Nursing education and beliefs towards tobacco cessation and control: a cross- sectional national survey (GHPSS) among nursing students in Greece

Tobacco use is included as one of the leading causes of death and disability worldwide and as it is estimated that almost 1.3 billion people are currently smokers, tobacco use is expected to be the cause of death of about 10 million people per year by 2030 [1].

Despite the above grim projections, health professionals, such as nurses, can play a critical role in tobacco control by providing effective interventions against tobacco use by counseling their patients to quit smoking [2‐5]. For the above to be facilitated, it is essential for health care facilities, educational institutes as also medical and nursing associations to acknowledge this role and assume a greater responsibility in promoting smoke-free facilities and practices among their staff and patients [6]. A main barrier in achieving this goal is the increased prevalence of smoking among physicians and nurses in a number of countries. Research has indicated that in several European countries and in USA the prevalence of smoking among physicians has decreased over the past decades, however, in several southern European countries, as well as in countries with transitional economies, the prevalence of tobacco use remains very high [7‐9]. In countries with elevated prevalence rates in tobacco consumption a reduction in physician smoking patterns has been shown to be followed by a decrease in the overall population [4]. This fact is of great interest, especially in countries such as Greece, where the tobacco consumption rates are high [6], because health care professionals could act as role models and provide society with a positive example in regards to smoking prevention and cessation [9]. Among others, the existing scientific literature has identified a number of barriers, which include the competing demands and time pressure during patient contacts, the lack of familiarity with effective treatments, perceptions of low receptivity to tobacco interventions, and the absence of adequate training or reimbursement for providing treatment [10‐12]. |Moreover the health professional students' own beliefs regarding tobacco cessation and their self-efficacy in providing effective interventions may be major barriers that affect the nurses' role in tobacco cessation [13]. As reported by Sarrna et al. the lack of education among nurses regarding tobacco control is a huge barrier for implementing cessation strategies, to which the World Health Organisation (WHO) has recommended the inclusion of tobacco control in all health professionals' curricula [2].

In light of the above, the main objectives of this study were: 1. To assess the prevalence of smoking among nursing students in Greece and their beliefs towards tobacco and, 2. to assess the interaction between their received undergraduate education on tobacco control and their perception of their role in patient smoking cessation.

This study revealed a high percentage of nursing students that were smokers in Greece. Furthermore, this study revealed that students' education on smoking cessation and tobacco control was highly associated with their positive perception that they can play a role in tobacco control issues and aid smoking cessation among patients, a fact that indicates the importance of adopting a relative curriculum within the undergraduate nursing curriculum in Greece.

Results of the international GHPSS study conducted among health professional students revealed that a 20% were current smokers, the majority of which believed that they should receive formal training on counseling their patients to quit tobacco, however, less than 40% of the students reported they have received such training during their undergraduate studies [14, 16]. Another, recent GHPSS study conducted in Lebanon among health professional students showed that the prevalence of smoking among nursing students was 26.9%, and that 9 in 10 health professional students believed that health professionals should receive training on smoking cessation techniques, percentages similar to those found within the context of our study [17]. In the same study the percentage of nursing students that reported that they had received training on tobacco related issues during their undergraduate studies reached almost 50% [17]. Our study confirmed the evidence that nurses with previous education on smoking cessation and training related issues were more likely to support the idea that nurses do have an advisory and informative role in counseling patients and should promote tobacco control and prevention. There is evidence supporting that nurses who had received training were more likely to perform tobacco control interventions than untrained ones while the absence of comprehensive tobacco prevention and cessation training in health care education can result in lost opportunities for such interventions [18].

It is critical to examine the perceptions towards tobacco control by health students as they form their professional roles and develop their basic practices while at university [19]. Nurses, as the largest group of health care professionals, and due to their role in the health care system spend more direct time with patients, and can perform health promotional activities. Nurses have the advantage that they could provide people with smoking cessation techniques and act as an effective approach to decrease tobacco use [1, 13]. It is necessary to put into practice educational programs in nursing schools, on the prevention and treatment of smoking. Our findings indicate an eminent need to improve the nursing curriculum within the area of tobacco control, including information on prevention, policy and dependency as the nursing students who had received formal training were more likely to acknowledge their position as a role model and as a vector for smoking cessation.

In Greece, currently there is a lack in the content of the nursing curriculum in preparing nursing students to provide adequate advice to patients in regards to their smoking habits. Moreover in all medical and nursing departments there is no separate educational module on tobacco control, only a number of separate lectures. Therefore, there is a need to re-examine the curriculum to enable students to diagnose, manage and treat smoking dependency and acknowledge the fundamental aspects of tobacco control. Knowledge on the basic, community based and clinical science related to tobacco use, attitudes and behaviours are minimal skills that should be core graduation requirement for nursing students. In the USA, it has been suggested that nursing students lack training on how to implement tobacco cessation techniques and that increased instructional efforts concerning the clinical treatment of tobacco dependence would be critical in order to achieve a decrease in smoking rates [18, 20]. Nursing students' knowledge of intervention techniques and methods to help people give up smoking was found to be poor overall, indicating the need to improve the content of current nursing degrees on the prevention and treatment of tobacco use [21]. Similarly, Sarna et al. concluded that nurses in four Asian countries (China, Korea, Japan and the Philippines) may not be adequately prepared to help tobacco users quit smoking, because the training programs do not offer content related to comprehensive cessation interventions [2, 20]. Furthermore, Sekijima et al. [22] mentioned that Japanese students and nursing staff did not consistently receive adequate education for the generation of skills needed to apply smoking cessation within the context of their training [22].

Currently there are already several educational methods and core competencies with clear learning objectives on smoking interventions that can be implemented in nursing schools [23]. Nursing schools need to take action aimed at including approaches to smoking in their curriculum, and also promote the adoption of continuing educational courses for established health care professionals, especially for those who practise within primary care. There is need for the development of a specific curriculum to teach students on how to assist smokers to quit and how to counsel non-smoking adolescents so as to prevent them from starting to smoke. These goals have been achieved in some countries that have a core competency and learning curriculum for tobacco education in medical schools [24], nursing schools could follow.

This study adds evidence to the growing body of knowledge that there is a link between receiving formal education during undergraduate studies on tobacco control and the students' beliefs regarding smoking cessation and their duty as role models towards their patients. Nevertheless, it is important to acknowledge that this was a cross- sectional study and thus it is not possible to make definitive statements regarding causality, while the relatively large confidence intervals can be explained by the relatively small sample size in each subgroup analyzed. On the other hand, the representative sampling frame and standardized procedures of the GHPSS study increase the validity and generalisability of our study's key findings among nursing students, and most likely recent graduates in Greece.

Educational institutes, public health organizations and education officials in Greece, should discourage tobacco use among health professional students and work together to design and implement programs that train all health professionals on tobacco control and on effective cessation counseling techniques. Nurses are a large and strategically planned occupational group, which could help avert the global tobacco epidemic [25]. As a result, resources should be invested in improving the quality of education of nurses with respect to tobacco control so as to empower them with the capability to successfully implement smoking prevention and cessation techniques during routine clinical practice.

The authors declare that they have no competing interests.

This work was partially supported by the HEART project (Hellenic Action for Research against Tobacco), funded by the Behrakis Foundation through the "Behrakis Project for making smoking history in Greece".