International Dental Education

Tobacco Use, Exposure to Secondhand Smoke, and Cessation Counseling Training of Dental Students Around the World
Charles W. Warren, Ph.D.; Dhirendra N. Sinha, M.D.; Juliette Lee, M.P.H.; Veronica Lea, M.P.H.; Nathan Jones, Ph.D.; Samira Asma, D.D.S.
Abstract: The Global Health Professions Student Survey (GHPSS) has been conducted among third-year dental students in schools in forty-four countries, the Gaza Strip/West Bank, and three cities (Baghdad, Rio de Janeiro, and Havana) (all called sites in this article). In more than half the sites, over 20 percent of the students currently smoked cigarettes, with males having higher rates than females in thirty sites. Over 60 percent of students reported having been exposed to secondhand smoke in public places in thirty-seven of forty-eight sites. The majority of students recognized that they are role models in society and believed they should receive training on counseling patients to quit using tobacco, but few reported receiving formal training. Tobacco control efforts must discourage tobacco use among dentists, promote smoke-free workplaces, and implement programs that train dentists in effective cessation-counseling techniques. Dr. Warren is a Statistician-Demographer, Office on Smoking and Health, Global Tobacco Control, Centers for Disease Control and Prevention; Dr. Sinha is Tobacco Focal Point, Southeast Asia Regional Office, Tobacco-Free Initiative, World Health Organization; Dr. Lee is an Epidemiologist, Office on Smoking and Health, Global Tobacco Control, Centers for Disease Control and Prevention; Dr. Lea is an Epidemiologist, Office on Smoking and Health, Global Tobacco Control, Centers for Disease Control and Prevention; Dr. Jones is a Scientist, Paul P. Carbone Comprehensive Cancer Center, University of Wisconsin; and Dr. Asma is Branch Chief, Office on Smoking and Health, Global Tobacco Control, Centers for Disease Control and Prevention. Direct correspondence and requests for reprints to Dr. Charles W. Warren, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-50, Atlanta, GA 30341; wcw1@cdc.gov. Charles W. Warren, Juliette Lee, Veronica Lea, and Samira Asma are obligated by their institution to have the following statement printed with this report: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. Keywords: tobacco use, health professionals, dental students, counseling training Submitted for publication 7/2/10; accepted 9/23/10

obacco use is a serious health problem around the world. The World Health Organization (WHO) estimates globally over one billion people currently smoke tobacco; with approximately five million deaths a year attributed to tobacco.1 If current trends continue, WHO estimates tobaccoattributable mortality will exceed eight million per year by 2030. A disproportionate share of the global tobacco burden falls on developing countries, where 84 percent of current smokers reside. Tobacco use is a significant risk factor for oral cancer and periodontal disease.2,3 It has been estimated that 80 percent of oral cancers are attributable to tobacco use.4,5 Oral cancers are largely preventable, but if diagnosed late, the prognosis is poor. Health professionals play an important role in educating their

patients about the health risks of tobacco use and in promoting cessation.6 Studies have found that smoking cessation rates increase after even brief or simple counseling by health professionals.7 Consequently, dentists have a very important role to play in tobacco control and should be trained to conduct cessation counseling with their patients. Previous studies have shown that patients who smoke are receptive to cessation counseling from a dentist; however, no international cross-country study has collected information on whether dental students have received training on cessation counseling while in school. The WHO, U.S. Centers for Disease Control and Prevention, and Canadian Public Health Association have attempted to fill this void by developing and implementing the Global Health Professions Student Survey (GHPSS).8

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The GHPSS project includes surveys of dental, medical, nursing, and pharmacy students. The data reported in this study come from GHPSS conducted among third-year dental students in forty-four countries, the Gaza Strip/West Bank, and three cities (Baghdad, Rio de Janeiro, and Havana) (all called sites in this article) from 2005 to 2009. All sites were nominated by their Ministries of Health in conjunction with their respective WHO regional offices. In most sites, national surveys are conducted, but in areas where this is not feasible, city-level surveys are conducted. This study includes data on tobacco use, exposure to secondhand smoke (SHS), and training to provide cessation counseling among dental students. Table 1 lists the sites that completed the Dental GHPSS by year, WHO region, and site.

Materials and Methods

Design
The Dental GHPSS is part of the Global Tobacco Surveillance System, which collects data through four surveys: the Global Youth Tobacco Survey, the Global School Personnel Survey, the Global Adult Tobacco Survey, and GHPSS.9 The GHPSS is a school-based survey of third-year students pursuing advanced degrees in dentistry, medicine, nursing, and pharmacy. GHPSS uses a core questionnaire on demographics, prevalence of cigarette smoking and use of other tobacco products, exposure to SHS, desire to quit smoking, and training received to provide patient counseling on cessation techniques. GHPSS has a

Table 1. Response rates by region and country, Dental Global Health Professions Student Survey, 200509
Country (Site) Algeria Senegal Gaza Strip/West Bank Iran Iraq (Baghdad) Lebanon Libyan Arab Sudan Syrian Arab Republic Tunisia Yemen Albania Armenia Bosnia & Herzegovina Bulgaria Czech Republic Greece Kyrgyzstan Latvia Lithuania Macedonia Republic of Moldova Russian Federation Serbia Slovakia Slovenia Year 2007 2009 2007 2007 2009 2006 2006 2007 2006 2007 2009 2005 2006 2006 2009 2006 2009 2008 2009 2006 2009 2008 2006 2006 2006 2007 School Response Rate (%) 100.0 100.0 100.0 93.3 100.0 100.0 50.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 80.0 100.0 100.0 100.0 Class Response Rate (%) 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Student Response Rate (%) 76.7 74.0 87.6 62.9 100.0 64.0 78.1 56.3 86.2 62.4 84.0 79.2 62.7 94.4 93.8 96.3 94.2 81.9 80.0 64.3 55.3 86.9 100.0 73.7 100.0 100.0 Overall Response Rate (%) 76.7 74.0 87.6 58.7 100.0 64.0 39.1 56.3 86.2 62.4 84.0 79.2 62.7 94.4 93.8 96.3 94.2 81.9 80.0 64.3 55.3 86.9 80.0 73.7 100.0 100.0 Number of Third-Year Students

AFRICAN REGION (AFR) 225 36 91 303 258 71 162 135 475 123 389 53 149 170 193 153 113 148 32 72 83 43 583 212 42 39 (continued)

EASTERN MEDITERRANEAN REGION (EMR)

EUROPEAN REGION (EUR)

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standardized methodology for selecting participating schools and uniform data-processing procedures. The Dental GHPSS included a census of both students and schools in all sites where all eligible schools and students were surveyedexcept in Mexico and India, where a sample of schools was selected with probability proportional to size from all dental schools in the country and a census of students in the selected schools were surveyed (Table 2). The Dental GHPSS was conducted in schools during regular lectures and class sessions. Anonymous, selfadministered data collection procedures were used. Where appropriate, the final country questionnaires were translated into local languages and back-translated to check for accuracy. SUDAAN, a software package for statistical analysis of complex survey data, was used to calculate weighted prevalence estimates and standard errors (SE) of the estimates (95 percent confidence intervals [CI] were calculated from the SEs).10 For all sites excluding India and

Mexico, a finite population correction factor was applied to take into account non-response and used in the variance of the estimates. T-tests were used to determine differences between subpopulations.11,12 In this article, differences in proportions are considered statistically significant if the t-test p-value was less than 0.05. For sites conducting the Dental GHPSS, the school response rate was 100 percent in forty of the forty-eight sites (lowest was 50.0 percent in Libya); the student response rate ranged from 55.3 percent (Macedonia) to 100 percent (Fiji, Guyana, Iraq [Baghdad], Russian Federation, Slovakia, Slovenia, and Mongolia); and the overall response rate ranged from 39.1 percent (Libya) to 100 percent (Fiji, Guyana, Iraq [Baghdad], Slovakia, Slovenia, and Mongolia) (Table 1). The number of students who participated in each survey varied due to the number of schools and student enrollment for each country in each sample design.

Table 1. Response rates by region and country, Dental Global Health Professions Student Survey, 200509 (continued)
Country (Site) Argentina Bolivia Brazil (Rio de Janeiro) Chile Cuba (Havana) Guatemala Guyana Mexico Panama Paraguay Uruguay SOUTH-EAST ASIA REGION (SEAR) Bangladesh India Indonesia Myanmar Nepal Thailand Cambodia Fiji Lao Peoples Democratic Republic Mongolia Papua New Guinea 2009 2009 2007 2009 2005 2006 2005 2009 2009 2007 2009 100.0 93.3 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 86.0 83.6 89.5 75.7 85.3 96.1 85.5 100.0 98.5 100.0 91.7 86.0 78.1 89.5 75.7 85.3 96.1 85.5 100.0 98.5 100.0 91.7 337 711 753 260 88 411 47 14 64 139 11 Year 2007 2007 2007 2008 2008 2008 2009 2006 2008 2008 2008 School Response Rate (%) 100.0 94.1 100.0 90.9 100.0 100.0 100.0 86.7 100.0 71.4 100.0 Class Response Rate (%) 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Student Response Rate (%) 95.7 97.5 84.2 79.4 78.3 86.4 100.0 85.5 86.1 92.0 94.3 Overall Response Rate (%) 95.7 91.8 84.2 72.2 78.3 86.4 100.0 74.1 86.1 65.7 94.3 Number of Third-Year Students

REGION OF THE AMERICAS (AMR) 237 1,658 304 792 146 99 13 1,301 57 147 95

WESTERN PACIFIC REGION (WPR)

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Measurement
This report includes information on current cigarette smoking, current use of tobacco products other than cigarettes (adapted by each country), exposure to SHS at home and in public places, the extent to which schools have official policies banning smoking in school buildings and clinics, and whether the policies are enforced. In addition, attitude questions were asked regarding health professionals as role models for their patients, whether health professionals think they should get training in patient cessation techniques, and if they have ever received formal training on such cessation counseling techniques. Results in this report are presented by WHO region with participating countries identified. The six WHO regions are the African Region (AFR), the Eastern Mediterranean Region (EMR), the European

Region (EUR), the Region of the Americas (AMR), the South-East Asian Region (SEAR), and the Western Pacific Region (WPR). Data presented here are an expansion on previously published data.

Results
The percentage of dental students who were females ranged from 5.0 percent in Moldova to over 70 percent in twelve countries (Fiji, Guatemala, Indonesia, Libya, Lithuania, Macedonia, Mongolia, Nepal, Paraguay, Slovenia, Tunisia, and Uruguay) (Table 2). Over 90 percent of the students were less than twenty-four years of age in every site except Argentina, Bolivia, Brazil, Cuba, Czech Republic, Fiji, Guatemala, Guyana, Laos, Papua New Guinea, Senegal, and Uruguay.

Table 2. Population characteristics by region and country, Dental Global Health Professions Student Survey, 200509

Country (Site)
Algeria

Year 2007 2009 2007 2007 2009 2006 2006 2007 2006 2007 2009 2005 2006 2006 2009 2006 2009 2008 2009 2006 2009 2008 2006 2006 2006 2007

Census or Sample? Census Census Census Census Census Census Census Census Census Census Census Census Census Census Census Census Census Census Census Census Census Census Census Census Census Census

Female (%) 62.5 52.8 57.5 53.7 67.3 67.2 71.8 61.3 38.2 79.5 64.3 66.1 58.7 66.9 59.4 68.6 62.8 50.2 56.9 82.6 74.7 5.0 63.2 41.5 66.7 87.2

Age 24 and Under (%) 96.4 83.3 95.7 92.9 99.2 100.0 95.3 NA 96.8 99.1 97.2 93.3 93.0 97.0 91.0 88.9 90.2 97.9 100.0 98.5 97.6 95.0 97.9 95.2 92.8 97.4

Age 2529 (%) 2.9 16.7 0.0 3.8 0.4 0.0 4.7 NA 2.6 0.8 2.5 6.7 7.0 3.0 5.4 9.7 8.9 1.4 0.0 1.5 2.4 2.6 2.1 3.8 7.1 2.6

Age 30+ (%) 0.7 0.0 4.3 3.4 0.4 0.0 0.0 NA 0.7 0.0 0.3 0.0 0.0 0.0 3.6 1.4 0.9 0.7 0.0 0.0 0.0 2.4 0.0 1.0 0.0 0.0 (continued)

AFRICAN REGION (AFR) Senegal

Gaza Strip/West Bank Iran Iraq (Baghdad) Lebanon Libyan Arab Sudan Syrian Arab Republic Tunisia

EASTERN MEDITERRANEAN REGION (EMR)

Yemen
Albania

EUROPEAN REGION (EUR)

Armenia Bosnia & Herzegovina Bulgaria Czech Republic Greece Kyrgyzstan Latvia Lithuania Macedonia Republic of Moldova Russian Federation Serbia Slovakia Slovenia

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Tobacco Use
Smoking rates among third-year dental students varied widely across the sites. Six sites had current smoking rates above 40 percent (Kyrgyzstan, Macedonia, Moldova, Russian Federation, Chile, and Mexico), and three sites had rates less than 5 percent (Libya, Thailand, and Cambodia) (Table 3). From the AFR, 10.2 percent currently smoked cigarettes in Algeria, and 16.7 percent currently smoked cigarettes in Senegal, with males significantly more likely to smoke than females in both sites. In EMR, current cigarette smoking ranged from 33.4 percent in Gaza Strip/West Bank to 2.3 percent in Libya, with two other sites (Lebanon [31.6 percent] and Syria [23.6 percent]) reporting rates over 20 percent. Males were significantly more likely than females to smoke in all EMR sites, except Lebanon (no gender difference). In EUR, current cigarette smoking was over 20 per-

cent in all sites except for Slovenia (17.9 percent) and Latvia (19.6 percent); five sites reported current cigarette smoking rates over 40 percent (Bulgaria [52.2 percent], Kyrgyzstan [44.0 percent], Macedonia [52.5 percent], Moldova [65.2 percent], and Russian Federation [43.7 percent]). Males were significantly more likely to smoke than females in every site, except Czech Republic, Bulgaria, and Slovakia (females significantly higher than males) and Albania, Bosnia & Herzegovina, Macedonia, and Serbia (no gender difference). In AMR, current cigarette smoking was at least 20 percent in all sites, except Guatemala, Guyana, Panama, and Paraguay, and over 40 percent in Chile and Mexico. Males were significantly more likely than females to smoke in every site with the exception of Chile and Uruguay, where females had significantly higher rates than males, and Argentina and Panama with no gender difference. In the SEAR sites, current cigarette smoking was over 20

Table 2. Population characteristics by region and country, Dental Global Health Professions Student Survey, 200509 (continued)

Country (Site)
Argentina Bolivia

Year 2007 2007 2007 2008 2008 2008 2009 2006 2008 2008 2008 2009 2009 2007 2009 2005 2006 2005 2009 2009 2007 2009

Census or Sample? Census Census Census Census Census Census Census Sample Census Census Census Census Sample Census Census Census Census Census Census Census Census Census

Female (%) 67.2 59.8 68.3 55.3 68.5 76.1 69.2 68.3 68.3 75.6 73.7 59.8 67.6 82.3 22.7 72.0 67.9 43.5 71.4 49.2 75.0 45.5

Age 24 and Under (%) 75.3 82.4 84.0 91.5 88.4 71.6 58.3 94.0 96.5 90.8 81.0 100.0 98.5 99.1 99.6 92.8 98.3 93.6 85.7 89.1 93.5 81.8

Age 2529 (%) 21.3 13.0 9.6 6.1 11.6 24.2 33.3 4.8 3.6 7.1 13.7 0.0 1.3 0.7 0.4 7.2 1.6 6.4 7.1 6.3 5.8 18.2

Age 30+ (%) 3.4 4.6 6.4 2.4 0.0 4.1 8.3 1.1 0.0 2.0 5.3 0.0 0.2 0.1 0.0 0.0 0.0 0.0 7.1 4.7 0.7 0.0

REGION OF THE AMERICAS (AMR)

Brazil (Rio de Janeiro) Chile Cuba (Havana) Guatemala Guyana Mexico Panama Paraguay Uruguay
Bangladesh India Indonesia Myanmar Nepal Thailand Cambodia Fiji

SOUTH-EAST ASIA REGION (SEAR)

WESTERN PACIFIC REGION (WPR)

Lao Peoples Democratic Republic Mongolia Papua New Guinea

NA=data not available

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390
Total % (95% CI) [n] P-Value 0.0000 5.1 (3.86.8) [215] 5.6 (2.611.5) [36] 30.9 (27.534.5) [91] 15.2 (12.218.8) [301] 21.3 (20.322.4) [258] 37.3 (30.145.1) [71] 55.0 (49.160.8) [39] 18.8 (13.725.3) [102] 52.4 (50.154.6) [84] 30.6 (21.042.4) [26] 11.8 (5.523.2) [17] 0.0 [19] 12.2 (9.216.1) [50] 11.6 (8.615.4) [197] 6.4 (5.67.2) [173] 40.5 (31.250.6) [45] 0.0000 10.6 (7.714.4) [85] 1.6 (0.83.2) [130] 10.2 (8.212.6) [198] 29.4 (18.942.7) [17] 48.8 (42.754.9) [36] 14.8 (10.520.5) [99] 41.3 (39.043.6) [80] 34.8 (23.248.7) [25] 8.4 (3.519.1) [45] [111] 2.4 (0.86.9) [86] 8.1 (6.69.8) [181] 8.3 (5.412.6) [96] 2.5 (1.83.5) [238] 0.0000 26.9 (17.838.5) [45] 33.2 (31.135.4) [289] 30.4 (19.943.5) [23] 34.8 (31.138.7) [130] 0.0 0.0244 30.0 (21.440.3) [44] 0.5518 5.3 (4.66.1) [170] 0.0000 5.9 (3.98.9) [197] 0.0017 19.9 (16.124.4) [49] 0.0000 5.3 (1.814.5) [19] 0.0007 20.1 (15.725.5) [72] 4.6 (3.16.8) [126] Current Cigarette Smokers Male % Female % (95% CI) (95% CI) [n] [n] Total % (95% CI) [n] P-Value 0.0000 Currently Use Other Tobacco Products Male % Female % (95% CI) (95% CI) [n] [n] 0.0082 33.4 (29.937.2) [87] 10.3 (7.913.2) [298] 17.1 (16.218.1) [251] 31.6 (24.439.7) [69] 2.3 (0.95.5) [158] 11.4 (7.616.7) [131] 23.6 (22.225.2) [472] 12.6 (9.316.9) [119] 14.4 (12.916.1) [384] 0.0356 0.0000 0.1929 5.5 (3.09.9) [162] 4.9 (2.78.7) [134] 0.0000 29.2 (27.630.8) [475] 0.0011 17.1 (13.321.7) [123] 0.0000 15.0 (13.516.7) [389] 15.7 (8.128.3) [47] 9.5 (4.718.0) [48] 38.5 (36.440.7) [292] 48.0 (35.960.3) [25] 25.4 (22.229.0) [134] 1.6 (0.55.7) [113] 2.2 (0.76.3) [86] 13.8 (11.915.9) [181] 8.2 (5.412.5) [97] 9.0 (7.510.9) [239] 0.0084 0.0353 0.0000 0.0000 0.0000

Table 3. Prevalence of current tobacco use, by gender, region, and country, Dental Global Health Professions Student Survey, 200509

Country (Site)

Year

AFRICAN REGION (AFR)

Algeria

2007

Senegal

16.7 (10.924.6) [36] EASTERN MEDITERRANEAN REGION (EMR)

2009

Gaza Strip/West Bank

2007

Iran

2007

Iraq (Baghdad)

2009

Lebanon

2006

Libyan Arab

2006

Sudan

2007

Syrian Arab Republic

2006

Tunisia

2007

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Yemen

2009

EUROPEAN REGION (EUR) 30.1 (23.238.1) [41] [35] 0.7 (0.22.9) [86] 2.7 (2.03.5) [114] 12.8 (11.214.6) [114] 7.6 (6.49.0) [104] 24.3 (21.926.8) [70] 23.7 (19.628.2) [73] 18.2 (10.829.0) [14] 21.9 (16.628.3) [72] 0.9850 14.5 (10.020.4) [83] NA * [2] 37.9 (35.939.9) [359] 31.0 (26.136.5) [88] 23.1 (19.626.9) [13] 32.1 (29.535.0) [28] 0.0000 9.4 (4.020.3) [42] 11.8 (10.812.9) [583] 0.0615 17.8 (15.120.7) [210] 0.0003 7.1 (6.08.5) [42] 70.3 (53.383.1) [13] 9.5 (3.722.2) [21] 9.9 (4.321.3) [40] 22.5 (20.424.8) [213] 16.8 (13.520.8) [119] 7.1 (5.39.6) [14] 5.6 (3.78.5) [74] 29.0 (20.040.1) [18] 11.7 (7.517.7) [59] 16.1 (10.823.4) [62] * [2] 5.7 (4.96.8) [366] 17.3 (13.421.9) [88] 7.1 (5.88.8) [28] 0.0000 0.0047 28.4 (23.234.3) [145] 36.1 (34.437.8) [169] 52.2 (50.354.1) [192] 33.3 (31.435.2) [152] 39.1 (36.941.3) [110] 44.0 (40.447.6) [141] 19.6 (13.627.3) [30] 29.6 (23.636.5) [72] 52.5 (45.059.9) [80] 65.2 (51.177.1) [38] 43.7 (42.145.3) [574] 28.5 (25.331.9) [211] 29.3 (27.131.5) [41] 24.7 (20.829.1) [120] 53.3 (50.655.9) [212] 69.1 (54.780.6) [36] 52.4 (38.066.4) [21] 52.5 (43.961.1) [59] 61.7 (44.776.3) [13] 22.9 (17.030.1) [59] 0.0002 32.1 (21.045.7) [12] 11.4 (6.020.8) [18] 0.0067 60.9 (55.865.8) [69] 27.8 (23.532.6) [72] 0.0000 14.5 (12.217.2) [147] 24.4 (18.032.1) [32] 31.7 (28.335.3) [41] 43.5 (40.646.4) [69] 0.0000 22.5 (20.724.5) [111] 29.4 (26.232.7) [47] 34.4 (32.236.8) [104] 0.0129 12.3 (11.013.6) [153] 20.8 (18.023.8) [48] 19.5 (16.722.7) [41] 49.3 (46.352.3) [78] 54.7 (52.157.1) [113] 0.0077 20.8 (19.322.4) [192] 32.9 (30.135.8) [77] 34.1 (31.237.1) [56] 37.1 (35.039.2) [113] 0.1069 2.5 (2.03.2) [162] 2.1 (1.33.3) [48] 60.2 (50.569.1) [57] 7.8 (4.513.1) [86] 0.0000 4.1 (2.37.2) [148] 8.9 (4.716.1) [60] 38.0 (24.953.1) [12] 27.1 (19.436.6) [29] 0.2016 2.2 (0.86.0) [51] 7.0 (2.518.0) [16] 0.0 0.0528

Albania

2005

Armenia

2006

Bosnia & Herzegovina

2006

0.3477

Bulgaria

2009

0.0000

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0.0000 0.0159 0.0000 0.1156 0.0000 0.2188 NA 0.8741 1.0000 (continued)

Czech Republic

2006

Greece

2009

Kyrgyzstan

2008

Latvia

2009

Lithuania

2006

Macedonia

2009

Republic of Moldova

2008

Russian Federation

2006

Serbia

2006

Slovakia

2006

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392
Total % (95% CI) [n] P-Value NA [39] 0.7807 5.5 (4.56.8) [237] 11.6 (11.212.0) [1,653] 10.5 (8.812.5) [304] 7.1 (6.28.2) [792] 4.8 (3.46.8) [146] 9.9 (7.113.6) [99] NA * [4] 48.0 (41.954.3) [395] 16.5 (9.926.2) [18] 25.3 (20.930.4) [33] 32.0 (26.538.0) [25] * [9] 40.5 (35.246.0) [879] 15.5 (10.821.6) [39] 13.7 (11.816.0) [114] 41.4 (37.845.1) [70] 0.0256 0.0 [13] 3.9 (3.34.7) [1,298] 0.8257 5.3 (3.18.9) [56] 0.0000 6.7 (5.58.1) [147] 0.0075 7.4 (5.99.2) [95] * [4] 8.6 (7.010.5) [401] 5.6 (2.213.3) [18] 7.4 (4.811.2) [33] 12.0 (8.616.6) [25] * [9] 1.7 (1.03.2) [880] 5.2 (2.79.7) [38] 6.4 (5.18.0) [114] 5.7 (4.27.7) [70] 0.0012 16.4 (15.617.1) [663] 18.1 (14.422.7) [94] 9.4 (7.911.1) [361] 8.7 (5.513.5) [46] 24.4 (16.235.0) [24] 13.1 (10.416.4) [77] * [5] [34] 1.9 (1.22.9) [158] 8.4 (7.98.8) [987] 7.2 (5.69.3) [206] 5.3 (4.26.7) [431] 3.0 (1.75.1) [100] 5.4 (3.19.0) [75] 0.0000 0.0 0.0 17.9 (14.821.6) [39] * [5] 38.7 (34.543.2) [75] 51.3 (50.252.4) [630] 24.4 (20.229.2) [94] 41.7 (38.844.7) [357] 38.6 (32.045.8) [44] 37.6 (27.548.9) [23] 13.0 (9.417.8) [75] 0.0001 21.0 (17.425.1) [100] 0.0000 46.5 (43.849.3) [425] 0.0195 18.3 (15.721.3) [205] 0.0245 30.2 (29.431.0) 951] 0.0000 38.0 (35.041.0) [156] 38.3 (35.940.8) [233] 38.7 (38.039.3) [1,584] 20.0 (17.722.5) [303] 44.4 (42.446.4) [782] 26.4 (23.130.0) [144] 18.7 (14.923.3) [98] 15.4 (10.222.5) [13] 42.8 (37.847.9) [1,291] 15.8 (11.820.8) [57] 16.6 (14.718.7) [147] 38.9 (35.942.0) [95] 17.6 (14.321.5) [34] NA Current Cigarette Smokers Male % Female % (95% CI) (95% CI) [n] [n] Total % (95% CI) [n] P-Value Currently Use Other Tobacco Products Male % Female % (95% CI) (95% CI) [n] [n] 0.0000 0.0000 0.0001 0.0092 0.0003 NA 0.8913 0.5668 0.0051

Table 3. Prevalence of current tobacco use, by gender, region, and country, Dental Global Health Professions Student Survey, 200509 (continued)

Country (Site)

Year

Slovenia

2007

REGION OF THE AMERICAS (AMR)

Argentina

2007

Bolivia

2007

Brazil (Rio de Janeiro)

2007

Chile

2008

Cuba (Havana)

2008

Guatemala

2008

Guyana

2009

Mexico

2006

Panama

2008

Paraguay

2008

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Uruguay

2008

SOUTH-EAST ASIA REGION (SEAR) 20.9 (19.222.6) [316] 6.5 (3.810.8) [689] 10.6 (9.611.7) [748] 34.4 (31.537.4) [258] 17.3 (14.021.2) [84] 3.9 (3.54.3) [411] 2.1 (1.04.5) [47] [20] 0.0 * [4] [10] 13.3 (11.915.0) [30] 25.0 [104] * [5] 0.0000 3.1 (2.44.0) [32] 58.8 [34] * [6] NA 14.3 (8.323.4) [14] 7.9 (7.18.8) [63] 33.3 [138] 9.1 (4.716.9) [11] 3.8 (1.88.1) [26] 0.0 0.0112 2.2 (1.04.7) [45] 7.1 (3.314.9) [14] 6.3 (5.57.0) [64] ** NA 10.1 [139] 9.1 (4.716.9) [11] 10.5 (9.411.8) [131] 0.7 (0.51.0) [280] 0.0000 0.3 (0.20.4) [411] 45.4 (36.454.8) [22] 7.8 (5.311.3) [61] 0.0000 19.1 (15.723.1) [88] 48.3 (39.657.0) [25] 0.8 (0.51.3) [131] 0.0 [26] * [4] 3.1 (2.44.0) [32] 11.8 [34] * [6] 44.1 (40.647.6) [199] 1.6 (0.64.4) [59] 0.0000 29.4 (26.732.3) [260] 37.0 (33.740.5) [201] 39.8 (36.043.8) [133] 4.2 (3.55.1) [608] 0.0000 1.2 (0.91.7) [753] 4.7 (3.26.7) [133] 0.5 (0.30.9) [613] 3.4 (1.76.7) [59] 6.5 (4.29.9) [62] 0.0 [280] 5.6 (2.611.6) [18] 0.0 [10] 9.7 (8.411.1) [31] 9.5 [105] * [5] 0.0000 0.0106 17.5 (10.627.4) [214] 1.5 (0.54.3) [467] 0.0029 8.6 (5.313.6) [710] 18.8 (14.024.8) [227] 3.7 (1.49.1) [474] 0.0008 41.0 (37.744.4) [121] 8.2 (6.99.8) [195] 0.0000 17.8 (16.319.4) [337] 17.9 (15.620.5) [134] 17.8 (15.919.9) [203] 0.9423

Bangladesh

2009

India

2009

Indonesia

2007

0.0000

Myanmar

2009

0.0000

March 2011 Journal of Dental Education

0.0000 0.0000 NA ** NA

Nepal

2005

Thailand

2006

WESTERN PACIFIC REGION (WPR)

Cambodia

2005

Fiji

2009

Lao Peoples Democratic Republic

2009

Mongolia

2007

Papua New Guinea

2009

NA=data not available

*Cell size <10 **Census and 100% school, class, and student response rates

393

percent in Bangladesh and Myanmar and less than 5 percent in Thailand; males had significantly higher smoking rates than females in all six sites. In WPR, current cigarette smoking ranged from 33.3 percent in Mongolia to 2.1 percent in Cambodia. Males were significantly more likely to smoke than females in Cambodia and Mongolia, while in Laos females had significantly higher rates than males. Use of other tobacco products also varied. Among dental students in AFR, current use of other tobacco products was 5.1 percent in Algeria and 5.6 percent in Senegal, with males significantly more likely than females to use other tobacco products in both sites (Table 3). In EMR, other tobacco use was over 20 percent in Gaza Strip/West Bank (30.9 percent), Iraq (Baghdad) (21.3 percent), Lebanon (37.3 percent), and Syria (29.2 percent) but less than 5 percent in Sudan. Males were significantly more likely than females to use other tobacco products in all EMR sites, except Lebanon (no gender difference). In EUR, other tobacco use ranged from 24.4 percent in Latvia to less than 5 percent in Albania, Armenia, Bosnia & Herzegovina, and Slovenia. Males were significantly more likely than females to use other tobacco products in six of the thirteen sites, while females had higher rates than males in Greece and there was no gender difference in the other six sites. In AMR, use of other tobacco products was less than 10 percent in all sites except Bolivia (11.6 percent) and Brazil (10.5 percent). Males had significantly higher use than females in all sites except Panama and Paraguay (no gender difference). In SEAR, use of other tobacco products ranged from 29.4 percent in Myanmar to less than 5 percent in Indonesia and Thailand; males had higher use than females in all sites except Bangladesh (no gender difference). In WPR, use of other tobacco products ranged from 2.2 percent in Cambodia to 10.1 percent in Mongolia; males had higher use than females in Mongolia, while females had higher rates in Cambodia and Laos.

in AMR; four of nine sites in EMR; one of five sites in WPR; and no sites in AFR. Regarding exposure to SHS in public places, over 70 percent of the students reported that they had experienced such exposure in the past seven days in thirty-two of the forty-eight sites (Table 4). Exposure to SHS in public places was greater than 70 percent in thirteen of fifteen sites in EUR (with a low of 30.0 percent in Lithuania); greater than 70 percent in eight of eleven sites in AMR (with a low of 54.4 percent in Panama and 56.8 percent in Uruguay); and greater than 70 percent in five of nine sites in EMR and in two of six sites in SEAR. Exposure to SHS in public places was 34.4 percent in Algeria (AFR) and, in WPR, 59.6 percent (Cambodia) and 79.9 percent (Mongolia). The proportion of students reporting their schools have an official policy banning smoking in school buildings and clinics was over 60 percent in sixteen of the forty-eight sites compared to a low of less than 5 percent in Brazil (Table 4). Having a policy was least likely in EMR (seven of nine sites reported less than 40 percent) and most likely in EUR (seven of fifteen sites had over 60 percent). Over 70 percent of the students reported enforcement of the policy in nineteen of the forty-four sites. Enforcement was reported to be less than 30 percent in Lebanon and Tunisia.

Health Professional Roles and Training

Over 80 percent of the students thought dentists have a role in giving advice about smoking cessation to patients in thirty-seven of forty-six sites, with twenty-six over 90 percent (including five of six sites in SEAR) (Table 5). The lowest percentage was in Slovakia (56.8 percent). Over 80 percent of the students thought health professionals should get specific training on cessation techniques in forty of the forty-seven sites, with twenty-five over 90 percent. The lowest was in Myanmar (69.3 percent). Less than 40 percent of the students reported having ever received some kind of formal training in their professional school on cessation approaches to use with their patients in forty of the forty-seven sites. This percentage was less than 20 percent in twentyseven sites and less than 10 percent in eight sites. Over 50 percent of the students had received formal training in Fiji (100 percent), India (54.8 percent), Lithuania (60.0 percent), and Moldova (61.3 percent).

Exposure to Secondhand Smoke

Regarding exposure to SHS in the students home, over 50 percent reported that they had experienced such exposure in the past seven days in twentytwo of the forty-eight sites (Table 4). Over 70 percent reported exposure to SHS at home in Albania (84.4 percent), Cuba (75.9 percent), Greece (73.5 percent), and Macedonia (77.5 percent). Exposure at home was greater than 50 percent in eleven of fifteen sites in EUR; two of six sites in SEAR; four of eleven sites

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Table 4. Exposure to secondhand smoke (at home and in public places) and school policy and enforcement regarding bans on smoking, region and country, Dental Global Health Professions Student Survey, 200509
In the past 7 days, had someone smoked in their presence and their home Total % (95% CI) [n] 28.0 (25.031.1) [219] 41.7 (33.150.8) [36] 58.3 (54.562.0) [91] 36.6 (32.241.1) [302] 50.8 (49.552.1) [258] 65.4 (57.772.4) [71] 35.7 (29.142.9) [162] 44.9 (38.251.9) [132] 65.3 (63.666.9) [469] 44.7 (39.250.3) [123] 48.4 (46.150.7) [386] 84.4 (78.389.0) [53] 61.4 (55.467.0) [149] In the past 7 days, had someone smoked in their presence other than in their home Total % (95% CI) [n] 34.4 (31.337.7) [219] 68.6 (59.576.4) [35] 83.2 (80.185.9) [91] 56.0 (51.460.5) [299] 76.3 (75.177.4) [257] 77.0 (69.982.9) [71] 44.1 (37.151.3) [161] 70.1 (63.376.1) [133] 86.8 (85.688.0) [474] 62.8 (57.268.1) [121] 72.4 (70.374.4) [386] 92.8 (88.195.7) [50] 82.7 (77.587.0) [148] Have an official policy banning smoking in school buildings and clinics Total % (95% CI) [n] 44.3 (40.947.7) [214] 37.1 (28.846.4) [35] 34.9 (31.438.7) [91] 40.5 (36.145.1) [297] 19.6 (18.620.7) [255] 50.6 (42.858.4) [71] 15.5 (10.821.6) [157] 37.3 (30.844.2) [135] 25.0 (23.526.6) [474] 33.9 (28.839.4) [121] 21.9 (20.023.8) [382] 29.3 (21.638.5) [33] 60.4 (54.366.2) [148] Have an official policy banning smoking in school buildings and clinics, and the policy is enforced Total % (95% CI) [n] 34.1 (29.439.2) [90] 36.4 (22.453.1) [11] 76.7 (68.583.4) [17] 76.8 (70.382.2) [107] 62.5 (59.365.6) [40] 28.8 (20.139.3) [31] 31.4 (15.752.9) [20] 83.3 (73.590.0) [45] 52.3 (48.755.9) [114] 20.0 (13.329.0) [40] 60.6 (55.565.5) [81]

Country (Site) AFRICAN REGION (AFR) Algeria

Year 2007

Senegal

2009

EASTERN MEDITERRANEAN REGION (EMR) Gaza Strip/West Bank 2007

Iran

2007

Iraq (Baghdad)

2009

Lebanon

2006

Libyan Arab

2006

Sudan

2007

Syrian Arab Republic

2006

Tunisia

2007

Yemen

2009

EUROPEAN REGION (EUR) Albania 2005 * [9] 81.6 (74.886.9) [95] (continued)

Armenia

2006

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Table 4. Exposure to secondhand smoke (at home and in public places) and school policy and enforcement regarding bans on smoking, region and country, Dental Global Health Professions Student Survey, 200509 (continued)
In the past 7 days, had someone smoked in their presence and their home Total % (95% CI) [n] 58.7 (56.960.5) [170] 57.6 (55.759.5) [193] 26.8 (25.128.6) [152] 73.5 (71.475.4) [113] 58.6 (55.162.0) [148] 15.2 (10.322.1) [32] 30.5 (24.337.5) [71] 77.5 (70.783.1) [80] 54.0 (41.166.5) [43] 52.5 (50.954.1) [583] 65.9 (62.369.2) [211] 57.1 (54.759.5) [42] 33.3 (29.337.6) [39] 53.9 (51.456.4) [236] In the past 7 days, had someone smoked in their presence other than in their home Total % (95% CI) [n] 93.5 (92.594.3) [169] 92.1 (90.993.0) [192] 85.8 (84.487.2) [153] 96.5 (95.597.2) [113] 78.2 (75.081.0) [144] 50.3 (42.158.5) [32] 30.0 (24.136.6) [72] 95.0 (90.597.4) [80] 79.2 (66.787.8) [43] 85.4 (84.286.5) [581] 91.1 (88.893.0) [212] 71.4 (69.273.6) [42] 74.4 (70.378.0) [39] 94.1 (92.795.1) [235] Have an official policy banning smoking in school buildings and clinics Total % (95% CI) [n] 52.7 (50.954.4) [170] 54.4 (52.556.4) [193] 89.3 (88.090.4) [151] 67.8 (65.470.2) [87] 30.5 (27.333.9) [142] 92.7 (86.596.1) [32] 55.9 (48.762.8) [72] 56.6 (49.363.7) [83] 49.9 (37.062.9) [42] 77.8 (76.479.1) [580] 44.2 (40.647.9) [211] 95.2 (94.196.2) [42] 89.7 (86.892.1) [39] 83.9 (82.085.7) [236] Have an official policy banning smoking in school buildings and clinics, and the policy is enforced Total % (95% CI) [n] 43 (40.545.5) [86] 54.9 (52.357.5) [103] 47.8 (45.550.1) [114] 69.5 (66.572.3) [59] 72.7 (66.378.3) [41] 90.7 (84.694.5) [29] 80.7 (72.986.6) [42] 52.2 (42.461.8) [46] 95.1 (77.099.1) [20] 36.5 (34.838.3) [449] 85.7 (81.389.2) [86] 55.3 (52.757.8) [38] 100.0 [35] 65.5 (62.968.1) [198] (continued)

Country (Site) Bosnia & Herzegovina

Year 2006

Bulgaria

2009

Czech Republic

2006

Greece

2009

Kyrgyzstan

2008

Latvia

2009

Lithuania

2006

Macedonia

2009

Republic of Moldova

2008

Russian Federation

2006

Serbia

2006

Slovakia

2006

Slovenia

2007

REGION OF THE AMERICAS (AMR) Argentina 2007

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Table 4. Exposure to secondhand smoke (at home and in public places) and school policy and enforcement regarding bans on smoking, region and country, Dental Global Health Professions Student Survey, 200509 (continued)
In the past 7 days, had someone smoked in their presence and their home Total % (95% CI) [n] 45.7 (45.146.4) [1,654] 29.4 (26.832.2) [304] 45.1 (43.147.1) [786] 75.9 (72.379.1) [145] 28.7 (24.133.8) [99] 46.2 (38.054.6) [13] 53.9 (47.560.1) [1,294] 28 (22.933.8) [57] 35.6 (33.138.2) [147] 65.2 (62.268.2) [95] 51.3 (49.353.3) [336] 40.0 (33.447.0) [701] 49.6 (47.951.3) [751] 59.5 (56.462.5) [260] In the past 7 days, had someone smoked in their presence other than in their home Total % (95% CI) [n] 70.1 (69.570.7) [1,645] 71.4 (68.774.0) [304] 92.3 (91.393.2) [786] 86.2 (83.388.7) [145] 70.6 (65.475.3) [99] 84.6 (77.589.8) [13] 87.5 (83.690.6) [1,285] 54.4 (48.360.4) [57] 63.1 (60.565.6) [147] 56.8 (53.759.9) [95] 69.5 (67.671.3) [334] 52.5 (43.960.9) [698] 82.3 (81.083.6) [742] 86.4 (84.288.4) [260] Have an official policy banning smoking in school buildings and clinics Total % (95% CI) [n] 27.1 (26.527.7) [1,610] 2.6 (1.54.3) [151] 53.4 (51.055.7) [584] 73.6 (70.076.9) [144] 76.4 (71.380.8) [96] 61.5 (53.169.3) [13] 49.1 (43.055.2) [1,291] 45.2 (39.251.3) [57] 37.6 (35.140.2) [147] 91.6 (89.793.2) [95] 58.0 (56.060.0) [334] 67.6 (56.776.9) [695] 53.0 (51.354.6) [751] 93.0 (91.294.4) [259] Have an official policy banning smoking in school buildings and clinics, and the policy is enforced Total % (95% CI) [n] 69.3 (68.070.5) [386] * [3] 70.3 (67.073.5) [299] 53.8 (49.258.4) [104] 36.9 (31.243.1) [74] * [8] 53.7 (42.964.2) [667] 55.8 (46.165.0) [23] 86.0 (82.688.8) [59] 96.5 (95.197.5) [86] 74.5 (71.977.0) [167] 90.8 (86.194.0) [442] 55.1 (52.757.5) [361] 55.1 (51.958.3) [238] (continued)

Country (Site) Bolivia

Year 2007

Brazil (Rio de Janeiro)

2007

Chile

2008

Cuba (Havana)

2008

Guatemala

2008

Guyana

2009

Mexico

2006

Panama

2008

Paraguay

2008

Uruguay

2008

SOUTH-EAST ASIA REGION (SEAR) Bangladesh 2009

India

2009

Indonesia

2007

Myanmar

2009

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Table 4. Exposure to secondhand smoke (at home and in public places) and school policy and enforcement regarding bans on smoking, region and country, Dental Global Health Professions Student Survey, 200509 (continued)
In the past 7 days, had someone smoked in their presence and their home Total % (95% CI) [n] 35.2 (30.939.8) [86] 27.4 (26.428.4) [411] 48.9 (43.354.6) [47] 42.9 (32.853.5) [14] 42.2 (40.743.7) [64] 40.3 [139] 63.6 (53.472.8) [11] In the past 7 days, had someone smoked in their presence other than in their home Total % (95% CI) [n] 54.1 (49.358.8) [85] 62.5 (61.463.6) [411] 59.6 (53.965.0) [47] 71.4 (61.080.0) [14] 43.8 (42.245.3) [64] 79.9 [139] 90.9 (83.195.3) [11] Have an official policy banning smoking in school buildings and clinics Total % (95% CI) [n] 26.3 (22.330.6) [86] 44.8 (43.745.9) [410] 52.2 (46.557.8) [46] 92.9 (85.196.7) [14] 59.4 (57.860.9) [64] 56.8 [139] 70.0 (59.478.8) [10] Have an official policy banning smoking in school buildings and clinics, and the policy is enforced Total % (95% CI) [n] 77.9 (68.285.3) [18] 88.9 (87.690.0) [140] 89.5 (82.693.8) [19] 66.7 (55.276.5) [12] 100.0 [34] 48.6 [72] * [7]

Country (Site) Nepal

Year 2005

Thailand

2006

WESTERN PACIFIC REGION (WPR) Cambodia 2005

Fiji

2009

Lao Peoples Democratic Republic Mongolia Papua New Guinea

2009

2007 2009

*Cell size <10

Table 5. Attitudes toward and training in patient smoking cessation counseling, region and country, Dental Global Health Professions Student Survey, 200509
Think health professionals have a role in giving advice or information about smoking cessation to patients Total % (95% CI) [n] 81.6 (78.884.1) [202] 97.2 (92.199.1) [36] Think health professionals should get specific training on cessation techniques Total % (95% CI) [n] 83.0 (80.385.3) [209] 94.4 (88.597.4) [36] Have ever received any formal training in smoking cessation approaches to use with patients in their dental school training Total % (95% CI) [n] 44.6 (41.248.1) [204] 8.6 (4.615.3) [35] (continued)

Country (Site) AFRICAN REGION (AFR) Algeria

Year 2007

Senegal

2009

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Table 5. Attitudes toward and training in patient smoking cessation counseling, region and country, Dental Global Health Professions Student Survey, 200509 (continued)
Think health professionals have a role in giving advice or information about smoking cessation to patients Total % (95% CI) [n] 90.8 (88.392.8) [90] 89.8 (86.792.2) [301] 85.6 (84.786.5) [257] 71.8 (63.978.6) [65] 84.3 (78.588.8) [161] 97.6 (94.299.0) [135] 97.7 (97.198.2) [475] 96.7 (94.098.2) [121] 93.9 (92.794.9) [388] 95.6 (91.297.9) [51] 78.9 (73.483.5) [146] 87.2 (86.088.3) [170] 84.1 (82.785.4) [192] 81.7 (80.183.2) [152] Think health professionals should get specific training on cessation techniques Total % (95% CI) [n] 86.9 (84.189.3) [90] 95.5 (93.397.0) [303] 88.7 (87.889.5) [256] 95.2 (91.597.4) [70] 85.6 (79.989.8) [161] 99.3 (96.699.8) [135] 96.1 (95.396.8) [472] 96.7 (94.198.2) [123] 97.0 (96.197.7) [383] 97.9 (94.299.3) [53] 79.9 (74.584.4) [146] 88.9 (87.890.0) [170] 83.3 (81.884.7) [193] 71.3 (69.573.1) [153] Have ever received any formal training in smoking cessation approaches to use with patients in their dental school training Total % (95% CI) [n] 24.8 (21.628.3) [90] 10.3 (7.913.2) [302] 12.9 (12.013.8) [256] 32.9 (26.240.3) [71] 31.7 (25.238.9) [157] 28.1 (22.634.4) [134] 13.9 (12.715.2) [473] 14.9 (11.319.4) [121] 11.5 (10.113.0) [386] 14.2 (9.720.2) [53] 36.6 (31.042.6) [147] 8.3 (7.49.3) [170] 17.8 (16.419.3) [192] 1.3 (0.91.8) [153] (continued)

Country (Site) Gaza Strip/West Bank

Year 2007

EASTERN MEDITERRANEAN REGION (EMR)

Iran

2007

Iraq (Baghdad)

2009

Lebanon

2006

Libyan Arab

2006

Sudan

2007

Syrian Arab Republic

2006

Tunisia

2007

Yemen

2009

EUROPEAN REGION (EUR) Albania 2005

Armenia

2006

Bosnia & Herzegovina

2005

Bulgaria

2009

Czech Republic

2006

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Table 5. Attitudes toward and training in patient smoking cessation counseling, region and country, Dental Global Health Professions Student Survey, 200509 (continued)
Think health professionals have a role in giving advice or information about smoking cessation to patients Total % (95% CI) [n] NA Think health professionals should get specific training on cessation techniques Total % (95% CI) [n] NA Have ever received any formal training in smoking cessation approaches to use with patients in their dental school training Total % (95% CI) [n] 19.6 (17.921.5) [112] 35.9 (32.539.4) [142] 43.8 (35.852.1) [32] 60.0 (52.966.6) [72] 48.2 (40.955.5) [83] 61.3 (47.873.2) [42] 22.3 (21.023.7) [582] 20.7 (17.923.8) [210] 14.3 (12.716.1) [42] 0.0 [39] 11.9 (10.313.6) [236] 23.3 (22.723.9) [1,607] 19.5 (17.221.9) [296] 4.2 (3.65.0) [791] (continued)

Country (Site) Greece

Year 2009

Kyrgyzstan

2008

76.9 (73.779.8) [146] 90.5 (84.494.3) [32] 80.3 (73.985.4) [72] 75.6 (68.781.4) [82] 97.3 (86.299.5) [41] NA

84.4 (81.786.8) [147] 90.0 (83.794.0) [32] 94.6 (90.996.8) [72] 78.0 (71.383.6) [82] 95.4 (85.698.6) [43] 78.9 (77.580.1) [582] 84.6 (81.887.1) [212] 82.5 (80.584.3) [40] 79.5 (75.782.8) [39] 87.7 (86.089.3) [237] 92.9 (92.693.3) [1,640] 91.7 (89.993.2) [304] 89.9 (88.791.0) [792]

Latvia

2009

Lithuania

2006

Macedonia

2009

Republic of Moldova

2008

Russian Federation

2006

Serbia

2006

88.6 (86.090.7) [209] 56.8 (54.259.3) [37] 100.0 [39]

Slovakia

2006

Slovenia

2007

REGION OF THE AMERICAS (AMR) Argentina 2007 75.2 (73.077.3) [234] 84.3 (83.884.7) [1,634] 76.8 (74.279.3) [304] 94.0 (93.094.9) [790]

Bolivia

2007

Brazil (Rio de Janeiro)

2007

Chile

2008

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Table 5. Attitudes toward and training in patient smoking cessation counseling, region and country, Dental Global Health Professions Student Survey, 200509 (continued)
Think health professionals have a role in giving advice or information about smoking cessation to patients Total % (95% CI) [n] 100.0 [145] Guatemala 2008 100.0 [99] Guyana 2009 100.0 [13] Mexico 2006 77.7 (70.583.6) [1,291] 100.0 [57] Paraguay 2008 92.8 (91.394.1) [147] 91.6 (89.693.2) [95] 91.6 (90.492.7) [336] 93.2 (90.395.4) [703] 98.7 (98.299.0) [753] 88.8 (86.790.5) [258] 95.3 (92.897.0) [86] 94.0 (93.594.5) [411] 100.0 [47] Think health professionals should get specific training on cessation techniques Total % (95% CI) [n] 97.2 (95.698.3) [144] 98.2 (96.399.2) [99] 92.3 (86.595.8) [13] 95.0 (93.596.1) [1,297] 96.4 (93.398.1) [57] 94.0 (92.595.3) [147] 73.7 (70.876.4) [95] 86.7 (85.288.0) [336] 93.7 (90.895.7) [694] 95.3 (94.596.0) [753] 69.3 (66.372.0) [258] 89.0 (85.591.7) [83] 80.9 (80.081.8) [411] 100.0 [47] Have ever received any formal training in smoking cessation approaches to use with patients in their dental school training Total % (95% CI) [n] 36.4 (32.640.2) [143] 16.9 (13.121.4) [98] 7.7 (4.213.5) [13] 10.2 (6.216.2) [1,295] 20.9 (16.426.3) [57] 21.7 (19.624.0) [147] 11.5 (9.713.7) [95] 26.8 (25.028.6) [335] 54.8 (44.964.4) [695] 10.3 (9.411.4) [752] 8.7 (7.110.6) [260] 11.8 (9.015.2) [83] 14.1 (13.314.9) [408] 17.0 (13.221.7) [47] (continued)

Country (Site) Cuba (Havana)

Year 2008

Panama

2008

Uruguay

2008

SOUTH-EAST ASIA REGION (SEAR) Bangladesh 2009

India

2009

Indonesia

2007

Myanmar

2009

Nepal

2005

Thailand

2006

WESTERN PACIFIC REGION (WPR) Cambodia 2005

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Table 5. Attitudes toward and training in patient smoking cessation counseling, region and country, Dental Global Health Professions Student Survey, 200509 (continued)
Think health professionals have a role in giving advice or information about smoking cessation to patients Total % (95% CI) [n] 100.0 [14] 95.2 (94.595.9) [63] 78.4 [139] 90.9 (83.195.3) [11] Think health professionals should get specific training on cessation techniques Total % (95% CI) [n] 100.0 [14] 95.2 (94.595.9) [63] 95.7 [139] 90.9 (83.195.3) [11] Have ever received any formal training in smoking cessation approaches to use with patients in their dental school training Total % (95% CI) [n] 100.0 [13] 19.4 (18.120.6) [62] 9.4 [139] * [9]

Country (Site) Fiji Lao Peoples Democratic Republic Mongolia Papua New Guinea

Year 2009 2009

2007 2009

NA=data not available

Discussion
The U.S. Department of Health and Human Services clinical practice guideline, which contains recommendations and guidelines on effective tobacco dependency treatments, states that tobacco use presents a rare confluence of circumstances: (1) a highly significant health threat; (2) a disinclination among clinicians to intervene consistently; and (3) the presence of effective interventions.7 With respect to clinician intervention, there is no debate over the fact that health professionals, including dentists, have important roles to play in tobacco control in delivering and supporting effective treatment for tobacco use, especially as it relates to their use of tobacco products and patient counseling on cessation. However, conclusions from previous studies do not reflect the current counseling influence and tobacco treatment dentists are practicing. Additionally, most health professions students, regardless of discipline, have reported being underprepared to provide effective tobacco cessation counseling.8 A study of health care providers found that dentists are less active than other health professionals in counseling patients on tobacco cessation.13 Studies in Australia, Britain, New Zealand, Sweden, and the United States have found that dentists are

not adequately trained in providing tobacco cessation counseling to their patients.14 Other studies have noted that forty-four of fifty-four dental schools in the United States have introduced tobacco cessation counseling into their curricula;15 but, to our knowledge, no published study has assessed the effectiveness of the training courses, nor has any study attempted to follow up with students after they have begun their clinical practice to see what, if any, techniques are being used. Regarding effective interventions, tobacco use is one of the major preventable causes of premature death and disease in the world. Effective tobacco control, as outlined in the 2008 WHO publication MPOWER: A Policy Package to Reverse the Tobacco Epidemic, can lead to a reduction in tobacco use.1 The findings from our study, however, are not encouraging. Results from the Dental GHPSS show that over 20 percent of dental students currently smoke cigarettes in twenty-six of forty-eight sites; this percentage is over 40 percent in seven sites (Bulgaria, Kyrgyzstan, Macedonia, Moldova, Russian Federation, Chile, and Mexico). Among the six WHO regions, current cigarette smoking was highest in EUR and AMR. Males were more likely than females to smoke cigarettes in thirty of forty-three sites; females had higher rates than males in Bulgaria, Chile, Czech Republic, Laos, Slovakia, and Uruguay; and there was

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no gender difference in six of the forty-three sites. Use of other forms of tobacco was over 10 percent in twenty-two of forty-eight sites and over 25 percent in Gaza Strip/West Bank, Lebanon, Myanmar, and Syria. Among the WHO regions, use of other tobacco products was highest in EMR, probably reflecting the high use of waterpipe (Shisha) in the region. Males were more likely than females to use other tobacco products in thirty-one of forty-three sites; females had a higher rate than males in Cambodia, Greece, and Mongolia; and there was no gender difference in ten sites.This widespread use of tobacco runs counter to the fact that tobacco use endangers the health of dental students and negatively influences the future workforce to deliver effective anti-tobacco counseling when they start seeing patients.7 Educational institutions training dental students should be helping their students quit using tobacco by providing encouragement and cessation information to students who are considering quitting and assistance to those who are motivated to quit. Educational institutions training dental students should also be encouraged to provide smoke-free work and study areas by banning smoking in their buildings and clinics. A smoke-free work environment has been shown to improve air quality, reduce health problems associated with exposure to tobacco smoke, and support and encourage cessation attempts among smokers trying to quit; also, bans on smoking generally receive high levels of public support from people who spend time in the area.7 Furthermore, the creation of smoke-free areas by educational institutions sends a clear message to educators, students, patients, and clinicians about the negative impact of tobacco. Results from the Dental GHPSS show high exposure to SHS: over 50 percent of the dental students reported they were exposed to SHS in their homes in twenty-two of the forty-eight sites, and over 70 percent were exposed to SHS in public places in thirty-two of the forty-eight sites. Dental students around the world should be trained to provide effective, accurate, and accessible advice to patients on all aspects of health. Results from the Dental GHPSS show that over 80 percent of dental students recognize that they are role models in society (in thirty-seven of forty-six sites) and over 80 percent think they should receive training on counseling and treating patients to quit using tobacco (forty of forty-seven sites), although less than 40 percent have received formal training in forty of forty-seven sites. Professional training for dental students should include courses detailing the harmful health effects of

tobacco use and exposure to SHS, as well as training in effective tobacco counseling and tobacco cessation treatment techniques. Curricula should include a course or supplements to existing courses specifically relevant to tobacco issues. If administrators are resistant to making changes in the core curricula, schools should be encouraged to incorporate tobacco-related modules within existing courses. The majority of evaluation research conducted on tobacco-related curricula has been conducted in high-income countries.16,17 Relatively little information about the process of teaching dental students in low- and middle-income countries about smoking prevention and cessation is accessible to the international tobacco control community. Peer-reviewed studies in international settings about educational materials and techniques to improve the capacity of dentists to counsel patients on cessation are necessary to focus limited resources on effective and efficient strategies to reduce the prevalence of tobacco use. Efforts should be made to assess and share the content of tobacco control components within the formal training curricula and continuing education courses for dental students. Further research should be carried out to assess the impact of existing tobacco control-related materials and training provided in dental schools in a variety of cultural and economic environments. The Dental GHPSS is subject to at least three limitations. First, this study reflects third-year students who have not had substantial interaction with patients, so these survey results should not be extrapolated to account for practicing health professionals. Second, the sites included in this study are not representative of individual WHO regions given the number of sites included per region (of the 193 WHO Member States we report data for forty-four countries, one geographic region, and three cities). Lastly, data were based on the self-report of students, who might underreport or overreport their behaviors or attitudes. The extent of this bias cannot be determined from these data; however, reliability studies in the United States have indicated good test-retest results for similar tobacco-related questions.18

Conclusions
The Dental GHPSS is helpful in evaluating the behavior and attitudes regarding tobacco use of dental students. Use of this survey in our global study has shown a significant gap in professional patient

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cessation training among dental students to provide effective assistance to their future patients. Educational institutions, public health organizations, and education officials should discourage tobacco use among dentists around the world. These groups should also work together to design and implement programs that train dental students on effective cessation counseling and treatment techniques. Concurrently, additional research is necessary to improve the evidence base for effective tobacco-related curricula, especially materials that are appropriate for a range of cultural and economic settings.

Acknowledgments

The authors would like to thank the following GHPSS Country Research Coordinators in WHO Regional Offices, who made completion of the Dental GHPSS possible: African Region, Jean-Pierre Baptiste, Nivo Ramanandraibe; Eastern Mediterranean Region, Fatimah El-Awa, Heba Fouad; European Region, Agis Tsouros, Kristina Mauer-Stender, Rula Nabil Khoury; Region of the Americas, Adriana Blanco, Roberta Caixeta; South-East Asia Region, Khalilur Rahman, Dhirendra N. Sinha; and Western Pacific Region, Susan Mercado, Ali Akbar. Within each region, we also thank the following: African Region: Djamel Zoughailech (Algeria), Malang Coly (Senegal). Eastern Mediterranean Region: Samah Eriqat, Salah Shaker Isa Soubani, Moein Al Kariry (Gaza Strip and West Bank); Ahmed Ali Bahaj, Ali Asghar Farshad, Hassan Azaripour Masooleh (Iran); Sameerah Jasim (Iraq [Baghdad]); Georges Saade, Nagib Ghosn (Lebanon); Mohamed Ibrahim Saleh Daganee (Libya); Ibrahim Abdelmageed Mohamed Ginawi, Ilham Abdalla Bashir (Sudan); Bassam Abu Al Zahab (Syria); Mohamed Nabil Ben Sahem, Alya Mahjoub Zarrouk, Mohamed Mokdad, Mongi Hamrouni (Tunisia); Al Khawlani (Yemen). European Region: Roland Shuperka (Albania); Alexander Bazarjyan (Armenia); Aida RamicCatak, Zivana Gavric (Bosnia & Herzegovina); Antoaneta Manolova (Bulgaria); Hana Sovinova (Czech Republic); Anastasia Barbouni (Greece); Aisha Tokobaeva (Kyrgyzstan); Nikola Tilgale (Latvia); Antanas Gostautas (Lithuania); Mome Spasovski (Macedonia); Vorfolomei Calmic (Republic of Moldova); Galina Sakharova (Russian Federation); Djordje Stojilkovic, Andjelka Dzeletovic (Republic

of Serbia); Tibor Baska (Slovakia); Mojca Juricic (Slovenia). Region of the Americas: Raul Pitarque, Hugo A. Miguez (Argentina); Franklin Alcaraz del Castillo (Bolivia); Luisa Goldfarb, Valeska Caralho Figueiredo, Adelemara Mattoso Allonzi, Leticia Casado Costa, Liz Maria de Almeida (Brazil); Claudia Gonzalez Wedmaier (Chile); Lucia Lances Cotilla (Cuba); Delmy Walesska Zecena Alarcon (Guatemala); Preeta Saywack (Guyana); Luz Reynales Shigematsu (Mexico); Reina Roa (Panama); Arnaldo Vera Morinigo (Paraguay); Raquel Magri, Gabriela Olivera (Uruguay). South-East Asia Region: Zulfiqar Ali (Bangladesh); Dhirendra N. Sinha, Mangesh Pednekar (India); Tjandra Aditama (Indonesia); Myo Paing (Myanmar); M.R. Pandey (Nepal); Ministry of Public Health and Mohidol University (Thailand). Western Pacific Region: Sin Sovann, Sung Vin Tak (Cambodia); Ali Tharid (Fiji); Vanphanom Sychareun (Lao Peoples Democratic Republic); Dondog Jargalsaikhan, L. Erdenebayar, Palam Enkhtuya, Tsogzolmaa Bayandorj (Mongolia); Thomas Vinit (Papua New Guinea). For CDC support, we thank Michelle Carlberg, Ann Goding, and Brandon M. OHara.

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8. Warren CW, Jones NR, Chauvin J, Peruga A. Tobacco use and cessation counseling: cross-country data from the global health professions student survey (GHPSS), 20057. Tob Control 2008;17:23847. 9. Warren CW, Asma S, Lee J, Lea V , Mackay J. The GTSS atlas. Atlanta: CDC Foundation, 2009. 10. Shah BV, Barnwell BG, Bieler GS. Software for the statistical analysis of correlated data (SUDAAN): users manual. Release 7.5. Research Triangle Park, NC: Research Triangle Institute, 1997. 11. Hinkle DE, Wiersma W, Jurs SG. Applied statistics for the behavioral sciences. 5th ed. Boston: Houghton Mifflin, 2003. 12. Donner A, Klar N. Design and analysis of cluster randomization trials in health research. New York: Oxford University Press, 2000. 13. Tomar SL. Dentistrys role in tobacco control. J Am Dent Assoc 2001;132(Suppl):30S35S.

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