Effectiveness of a course in the control of tobacco use for university health students: A quasi-experimental community intervention trial

doi:10.4236/ojn.2013.34047

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Open Journal of Nursing, 2013, 3, 351-357 OJN

http://dx.doi.org/10.4236/ojn.2013.34047 Published Online August 2013 (http://www.scirp.org/journal/ojn/)

Effectiveness of a course in the control of tobacco use for

university health students: A quasi-experimental

community intervention trial

Daniel Fernandez, Antonio Molina, Vicente Martin, Beatriz Ordas, Jose Manuel De Luis

Leon University Hospital, University of Leon, Leon, Spain

Email: [email protected]

Received 12 March 2013; revised 13 April 2013; accepted 15 May 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Introduction: The aim of the study was to evaluate

the effectiveness of a tobacco control course in the

reduction of prevalence and the improvement of

knowledge and attitudes among university health

students. Method: Quasi-experimental study on a

community based intervention. Interventional cam-

pus students received a tobacco control course in the

first year of the degree. Data were collected by Self-

Answered Questionnaire during three academic years

in two graduations years among health students in

both campuses. Results: 84.4% of students partici-

pated in the study. In both campuses tobacco use was

reduced, not significantly, above all in those joining

courses from origins other than baccalaureate. In the

intervention and control campus showed an increase

in the nicotine dependency according to Fagerström

test and a little change in motivation according to

Richmond test. The regression model best explaining

the improving of the knowledge included academic

course mainly and campus and academic background

too. With regard to opinions and beliefs tobacco use

was not influenced, being associated in general to the

academic course. Conclusions: A specific tobacco con-

trol course did not change prevalence of tobacco,

nicotine dependence and motivation to give up. The

improvement in knowledge was associated with aca-

demic course in both campuses. We recommend to

commence smoking cessation strategies in university

health students.

Keywords: Tobacco; Students; Nursing; University;

Intervention

1. INTRODUCTION

The prevention and control of tobacco consumption is a

major challenge for health science professionals, for it

affects their effectiveness as promoters of health with

regard to, among other things, giving up smoking. Their

period as students is an optimal time to intervene in the

knowledge of these professionals, and in their belief sys-

tems and attitudes regarding tobacco [1-3]. Indeed, the

correct training at university leads to health professionals

developing interventions effective against tobacco use

[4-8]. In Spain, students of health sciences are not nor-

mally the subject of studies on tobacco consumption,

such studies that have been made relying on small popu-

lations [9-15]. In general, the prevalence and distribution

of smokers among students of health sciences vary by

country and the duration of studies [16,17]. Few inter-

ventions, however, have been carried out to establish the

most effective strategies for a positive influence on their

future roles as health promoters and to reduce the to-

bacco use [16,18-20], especially those who smoke [21].

1.1. Purpose

The aim of our study was to assess the effectiveness of a

specific training course on tobacco use on the reduction

of the prevalence of consumption and on the improve-

ment of knowledge and attitudes among health science

students. Thus this is the aim of our study, we hypothe-

sized that the active engagement with the topics of our

specific training course on tobacco addiction would re-

duce the tobacco use and lead to a change in smoking-

related attitudes and behaviors.

2. METHOD

Quasi-experimental community intervention trial. The

target population comprised all the students enrolled in

the first year of Nursing and Physiotherapy at the School

of Health Sciences of the University of León at its

campuses in León (Nursing) and Ponferrada (Nursing

OPEN ACCESS

D. Fernandez et al. / Open Journal of Nursing 3 (2013) 351-357

352

and Physiotherapy) in the years 2005-2006 and 2006-

2007. Both courses have a total duration of three years.

The students at Ponferrada (the intervention campus)

attended a specific training course on tobacco addiction,

while those at León (the control campus) did not. Al-

though the impact of Law 28/2005, which came into

effect on the 1st January 2006, was not studied, one of its

articles deals with measures on health education and

assistance in cessation of the smoking habit [22].

The intervention consisted in a free course of 45 hours

carrying 4.5 credits. The aim was to improve knowledge,

belief and attitudes towards tobacco use and to stress

health professionals’ position as role models in its con-

trol, prevention and treatment. The students carried out

related activities like the preparation of leaflets and pos-

ters in groups: some focused on cessation and others on

advice against starting. Role-play was used for diagnos-

ing smokers and for minimal advice.

We used an anonymous questionnaire designed ac-

cording to the European Regional Office of the World

Health Organization [23] and validated in previous

studies [13,14]. collection was performed among all the

students enrolled in Nursing and Physiotherapy at the

University of León during practical laboratory sessions

in October 2005, May 2007 and May 2008 for those

graduating in 2008; and October 2006, May 2008 and

May 2009 for those finishing in 2009. At the time of data

collection, a total of 440 students were enrolled.

A smoker was defined as anyone smoking daily (at

least one cigarette) or occasionally (less than one ciga-

rette per day) at the time of the survey, while those who

had never smoked or who were abstinent were classed as

non-smokers. Factors taken into account for smokers

were age on starting, nicotine dependence as measured

by the Fagerström test (potential range 0 - 10) and moti-

vation for cessation according to the Richmond test (po-

tential range 0-10). Information was also collected on

age, sex, year of study and previous studies.

Knowledge of the consequences of smoking was mea-

sured by means of a question requiring the student to

identify the link between tobacco use and certain health

problems on the following scale:

1) Tobacco use is the main cause of illness.

2) Tobacco use is one of the main causes of illness.

3) There is no link between tobacco use and illness.

4) I don’t know if there is a link.

Likewise, another question with the same scale was

used for the students to identify the link between air pol-

luted with tobacco smoke and a list of health problems.

Those answering 1 or 2 (main cause and one more cause)

scored 1 (positive event), those answering 3 (no link)

scored −1 (negative event) and those answering 4, were

given a 0 (neutral event). The study group considered the

respondent to have “sufficient knowledge” of the first

question for scores of 7 and above, and of the second

question for scores of 5 or above.

Students’ opinions and beliefs were measured on a

scale from 1 - 4, where 1 = totally disagree, 2 = partly

agree, 3 = mostly agree and 4 = totally agree. On the

basis of this, the average was calculated for each of the

items measured.

2.1. Data Analysis

The Epiinfo for Windows program was used for statistic-

cal analysis of the data. On the bivariate level, for cate-

gorical variables we used the Chi-square test while for

continuous variables we applied the T-test in the event of

normality for variances as shown by the Wilcoxon test,

and the Kruskall-Wallis non-parametric test where there

was no such homogeneity. On the multivariate level, we

used a logistic regression model including the variables

associated with tobacco use with a p-value less than 0.20.

Changes in percentages, both in consumption prevalence

and in students with sufficient knowledge, were calcu-

lated from the percentage of difference with regard to the

first year, which was used as base 100.

2.2. Ethical Considerations

Principles of informed consent and confidentiality were

observed during the data collection. The students were

assured that their participation or non-participation would

in no way affect their academic progress. The study, fi-

nanced by the Carlos III Health Research Fund of the

Spanish Ministry of Health and Consumption, was ap-

proved by the Ethics Committee of the University of

León.

3. FINDINGS

3.1. Description of Participants

84.8% (373/440) of the students took part in the study,

whose characteristics as found in the first survey, along

with their distribution by group and intervention, are

shown in Table 1, which also reveals that those in the

intervention group were younger and included more

males than the controls, and that no differences were

observed between the two groups in tobacco consump-

tion prevalence or in the age when they started smoking.

3.2. History of Tobacco Use

On both campuses there was a drop in the prevalence of

smokers from the first to the second year, 8% on the in-

tervention campus and 4% on the control one (Table 2).

These decreases were observed mainly among students

with a background other than the baccalaureate, preva-

lence increasing among those who had studied the bac-

calaureate, in both groups (Table 2).

D. Fernandez et al. / Open Journal of Nursing 3 (2013) 351-357

353

OPEN ACCESS

Table 1. Distribution of the participants in the first year of the university health science courses.

Control Cam pus (173) Intervention Campus (200) p

Men 10.4% (18) 17.5% (35)

Sex

Women 89.6% (155) 82.5% (165)

0.06

Baccalaureate 68.2% (118) 63.5% (127)

Academic background

Others 31.8% (55) 36.5% (73)

0.34

2005-08 46.8% (81) 48% (96)

Graduation year

2006-09 53.2% (92) 52% (104)

0.82

Age Average (SD) 19.9 (3.3) 20.7 (4.3) 0.04

Consumption Smokers 27.2% (47) 28.0% (56) 0.85

Age of smokers Average (SD) 21.8 (4) 21.6 (3.7) 0.61

Age of non smokers Average (SD) 21.1 (4.2) 21.9 (4.3) 0.08

Ageo on starting to smoke Average (SD) 14.7 (1.7) 14.7 (1.9) 0.95

Table 2. Distribution of prevalences by campus, year of study, academic background and total per campus

CONTROL CAMPUS INTERVE NTION CAMPUS

Baccalaureate Non Baccalaureate TOTAL Baccalaureate Non Baccalaureate TOTAL

% Change % % Change % Change % Change % Change

1˚ 21.2 40 27.2 25.2 32.9 28.0

2˚ 23.9 +12.7 37.1 −7.2 28.1+3.3 29.4 +14.2 21.3−35.2 26.3 −6.1

3˚ 21.4 +0.94 35.6 −11 26.1−4.0 28.1 +11.5 21.1−35.8 25.7 −8.2

Of the smokers, 248 (84.6%) had started before begin-

ning their university studies and 45 (15.4%) took up the

habit during their studies, giving an initiation incidence

of 5.1% (45/[1126-248]). In this regard, there were no

statistical differences by campus or year of study, but

there were differences according to academic back-

ground, 33 students (5.5% or 33/[736-144]) with the

baccalaureate taking up the habit in comparison with 12

(4.2% or 12/[390-104]) from other backgrounds (p =

0.05). Differences in nicotine dependence according to

the Fagerström test were found between the campuses,

with the control campus showing an average of 3.6 + 2.2

and the intervention campus 2.6 + 2.1 (p = 0.0001) in the

pre-course survey. Dependence rose on both campuses

(Table 3). No differences were observed in motivation to

stop as measured by the Richmond test either at the be-

ginning of the study or during the students’ time at uni-

versity (Table 3).

3.3. Knowledge

With regard to knowledge of the effects of tobacco on

health, in the pre-intervention survey, more students at

the intervention campus had a sufficient level of knowl-

Table 3. Distribution of averages for the Fagerström nicotine

dependence test and the Richmond test for motivation for

cessation organized by campus and year of study.

Control

Campus

Intervention

Campus

Average SD Average SD p

1st 3.4 2.1 2.3 2.2 0.01

2nd 3.4 2.4 2.4 2.2 0.03

Fagerström

Test

3rd 4.1 2.0 3.0 2.1 0.01

1st 5.2 2.4 5.4 2.7 -

2nd 4.4 2.3 4.8 2.5 -

Richmond

Test

3rd 5 2.6 4.8 3.2 -

edge (64.5% vs 53.8%; p = 0.03, Table 4). On both

campuses the percentage rose as their studies progressed,

although the percentage remained higher on the interven-

tion campus (Table 4). From the logistic regression

analysis, which included all the variables studied, the

model best explaining the prevalence of sufficient

knowledge included the variables of year of study, cam-

pus and academic background. Thus, third-year students,

D. Fernandez et al. / Open Journal of Nursing 3 (2013) 351-357

354

Table 4. Distribution of the prevalence of “sufficient knowledge” regarding health problems and tobacco use organized by campus

and year of study.

CONTROL Campus* INTERVENTION Campus*

n/N % Change n/N % Change p

1st 93/173 53.8 129/200 64.5 0.03

2nd 153/196 78.1

+45.1 172/194 88.7 +37.5 0.005

3rd 156/176 88.6

+64.7 180/187 96.3 +49.3 0.005

*p ˂ 0.0001.

students on the intervention campus and those from a

non-baccalaureate background registered differences of

9.1, 1.9 and 1.9 with regard respectively to first-year

students, controls and those with a baccalaureate back-

ground (p < 0.001).

Smokers on the control campus with sufficient knowl-

edge increased from 61.7% in the first year to 84.8% in

the third (p < 0.001), with a corresponding increase on

the intervention campus from 75% to 97.9% (p < 0.001).

Among non-smokers, the respective increases were from

50% - 8% to 90% (p < 0.001) and from 60.4% to 95% -

7% (p < 0.001).

Regarding knowledge of the link between environ-

mental smoke and health problems, significant differ-

ences were observed between the two campuses as early

as the first interview, these differences persisting in the

second interview and losing statistical significance in the

third year (Table 5). Logistic regression analysis re-

vealed ORs of 8, 2.2 and 1.5 for the intervention campus,

third year and non-baccalaureate background with regard

to the control campus, first year and baccalaureate back-

ground.

3.4. Beliefs Concerning Tobacco Addiction

Table 6 shows students’ average degree of agreement on

opinions concerning tobacco use. Students’ year of study

has a statistically significant influence at both campuses

except regarding the item “Smokers take your recom-

mendations into account”, where there was a statistical

increase on the intervention campus (p < 0.0018), but not

on the control one. For the statements “Students should

receive specific training regarding tobacco use” and

“Topics concerning prevention should be included in the

training” there were statistical differences in the last year,

with a higher average on the control campus. The bivari-

ate analysis revealed no differences in averages concern-

ing consumption, sex or academic background.

4. DISCUSSION

The educational intervention carried out reduced the per-

centage of tobacco addiction in comparison with the con-

trol campus, but without statistical significance, to an ex-

tent similar to studies performed in other countries [18-

20]. Among our students the greatest decrease was among

those from non-baccalaureate backgrounds, which sug-

gests a greater effectiveness among this section of the

population.

The intervention had no effect on nicotine dependence

levels, which rose on both campuses in the way de-

scribed by Boccoli [25]. The low initial dependence lev-

els as compared with those recorded in similar studies

concerning health science students [4,21,26-28] may

have hindered the good results of the intervention, to-

gether with the fact that it was not designed for this end.

Likewise, the intervention did not alter motivation to

cease as measured by the Richmond test, which showed

a minimal change on both campuses.

As in previous studies [12,21,28-30], most of the stu-

dents smoked before coming to university and the num-

ber of new smokers was similar on the two campuses.

Follow-up studies would, however, be useful to deter-

mine the exact incidence of new smokers.

Although improved knowledge is significantly associ-

ated with both the intervention and the years of study, the

latter seemed to be the most important factor, with ORs

near to 9.

The effect of the intervention, despite reaching an OR

approaching 2, was weakened by the knowledge acquired

during their studies. Whether students were smokers or

nonsmokers had no significant influence, unlike other

studies, where tobacco use was a determining factor

[12,21,31].

The year of study had a significant influence on all

items in the section on opinions and beliefs, except num-

ber 2, where there was no modification on the intervene-

tion campus, whereas on the other, probably owing to the

intervention, as students were taught the importance they

would have as future health professionals on the control

of tobacco use.

For Sections 4 and 6, the average degree of agreement

in the third year was higher on the control campus, per-

haps because students on the intervention campus do not

perceive these aspects as necessary. This study revealed

no differences in knowledge, attitudes and beliefs be-

tween smokers and non-smokers on either campus, un-

D. Fernandez et al. / Open Journal of Nursing 3 (2013) 351-357 355

Table 5. Distribution of students with “sufficient knowledge” of the link between health problems and air polluted by tobacco smoke,

organized by campus and year of study.

CONTROL Campus* INTERVENTION Campus*

n/N % Change n/N % Change P

1st 83/172 48,3 130/199 65,3 <0,0001

2nd 143/196 73 +51.1 172/192 89.6 +37.3 <0.0001

3rd 156/176 88.6 +83.4 174/187 93 +42.4 0.14

*p ˂ 0.0001.

Table 6. Distribution of average of students’ degree of agreement at the beginning and end of the period of study.

CONTROL CAMPUS INTERVE NTION CAMPUS

1ST 3RD p* 1ST 3RD p* p**

1. Health professionals

should be role models. 2.50 ± 0.83 3.25 ± 0.71 <0.0001 2.37 ± 1 3.27 ± 0.72 <0.0001 1º p = 0.19 3º

p = 0.76

2. Smokers heed our

recommendatioins 2.45 ± 0.78 2.60 ± 0.77 0.15 2.34 ± 0.69 2.60 ± 0.75 0.0018 1º p = 0.14 3º

p = 0.98

3. My knowledge allows me to

give correct information on the

consequences of tobacco use.

2.69 ± 0.86 3.19 ± 0.60 <0.0001 2.52 ± 0.86 3.09 ± 0.66 <0.0001 1º p = 0.06 3º

p = 0.12

4. Students should receive

specific training regarding

tobacco consumption

2.59 ± 1.08 3.60 ± 0.56 <0.0001 2.49 ± 1.14 3.32 ± 0.65 <0.0001 1º p = 0.42 3º

p ˂ 0.0001

5. I know strategies and

methods for helping people

to give up.

2.05 ± 0.76 2.76 ± 0.82 <0.0001 1.92 ± 0.81 2.71 ± 0.85 <0.0001 1º p = 0.12 3º

p = 0.52

6. Topics concerning

prevention should be included

in our courses

2.56 ± 0.95 3.52 ± 0.57 <0.0001 2.47 ± 1 3.21 ± 0.70 <0.0001 1º p = 0.42 3º

p ˂ 0.0001

*p: analysis on comparing 1st & 3rd years; **p: analysis on comparing 1st & 3rd years on the control and intervention campuses.

like most studies carried out among health science stu-

dents [9,10,15,24,29,32-35], where consumption did have

an influence regarding these sections.

5. CONCLUSIONS

The specific training course on tobacco use carried out

does not appear to alter the overall prevalence of con-

sumption among students of nursing and physiotherapy.

Among those with a non-baccalaureate background,

consumption decreased in a statistically significant way,

35% in comparison with the first year. The intervention

did not influence nicotine dependence or motivation to

give up. Improved knowledge of tobacco use is strongly

linked to their education, less to their background and to

the intervention on the intervention campus.

Opinions and beliefs were not affected by tobacco use

or by the specific course, but did improve with year of

study. The results reveal the need to initiate strategies for

cessation of the habit among health science students and

set up anti-smoking programmes in the years immedi-

ately prior to university in order to reduce or delay the

onset of the habit.

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