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International Journal of Nursing Studies 44 (2007) 780–785

www.elsevier.com/locate/ijnurstu

Tobacco use amongst nursing and physiotherapy students:a cross sectional questionnaire survey

Daniel Fernandez Garcıaa,�, Vicente Martın Sanchezb,Ana M %

a. Vazquez Casaresa, Cristina Liebana Presaa,M %

a Elena Fernandez Martıneza, Jose Manuel De Luis Gonzaleza

aSchool of Health Sciences, Department of Nursing and Physiotherapy, Campus of Ponferrada, University of Leon, SpainbSchool of Health Sciences, Department of Preventive Medicine and Public Health, Campus of Ponferrada, University of Leon, Spain

Received 12 September 2005; received in revised form 5 February 2006; accepted 14 February 2006

Abstract

Aim: The aim of this research was to evaluate the prevalence, knowledge and attitudes of tobacco use in the students of

the School of Health Sciences in the Campus of Ponferrada (University of Leon, Spain). Two-hundred and sixty-six

(88.3% of respondents) students were assessed by a confidential questionnaire, which was distributed, completed by the

students and collected in the same session.

Methods: This was a descriptive quantitative survey research design to examine the tobacco use among nursing and

physiotherapy students.

Results: The global prevalence was 29.3%. In relation to academic courses we have observed statistical significance

(p ¼ 0:006). Therefore students increased tobacco use while their training at the school. Seventy (89.7%) of students

were smokers prior to commencing degree. Nursing students declared were unfamiliar with strategies and methods to

help people to quit.The first academic course students (78.6%) significantly differed (p ¼ 0:009) from second and third

course. We have found scores statistically significant (p ¼ 0:04) about the students opinion about health professionals

social role function.

Conclusion: Tobacco consumption in university health students in the third year was higher than people aged 16–24

years old reported from the National Health Survey. The findings showed a great need to improve the curricular

content in the area of tobacco including information, prevention, and treatment.

r 2006 Elsevier Ltd. All rights reserved.

Keywords: Tobacco; Nursing students; University; Health students

e front matter r 2006 Elsevier Ltd. All rights reserve

urstu.2006.02.008

ing author. Escuela de Ciencias de la Salud,

erıa, Campus de Ponferrada, Avda. Astorga s/n

da, Leon, Spain. Tel.: +34 639641067;

2049.

ss: danielfg@unileon.es (D. Fernandez Garcıa).

What is already known about the topic?

�

d.

Tobacco use by nursing students equates to that of

women in the general population.

�

Health students are tobacco users, in spite of their

knowledge and status.

�

Tobacco use by health students reduces the like-

lihood of them seeing themselves as role models of a

ARTICLE IN PRESSD. Fernandez Garcıa et al. / International Journal of Nursing Studies 44 (2007) 780–785 781

healthy lifestyle and reduces their effectiveness in

tobacco control practice.

What this paper adds

�

Tobacco consumption by third year health care

students in one Spanish university was higher than

people aged 16–24 in the general population.

�

Students increased their tobacco use during their

professional training.

�

Nursing students’ knowledge of strategies and

methods to help people quit smoking was poor

overall, indicating the need to improve curriculum

content on prevention and treatment of tobacco

use.

1. Background

Addiction to tobacco is considered a chronic addictive

disease that can cause premature death to half of the

people who smoke (Fiore et al., 2000). In 1998, tobacco-

related illnesses worldwide resulted in about four million

deaths (World Health Organization, 2000). In Spain the

recent facts indicate that tobacco kills 56,000 people

each year (Banegas et al., 2001). Since at this time about

one-third of the world’s adult population smokes and

youth rates are increasing (World Health Organization,

2000), tobacco use will continue to be a primary factor

contributing to preventable morbidity and mortality

during the 21st century (Sheahan and Wilson, 1996).

In Spain the data from the Encuesta Nacional de Salud

(National Health Survey) (Ministerio de Sanidad y

Consumo, 2003) in 2003, showed that 36.98% of the

people between 16 and 24 years stated smoked daily and

occasionally, those proportions are slightly higher in

males (38.54%) in relation to females (35.34%).

Nurses have been identified as an instrumental

partner in tobacco reduction because they are the largest

health professional group, they have extensive exposure

to various populations through direct client contact in a

diversity of care settings, and nurses are trusted by the

public (Internacional Council of Nurses, 1999; Rice and

Stead, 2001; Haughey et al., 1986). There seems to be a

general consensus from literature that the incidence of

smoking among nurses is equal to that of women in the

population in general (Rowe and Macleod Clark, 2000).

It is critical to examine tobacco control by health

students as they form their professional roles and

develop their basic practices while at school. During

this formative socialization period, they establish their

attitudes and beliefs toward nursing, as well as develop

many of their patterns of professional practice (Rowe

and Macleod Clark, 2000). In USA, it has been

suggested that nursing students lacked curricular con-

tent in the area of clinical tobacco cessation techniques

and increased instructional efforts concerning the

clinical treatment of tobacco dependence would be

critical in order to achieve a reduction in tobacco use

prevalence (Wewers et al., 2004).

In general terms tobacco consumption among nursing

and physiotherapy students has been studied for

decades, much more in the first group (Adriaanse et

al., 1991; Chalmers et al., 2000). In these studies the

authors identified nurses as special population of

tobacco users despite their knowledge of health, their

position as educators and their status as behavioural

model in health. Numerous studies have recognized that

nurses own smoking reduces their likelihood of seeing

themselves as examples and their efficacy in tobacco

control practice (Reeve et al., 1996). Despite extensive

data indicating that health-care providers can help

smokers to quit, medical and nursing practitioners have

generally not been proactive in providing smoking

cessation services to patients (Thorndike et al., 1997;

McEwan and West, 2001). In general their professional

responsibilities place them in a position where their

professional behaviour influences the health promotion

of their patients.

1.1. Purpose

The purpose of this study is to evaluate the

prevalence, knowledge and attitudes of tobacco use

among the students of the School of Health Sciences in

the Campus of Ponferrada (University of Leon, Spain).

2. Method

This was a descriptive quantitative survey research

design to examine tobacco use in the nursing and

physiotherapy students in the School of Health Sciences

in the Campus of Ponferrada (University of Leon,

Spain). In Spain the degree in Nursing and Physiother-

apy lasts three years. A self-filling anonymous ques-

tionnaire was designed following the guidelines of the

European Regional Office of the WHO At the time of

data collection, the total population of nursing and

physiotherapy students was 300 (150 in nursing and

physiotherapy, respectively, and 50 in each of the three

year academic courses). Inclusion criteria was, those

male and female undergraduates in the School of Health

Science in the Campus of Ponferrada who provided

implied consent by returning the study questionnaire.

A database was created with Epiinfo 6.02 (Dean et al.,

1994). Univariate analysis for qualitative variables was

carried out with w2test and t-Test in the case of

quantitative variables. The stratified analysis was carried

out with the test of Mantel–Haenzsel.

ARTICLE IN PRESS

Table 1

Students’ opinion about tobacco as a main cause in various

disease

Diseases Main cause One more There is no

D. Fernandez Garcıa et al. / International Journal of Nursing Studies 44 (2007) 780–785782

3. Findings

3.1. Description of participants

In the study 88.3% (265 of 300) students participated :

80.4% females and 19.6% males, mean age 21.6, SD 3.5.

In relation to university degree 54.1% are respondents

from nursing degree and 45.9% from physiotherapy

degree. Classifying by academic course, degree of

response in nursing by year is 49 (34%), 45 (31.2%)

and 50 (34.7%), respectivey, and in physiotherapy, 49

(40.2%), 40 (32.8%) and 33 (27%). The 100% of

students were Spanish and were originally from Spain.

3.2. Smoking history

More than half of the respondents (54.1%) reported

they had never smoked, 16.6% reported experimenting

with cigarettes in the past (former smokers) and 78

(29.3%) students were current smokers (defined as

smoking cigarettes daily and occasionally). From these

61 (78.2%) students were daily smokers and 17 (21.8%)

occasionally smokers (not daily smokers).

We could conclude that the actual global prevalence

of tobacco use in students was 29.3% (95% CI:

23.9–34.9). 70 (89.7%) of 78 students were smokers

prior to commencing degree and 8 (10.3%) started

smoking during the training at the school: 4 in the second

year and another 4 in the third year. That meant incidence

of initiation during training was 4.1% (8/(265-70)).

With regard to university degree, gender and age

prevalence there are no significant differences but in

relation to academic courses we have observed statisti-

cally significant difference (p ¼ 0:006) (Fig. 1): in the

first year the prevalence of smoking was 19.4%(19 of 98)

while in the second and third year it reached 29.4% (25

of 85) and 41% (34 of 83).

3.3. Beliefs, attitudes and knowledge

We asked students opinion about risk and conse-

quences of tobacco use on health and consequences of

passive smoking in non-smokers. 6.4% (17 of 265)

Glo

bal

; 29.

3

Fir

st y

ear;

19.

4

Sec

on

d y

ear;

29.

4

Th

ird

yea

r; 4

1

0

10

20

30

40

50

60

Prevalence

Fig. 1.

reported being little or not at all worried about the risk

of tobacco smoke (95% CI ¼ 3.5–9.3) and 9.8% (26 of

265) answered the same towards the health effects of

passive smoking (95 CI ¼ 6.2–13.3). Sex and degree

have not had any influence in their worries about health

effects of tobacco use and passive smoking. But

significant differences (p ¼ 0:01) were observed in

academic courses, in relation to passive smoking: 2%

(2 of 98; 95% CI ¼ 0–4.8), 12.9% (11 of 85;

95%CI ¼ 5.8–20.1) and 15.7% (13 of 83; 95%

CI ¼ 7.8–23.5), respectively, in the first, the second

and the third years of the academic course. They

reported being little or not at all worried about the

health consequences of involuntary smoking. Therefore

the increase of tobacco use decreased the worries about

passive smoking.7.5% of students stated that tobacco

was the main cause of diseases strongly related to

tobacco (Table 1).

In general, females (10% CI95%:5.9–14) declared

disagreement about the importance of not smoking in

front of patients to set an example (OR ¼ 5.64

CI95%:0.76–11.7). 10% of females (20 of 211; CI95%:

5.9–14%) and 1.9% males (1 of 52; CI95%:0–5.7%)

answered negatively to this item in the questionnaire.

We have found scores statistically significant

(p ¼ 0:04) about the students opinion about health

professionals’ social role function. We observed 28.9%

females and 15.3% of males stated less agreement about

it (OR ¼ 2.24; CI95%:0.94–5.52).

Stratified by degree, females stated less agreement

more frequently (OR ¼ 2.07; CI95%:0.91–4.68) about

the health professionals’ social role function related to

tobacco habit. And stratified by sex we have found that

female nurses (OR ¼ 1.67; CI95%:2.94–0.93) showed

little or no agreement about the health professionals

social role function (Table 2).

cause relation

Lung Cancer 234 (88%) 31 (11.7%) 1 (0.4%)

Chronic Bronchitis 142 (53.4%) 122 (45.9%) 2 (0.8%)

Pulmonary

Emphysema

134 (50.8%) 120 (45.5%) 10 (3.8%)

Throat Cancer 204 (77%) 59 (22.3%) 2 (0.8%)

Pheripheral

vascular disease

49 (18.4%) 204 (76.7%) 13 (4.9%)

Bladder Cancer 31 (11.7%) 150 (56.4%) 85 (32%)

Coronary artery

disease

54 (20.3%) 202 (75.9%) 10 (3.8%)

Larynx Cancer 207 (77.8%) 57 (21.4%) 2 (0.8%)

Leukoplakia 172 (64.7%) 88 (33.1%) 6 (2.3%)

ARTICLE IN PRESSD. Fernandez Garcıa et al. / International Journal of Nursing Studies 44 (2007) 780–785 783

Among the students 19.3% (51 of 264; 95%

CI ¼ 14.6–24.1) declared that their knowledge did not

or hardly allowed them to inform rigorously about the

harmful effects of tobacco. This was statistically

significant (p ¼ 0:04) in the first year of the academic

course (26.5%) and in the second (12.0%) and third

courses also (18.1%) (Table 3).

26.5% of students in the first year considered their

knowledge was not enough to inform about the harmful

effects of tobacco use, 7.6% (20 of 264; 95%

CI ¼ 4.4–10.8) affirmed little or there was no agreement

about the need to receive specific education on addiction

to tobacco. We found statistically significant difference

in the opinion of physiotherapists (OR ¼ 5.21;

CI95%:1.56–19.23) and nursing students (p ¼ 0:003),especially physiotherapist students in the third year of

the academic course (p ¼ 0:003) (Table 4).

Nursing students declared they were unfamiliar with

strategies and methods to help people to quit. The

Table 3

Percentage of students who disagree with the statement according ac

Statement 1st year 2nd year

Percentage (%) Percentag

Value (%) 95%

Confidence

interval

Value (%

My knowledge allows me to

inform rigorously about

tobacco’s harmful effects

26.5 17.8–35.3 12

There is a need for students

to receive specific education

4.1 0.2–8.0 3.6

I know strategies and

methods to help patients to

quit smoking

78.6 70.4–86.7 71.1

Table 2

Distribution of the answer ‘‘less agreement’’ to the statement ‘‘Healt

addiction’’ by gender and degree

Degree Gender N n Percentage (%)

Value Confi

Nursing Male 21 3 14.3% 0–29

Female 120 41 34.2% 25.7–

Total 141 44

Physiotherapy Male 31 5 16.1% 3.2–2

Female 91 20 22.0% 13.5–

Total 122 25

Note: (N) number of responses, (n) number of responses ‘‘less ag

(0.91–4.68).Stratified by degree: OR ¼ 1.67 (0.93–2.94).

problem was acute in the first academic course (78.6%;

95% CI ¼ 70.4–86.7) as there was significant difference

(p ¼ 0:009) (Table 3). Also we have observed nursing

students (76.1%; CI95% ¼ 69.0–83.1) expressed to a

significant extent to not know of strategies and methods

to help patients to quit smoking (p ¼ 0:02) (Table 4).

4. Discussion

The percentage of respondents (88.3%) was similar

compared with other studies developed in different

countries, where the response rates varied from 80% to

95% (Harrison et al., 1991; Cordon Granados et al.,

1992; Gorin, 2001; Carmichael and Cockcroft, 1997;

Blakey and Seaton, 1992). The number of participants

fluctuated from a minimum of 69 in Elkind (1988) to a

maximum of 2104 in Harrison et al. (1991). The global

prevalence of smoking in our students was 29.3%.

ademic course

3rd year Test of

significance

(p)

e (%) Percentage (%)

) 95%

Confidence

interval

Value (%) 95%

Confidence

interval

5.0–19.1 18.1 9.8–26.4 0.04

0–7.6 15.7 7.9–23.5 0.003

61.3–80.8 57.8 47.2–68.5 0.009

h professionals should have a social role function about tobacco

OR

dence interval 95% Value Confidence interval 95%

.3 1

42.7 3.11 0.79–14.3

9.1 1

30.5 1.46 0.45–5.04

reement’’, (OR) Odds Ratio.Stratified by gender: OR ¼ 2.07

ARTICLE IN PRESS

Table 4

Percentage of students who disagree with the statement according degree

Statement Nursing Physiotherapy Odds ratio

Percentage (%) Percentage (%)

Value (%) 95% Confidence

interval

Value (%) 95% Confidence

interval

There is a need for students to

receive specific education

2.8 0.1–5.5 13.1 7.1–19.1 5.21 (1.56–19.23)

I know strategies and methods

to help patients to quit

smoking

76.1 69.0–83.1 62.3 53.7–70.9

D. Fernandez Garcıa et al. / International Journal of Nursing Studies 44 (2007) 780–785784

Nursing and physiotherapy students have slightly lower

smoking rates than those reported for females and males

aged 16–24 years in general population (36.7% of daily

smokers) (Ministerio de Sanidad y Consumo, 2003),

according to the Spanish National Health Survey. In

England similar studies were carried out. Some obtained

a rate of 28% (Charlton et al., 1997), some 33.1%

(Blakey and Seaton, 1992), 43% (Carmichael and

Cockcroft, 1997) and some 46% (Rowe and Macleod

Clark, 1999). In Spain some of the studies observed

smoking prevalence of 34.3% (Cordon Granados et al.,

1992) and some 38.7% (Heras Tebar, 1997). The lowest

smoking prevalence was in Japan 16% (Okada et al.,

1995) and in USA still less, where recently Jenkins and

Ahijevych (2003) found a 6% smoking rate in nursing

students. In our view, the percentage of smokers is high

among the students, considering the role and increased

efforts to promote tobacco reduction among students

seems necessary.

Our findings by academic course differed from those

reported in the majority of studies, where the increase in

cigarette consumption as students progress through

student education was observed. The end findings

showed that 19.4% of first-year students were smokers,

29.4% of second-year students currently smoke and by

the time the students reached the third year of their

training 41.0% were regular smokers. On the contrary

Rowe and Macleod Clark (1999) showed results that

revealed that first-year students had the highest propor-

tion of smokers (52%), compared with second-year

students (42%) and third-year students (43%), exceed-

ing the smoking national rates of young females aged

16–20 (27%). Charlton et al. (1997) got similar results

therefore in the first-year (45%) students smoking was

more prevalent than in the second (16%) and third-year

(38%). This points to a need to implement educational

programs aimed at decreasingthe number of smokers as

education progresses.

Most respondents who were still smoking began the

habit prior to commencing their degree (89.7%). There-

fore the incidence reaches 1%. Other studies obtained

similar results, close to 85% of students smokers prior to

commencing nursing (Chalmers et al., 2000; Carmichael

and Cockcroft, 1997; Blakey and Seaton, 1992; Rowe

and Macleod Clark, 1999). However in Gorin (2001)

where 48% of smokers started or resumed smoking at

the nursing school.

Nursing and physiotherapy students in second and

third year gave reduced importance to passive smoking,

and this is strongly related to tobacco consumption and

lack of information. With respect to the exemplar role,

we have noticed that females (10%) declared a

disagreement to smoking in front of patients. In the

same way, on the social role function, as a future

professional health worker, there was a high rate of

negative attitudes.

We have found a lack of knowledge about tobacco’s

harmful effects, especially in first year, in both degrees

that could be solved. The need to receive specific

education about addiction to tobacco was underrated

by students in third year and the high prevalence in the

third academic year could be the explanation for this.

Nursing and physiotherapy students had greater

generic than specialized knowledge about causes of

diseases related to tobacco use. Thus students showed a

lack of knowledge about diseases strongly related to

tobacco, 32% found that there was no relation between

bladder cancer and tobacco (Table 1). Students in the

three years expressed an absolute absence of knowledge

about methods to help people quit, which should be

avoided.

5. Conclusion

Tobacco consumption in university health students in

the third year was higher than people aged 16–24 years-

old reported from the National Health Survey. There

were no significant differences in prevalence of smoking

among nursing and physiotherapy students. However,

ARTICLE IN PRESSD. Fernandez Garcıa et al. / International Journal of Nursing Studies 44 (2007) 780–785 785

we found nursing students more concerned about the

methods and strategies to help people to quit, in third

year in particular.

The increase of tobacco use in nursing students was

significant, thus in first year prevalence was 19% and in

the third year the figure reached a high of 41%. In

general terms smokers played down the harmful effects

of tobacco use and even the consequences of passive

smoking. In relation to gender, females in both degrees,

declared little or no agreement on the health profes-

sionals social role and exemplar function. The findings

showed a great need to improve the curricular content in

the area of tobacco, including information, prevention,

and treatment. More attention needs to be given in

health students programmes to smoking and smoking-

related illnesses, and to students’ role in health promo-

tion.

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