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March 2011 Journal of Dental Education 385

International Dental Education

Tobacco Use, Exposure to Secondhand

Smoke, and Cessation Counseling Trainingof Dental Students Around the WorldCharles 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. Tobaccocontrol 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, Ofce on Smoking and Health, Global Tobacco Control, Centers for Disease Control

and Prevention; Dr. Sinha is Tobacco Focal Point, Southeast Asia Regional Ofce, Tobacco-Free Initiative, World Health Orga-

nization; Dr. Lee is an Epidemiologist, Ofce on Smoking and Health, Global Tobacco Control, Centers for Disease Control and

Prevention; Dr. Lea is an Epidemiologist, Ofce 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, Ofce on Smoking and Health, Global Tobacco Control, Centers for Disease Control and Prevention. Direct corre-

spondence 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; [email protected].

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 ndings 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

Tobacco 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

ve million deaths a year attributed to tobacco.1 If

current trends continue, WHO estimates tobacco-

attributable 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 signicant risk factor for oral

cancer and periodontal disease.2,3 It has been esti-

mated 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 smok-

ing 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 cessa-

tion counseling from a dentist; however, no interna-

tional 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 ll this void by developing and implementing the

Global Health Professions Student Survey (GHPSS).8


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386 Journal of Dental Education Volume 75, Number 3

The GHPSS project includes surveys of dental, medi-

cal, 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 Ha-

vana) (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 ofces. 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

DesignThe Dental GHPSS is part of the Global

Tobacco Surveillance System, which collects data

through four surveys: the Global Youth Tobacco Sur-

vey, 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 de-

mographics, 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

School Class Student Overall Numberof Response Response Response Response Third-Year Rate Rate Rate Rate StudentsCountry(Site) Year (%) (%) (%) (%)

AFRICAN REGION (AFR)

Algeria 2007 100.0 100.0 76.7 76.7 225

Senegal 2009 100.0 100.0 74.0 74.0 36

EASTERN MEDITERRANEAN REGION (EMR)

GazaStrip/WestBank 2007 100.0 100.0 87.6 87.6 91

Iran 2007 93.3 100.0 62.9 58.7 303Iraq(Baghdad) 2009 100.0 100.0 100.0 100.0 258

Lebanon 2006 100.0 100.0 64.0 64.0 71LibyanArab 2006 50.0 100.0 78.1 39.1 162

Sudan 2007 100.0 100.0 56.3 56.3 135SyrianArabRepublic 2006 100.0 100.0 86.2 86.2 475

Tunisia 2007 100.0 100.0 62.4 62.4 123Yemen 2009 100.0 100.0 84.0 84.0 389

EUROPEAN REGION (EUR)

Albania 2005 100.0 100.0 79.2 79.2 53

Armenia 2006 100.0 100.0 62.7 62.7 149Bosnia&Herzegovina 2006 100.0 100.0 94.4 94.4 170

Bulgaria 2009 100.0 100.0 93.8 93.8 193

CzechRepublic 2006 100.0 100.0 96.3 96.3 153Greece 2009 100.0 100.0 94.2 94.2 113Kyrgyzstan 2008 100.0 100.0 81.9 81.9 148

Latvia 2009 100.0 100.0 80.0 80.0 32

Lithuania 2006 100.0 100.0 64.3 64.3 72Macedonia 2009 100.0 100.0 55.3 55.3 83

RepublicofMoldova 2008 100.0 100.0 86.9 86.9 43RussianFederation 2006 80.0 100.0 100.0 80.0 583

Serbia 2006 100.0 100.0 73.7 73.7 212Slovakia 2006 100.0 100.0 100.0 100.0 42

Slovenia 2007 100.0 100.0 100.0 100.0 39(continued)


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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, self-

administered data collection procedures were used.

Where appropriate, the nal country questionnaires

were translated into local languages and back-trans-

lated 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 condence intervals [CI] were calculated

from the SEs).10 For all sites excluding India and

Mexico, a nite 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 signicant 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.

REGION OF THE AMERICAS (AMR)

Argentina 2007 100.0 100.0 95.7 95.7 237

Bolivia 2007 94.1 100.0 97.5 91.8 1,658Brazil(RiodeJaneiro) 2007 100.0 100.0 84.2 84.2 304Chile 2008 90.9 100.0 79.4 72.2 792

Cuba(Havana) 2008 100.0 100.0 78.3 78.3 146Guatemala 2008 100.0 100.0 86.4 86.4 99

Guyana 2009 100.0 100.0 100.0 100.0 13Mexico 2006 86.7 100.0 85.5 74.1 1,301

Panama 2008 100.0 100.0 86.1 86.1 57Paraguay 2008 71.4 100.0 92.0 65.7 147

Uruguay 2008 100.0 100.0 94.3 94.3 95

SOUTH-EAST ASIA REGION (SEAR)

Bangladesh 2009 100.0 100.0 86.0 86.0 337

India 2009 93.3 100.0 83.6 78.1 711

Indonesia 2007 100.0 100.0 89.5 89.5 753Myanmar 2009 100.0 100.0 75.7 75.7 260Nepal 2005 100.0 100.0 85.3 85.3 88

Thailand 2006 100.0 100.0 96.1 96.1 411

WESTERN PACIFIC REGION (WPR)

Cambodia 2005 100.0 100.0 85.5 85.5 47Fiji 2009 100.0 100.0 100.0 100.0 14

LaoPeoplesDemocraticRepublic 2009 100.0 100.0 98.5 98.5 64

Mongolia 2007 100.0 100.0 100.0 100.0 139PapuaNewGuinea 2009 100.0 100.0 91.7 91.7 11

Table 1. Response rates by region and country, Dental Global Health Professions Student Survey, 200509 (continued)

School Class Student Overall Numberof Response Response Response Response Third-Year Rate Rate Rate Rate StudentsCountry(Site) Year (%) (%) (%) (%)


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MeasurementThis report includes information on current

cigarette smoking, current use of tobacco products

other than cigarettes (adapted by each country), expo-

sure to SHS at home and in public places, the extent

to which schools have ofcial policies banning smok-ing 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 profession-

als 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 identied. 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 West-

ern Pacic Region (WPR). Data presented here are

an expansion on previously published data.

ResultsThe 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

Census Age24and Age or Female Under 2529 Age30+Country(Site) Year Sample? (%) (%) (%) (%)


Algeria 2007 Census 62.5 96.4 2.9 0.7Senegal 2009 Census 52.8 83.3 16.7 0.0


GazaStrip/WestBank 2007 Census 57.5 95.7 0.0 4.3

Iran 2007 Census 53.7 92.9 3.8 3.4Iraq(Baghdad) 2009 Census 67.3 99.2 0.4 0.4Lebanon 2006 Census 67.2 100.0 0.0 0.0LibyanArab 2006 Census 71.8 95.3 4.7 0.0Sudan 2007 Census 61.3 NA NA NASyrianArabRepublic 2006 Census 38.2 96.8 2.6 0.7Tunisia 2007 Census 79.5 99.1 0.8 0.0Yemen 2009 Census 64.3 97.2 2.5 0.3


Albania 2005 Census 66.1 93.3 6.7 0.0Armenia 2006 Census 58.7 93.0 7.0 0.0Bosnia&Herzegovina 2006 Census 66.9 97.0 3.0 0.0Bulgaria 2009 Census 59.4 91.0 5.4 3.6

CzechRepublic 2006 Census 68.6 88.9 9.7 1.4Greece 2009 Census 62.8 90.2 8.9 0.9Kyrgyzstan 2008 Census 50.2 97.9 1.4 0.7Latvia 2009 Census 56.9 100.0 0.0 0.0Lithuania 2006 Census 82.6 98.5 1.5 0.0Macedonia 2009 Census 74.7 97.6 2.4 0.0RepublicofMoldova 2008 Census 5.0 95.0 2.6 2.4RussianFederation 2006 Census 63.2 97.9 2.1 0.0Serbia 2006 Census 41.5 95.2 3.8 1.0Slovakia 2006 Census 66.7 92.8 7.1 0.0Slovenia 2007 Census 87.2 97.4 2.6 0.0

(continued)


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Tobacco UseSmoking rates among third-year dental stu-

dents 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 signicantly 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

signicantly 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); ve 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 signicantly

more likely to smoke than females in every site, ex-

cept Czech Republic, Bulgaria, and Slovakia (females

signicantly 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 signicantly more

likely than females to smoke in every site with the

exception of Chile and Uruguay, where females had

signicantly higher rates than males, and Argen-

tina and Panama with no gender difference. In the

SEAR sites, current cigarette smoking was over 20


Argentina 2007 Census 67.2 75.3 21.3 3.4

Bolivia 2007 Census 59.8 82.4 13.0 4.6Brazil(RiodeJaneiro) 2007 Census 68.3 84.0 9.6 6.4Chile 2008 Census 55.3 91.5 6.1 2.4Cuba(Havana) 2008 Census 68.5 88.4 11.6 0.0Guatemala 2008 Census 76.1 71.6 24.2 4.1Guyana 2009 Census 69.2 58.3 33.3 8.3Mexico 2006 Sample 68.3 94.0 4.8 1.1Panama 2008 Census 68.3 96.5 3.6 0.0Paraguay 2008 Census 75.6 90.8 7.1 2.0Uruguay 2008 Census 73.7 81.0 13.7 5.3


Bangladesh 2009 Census 59.8 100.0 0.0 0.0India 2009 Sample 67.6 98.5 1.3 0.2Indonesia 2007 Census 82.3 99.1 0.7 0.1

Myanmar 2009 Census 22.7 99.6 0.4 0.0Nepal 2005 Census 72.0 92.8 7.2 0.0Thailand 2006 Census 67.9 98.3 1.6 0.0


Cambodia 2005 Census 43.5 93.6 6.4 0.0

Fiji 2009 Census 71.4 85.7 7.1 7.1LaoPeoplesDemocraticRepublic 2009 Census 49.2 89.1 6.3 4.7Mongolia 2007 Census 75.0 93.5 5.8 0.7PapuaNewGuinea 2009 Census 45.5 81.8 18.2 0.0

NA=datanotavailable

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

Census Age24and Age or Female Under 2529 Age30+Country(Site) Year Sample? (%) (%) (%) (%)


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percent in Bangladesh and Myanmar and less than 5

percent in Thailand; males had signicantly 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

signicantly more likely to smoke than females in

Cambodia and Mongolia, while in Laos females had

signicantly 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 signicantly 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 per-

cent), Iraq (Baghdad) (21.3 percent), Lebanon (37.3

percent), and Syria (29.2 percent) but less than 5 per-

cent in Sudan. Males were signicantly 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

signicantly 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 signicantlyhigher 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.

Exposure to Secondhand SmokeRegarding exposure to SHS in the students

home, over 50 percent reported that they had experi-

enced such exposure in the past seven days in twenty-

two 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 fteen sites in

EUR; two of six sites in SEAR; four of eleven sites

in AMR; four of nine sites in EMR; one of ve 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 fteen 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 ve 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 ofcial 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 fteen 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 andTraining

Over 80 percent of the students thought dentists

have a role in giving advice about smoking cessa-

tion to patients in thirty-seven of forty-six sites,

with twenty-six over 90 percent (including ve 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

specic training on cessation techniques in forty

of the forty-seven sites, with twenty-ve 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 twenty-

seven 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).


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Table 4. Exposure to secondhand smoke (at home and in public places) and school policy and enforcement regardingbans on smoking, region and country, Dental Global Health Professions Student Survey, 200509

Country(Site) Year

Inthepast7days,had

someonesmokedin

theirpresenceandtheirhome

Inthepast7days,had

someonesmokedintheir

presenceotherthanintheirhome

Haveanofcial

policybanningsmoking

inschoolbuildingsandclinics

Haveanofcialpolicybanning

smokinginschoolbuildingsand

clinics,andthepolicyisenforced

Total% Total% Total% Total%(95%CI)

[n](95%CI)

[n](95%CI)

[n](95%CI)

[n]


Algeria 2007 28.0 34.4 44.3 34.1(25.031.1)

[219](31.337.7)

[219](40.947.7)

[214](29.439.2)

[90]

Senegal 2009 41.7 68.6 37.1 36.4(33.150.8)

[36](59.576.4)

[35](28.846.4)

[35](22.453.1)

[11]


GazaStrip/WestBank 2007 58.3 83.2 34.9 76.7(54.562.0)

[91](80.185.9)

[91](31.438.7)

[91](68.583.4)

[17]

Iran 2007 36.6 56.0 40.5 76.8(32.241.1)

[302](51.460.5)

[299](36.145.1)

[297](70.382.2)

[107]

Iraq(Baghdad) 2009 50.8 76.3 19.6 62.5(49.552.1)

[258](75.177.4)

[257](18.620.7)

[255](59.365.6)

[40]

Lebanon 2006 65.4 77.0 50.6 28.8(57.772.4)

[71](69.982.9)

[71](42.858.4)

[71](20.139.3)

[31]

LibyanArab 2006 35.7 44.1 15.5 31.4(29.142.9)

[162]

(37.151.3)

[161]

(10.821.6)

[157]

(15.752.9)

[20]

Sudan 2007 44.9 70.1 37.3 83.3(38.251.9)

[132]

(63.376.1)

[133]

(30.844.2)

[135]

(73.590.0)

[45]

SyrianArabRepublic 2006 65.3 86.8 25.0 52.3(63.666.9)

[469]

(85.688.0)

[474]

(23.526.6)

[474]

(48.755.9)

[114]

Tunisia 2007 44.7 62.8 33.9 20.0(39.250.3)

[123](57.268.1)

[121](28.839.4)

[121](13.329.0)

[40]

Yemen 2009 48.4 72.4 21.9 60.6(46.150.7)

[386](70.374.4)

[386](20.023.8)

[382](55.565.5)

[81]


Albania 2005 84.4 92.8 29.3*

[9](78.389.0)

[53](88.195.7)

[50](21.638.5)

[33]

Armenia 2006 61.4 82.7 60.4 81.6(55.467.0)

[149](77.587.0)

[148](54.366.2)

[148](74.886.9)

[95]

(continued)


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Country(Site) Year

Inthepast7days,had

someonesmokedin


Inthepast7days,had



Haveanofcial







[n](95%CI)

[n](95%CI)

[n](95%CI)

[n]

Bosnia&Herzegovina 2006 58.7 93.5 52.7 43(56.960.5)

[170](92.594.3)

[169](50.954.4)

[170](40.545.5)

[86]

Bulgaria 2009 57.6 92.1 54.4 54.9(55.759.5)

[193](90.993.0)

[192](52.556.4)

[193](52.357.5)

[103]

CzechRepublic 2006 26.8 85.8 89.3 47.8

(25.128.6)[152]

(84.487.2)[153]

(88.090.4)[151]

(45.550.1)[114]

Greece 2009 73.5 96.5 67.8 69.5(71.475.4)

[113]

(95.597.2)

[113]

(65.470.2)

[87]

(66.572.3)

[59]

Kyrgyzstan 2008 58.6 78.2 30.5 72.7(55.162.0)

[148]

(75.081.0)

[144]

(27.333.9)

[142]

(66.378.3)

[41]

Latvia 2009 15.2 50.3 92.7 90.7(10.322.1)

[32]

(42.158.5)

[32]

(86.596.1)

[32]

(84.694.5)

[29]

Lithuania 2006 30.5 30.0 55.9 80.7(24.337.5)

[71]

(24.136.6)

[72]

(48.762.8)

[72]

(72.986.6)

[42]Macedonia 2009 77.5 95.0 56.6 52.2

(70.783.1)[80]

(90.597.4)[80]

(49.363.7)[83]

(42.461.8)[46]

RepublicofMoldova 2008 54.0 79.2 49.9 95.1(41.166.5)

[43](66.787.8)

[43](37.062.9)

[42](77.099.1)

[20]

RussianFederation 2006 52.5 85.4 77.8 36.5(50.954.1)

[583](84.286.5)

[581](76.479.1)

[580](34.838.3)

[449]

Serbia 2006 65.9 91.1 44.2 85.7(62.369.2)

[211](88.893.0)

[212](40.647.9)

[211](81.389.2)

[86]

Slovakia 2006 57.1 71.4 95.2 55.3(54.759.5)

[42]

(69.273.6)

[42]

(94.196.2)

[42]

(52.757.8)

[38]

Slovenia 2007 33.3 74.4 89.7 100.0(29.337.6)

[39]

(70.378.0)

[39]

(86.892.1)

[39] [35]


Argentina 2007 53.9 94.1 83.9 65.5(51.456.4)

[236]

(92.795.1)

[235]

(82.085.7)

[236]

(62.968.1)

[198]

(continued)

(continued)


13/21



Country(Site) Year

Inthepast7days,had

someonesmokedin


Inthepast7days,had



Haveanofcial







[n](95%CI)

[n](95%CI)

[n](95%CI)

[n]

Bolivia 2007 45.7 70.1 27.1 69.3(45.146.4)

[1,654](69.570.7)

[1,645](26.527.7)

[1,610](68.070.5)

[386]

Brazil(RiodeJaneiro) 2007 29.4 71.4 2.6*

[3](26.832.2)

[304](68.774.0)

[304](1.54.3)

[151]

Chile 2008 45.1 92.3 53.4 70.3

(43.147.1)[786]

(91.393.2)[786]

(51.055.7)[584]

(67.073.5)[299]

Cuba(Havana) 2008 75.9 86.2 73.6 53.8(72.379.1)

[145]

(83.388.7)

[145]

(70.076.9)

[144]

(49.258.4)

[104]

Guatemala 2008 28.7 70.6 76.4 36.9(24.133.8)

[99]

(65.475.3)

[99]

(71.380.8)

[96]

(31.243.1)

[74]

Guyana 2009 46.2 84.6 61.5*

[8]

(38.054.6)

[13]

(77.589.8)

[13]

(53.169.3)

[13]

Mexico 2006 53.9 87.5 49.1 53.7(47.560.1)

[1,294]

(83.690.6)

[1,285]

(43.055.2)

[1,291]

(42.964.2)

[667]Panama 2008 28 54.4 45.2 55.8

(22.933.8)[57]

(48.360.4)[57]

(39.251.3)[57]

(46.165.0)[23]

Paraguay 2008 35.6 63.1 37.6 86.0(33.138.2)

[147](60.565.6)

[147](35.140.2)

[147](82.688.8)

[59]

Uruguay 2008 65.2 56.8 91.6 96.5(62.268.2)

[95](53.759.9)

[95](89.793.2)

[95](95.197.5)

[86]


Bangladesh 2009 51.3 69.5 58.0 74.5(49.353.3)

[336]

(67.671.3)

[334]

(56.060.0)

[334]

(71.977.0)

[167]India 2009 40.0 52.5 67.6 90.8

(33.447.0)[701]

(43.960.9)[698]

(56.776.9)[695]

(86.194.0)[442]

Indonesia 2007 49.6 82.3 53.0 55.1(47.951.3)

[751]

(81.083.6)

[742]

(51.354.6)

[751]

(52.757.5)

[361]

Myanmar 2009 59.5 86.4 93.0 55.1(56.462.5)

[260]

(84.288.4)

[260]

(91.294.4)

[259]

(51.958.3)

[238]

(continued)

(continued)


14/21



Country(Site) Year

Inthepast7days,had

someonesmokedin


Inthepast7days,had



Haveanofcial







[n](95%CI)

[n](95%CI)

[n](95%CI)

[n]

Nepal 2005 35.2 54.1 26.3 77.9(30.939.8)

[86](49.358.8)

[85](22.330.6)

[86](68.285.3)

[18]

Thailand 2006 27.4 62.5 44.8 88.9(26.428.4)

[411]

(61.463.6)

[411]

(43.745.9)

[410]

(87.690.0)

[140]


Cambodia 2005 48.9 59.6 52.2 89.5(43.354.6)

[47](53.965.0)

[47](46.557.8)

[46](82.693.8)

[19]

Fiji 2009 42.9 71.4 92.9 66.7(32.853.5)

[14]

(61.080.0)

[14]

(85.196.7)

[14]

(55.276.5)

[12]

LaoPeoplesDemocraticRepublic

2009 42.2 43.8 59.4 100.0(40.743.7)

[64]

(42.245.3)

[64]

(57.860.9)

[64] [34]

Mongolia 2007 40.3[139]

79.9[139]

56.8[139]

48.6[72]

PapuaNewGuinea 2009 63.6 90.9 70.0*

[7]

(53.472.8)

[11]

(83.195.3)

[11]

(59.478.8)

[10]*Cellsize


15/21


Table 5. Attitudes toward and training in patient smoking cessation counseling, region and country, Dental GlobalHealth Professions Student Survey, 200509 (continued)

Year

Thinkhealthprofessionalshavea

roleingivingadviceorinformationaboutsmokingcessation

topatients

Thinkhealthprofessionalsshouldgetspecictraining

oncessationtechniques

Haveeverreceivedanyformaltrainingin

smokingcessationapproachestousewithpatientsintheirdental

schooltraining

Total% Total% Total%

Country(Site)(95%CI)

[n](95%CI)

[n](95%CI)

[n]


GazaStrip/WestBank 2007 90.8 86.9 24.8(88.392.8)

[90]

(84.189.3)

[90]

(21.628.3)

[90]

Iran 2007 89.8 95.5 10.3(86.792.2)

[301]

(93.397.0)

[303]

(7.913.2)

[302]

Iraq(Baghdad) 2009 85.6 88.7 12.9(84.786.5)

[257](87.889.5)

[256](12.013.8)

[256]

Lebanon 2006 71.8 95.2 32.9(63.978.6)

[65](91.597.4)

[70](26.240.3)

[71]

LibyanArab 2006 84.3 85.6 31.7(78.588.8)

[161](79.989.8)

[161](25.238.9)

[157]

Sudan 2007 97.6 99.3 28.1(94.299.0)

[135]

(96.699.8)

[135]

(22.634.4)

[134]

SyrianArabRepublic 2006 97.7 96.1 13.9

(97.198.2)[475]

(95.396.8)[472]

(12.715.2)[473]

Tunisia 2007 96.7 96.7 14.9(94.098.2)

[121]

(94.198.2)

[123]

(11.319.4)

[121]

Yemen 2009 93.9 97.0 11.5(92.794.9)

[388]

(96.197.7)

[383]

(10.113.0)

[386]


Albania 2005 95.6 97.9 14.2(91.297.9)

[51]

(94.299.3)

[53]

(9.720.2)

[53]

Armenia 2006 78.9 79.9 36.6

(73.483.5)[146]

(74.584.4)[146]

(31.042.6)[147]

Bosnia&Herzegovina 2005 87.2 88.9 8.3(86.088.3)

[170](87.890.0)

[170](7.49.3)

[170]

Bulgaria 2009 84.1 83.3 17.8(82.785.4)

[192](81.884.7)

[193](16.419.3)

[192]

CzechRepublic 2006 81.7 71.3 1.3(80.183.2)

[152](69.573.1)

[153](0.91.8)

[153](continued)


16/21


Year


roleingivingadviceor

informationaboutsmokingcessationtopatients

Thinkhealthprofessionalsshould

getspecictrainingoncessationtechniques


smokingcessation

approachestousewithpatientsintheirdentalschooltraining


Country(Site)

(95%CI)

[n]

(95%CI)

[n]

(95%CI)

[n]

Greece 2009 NA NA 19.6(17.921.5)

[112]

Kyrgyzstan 2008 76.9 84.4 35.9(73.779.8)

[146]

(81.786.8)

[147]

(32.539.4)

[142]

Latvia 2009 90.5 90.0 43.8

(84.494.3)[32]

(83.794.0)[32]

(35.852.1)[32]

Lithuania 2006 80.3 94.6 60.0(73.985.4)

[72](90.996.8)

[72](52.966.6)

[72]

Macedonia 2009 75.6 78.0 48.2(68.781.4)

[82](71.383.6)

[82](40.955.5)

[83]

RepublicofMoldova 2008 97.3 95.4 61.3(86.299.5)

[41](85.698.6)

[43](47.873.2)

[42]

RussianFederation 2006 NA 78.9 22.3(77.580.1)

[582]

(21.023.7)

[582]Serbia 2006 88.6 84.6 20.7

(86.090.7)

[209]

(81.887.1)

[212]

(17.923.8)

[210]

Slovakia 2006 56.8 82.5 14.3(54.259.3)

[37]

(80.584.3)

[40]

(12.716.1)

[42]

Slovenia 2007 100.0 79.5 0.0

[39]

(75.782.8)

[39] [39]


Argentina 2007 75.2 87.7 11.9(73.077.3)

[234]

(86.089.3)

[237]

(10.313.6)

[236]Bolivia 2007 84.3 92.9 23.3

(83.884.7)

[1,634]

(92.693.3)

[1,640]

(22.723.9)

[1,607]

Brazil(RiodeJaneiro) 2007 76.8 91.7 19.5(74.279.3)

[304](89.993.2)

[304](17.221.9)

[296]

Chile 2008 94.0 89.9 4.2(93.094.9)

[790](88.791.0)

[792](3.65.0)

[791]


(continued)


17/21


Year







smokingcessation



Country(Site)

(95%CI)

[n]

(95%CI)

[n]

(95%CI)

[n]

Cuba(Havana) 2008 100.0 97.2 36.4

[145]

(95.698.3)

[144]

(32.640.2)

[143]

Guatemala 2008 100.0 98.2 16.9

[99]

(96.399.2)

[99]

(13.121.4)

[98]

Guyana 2009 100.0 92.3 7.7

[13](86.595.8)

[13](4.213.5)

[13]

Mexico 2006 77.7 95.0 10.2(70.583.6)

[1,291]

(93.596.1)

[1,297]

(6.216.2)

[1,295]

Panama 2008 100.0 96.4 20.9

[57](93.398.1)

[57](16.426.3)

[57]

Paraguay 2008 92.8 94.0 21.7(91.394.1)

[147](92.595.3)

[147](19.624.0)

[147]

Uruguay 2008 91.6 73.7 11.5(89.693.2)

[95]

(70.876.4)

[95]

(9.713.7)

[95]SOUTH-EAST ASIA REGION (SEAR)

Bangladesh 2009 91.6 86.7 26.8(90.492.7)

[336](85.288.0)

[336](25.028.6)

[335]

India 2009 93.2 93.7 54.8(90.395.4)

[703](90.895.7)

[694](44.964.4)

[695]

Indonesia 2007 98.7 95.3 10.3(98.299.0)

[753]

(94.596.0)

[753]

(9.411.4)

[752]

Myanmar 2009 88.8 69.3 8.7(86.790.5)

[258]

(66.372.0)

[258]

(7.110.6)

[260]Nepal 2005 95.3 89.0 11.8

(92.897.0)

[86]

(85.591.7)

[83]

(9.015.2)

[83]

Thailand 2006 94.0 80.9 14.1(93.594.5)

[411]

(80.081.8)

[411]

(13.314.9)

[408]


Cambodia 2005 100.0 100.0 17.0

[47] [47]

(13.221.7)

[47]


(continued)


18/21


Year







smokingcessation



Country(Site)(95%CI)

[n](95%CI)

[n](95%CI)

[n]

Fiji 2009 100.0

[14]

100.0

[14]

100.0

[13]

LaoPeoplesDemocraticRepublic

2009 95.2 95.2 19.4(94.595.9)

[63]

(94.595.9)

[63]

(18.120.6)

[62]

Mongolia 2007 78.4

[139]

95.7

[139]

9.4

[139]

PapuaNewGuinea 2009 90.9 90.9 *(83.195.3)

[11]

(83.195.3)

[11] [9]NA=datanotavailable


DiscussionThe U.S. Department of Health and Human

Services clinical practice guideline, which contains

recommendations and guidelines on effective to-

bacco dependency treatments, states that tobacco

use presents a rare conuence of circumstances: (1)

a highly signicant 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

reect the current counseling inuence and tobaccotreatment dentists are practicing. Additionally, most

health professions students, regardless of discipline,

have reported being underprepared to provide effec-

tive tobacco cessation counseling.8

A study of health care providers found that

dentists are less active than other health profession-

als 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 cessa-

tion counseling to their patients.14 Other studies have

noted that forty-four of fty-four dental schools in

the United States have introduced tobacco cessa-

tion counseling into their curricula;15 but, to our

knowledge, no published study has assessed the

effectiveness of the training courses, nor has anystudy 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

ndings from our study, however, are not encourag-

ing. Results from the Dental GHPSS show that over

20 percent of dental students currently smoke ciga-rettes in twenty-six of forty-eight sites; this percent-

age is over 40 percent in seven sites (Bulgaria, Kyr-

gyzstan, 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


19/21


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 reecting 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 inuences the future

workforce to deliver effective anti-tobacco counsel-

ing when they start seeing patients.7 Educational

institutions training dental students should be help-

ing 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 environ-

ment 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 frompeople who spend time in the area.7 Furthermore, the

creation of smoke-free areas by educational institu-

tions 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 accessibleadvice 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 counsel-

ing 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 cessa-

tion treatment techniques. Curricula should include a

course or supplements to existing courses specically

relevant to tobacco issues. If administrators are resis-

tant 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 informa-

tion about the process of teaching dental students in

low- and middle-income countries about smoking

prevention and cessation is accessible to the inter-

national 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 neces-

sary to focus limited resources on effective and ef-

cient 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-yearstudents who have not had substantial interaction

with patients, so these survey results should not be

extrapolated to account for practicing health profes-

sionals. 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 deter-

mined from these data; however, reliability studiesin the United States have indicated good test-retest

results for similar tobacco-related questions.18

ConclusionsThe 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 signicant gap in professional patient


20/21


cessation training among dental students to provide

effective assistance to their future patients.

Educational institutions, public health orga-

nizations, and education ofcials should discour-

age 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.

AcknowledgmentsThe authors would like to thank the following

GHPSS Country Research Coordinators in WHO

Regional Ofces, who made completion of the DentalGHPSS possible: African Region, Jean-Pierre Bap-

tiste, 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

Pacic Region, Susan Mercado, Ali Akbar.

Within each region, we also thank the follow-

ing:

Arican Region: Djamel Zoughailech (Alge-

ria), 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 (Alba-nia); Alexander Bazarjyan (Armenia); Aida Ramic-

Catak, Zivana Gavric (Bosnia & Herzegovina);

Antoaneta Manolova (Bulgaria); Hana Sovinova

(Czech Republic); Anastasia Barbouni (Greece);

Aisha Tokobaeva (Kyrgyzstan); Nikola Tilgale (Lat-

via); Antanas Gostautas (Lithuania); Mome Spaso-

vski (Macedonia); Vorfolomei Calmic (Republic of

Moldova);Galina Sakharova (Russian Federation);

Djordje Stojilkovic, Andjelka Dzeletovic (Republic

of Serbia); Tibor Baska (Slovakia);Mojca Juricic

(Slovenia).

Region o the Americas: Raul Pitarque,

Hugo A. Miguez (Argentina); Franklin Alcaraz del

Castillo (Bolivia); Luisa Goldfarb, Valeska Caralho

Figueiredo, Adelemara Mattoso Allonzi, Leticia Ca-

sado Costa, Liz Maria de Almeida (Brazil); Claudia

Gonzalez Wedmaier (Chile); Lucia Lances Cotilla

(Cuba); Delmy Walesska Zecena Alarcon (Guate-

mala); Preeta Saywack (Guyana); Luz Reynales

Shigematsu (Mexico); Reina Roa (Panama); Arnaldo

Vera Morinigo (Paraguay); Raquel Magri, Gabriela

Olivera (Uruguay).

South-East Asia Region: Zulqar Ali (Ban-

gladesh); 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 Pacifc Region: Sin Sovann, Sung

Vin Tak (Cambodia); Ali Tharid (Fiji); Vanphanom

Sychareun (Lao Peoples Democratic Republic);

Dondog Jargalsaikhan, L. Erdenebayar, Palam Enkh-

tuya, 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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