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Tobacco control: are we appropriately training future professionals?

Abstract: Information on how health professionals perceive tobacco use as well as their attitudes toward tobacco control is scarce. This study assessed the attitudes and perceptions of public health students toward tobacco use and tobacco control, which constitutes a necessary first step in designing effective training strategies. Although the majority of respondents In the context of marketing research, a representative sample drawn from a larger population of people from whom information is collected and used to develop or confirm marketing strategy.  agreed that tobacco use constitutes a relevant public health problem, they did not perceive tobacco control to be a public health priority. Academic institutions may not be properly training public health students, and may therefore be missing the opportunity to advance tobacco control at the national and global levels.


The need for effective tobacco control initiatives has been sufficiently established. Smoking continues to be the single most important cause of preventable death in the US, responsible for 440,000 deaths yearly (CDC See Control Data, century date change and Back Orifice.

CDC - Control Data Corporation
, 2002). Globally, tobacco kills almost 5 million people annually, and by the year 2030, smoking will be responsible for 10 million deaths per year. This represents higher mortality than that caused by AIDS, tuberculosis tuberculosis (TB), contagious, wasting disease caused by any of several mycobacteria. The most common form of the disease is tuberculosis of the lungs (pulmonary consumption, or phthisis), but the intestines, bones and joints, the skin, and the genitourinary, , traffic accidents, killings, and suicides altogether (World Health Organization, 2002).

One of the US public health objectives for the year 2010 is to reduce the prevalence of cigarette smoking among adults to [less than or equal to] 12% (objective 27.1a) (USDHHS USDHHS, See United States Department of Health and Human Services.
, 2000). Despite the consistent decline in smoking prevalence from 25% in 1993 to 22.8% in 2001, a recent study by the CDC estimated that overall prevalence is not decreasing at a rate that will meet the national health objective by 2010. The study recommends an increased emphasis on state-level comprehensive tobacco control programs (CDC, 2003). Such programs consist of a combination of interventions and initiatives with the goal of reducing tobacco-related disease, disability, and death.


The response of public health to the devastating dev·as·tate  
tr.v. dev·as·tat·ed, dev·as·tat·ing, dev·as·tates
1. To lay waste; destroy.

2. To overwhelm; confound; stun: was devastated by the rude remark.
 consequences of tobacco use includes the implementation of "evidence-based" state and community level interventions that involve education, prevention and smoking cessation smoking cessation Public health Temporary or permanent halting of habitual cigarette smoking; withdrawal therapies–eg, hypnosis, psychotherapy, group counseling, exposing smokers to Pts with terminal lung CA and nicotine chewing gum are often ineffective.  programs for youth and adults, advocacy and policy development, and counter-marketing campaigns. In this context, "evidence-based" implies strong evaluation and management components (CDC, 1999).

The CDC's recommendations mean that states willing to implement comprehensive programs must rely on highly skilled personnel and support staff. Best Practices for Comprehensive Tobacco Control Programs, the CDC's sponsored guide for planning and implementing state level programs, consists of a multifaceted mul·ti·fac·et·ed  
Having many facets or aspects. See Synonyms at versatile.

Adj. 1. multifaceted - having many aspects; "a many-sided subject"; "a multifaceted undertaking"; "multifarious interests"; "the multifarious
 intervention A procedure used in a lawsuit by which the court allows a third person who was not originally a party to the suit to become a party, by joining with either the plaintiff or the defendant.  aimed at: 1) preventing the initiation of tobacco use among young people, 2) promoting quitting among young people and adults, 3) eliminating nonsmokers' exposure to environmental tobacco smoke environmental tobacco smoke (ETS/passive smoke),
n the gaseous by-product of burning tobacco products, including but not limited to commercially manufactured cigarettes and cigars; contains toxic elements harmful to the health of adults and children
 (ETS ETS Educational Testing Service (nonprofit private educational testing and measurement organization)
ETS Emergency Telecommunications Service
ETS Electronic Trading System
ETS Engineering (&) Technical Services
), and 4) identifying and eliminating the disparities related to tobacco use and its effects on different population groups. The CDC recommends that programs implement all nine components of comprehensive tobacco control programs identified in the guide (CDC, 1999) (see Figure 1).
Figure 1. Nine components of comprehensive tobacco control programs.

1. Community Programs to Reduce Tobacco Use

2. Chronic Disease Programs to Reduce the Burden of Tobacco-Related

3. School Programs

4. Enforcement

5. Statewide Programs

6. Counter-Marketing

7. Cessation Programs

8. Surveillance and Evaluation

9. Administration and Management

The complexity of comprehensive, evidence-based, multilevel mul·ti·lev·el  
Having several levels: a multilevel parking garage.

Adj. 1. multilevel - of a building having more than one level
 programs require the active involvement of public health professionals with specific training in tobacco control. How are public health training institutions responding to the challenge? A recent survey conducted by the Association of Schools of Public Health (ASPH ASPH Association of Schools of Public Health ) among its 32 member schools found that, although the majority of the institutions that answered the survey (81%) offered "some kind of tobacco-related education and training," only about half of them offered tobacco-related courses in which students could earn academic credit hours. More significantly, during the academic year 2001-2002, less than 5% of all master's and doctoral students were involved in tobacco-related studies. There were no schools offering tracks for academic specialization A career option pursued by some attorneys that entails the acquisition of detailed knowledge of, and proficiency in, a particular area of law.

As the law in the United States becomes increasingly complex and covers a greater number of subjects, more and more attorneys are
 in tobacco use prevention and control (ASPH, n.d.). Although ASPH members may not constitute a comprehensive representation of the more than 300 academic programs offering bachelor's, master's, and doctoral degrees in health education and health promotion (Wright, Hann, McLeroy, Steckler, Matulionis, Auld auld  
adj. Scots

Adj. 1. auld - a Scottish word; "auld lang syne"
old - of long duration; not new; "old tradition"; "old house"; "old wine"; "old country"; "old friendships"; "old money"
, M., et al., 2003), it can be assumed that they include those schools with the most comprehensive academic programs, as they must pass an exhaustive accreditation accreditation,
n a process of formal recognition of a school or institution attesting to the required ability and performance in an area of education, training, or practice.
 process. Despite the limitations of the ASPH study, it does appear that the availability of tobacco control training in academic institutions could and should be increased.

Because of the public health relevance of tobacco use, a systematic assessment of the training and research opportunities of future public health professionals is a necessary endeavor. Equally important is to understand how public health students perceive tobacco control, an issue that has not been discussed in the literature. Published research on health students' views of tobacco-related issues have explored a variety of topics, from policy to training, but most of these studies focus on those students pursuing careers in clinical practice such as medicine, nursing, pharmacy pharmacy, art of compounding and dispensing drugs and medication. The term is also applied to an establishment used for such purposes. Until modern times medication was prepared and dispensed by the physician himself. In the 18th cent. , dentistry dentistry, treatment and care of the teeth and associated oral structures. Dentistry is mainly concerned with tooth decay, disease of the supporting structures, such as the gums, and faulty positioning of the teeth.  or physiotherapy physiotherapy: see physical therapy.  (Fried, Reid, & DeVore, 2004; Nagy, Barabas, & Nyari, 2004; Jenkins & Ahijevych, 2003; Rigotti, Moran Moran

equitable councillor to King Feredach. [Irish Hist.: Brewer Dictionary, 728]

See : Justice
, & Wechsler, 2003; Rikard-Bell, Groenlund, & Ward, 2003; Piko, 2002; Spangler, George, Long Foley fo·ley  
1. A technical process by which sounds are created or altered for use in a film, video, or other electronically produced work.

2. A person who creates or alters sounds using this process.
, & Crandall, 2002; Steptoe, Wardle, Cui, Baban, Glass, Pelzer, et al., 2002; Daudt, 1999; Richmond, Debono, Larcos, & Kehoe, 1998; O'Connor & Harrison, 1992; Lee, 1989). The purpose of this study was to assess the attitudes and perceptions of public health students towards tobacco use and tobacco control initiatives.


Participants consisted of master's level public health students at Boston University School of Public Health Boston University School of Public Health (BUSPH) is Boston University's graduate School of Public Health. It is located in the heart of Boston University's Medical Campus in the South End neighborhood of Boston, Massachusetts. The Dean is Robert Meenan.  (BUSPH BUSPH Boston University School of Public Health (Boston, MA) ). The email-based survey was developed by the research team. Questions were selected for each domain of interest and discussed by team members. The first draft of the survey was then presented to a panel of three experts that included a tobacco control specialist, a health educator, and a linguist lin·guist  
1. A person who speaks several languages fluently.

2. A specialist in linguistics.

[Latin lingua, language; see
, who provided comments on both content and grammar. After incorporating experts' comments, the survey was piloted with 23 prospective participants to obtain logistical lo·gis·tic   also lo·gis·ti·cal
1. Of or relating to symbolic logic.

2. Of or relating to logistics.

[Medieval Latin logisticus, of calculation
 information on survey administration and improve its face validity face validity (fāsˑ v·liˑ·di·tē),
. The purpose was to involve those who would ultimately use the instrument in the development process. The group represented a broad range of prospective participants, with varied nationality nationality, in political theory, the quality of belonging to a nation, in the sense of a group united by various strong ties. Among the usual ties are membership in the same general community, common customs, culture, tradition, history, and language. , age, occupation, etc. Electronic addresses were obtained through the Office for Student Services. The survey was inserted in the body of an e-mail message, which also included information on confidentiality, purpose of the study, and instructions for completing and returning the survey. One week after the first mailing, a follow-up e-mail was sent to non-respondents. Pilot test participants were asked to provide feedback on format, content, and completion time. Overall response rate was 74% (n = 17). A hard copy of every message containing the completed returned survey was obtained, and e-mail addresses See Internet address.

e-mail address - electronic mail address
 were removed from the messages upon receipt. Respondents provided positive feedback and only one question regarding nationality was reworded based on their comments. The reported average completion time was 8.5 minutes.


The final instrument consisted of 19 items, including eligibility confirmation and demographic questions. The survey was emailed to the entire BUSPH student roster (n = 751). A follow-up message was sent approximately two months after the first mailing. Participants were asked to report on current and past tobacco use, as well as their perceived role in tobacco control. Other questions explored participants' attitudes and perceptions regarding the public health burden of tobacco use, risks and consequences of tobacco use, and specific tobacco control activities (such as legislation on tobacco advertising and second-hand smoke second-hand smoke Passive smoking, see there ). Response scales included 4-item Likert-type scales of agreement, from "strongly agree" to "strongly disagree", and categorical That which is unqualified or unconditional.

A categorical imperative is a rule, command, or moral obligation that is absolutely and universally binding.

Categorical is also used to describe programs limited to or designed for certain classes of people.
 scales. An open-ended question A closed-ended question is a form of question, which normally can be answered with a simple "yes/no" dichotomous question, a specific simple piece of information, or a selection from multiple choices (multiple-choice question), if one excludes such non-answer responses as dodging a  was included for country of residence.


Respondents were classified in two categories: 1) national (those reporting US as country of permanent residency Permanent residency refers to a person's visa status: the person is allowed to reside indefinitely within a country despite not having citizenship. A person with such status is known as a permanent resident. ) vs. international (those reporting country of residency A duration of stay required by state and local laws that entitles a person to the legal protection and benefits provided by applicable statutes.

States have required state residency for a variety of rights, including the right to vote, the right to run for public office, the
 other than the US). Statistical analyses were performed using SPSS A statistical package from SPSS, Inc., Chicago ( that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance.  11.5.0 (Chicago, Ill: SPSS, Inc. 1989-2002), and included frequencies, chi-square, and t-test. Confidence intervals confidence interval,
n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%.
 for smoking prevalence were computed using the Exact Confidence Interval Calculator calculator or calculating machine, device for performing numerical computations; it may be mechanical, electromechanical, or electronic. The electronic computer is also a calculator but performs other functions as well.  ( math_stat/ProportionCI.html). Independent samples t-tests were performed on tobacco priority scores using residency status and current smoking status as independent variables. Variables that represented rank were recorded so that the higher the rank (1st, 2nd, etc.) the greater the value (7, 6, etc.).


The overall response rate was 32.3% (n = 243). Demographic characteristics of respondents, including country of permanent residency and occupation, are summarized in Table 1. The majority of respondents (79%) were US residents. Statistically significant differences by age and gender were found. Although in both groups most respondents were females, US residents were 4.2 times more likely to be females (95% Confidence Interval: 1.995 to 8.840). Significant differences (p < 0.001) were also observed in the distribution of occupation. More than half of non-US resident students reported being physicians. Occupations most frequently reported among US residents included health research (26.1%) and public health (22.2%). Regarding smoking status of respondents, no significant differences were found in the frequency of "ever smoked" (p = 0.631) or "current smoking" status (p = 0.687) (see Table 2).

Most respondents (97.9%) considered tobacco to be a public health problem, and agreed (95.8%) that tobacco control should be a public health priority. However, more than 41% responded being little or not concerned about the risks and consequences of tobacco use, with a significantly higher percentage of US resident students (65.1%; p < 0.001) being very concerned about the risks and consequences of tobacco use, as compared to non-US residents (35.3%). In contrast, a significantly higher relative frequency (84.6%; p = 0.029) of non-US residents felt that they could play a role in tobacco use prevention and control in their countries of residency.

The following seven measures for tobacco use prevention and control were ranked by respondents: advertising restrictions, policy and regulation, health education, cessation cessation Vox populi The stopping of a thing. See Smoking cessation.  programs, school-based programs, increased taxation, and law enforcement (see Table 3). Respondents ranked policy and regulation as the most important measure for tobacco use prevention and control. Similarly, they agreed that health education was the second most important measure.

Although the majority of respondents recognized the public health importance of tobacco use, tobacco control was not identified as a primary (highest or high) public health priority. HIV/AIDS HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome  and other infectious diseases infectious diseases: see communicable diseases. , maternal MATERNAL. That which belongs to, or comes from the mother: as, maternal authority, maternal relation, maternal estate, maternal line. Vide Line.  and child health, and water and sanitation sanitation: see plumbing; sanitary science.  were given higher public health priority scores by respondents (see Table 4). When asked about the most effective measures for tobacco use prevention and control, less than 40% felt that tobacco advertising should be forbidden, less than 4% felt that smoking in public places should be legislated. Fifty-two percent felt that smoking in public places should not be forbidden. Regarding tobacco farming, 47% felt that tobacco farming should be legislated, and 22% believed that it constitutes an income generating activity (see Table 5).

Results of t-test scores indicated that US residents had higher tobacco priority scores than non-US residents (t = 2.592, df = 239, p = 0.010), and current smokers had lower scores than nonsmokers (t = 3.804, df = 239, p < 0.001).


The national public health objective of halving adult smoking by the year 2010 is very ambitious, and only through sustained, coordinated effort will the objective be obtainable. Comprehensive programs have the potential of contributing to tobacco control, and given their complexity, such programs require the involvement of public health professionals with specific training in tobacco control. Unfortunately, we are not providing public health students with the necessary training opportunities they need to contribute to the achievement of the Healthy People 2010 tobacco objectives.

The results of this study indicate that, although the majority of participating public health students agreed that tobacco use constitutes a relevant public health problem, fewer were concerned about the risks and consequences of tobacco use. Consistently, tobacco control was not prioritized accordingly: HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. , maternal and child health, and bioterrorism bi·o·ter·ror·ism
The use of biological agents, such as pathogenic organisms or agricultural pests, for terrorist purposes.

 obtained a higher rank in the public health priority list of respondents. These results indicate that participants in this survey might not be appropriately trained in tobacco control, and that their attitudes and perceptions toward tobacco use and tobacco control are not consistent with the public health burden of tobacco use. Additionally, US institutions may be missing the opportunity to educate international students on the potential dangers of tobacco use and the need for coordinated and aggressive global tobacco control.

Non-US residents gave tobacco control a lower priority score than U.S residents. This was an expected response that may be explained by a perceived need for addressing current pressing health problems, and the fact that the cigarette epidemic epidemic, outbreak of disease that affects a much greater number of people than is usual for the locality or that spreads to regions where it is ordinarily not present.  may be in its initial stages in many respondents' countries of residence. Similarly, the relevance given to bioterrorism may be the consequence of the current US and global sociopolitical so·ci·o·po·li·ti·cal  
Involving both social and political factors.


of or involving political and social factors
 situation caused by recent terrorist events.

Respondents' opinions on advertising were consistent with current tobacco control efforts, and only a small percentage supported no restrictions. On the other hand, it seems that respondents did not understand the relevance of smoking in public places and secondhand smoke sec·ond·hand smoke
Cigarette, cigar, or pipe smoke that is inhaled unintentionally by nonsmokers and may be injurious to their health if inhaled regularly over a long period. Also called passive smoke.
 as a risk factor for several health-related problems, including cancer, pregnancy and neonatal neonatal /neo·na·tal/ (ne?o-nat´'l) pertaining to the first four weeks after birth.

Of or relating to the first 28 days of an infant's life.
 problems, pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.

Of or relating to pediatrics.
 chronic and acute conditions, and cardiovascular disease Cardiovascular disease
Disease that affects the heart and blood vessels.

Mentioned in: Lipoproteins Test

cardiovascular disease 
. Consistently, less than half supported complete smoking ban in public places. Finally, the majority of respondents tended to believe that tobacco farming is a source of income. They did not indicate awareness of the fact that in most countries subsidies make tobacco farming a profitable activity, as do the manufacturing and selling of tobacco products.

The fact that smokers gave tobacco control a lower priority score than non-smokers was an expected result consistent with the literature. Furthermore, we believe that the high education level of respondents influenced their reported low smoking prevalence, which is consistent with other studies.

To our knowledge, this is the first study assessing the attitudes and perceptions of public health students toward tobacco use and control. The results of this study are consistent with the 2001-2002 ASPH tobacco-related survey, and both indicate the need for increased resources to train future public health professionals in tobacco control. Additionally, since this was an exploratory study, we recommend further research on the attitudes and perceptions of public health students. Tobacco continues to be the most significant preventable cause of death and disability in the US If we are to reach our health objectives for the year 2010, public and private agencies must support academic and research-related tobacco control training opportunities in schools of public health.

It is important to mention a number of limitations to this study. First, the response rate was low. Electronic mail was selected due to cost considerations, but also because recent graduates are a group that may be difficult to reach. It was assumed that the participant population in this study could best be reached by email. Secondly, smokers are known to have a lower response rate to tobacco use surveys. Because of the focus of the study, survey respondents' probably under-represented smokers. It is also assumed that those who were less interested in tobacco control were probably less likely to respond.

Regarding validity, it is important to note that respondents may have provided answers that they believed would meet the approval of the investigators. The non-response analysis, though weakly weak·ly  
adj. weak·li·er, weak·li·est
Delicate in constitution; frail or sickly.

1. With little physical strength or force.

2. With little strength of character.
 powered, did not find any significant differences between early and late responders. Both the non-response bias and the appeasement appeasement

Foreign policy of pacifying an aggrieved nation through negotiation in order to prevent war. The prime example is Britain's policy toward Fascist Italy and Nazi Germany in the 1930s.
 bias suggest that findings represent an optimistic op·ti·mist  
1. One who usually expects a favorable outcome.

2. A believer in philosophical optimism.

 estimate of priority given to tobacco control. It is likely that respondents' attitude toward tobacco control is more progressive than that of the general public. Yet, the possibility that any non response bias would actually go in the other direction cannot be discarded dis·card  
v. dis·card·ed, dis·card·ing, dis·cards
1. To throw away; reject.

a. To throw out (a playing card) from one's hand.

. Also, since this is a cross sectional sec·tion·al  
1. Of, relating to, or characteristic of a particular district.

2. Composed of or divided into component sections.

 study, any assumption about causality causality, in philosophy, the relationship between cause and effect. A distinction is often made between a cause that produces something new (e.g., a moth from a caterpillar) and one that produces a change in an existing substance (e.g.  is limited.

In conclusion, this pilot project found sufficient evidence for supporting increased tobacco control training in US public health schools. Similarly, it supports the need for collecting data on the attitudes and perceptions of public health students related to tobacco use and tobacco control.


Responsibility X: Advancing the Profession of Health Education

Competency COMPETENCY, evidence. The legal fitness or ability of a witness to be heard on the trial of a cause. This term is also applied to written or other evidence which may be legally given on such trial, as, depositions, letters, account-books, and the like.
 A: Provide a critical analysis of current and future needs in health education.


We would like to thank Rosa Rosario, Ella Nkhoma, and Subi Gandhi, graduate students in the School of Public Health, UNTHSC UNTHSC University of North Texas Health Science Center , for their contribution to this paper.


Association of Schools of Public Health. (n.d.). Tobacco Studies Survey 2001-2002. Retrieved November 14, 2003, from

CDC. (2003). Cigarette Smoking Among Adults. United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , 2001. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, , 52(40), 953-956.

CDC. (2002). Annual smoking-attributable mortality, years of potential life lost years of potential life lost Public health A measure of the impact of premature mortality on a population, calculated as the sum of the differences between a predetermined minimum or desired life span usually set at 65 in calculations and the age of death for , and economic costs-United States, 1995-1999. MMWR, 51, 300-303.

CDC. (1999). Best Practices for Comprehensive Tobacco Control Programs, August. Retrieved November 18, 2003, from

Daudt, A., Alberg, A., Prola, J., Fialho, L., Petracco, A., Wilhelms, A., et al. (1999). A first step incorporating smoking education into Brazilian medical school curriculum: Results of a survey to assess the cigarette smoking knowledge, attitudes, behaviour, and clinical practices of medical students. Journal of Addictive ad·dic·tive
1. Causing or tending to cause addiction.

2. Characterized by or susceptible to addiction.

addictive (
 Diseases, 18(1), 1929.

Fried, J., Reid, B., & DeVore, L. (2004). A comparison of health professions student attitudes regarding tobacco curricula and interventionist roles. Journal of Dental Education, 68(3), 370-377.

Jenkins, K., & Ahijevych, K. (2003). Nursing students' belief about smoking, their own smoking behaviors, and use of professional tobacco treatment intervention. Applied Nursing Research, 16(3), 164-172.

Lee, C. (1989). Stereotypes of smokers among health science students. Addictive Behaviors Addictive behavior is any activity, substance, object, or behavior that has become the major focus of a person's life to the exclusion of other activities, or that has begun to harm the individual or others physically, mentally, or socially. , 14(2), 327-333.

Nagy, K., Barabas, K., & Nyari, T. (2004). Attitudes of Hungarian healthcare professional students to tobacco and alcohol. European Journal European Journal is a weekly Deutsche Welle (DW) news program produced in English. It is broadcast from Brussels, Belgium and primarily covers political and economic developments across the European Union and the rest of Europe, as well as issues of particular concern to  of Dental Education, (Feb 8, Suppl 4), 32-35.

O'Connor, A., & Harrison, M. (1992). Survey of smoking prevalence among Canadian students and registered nurses. Canadian Journal of Public Health, 83(6), 417-421.

Piko, B. (2002). Does knowledge count? Attitudes toward smoking among medical, nursing, and pharmacy students in Hungary. Journal of Community Health, 27(4), 269-276.

Richmond, R., Debono, D., Larcos, D., & Kehoe, L. (1998). Worldwide survey of education on tobacco in medical schools. Tobacco Control, 7, 247-252.

Rigotti, N., Moran, S., & Wechsler, H. (2003). Students' opinion of tobacco control policies recommended for US colleges: A national survey. Tobacco Control, 12, 251-256.

Rikard-Bell, G., Groenlund, C., & Ward, J. (2003). Australian dental students' views about smoking cessation counseling and their skills as counselors. Journal of Public Health Dentistry, 63(3), 200-206.

Spangler, J., George, G., Long Foley, K., & Crandall, S. (2002). Tobacco intervention training: current efforts and gaps in US medical schools. JAMA JAMA
Journal of the American Medical Association
, 288, 1102-1109.

Steptoe, A., Wardle, J., Cui, W., Baban, A., Glass, K., Pelzer, K., et al. (2002). An international comparison of tobacco smoking, beliefs and risk awareness in university students from 23 countries. Addiction addiction: see drug addiction and drug abuse. , 97, 1561-1571.

USDHHS. (2000). Healthy People 2010: Understanding and Improving Health (2nd ed.). Washington, DC: US Government Printing Office.

World Health Organization. (2002). Quantifying selected major risks to health. World health report 2002. Geneva Geneva, canton and city, Switzerland
Geneva (jənē`və), Fr. Genève, canton (1990 pop. 373,019), 109 sq mi (282 sq km), SW Switzerland, surrounding the southwest tip of the Lake of Geneva.
: World Health Organization. Retrieved January 21, 2004, from Chapter4.pdf

Wright, K., Hann, N., McLeroy, K., Steckler, A., Matulionis, R., Auld, M., et al. (2003). Health education leadership development: A conceptual model and competency framework. Health Promotion Practice, 4(3), 293-302.

Francisco Soto Mas, MD, PhD, MPH MPH Master of Public Health.
MPH Master's Degree in Public Health
 is affiliated with the Department of Social and Behavioral Sciences behavioral sciences, those sciences devoted to the study of human and animal behavior.
, School of Public Health at the University of North Texas Health Science Center. Julia Valderrama Alberola, MD, MPH is affiliated with the Pan American Health Organization The Pan American Health Organization (PAHO) is an international public health agency with 100 years of experience in working to improve health and living standards of the countries of the Americas. It serves as the specialized organization for health of the Inter-American System.  in Washington, DC. Jan Brogger, MD, PhD is affiliated with the Center for Clinical Molecular Medicine and Medical Genetics medical genetics
The study of the etiology, pathogenesis, and natural history of diseases and disorders that are at least partially genetic in origin.
 at the Haukeland University Hospital. Chiehwen Ed Hsu, PhD, MPH is affiliated with the Department of Public and Community Health at the University of Maryland University of Maryland can refer to:
  • University of Maryland, College Park, a research-extensive and flagship university; when the term "University of Maryland" is used without any qualification, it generally refers to this school
. Address all correspondence to Francisco Soto Mas, Department of Social and Behavioral Sciences, School of Public Health, University of North Texas Health Science Center, 1900 Tremont Ave., Fort Worth, Texas Fort Worth is the fifth-largest city in the state of Texas, 18th-largest city in the United States[1], and voted one of "America’s Most Livable Communities.  76107; PHONE: 817-763-5701; FAX: 817-763-5701; E-MAIL:
Table 1. Study Participants by age Group, Gender,
Occupation, and Residency


                      National      International
                    (US resident)    (All other)

                      (n = 190)       (n = 51)

                     N      (%)     N     (%)

  <=25               62    (32.8)    8   (15.7)
  26-35             100    (52.9)   29   (56.9)
  >=36               27    (14.3)   14   (27.5)
  Female            168    (89.4)   34   (66.7)
  Male               20    (10.6)   17   (33.3)
  MD                 16     (8.9)   23   (51.1)
  Public Health      40    (22.2)    6   (13.3)
  Health Research    47    (26.1)    3    (6.7)
  Other              77   (42.8%)   13   (28.9)



                     (n = 241)

                     N     (%)     [X.sup.2]   (p-value)

  <=25               70   (29.2)     8.227      (0.016)
  26-35             129   (53.8)
  >=36               41   (17.1)
  Female            202   (84.5)    15.792     (<0.001)
  Male               37   (15.5)
  MD                 39   (17.3)    46.278     (<0.001)
  Public Health      46   (20.4)
  Health Research    50   (22.2)
  Other              90   (40.0)

Table 2. Participant's Answers to key Tobacco Questions, by Residency


                                        (US resident)

                                          (n = 190)

                                         N     (%)

Ever smoked
  Yes                                    60   (31.7)
  No                                    129   (68.3)
Currently smoke
  Yes                                    12    (6.3)
  No                                     48   (25.4)
  Never smoked                          129   (68.3)
Tobacco public health problem
  Yes                                   183   (97.9)
  No                                      4    (2.1)
Tobacco public health priority
  Strongly agree/Agree                  179   (95.2)
  Disagree                                9    (4.8)
Concerned risks
  Very concerned/
    Concerned                           123   (65.1)
  Little concerned                       66   (34.9)
Impact tobacco use prevention/control
  Yes                                    78   (62.4)
  No                                     47   (37.6)


                                        International      Total
                                         (All other)

                                          (n = 51)       (n = 141)

                                        N     (%)        N     (%)

Ever smoked
  Yes                                   18   (35.3)      78   (32.5)
  No                                    33   (64.7)     162   (67.5)
Currently smoke
  Yes                                    5    (9.8)      17    (7.1)
  No                                    13   (25.5)      61   (25.4)
  Never smoked                          33   (64.7)     162   (67.5)
Tobacco public health problem
  Yes                                   47   (97.9)     230   (97.9)
  No                                     1    (2.1)       5    (2.1)
Tobacco public health priority
  Strongly agree/Agree                  50   (98.0)     229   (95.8)
  Disagree                               1    (2.0)      10    (4.2)
Concerned risks
  Very concerned/
    Concerned                           18   (35.3)     141   (58.8)
  Little concerned                      33   (64.7)      99   (41.3)
Impact tobacco use prevention/control
  Yes                                   22   (84.6)     100   (66.2)
  No                                     4   (15.4)      51   (33.8)

                                        [X.sup.2]   (p-value)

Ever smoked
  Yes                                     0.230      (0.631)
Currently smoke
  Yes                                     0.752      (0.687)
  Never smoked
Tobacco public health problem
Tobacco public health priority
  Strongly agree/Agree                              (0.694) *
Concerned risks
  Very concerned/
    Concerned                            14.703     (<0.001)
  Little concerned
Impact tobacco use prevention/control
  Yes                                     4.749      (0.029)

* Fisher's Exact Test

Table 3. Ranking of most Effective Measures for Tobacco use
Prevention and Control, by Residency


                                     National (US resident)

                                           (n = 190)

Measures                   1         2         3         4         5

Advertising              N=14      N=34      N=28      N=37      N=17
  restrictions           (7.4%)   (17.9%)   (14.7%)   (19.5%)    (8.9%)
Policy and regulation    N=43      N=24      N=34      N=20      N=28
                        (22.6%)   (12.6%)   (17.9%)   (10.5%)   (14.7%)
Health education         N=33      N=37      N=26      N=20      N=22
                        (17.4%)   (19.5%)   (13.7%)   (10.5%)   (11.6%)
Cessation programs       N=16      N=22      N=28      N=36      N=36
                         (8.4%)   (11.6%)   (14.7%)   (18.9%)   (18.9%)
School-based programs    N=37      N=33      N=33      N=26      N=24
                        (19.5%)   (17.4%)   (17.4%)   (13.7%)   (12.6%)
Increased taxation       N=35      N=23      N=20      N=21      N=21
                        (18.4%)   (12.1%)   (10.5%)   (11.1%)   (11.1%)
Law enforcement           N=5       N=6       N=8      N=14      N=24
                         (2.6%)    (3.2%)    (4.2%)    (7.4%)   (12.6%)


                                 International (All other)

                                          (n = 51)

Measures                   1         2         3         4         5

Advertising               N=8       N=4       N=4       N=9       N=8
  restrictions          (15.7%)   (7.8%)     (7.8%)   (17.6%)   (15.7%)
Policy and regulation    N=13      N=10       N=8       N=9       N=2
                        (25.5%)   (19.6%)   (15.7%)   (17.6%)   (3.9%)
Health education         N=11      N=13       N=9       N=4       N=3
                        (21.6%)   (25.5%)   (17.6%)    (7.8%)    (5.9%)
Cessation programs        N=0       N=6       N=2       N=5       N=9
                         (0.0%)   (11.8%)    (3.9%)    (9.8%)   (17.6%)
School-based programs     N=8       N=8      N=14       N=5       N=6
                        (15.7%)   (15.7%)   (27.5%)    (9.8%)   (11.8%)
Increased taxation       N=10       N=7       N=5       N=6       N=6
                        (19.6%)   (13.7%)    (9.8%)   (11.8%)   (11.8%)
Law enforcement           N=6       N=4       N=4       N=6       N=9
                        (11.8%)    (7.8%)    (7.8%)   (11.8%)   (17.6%)

Table 4. Public Health Priority Topic by Category of Priority
and Residency


                                 National (US resident)

                                        (n = 190)

Topic                Highest    High     Priority     Low     Lowest

HIV/AIDS &            N=47      N=74       N=51      N=10       N=3
  infectious         (24.7%)   (38.9%)   (26.8%)     (5.3%)    (1.6%)
Maternal and child    N=43      N=46       N=49      N=35      N=17
  care               (22.6%)   (24.2%)   (25.8%)    (18.4%)    (8.9%)
Tobacco control       N=39      N=48       N=50      N=35      N=18
                     (20.5%)   (25.3%)   (26.3%)    (18.4%)    (9.5%)
Water & sanitation    N=16      N=21       N=31      N=51      N=68
                      (8.4%)   (11.1%)   (16.3%)    (26.8%)   (35.8%)
Bio-terrorism         N=44      N=27       N=19      N=44      N=55
                     (23.2%)   (14.2%)   (10.0%)    (23.2%)   (28.9%)


                                International (All other)

                                         (n = 51)

Topic                Highest    High     Priority     Low     Lowest

HIV/AIDS &            N=18      N=15       N=10       N=7       N=1
  infectious         (35.3%)   (29.4%)   (19.6%)    (13.7%)    (2.0%)
Maternal and child    N=20      N=16       N=10       N=5       N=0
  care               (39.2%)   (31.4%)   (19.6%)     (9.8%)    (0.0%)
Tobacco control        N=4       N=7       N=19      N=19       N=2
                      (7.8%)   (13.7%)   (37.3%)    (37.3%)    (3.9%)
Water & sanitation     N=6      N=17       N=14      N=11       N=3
                     (11.8%)   (33.3%)   (27.5%)    (21.6%)    (5.9%)
Bio-terrorism          N=2       N=2       N=2        N=5      N=39
                      (3.9%)    (3.9%)    (3.9%)     (9.8%)   (76.5%)

* Participants could select more than one issue per category of

Table 5. Study Participants by Support of Legislative Approaches,
and Residency


                                National      Inter-       Total
                                (US only)    national
                                (n = 190)    (n = 51)

Tobacco advertising should be    N   (%)     N   (%)      N   (%)

Legislated & restricted to
  certain locations and media   114 (60.6)   22 (43.1)   136 (56.9)
Forbidden everywhere             68 (36.2)   26 (51.0)    94 (39.3)
Allowed everywhere                6  (3.2)    3  (5.9)     9  (3.8)

Smoking in public places
should be

Allowed                           2  (1.1)    0  (0.0)     2  (0.8)
Legislated                        6  (3.2)    3  (6.0)     9  (3.8)
The existing legislation
  should be enforced             19 (10.1)    6 (12.0)    25 (10.5)
Smoking in public places
  should be restricted to
  designated areas only          68 (36.2)   20 (40.0)    88 (37.0)
Smoking in public places
  should be forbidden
  completely                      3 (49.5)   21 (42.0)   114 (47.9)

Tobacco farming should be

Allowed because it is an
  income generating activity     39 (21.7)    9 (23.1)    48 (21.9)
Legislated                       88 (48.9)   14 (35.9)   102 (46.6)
Forbidden, but an alternative
  provided                       53 (29.4)   16 (41.0)    69 (31.5)
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Author:Hsu, Chiehwen Ed
Publication:American Journal of Health Studies
Geographic Code:1USA
Date:Jan 1, 2005
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