Tobacco smoking is the major cause of morbidity and avoidable death worldwide.1 Globally, there are over a billion smokers and approximately 80% are in low-and-middle-income countries.2 More than 6 million of the deaths resulted from direct tobacco consumption while estimated 900,000 mortality records were due to exposure of nonsmokers to secondhand smoke.2 It is estimated that by 2030, the death toll could rise to over 8 million yearly.3
Non-infectious diseases account for about 80% of preventable deaths in Nigeria and most other developing nations and the lone major preventable risk factor these diseases is tobacco smoking.4 Training pharmacy students to educate patients about lifestyle-modification strategies such as smoking cessation might reduce the burdens of chronic diseases.5
Traditional training for healthcare students focuses on treating diseases with little attention towards preventing disease occurrence .6,7 Based on the need to change the landscape of healthcare students training, various stakeholders now recommend curriculum changes to include courses about public health ranging from health promotion, wellness, and disease prevention.8-10
The much-needed roles of pharmacists in providing smoking cessation advice and services have been well-documented in many literatures11-13, being one of the most accessible healthcare providers. The International Pharmaceutical Federation (FIP) published a policy statement that promotes pharmacist’s roles in reducing tobacco consumption. This policy statements further reiterated that pharmacists should provide smoking cessation services to anyone who wants to quit tobacco consumption or to anyone who suffers from smoking-related diseases.14
Owing to the fact that the origin of knowledge that contribute to one’s career are usually acquired while undertaking a degree, it is therefore essential that mapping knowledge and attitude of future pharmacists would be an important marker of their “level of awareness” about smoking cessation. It may also be hypothesized that experience with providing smoking cessation services and counselling practice should increase the knowledge and skill base of pharmacy students and that pharmacists would have greater understanding, awareness and more positive attitudes toward their role in pharmacy-based smoking cessation services.
Currently, there is paucity of data/information on whether pharmacy schools in Nigeria train future pharmacists on smoking cessation or not. Therefore, this study aimed at assessing knowledge and attitude of pharmacy students in the University of Ibadan, Nigeria regarding smoking cessation.
Study design and settings
This study was a cross-sectional survey using self-administered questionnaire among undergraduates of the Faculty of Pharmacy, University of Ibadan between August and December 2019. Eligible participants were registered undergraduate pharmacy students (first year to fifth year) for 2018/2019 academic session and consented to partake in the study. Students that were absent and non-consenting were excluded from the study.
Sample Size Determination
Based on the population of 360 registered students obtained from the faculty management, the confidence level was set at 95% and the alpha error at 5%, a sample size of 189 was obtained using Yamane’s formula.15 Additionally, to cater for the possibility of low response rate which is not uncommon among students, an attrition rate of 60% that will allow for a large sample size of 315 was agreed to by the researchers.
Sampling and data collection procedure
From first year to fifth year in the faculty of pharmacy, a compulsory course was identified. The study respondents were consecutively approached shortly after the mandatory course. The researcher informed them on the aims and objectives of the study. The questionnaire was then self-administered to all consented pharmacy students and retrieved within 20–25 minutes of completion of the questionnaire. Study participation was voluntary and the students were informed of the possibility of withdrawing from the study anytime. Response anonymity and confidentiality were reiterated to the respondents. Measures were put in place to prevent multiple filling of the questionnaire by the respondents.
Pretest and content validation
Content validity of the questionnaire was conducted by two pharmacists in academia from the department of Clinical Pharmacy and Pharmacy Administration, University of Ibadan, to ascertain the inclusiveness of question-items vis-à-vis the study objectives, as well as ensuring appropriateness and specificity of questions or statements. The questionnaire was then administered to eight students from the Faculty of Pharmacy, University of Ibadan to be sure of ease of comprehension of questions or statements in the questionnaire. These students were not included in the actual study and the feedback from the students led to some modifications in the questionnaire.
Data Collection Instrument
A semi-structured questionnaire was developed by the researchers following comprehensive review of relevant studies16,17, as well as employing researchers experience. The questionnaire consisted of three parts. Part A captured socio-demographic (participants) characteristics, Part B comprised questions on smoking status and habit, Part C comprised knowledge and attitude statements. The questionnaire consisted of 17 knowledge statements and 12 attitude statements.
Knowledge and Attitude Index
For each knowledge statements, a correct response was assigned a score of “1,” and an incorrect response, I don’t know and neither agree nor disagree response were scored as “0.” The overall knowledge score was attained by adding the scores for all knowledge responses. Then, an “overall knowledge percent score” was calculated by multiplying the total knowledge score for each participant by 100 and diving by 17.
For each attitude question, a correct response was assigned a score of “1,” and an incorrect response, I don’t know and neither agree nor disagree responses were scored as “0.” The total attitude score was obtained by adding the scores for all attitude responses. Then, an “overall attitude percent score” was calculated by multiplying the total attitude score for each participant by 100 and diving by 9.
The administered questionnaires were sorted, crosschecked and coded serially at the end of each day of the study. Data were sorted, coded and analysed using SPSS (version 23). The data were summarized using descriptive statistics with frequency and percentage. In this study, the overall score by our respondents in the knowledge and attitude domains was converted into percentage to ensure uniformity in the scores.
In the knowledge domain, a total score 60 % was considered as “good” knowledge, while score < 60 % signified “poor” knowledge. Thus, a percent score 60 % indicates a raw score of >10 out of the 17 questions that evaluated the general knowledge of smoking and smoking cessation among pharmacy students. While for the attitude domain, a total score of 80 % was considered as “good” attitude, while score < 80 % signified “poor” attitude. Thus, a percent score 80 % indicates a raw score of >7 out of 9 questions on attitude. Bloom’s cut-off point criteria, as well as review of other studies were employed in determining the binary categorization.18,19
Demographics characteristics and smoking cessation related descriptive
Table 1 shows out of the 315 copies of questionnaire administered to the pharmacy students, 277 completely filled questionnaires were returned given a response rate of 81.5 %. One hundred and fifty (54.2%) were males. The mean age was 21.55 (±3.12), with majority 168 (60.0%) aged above 20 years. Most of the participants 263 (94.9%) have not attended any specific smoking cessation training and 180 (65.0%) are willing to attend smoking cessation training. Majority 265 (95.7%) were nonsmokers and 70 (25.3%) of the participants claimed that pharmacy school provided knowledge and skills on smoking cessation.
Students’ knowledge on smoking and smoking cessation
Three-quarters of the students were aware tobacco smoking is an addiction 207 (74.7%), while 33 (11.9%) knew nicotine does not cause cancer. In all, 74 (26.7%) had score 60 % indicating “good” knowledge of smoking and smoking cessation among pharmacy students. Table 2
Pharmacy students’ attitudes toward smoking and smoking cessation
Two hundred and three (73.2%) agreed that “It is pharmacists' responsibility to help their patients quit smoking.” Majority 226 (81.6%) agreed that “Pharmacy students need more training on how to counsel patients on smoking cessation.” In all, 152 (54.9%) had a score ≥ 80 indicating “good” attitude toward smoking cessation. Table 3
Awareness of smoking cessation products among pharmacy students
Less than one-tenth 27 (9.7%) of the respondents had learnt about available options to smoking cessation, while nicotine gum 13 (48.1%) was the most identified products among the students. See Table 4.
After an extensive review of the literature, it was observed that a survey of pharmacy students related to the knowledge and attitude regarding smoking cessation has not been conducted in Nigeria. Our study revealed relatively low smoking rate, positive attitudes towards smoking cessation and a poor knowledge of smoking cessation among pharmacy students. Compared to a study among University of Lagos pharmacy students20, our study revealed lower smoking prevalence. However, the smoking prevalence in our study was higher than the prevalence reported among medical students of University of Ibadan.21
Poor knowledge of smoking and smoking cessation was reported in more than three-quarters of our respondents. Furthermore, a knowledge gap on the awareness of smoking cessation products was documented among the pharmacy students and majority of the students reported that smoking cessation training content of their curriculum is not satisfactory. The gap in awareness and knowledge might signify the need for creating awareness as well as advocating training among pharmacy students on smoking cessation. This finding is similar to a study conducted in a university community, where awareness level of smoking cessation products was low22, and another study reported in Japan among pharmacy students where only one pharmacy school teaches smoking cessation.23 Various study in the literature had reported the inadequate knowledge of smoking cessation and tobacco dependence treatment among medical students.24-28 A possible explanation for the low awareness of the products might be deficient pharmacy school curriculum on smoking cessation products, non-availability of the products in the pharmacies and cost implication of the product in Nigeria. Studies conducted in Germany, Italy and England among medical students showed that the knowledge of smoking epidemiology was also unsatisfactory.26,28
The literature encourages the inculcation of tobacco cessation in the curricula of undergraduate future health professionals.29 Studies have also shown that healthcare professionals who do not receive formal training on smoking cessation are less likely to have positive impacts on quitting rates than those who are formally trained.30,31 Tobacco cessation counselling and services are an essential public health service rendered by pharmacists globally. To deliver these services effectively and with much-needed impacts, incorporation into the pharmacy curriculum is advocated.32
The overall positive attitudes to smoking cessation and practice were observed among the pharmacy students. Majority advocated for more training on how to counsel patient on smoking cessation and most believes that pharmacists should not smoke and set good examples for their patient. Although, majority of the student shows anti-smoking attitude, about half of the students agreed that medical advice has little effect on smoking cessation. This can be compared to similar study carried out in Argentina, where 30.9% agreed that medical advice has little effect on smoking cessation.16
There is possibility of response bias from respondents either due to over- or under-reporting of the information provided. In addition to this, the study was conducted in one pharmacy school, therefore, there is a need for cautiousness in generalising outcomes to the whole pharmacy students in Nigeria.
There is a deficit in smoking cessation knowledge among our respondents. However, pharmacy students’ show positive attitude toward smoking cessation. Therefore, there is a need for inclusion of smoking cessation strategies and procedures in pharmacy school curriculum, so as to equip the future healthcare providers and improve the quality of public health especially smokers in Nigeria.