–9.4) [20]
8.8 (0–18.9) [3] 0 8.8 (0–18.9) [3]
9.1 (0–19.4) [3] 3.0 (0–9.2) [1] 6.1 (0–14.7) [2]
9.0 (0–16.0) [6] 1.5 (0–4.5) [1] 7.5 (1.0–13.9) [5]
Place of smoking on campus University premises Inside university building
1.1 (0–2.6) [2] 1.1 (0–2.7) [2]
2.5 (0–5.4) [3] 1.7 (0–4.1) [2]
1.2 (0.2–3.1) [5] 1.3 (0–2.7) [4]
0 0
0 0
0 0
11.8 (0.4-23.2) [4] 76.5 (61.4-91.5) [26]
24.2 (8.8–39.7) [8] 42.4 (24.6–60.2) [14]
17.9 (8.5–27.3) [12] 59.7 (47.6–71.8) [40]
Sources of ETS exposure Home Place other than home
20 (14.2–25.8) [37] 65.4 (58.5–72.3) [121]
18.3 (11.3–25.4) [22] 55.8 (46.8–64.9) [67]
19.3 (14.9–23.8) [59] 61.6 (56.2–67.1) [188]
98.5 (95.5–100) [66] 16.4 (7.3–25.5) [11] 98.5 (95.5–100) [66]
professionals should obtain specific training on cessation techniques, serve as role models for their patients and the public, and give advice or information about smoking cessation to patients’. However, 30.8% (95% CI 25.6–36.0%) of the students disagreed with banning smoking in disco/bars/pubs. About two-thirds of the students believed that health professionals who smoke or use other tobacco products were less likely to advise patients to stop smoking. Although the patterns of the attitudes and beliefs towards tobacco control in the third-year students were generally similar to the students in other years of study, more third-year students thought that smoking should be banned in disco/bars/ pubs. There were no significant differences in the attitudes, beliefs and training regarding tobacco control between male and female students. Although 92.5% (95% CI 89.5–95.4) of the respondents reported that they had received training regarding the hazards of smoking, and 90.8% (95% CI 87.5–94.1) had heard of nicotine replacement products during their medical school training, only 38.0% (95% CI 32.5–43.5) had received formal training regarding counselling for smoking cessation. In fact, 93.1% (95% CI 90.3–96.0) of the respondents believed that health professionals should be given specific training about smoking cessation techniques. Third-year students had similar positive attitudes and beliefs towards tobacco control, but a lower proportion (16.4%, 95% CI 7.3–25.5) were in favour of receiving formal training regarding smoking cessation techniques compared with medical students in other years of study. Discussion
97.1 (91.1–100) [33] 11.8 (0.4–23.2) [4] 97.1 (91.1–100) [33] * P < 0.05 for comparison between males and females.
Curriculum/training Received knowledge about hazards of smoking Received formal training regarding smoking cessation approaches Ever heard of nicotine replacement products
93.5 (89.9–97.1) [173] 39.1 (32.0–46.3) [72] 91.4 (87.3–95.4) [169]
90.8 (85.6–96.1) [109] 36.1 (27.4–44.9) [43] 89.9 (84.4–95.4) [107]
92.5 (89.5–95.4) [282] 38.0 (32.5–43.5) [115] 90.8 (87.5–94.1) [276]
100.0 [33] 21.2 (6.5–35.9) [7] 100.0 [33]
74.2 (63.4–85.1) [49] 75.4 (64.6–86.1) [49] 70.6(54.5–86.7) [24] 75.8(60.3–91.2) [25] Beliefs Health professionals who smoke are less likely to advise patients to smoke Health professionals who use other tobacco products were less likely to advise to stop smoking
77.2 (71.0–83.3) [142] 74.9 (68.5–81.2) [137]
78.2 (70.6–85.7) [93] 75.6 (67.8–83.5) [90]
77.6 (72.8–82.3) [235] 75.2 (70.3–80.1) [227]
78.1 (63.0–93.3) [25] 75.0 (59.1–90.9) [24]
100 [67] 100 [34] 93.3 (88.8–97.9) [112] 93.0 (89.3–96.7) [172]
93.1 (90.3–96.0) [284]
100 [33]
95.5 (90.4–100) [64] 97.1(91.1–100) [33] 84.2 (77.5–90.8) [101] 91.9 (87.9–95.9) [170]
88.9 (85.3–92.4) [271]
93.9 (85.3–100) [31]
88.1 83.6 98.5 80.6 95.5 97.0 90.9 (80.6–100) [30] 75.8 (60.3–91.2) [25] 97.0 (90.8–100) [32] 81.8 (67.9–95.7) [27] 93.9 (85.3–100) [31] 100.0 [33] 85.3 (72.8–97.8) [29] 91.2 (81.1–100) [31] 100.0 [34] 79.4 (65.1–93.7) [27] 97.0(90.8–100) [32] 94.1(85.8–100) [32] (86.8–93.5) [274] (81.9–90.0) [261] (94.3–98.5) [294] (64.0–74.4) [211] (87.5–94.1) [274] (90.3–96.0) [284]
Attitudes Tobacco sales to adolescents should be banned A complete ban of the advertising of tobacco products* Ban smoking in restaurants Ban smoking in discos/bars/pubs Ban smoking in all enclosed public places Believe health professionals should obtain specific training on cessation techniques Believe health professionals serve as role models for their patients and the public* Believe health professionals should give advice or information about smoking cessation to patients
90.8 89.2 97.3 68.1 91.9 94.1
(86.5–95.0) [167] (84.7–93.7) [165] (94.9–99.7) [180] (61.3–74.9) [126] (87.9–95.8) [169] (90.6–97.5) [174]
89.2 80.7 95 70.8 89.2 91.7
(83.5–94.8) [107] (73.5–87.9) [96] (91.0–99.0) [114] (62.6–79.1) [85] (83.5–94.8) [107] (86.7–96.7) [110]
90.1 85.9 96.4 69.2 90.1 93.1
Male (n ¼ 33) % (95% CI) [n] Third-year students
Female (n ¼ 34) % (95% CI) [n] Total (n ¼ 305) % (95% CI) [n] Male (n ¼ 120) % (95% CI) [n] Female (n ¼ 185) % (95% CI) [n]
All students
Table 2 Attitudes, beliefs and training regarding tobacco control among Hong Kong medical students by gender, 2006 (%)
(80.1–96.0) [59] (74.5–92.7) [56] (95.5–100) [66] (70.9–90.3) [54] (90.3–100) [63] (92.8–100) [65]
T.S. Lam et al. / Public Health 123 (2009) 42–46
Total (n ¼ 67) % (95% CI) [n]
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This study found that the prevalence of tobacco smoking among Hong Kong medical students is low, but the prevalence of ETS exposure in public places is high. Although most students showed positive attitudes towards tobacco control, and perceived that health professionals should be given specific training regarding cessation techniques, only 38% (95% CI 32.5–43.5%) of students had received any formal training in counselling for smoking cessation. Third-year students had a slightly higher prevalence of ever (9%) and current (1.5%) smoking than the students in other study years. Nevertheless, such figures were only in the lowest range compared with the third-year medical students in other countries included in the GHPS pilot study in 2005 (Fig. 1).6 In the GHPS pilot study, the majority (range 71.7–99.0%) of third-year students from several disciplines/professions (medical, nursing, dental and pharmacy) believed that health professionals should be trained to provide smoking cessation counselling.6 Highly positive attitudes were also observed in Hong Kong’s third-year medical students (97.1%). Data from the GHPS pilot study showed that the proportion of third-year students who had received formal training in tobacco cessation counselling was low, with wide variation between disciplines and countries ranging from 5.2% among medical students in Argentina to 36.6% among pharmacy students in the Philippines. Formal training received at medical schools included classroom lectures, special seminars, clinical practicum and other problem-based learning opportunities.6 Similar experiences were recorded in Hong Kong, where the majority of third-year medical students perceived a need for specific training about smoking cessation approaches, but only a few (16.4%, 95% CI 7.3–25.5%) had received formal training in this area (Table 2). Overall, relatively little has been done regarding smoking cessation in Asia. As populations are becoming increasingly aware of the harmfulness of smoking, there is a need to address smoking cessation; this needs to be taught in medical and allied health schools. To the best of the authors’ knowledge, very little postgraduate training in smoking
T.S. Lam et al. / Public Health 123 (2009) 42–46
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80 70
40
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95 CI
35
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Prevalence (
)
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30 25 20 15 10
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tia
oa
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Figure 1. Comparison of current smoking prevalence between third-year medical students in Hong Kong and other areas by gender.6
cessation is formally provided in Hong Kong. There is an urgent need to enhance specific training in smoking cessation counselling, building it into the medical curriculum. The action checklist for medical students suggested by the Tobacco Control Research Centre provides a very good reference for Hong Kong medical students.7 Compared with the survey of local medical students in 1989,5 15% more students in the present survey showed positive attitudes towards a ban on advertising of tobacco products. Moreover, the moderate to high prevalence of ETS exposure at home and in public places presents an urgent need for tobacco control in the general population. Selection bias may not be totally excluded because the response rate of this study was not high (44.7%). Age and gender distributions of the participants did not differ significantly from the target population (all 687 medical students currently studying at the university from first to fifth year). Therefore, it was considered that these results were largely representative. Nevertheless, it is still possible that the attitudes and beliefs regarding tobacco control of the respondents are more positive than those of the non-respondents, which would mean that the proportions of positive attitudes and beliefs regarding tobacco control in the current sample were overestimated. Under-reporting of smoking habits was possible because medical students may be more sensitized than the general population to reporting their smoking behaviour, and deny smoking habits more frequently.8 Misclassifications on ETS exposure and attitudes toward tobacco control were possible, but were likely to be non-differential given the similar training background of these students. While it was gratifying to see relatively high levels of support for most tobacco control measures, 30% of Hong Kong medical students did not support a smoking ban in discos, bars and pubs. Medical students are tomorrow’s doctors. Their attitudes and beliefs towards tobacco control will influence their patients’ or the public’s health behaviours in their future medical practices. Brief and consistent advice from a health professional to stop smoking has been identified as a major factor in whether or not a person tries and succeeds to quit smoking.9 There is evidence that comprehensive tobacco control programmes including mass media
campaigns can be effective in changing smoking behaviour.10 The authors believe that the effect size of smoking cessation could be larger if joint efforts were made by the media, medical professionals, smokers and their families. In conclusion, this cross-sectional study revealed a low prevalence of tobacco smoking but a high prevalence of ETS exposure among Hong Kong medical students. Most of the students have positive attitudes towards tobacco control. Although most of the students thought that health professionals should be given specific training in smoking cessation counselling, only one-third had received formal training in this area. This study suggests an urgent need for a specific professional training programme for counselling on smoking cessation, which should be built into the curriculum. Meanwhile, other aspects of training on tobacco control, especially regarding legislation and tobacco tax policy, is also strongly recommended and should be built formally into the undergraduate medical curriculum, since it is clear that the medical model is inadequate for dealing with the tobacco epidemic. These newly developed curricula and materials could be shared with Mainland China. Ethical approval Research Committee of the Chinese University of Hong Kong. Funding None declared. Competing interests None declared. References 1. Peto R, Chen ZM, Boreham J. Tobaccodthe growing epidemic. Nat Med 1999;5:15–7. 2. Department of health. Tobacco control office: Hong Kong smoking prevalence. Available from: http://www.tco.gov.hk/tc_chi/infostation/infostation_sta_01. html [accessed 29.11.07].
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3. Millar S. Hong Kong human ecology programme. The biosocial survey in Hong Kong. Canberra: Central Printery: Australian National University; 1979. 4. Mackay JM, Barnes GT. Effects of strong government measures against tobacco in Hong Kong. BMJ 1986;292:1435–7. 5. Cheng KK, Lam TH, Ratanasiri A. Smoking among medical students in Hong Kong. Asia Pac J Public Health 1989;3:306–9. 6. GTSS Collaborative Group. Tobacco use and cessation counseling: global health professionals survey pilot study, 10 countries, 2005. Tob Control 2006; 15(Suppl. II):II31–4.
7. Tobacco Resource Control Centre, British Medical Association. Doctors and tobacco medicine’s big challenge. Available from: http://www.doctorsandtobacco. org/resources/files/3-1.pdf [accessed 26.06.08]. 8. Xiang H, Wang Z, Stallones L, Yu S, Gimbel HW, Yang P. Cigarette smoking among medical college students in Wuhan, People’s Republic of China. Prev Med 1999;29:210–5. 9. Zapka JG, Fletcher KE, Ma YS, Pbert L. Physicians and smoking cessation development of survey measures. Eval Health Prof 1997;20:407–27. 10. Bala M, Strzeszynski L, Cahill K. Mass media interventions for smoking cessation in adults. Cochrane Database Syst Rev 2008;1. CD004704.