This survey was carried out to assess the use of tobacco products and the tobacco-related attitudes, knowledge, and education of University of Alberta medical students. Self-reported cigarette use among our survey population was low, but lifetime exposure to alternative methods of tobacco consumption (waterpipe, cigars) was surprisingly common. While students reported some exposure to all domains of tobacco education surveyed, they expressed only moderate confidence in their own ability to counsel and treat smokers. This was despite correctly identifying the key role of tobacco in the pathogenesis of lung cancer, chronic obstructive pulmonary disease and coronary artery disease.
Self-reported current cigarette use among our study population was low (3.3%). In contrast, recent surveys of medical students in Germany, the USA and the UK reported much higher rates of cigarette use (20%, 11% and 10%, respectively) [11–13]. The only other recent survey of cigarette use among Canadian medical students reported similar data to that reported in this study . The latest WHO estimates for adult cigarette smoking prevalence were 29% in Germany, 24% in the United Kingdom, 26% in the United States, and 17% in Canada . Although self-reported cigarette use among medical students in Canada is lower than the use of cigarettes among the general population, it is concerning that current cigar/cigarillo use among this health aware group is equivalent to that in the general population and exceeds it in the case of the use of the waterpipe . Although 40% of respondents indicated that they had smoked a waterpipe at some point, they were skeptical of the alleged safety of this practice. Several studies confirm their suspicions, asserting that waterpipe smoking is both harmful and addictive; smokers are exposed to high levels of particulate matters, carbon monoxide, and other chemicals, which affect lung health . More than half of those who had ever smoked a waterpipe did so in a public café. The proportion of students being introduced to waterpipe in these venues highlights the importance of smoke-free legislation being applied to waterpipe cafes . Almost half of the students who ever smoked the waterpipe did so at home or in other locations, suggesting that we may be witnessing a normalization of waterpipe smoking in Canada among young adults. Most respondents indicated that they chose to smoke tobacco in their waterpipes, a practice that carries with it the real risk of nicotine addiction .
While the causative role of tobacco in the etiology of disease was well known by respondents, they indicated that they received less education about the management of tobacco use in pregnancy and childhood. This may well be a reflection of the relative paucity of research and the difficulty in treating tobacco addiction in both these groups. Tobacco use during pregnancy is a key modifiable risk factor for innumerable perinatal complications but poor implementation and psychosocial barriers frequently compromise the success of cessation efforts . Nevertheless, it is vital that physicians champion smoking cessation interventions as a routine part of prenatal care, as the long term benefits to both child and mother are inestimable. The adverse consequences of second hand smoke on child health have been well described and the imperative for treatment of nicotine addiction compelling . The results of our survey suggest that a focused tobacco management module in both the pediatric and obstetric blocks could well be appropriate with an emphasis on motivational techniques to promote behavior change.
Less than 10% of graduating respondents strongly agreed that they were familiar with the current guidelines for treating tobacco use, in comparison, 99% of general practitioners are familiar with hypertension guidelines and 90% of clinicians are familiar with the guidelines for the treatment of angina [21, 22].
These data point to the need to encourage widespread exposure of medical students in Canada to the excellent CAN-ADAPTT resource which includes not only guideline information but also links to a range of educational resources including instruction of motivational interviewing techniques .
It was disappointing that although a role for leadership by physicians in tobacco addiction management was acknowledged, one-third of respondents believed that physicians were not motivated to implement tobacco cessation programs and more than half thought that their advice would be ineffective. These data mirrored findings in a Quebec study which demonstrated that while many physicians discussed tobacco addiction with their patients in two years of seeing them , a significant minority perceived that these interventions took too much time or were not effective . As knowledge-based learning is cultivated and reinforced through clinical observation, it is important that practicing physicians model the appropriate attitudes and actions towards tobacco use . Although medical students from different countries agreed on the dangers of tobacco use, they differed in their perception of effective cessation methods. While medical students in London and Edmonton rated pharmacotherapy as more effective than physician advice, willpower or alternative therapy, and perceived “group cessation programs including nicotine replacement therapy (NRT)” to be the most effective tobacco cessation intervention, German medical students viewed “willpower alone” to be extremely effective . Though advice from a physician doubles a smoker’s chances of quitting , the majority of students from medical schools in Canada, Britain and Germany viewed “GP advice” as ineffective. Despite their confidence in counseling and medicating tobacco users, this view may discourage clinical students at the University of Alberta from offering appropriate advice to current smokers.
A self-administered survey is a convenient and effective way to measure knowledge and opinions but has inherent drawbacks. Our survey was only able to measure education and competency subjectively, relying on students to report on these parameters accurately. Objective measures of clinical competency must be sought through other modalities.
Within these constraints, we took steps to ensure that the data we did obtain were of optimal quality by developing clear and concise wording and placement of question items and providing a logical flow to reduce respondent bias, burden and the length of the survey instrument. Heerwegh and Looseveldt found that, when comparing data quality in face-to-face versus on-line survey responses, those who responded on a web survey were more inclined to opt for “don’t know” responses. To minimize this effect, our survey instrument contained only one item with a “don’t know” response category. The use of on-line surveys has been found to increase reporting of sensitive issues (like smoking behavior), increase the accuracy of reporting and decrease the likelihood of a question being skipped compared to other methods of data collection, especially among young, well-educated and computer literate populations .
A response rate of 44.2% is well within an acceptable range for online surveys of medical students. For example, a one-week survey of New York medical students resulted in a 30% response rate ; a 25-week mixed mode survey of Canadian physicians and medical students produced an email response rate of 29.9%  and an on-line survey of fourth-year medical students enrolled in six schools in New York City, which ran for 13.5 weeks, garnered a response rate of 50% . Response rates were not uniform across the University of Alberta medical classes. Conclusions, especially those concerning the class of 2012, must be interpreted with caution. Our overall data suggest that there may be room for improvement in tobacco cessation intervention training. As the sampling frame was limited to one university, it may not be representative of medical education in all of Canada. Nonetheless, given the limited numbers of medical schools in Canada and the standardization of medical curriculum through licensing exams, we can assume that some of these findings may be relevant to other Canadian institutions.