Journal of Health Policy, Insurance and Management – Polityka Zdrowotna 107

Smoking prevalence among medical students in Ukraine

SMOKING PREVALENCE AMONG MEDICAL STUDENTS IN UKRAINE

Rozpowszechnienie palenia wśród studentów medycyny na Ukrainie

AbstrAct

Tobacco use is one of the leading preventable causes of premature death and disease in the world. Recently, literature has emerged suggesting that health professionals can play a critical role in reducing of tobacco use. Importantly, the effectiveness of disease prevention activities and a healthy lifestyle pro-motion by medical personnel largely depends on their own attitude to smoking, their smoking status, understanding of the importance of this problem, and their responsibility for tobacco control activities among patients and the public. This article describes the methodology and results of the study on the prevalence of smoking among students of higher medical educational institutions in different regions of Ukraine, carried out within the framework of global survey under the egis of the World Health Organization’s European Region, and the United States Centers for Disease Control and Prevention (CDC). The data on the tobacco use prevalence, presense in tobacco smoke polluted environment, atti-tudes towards smoking, desire to quit smoking, and training received to provide patient counseling on cessation techniques have been collected and analyzed.

Keywords: smoking prevalence, air pollution, attitude towards smoking, smoking cessation, educational needs

Słowa kluczowe: rozpowszechnienie palenia, zanieczyszczenie powietrza, zaprzestanie palenia tytoniu, potrzeby edukacyjne

IntroductIon

In the XXI century, public health is influenced by the complex of factors, among which smoking has one of the leading roles. According to WHO data, tobacco is one of the most significant risk factors for chronic noncommunicable diseases, one of the causes of global burden of diseases, as well as preventable death.1 In 2008, tobacco caused more than 5 million deaths in the world. The number is expected to exceed 8 million deaths by 2030, with approximately 70% of these deaths occurring in developing countries.2 Furthermore, thousands of people die from the negative effects of passive smoking every year.

Olena Gruzieva, National O.O. Bohomolets Medical University, Ukraine

Medical consequences of smoking for the WHO European Region are enormous; 30% of the population are smokers, about 1.2 million people die from smoking, which constitutes 14% of the total number of deaths.3

A significant increase in smoking prevalence among women and girls is of particular concern, which is largely attributable to creative marketing strategies.4 A total of 22% of women smoke in the region. This figure is much higher than in Africa, Asia and the Middle East, where the correspond-ing prevalences are 3-5%. Previously, smoking was mainly a male phenomenon.

1 Jha P, Chaloupka F J. Tobacco control in developing countries. Oxford University Press. Oxford. UK 2000.2 World Health Organization. MPOWER: A policy package to reverse the tobacco epidemic. World Health Organi-

zation. Geneva 2008.3 South-Eastern Europe Health Network. Reversing the Tobacco Epidemic. Saving lives in south-eastern Europe.

WHO. 2008: 90.4 Empower Women - Combating Tobacco Industry Marketing in the WHO European Region. Copenhagen.

Denmark 2010.

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However, today the difference in smoking preva-lence among adult men and women in such coun-tries as Austria, Denmark, Ireland, Norway, Netherlands, Sweden and the UK is very small, and in other countries it is also decreasing. Girls more often than boys use tobacco products in Bulgaria, Poland, Slovenia and Croatia.5

An increased prevalence of smoking among youth, including students, high levels of smoking among medical students - the future health care professionals- is of particular concern in Europe and in the world, as evidenced by numerous sci-entific publications, statistical data, discussion of smoking related issues at various international and national conferences.6 This issue is extremely important for Ukraine, where the negative ten-dency in the prevalence of smoking among young adults, including health care workers, has been observed for years.7 Health professions students have been found to play an important role in ces-sation and prevention of tobacco use among their patients.8 Counseling by health professions stu-dents has been shown to increase smoking ces-sation.9 Despite the involvement of health pro-fessions students, as the largest group of health-care professionals in tobacco control, only a few studies have collected information on tobacco use, exposure to secondhand smoke, and training

to provide cessation counseling among health professions students. These studies used differ-ent sampling methods, questionnaires, and data collection procedures, and very few are from low or middle-income countries.10 The WHO and the U.S. Centers for Disease Control and Prevention have attempted to overcome these limitations by developing and implementing the Global Health Professions Student Survey (GHPSS).11

As the formation of attitude towards smoking in health professionals begins at school age and continues during university studies, it is crucial to enhence understanding of this problem by the medical students. Considering the key role that health workers play in the formation of healthy lifestile, reduction in smoking prevalence among medical students is critical for its significant reduction in the whole population.

purpose And rAtIonAle

Health professionals can play a crutial role in tobacco control. Even brief and simple advice from health professionals can substantially increase smoking-cessation rates. Therefore, one of the strategies to reduce the number of smoking-related deaths is to encourage the involvement

Olena Gruzieva

5 Kills when used as prescribed – tobacco industry successfully targets girls with new marketing tactics /Information for the media, WHO ER. Copenhagen. Denmark 30 May 2012.

6 Edwards R. et al. Low and declining cigarette smoking rates among doctors and nurses. New Zealand Medical Journal (121) 1284. 2008; Blumenthal D S. Barriers to the provision of smoking cessation services. J Am Board Family Medi-cine (20) 3. 2007: 272-279; Ceraso M. et al. Smoking, barriers to quitting, and smoking-related knowledge, attitudes, and patient practices among male physicians in China. Preventing Chronic Disease (6) 1. 2009: A06; Thomas K, Yaphe J, Ma-talon A. Current primary care physician interventions to promote smoking cessation in Israel. The Israel Medical Associa-tion Journal (9). 2007: 645-648; Han Zao Li et al. Cigarette smoking status and smoking cessation counseling of Chinese physicians. Asia-Pacific Journal of Public Health (20) 3. 2008:183-192.

7 Tobacco control in Ukraine. National Report. 2009: 127; Global survey of adult tobacco use (GATS). Reporting of study results. Ukraine. - K. 2010: 160; Chaban T I, Turansky A I. Tobacco smoking among Medical Students. Ukrainian Medical Almanac (4). 2003: 171-172; Andreeva T, Krasovskyy K. Smoking among health professionals. Vascular disease of the brain (6). 2007: 23 -25.

8 Rice V H, Stead L F Nursing interventions for smoking cessation. Cochrane Database of Systematic Reviews (1) Jan 23. 2008: CD001188; Sarna L, Danao L L, Chan S S, Shin S R, Baldago L A, Endo E, Minegishi H, Wewers M E. Tobacco control curricula content in baccalaureate nursing programs in four Asian nations. Nurs Outlook (6) 54. 2006: 334-344; Preechawong S. Thai Nurses and Tobacco Cessation Activities in Clinical Practice. Thai Journal of Nursing Research (1) 11. 2007: 62-71; Chan S S, Sarna L, Danao L L. Are nurses prepared to curb the tobacco epidemic in China? A question-naire survey of schools of nursing. International Journal of Nursing Studies (5) 45. 2008: 706-713.

9 Rice V H, Stead L F Nursing interventions for smoking cessation. Cochrane Database of Systematic Reviews (1) Jan 23. 2008: CD001188.

10 Barta S, Richard D. The effects of a theory-based training program on nurses’ self-efficacy and behavior for smoking ces-sation through counseling. The Journal of Continuing Education in Nursing (36). 2005: 117–23; Jenkins K, Ahijevych K. Nursing students' beliefs about smoking, their own smoking behaviors, and use of professional tobacco treatment interven-tion. Applied Nursing Research (3) 6. 2003:164-172; Lenz B K. Beliefs, knowledge, and self-efficacy of nursing students regarding tobacco cessation. American Journal of Preventive Medicine (35) suppl. 6 2008: 494-500; Durkin A. Promoting smoking cessation among nursing students: how faculty can help. Nursing Education Perspectives (3) 28. 2007: 150-154.

11 Warren C W, Jones N R, Chauvin J, Peruga A. Tobacco use and cessation counseling: Cross-country data from the Global Health Professions Student Survey (GHPSS). 2005-2007. Tobacco Control (17). 2008: 238-247.

Journal of Health Policy, Insurance and Management – Polityka Zdrowotna 109

of health professionals in tobacco-use preven-tion and cessation counseling. The GHPSS was designed to collect data on tobacco use and ces-sation counseling among health professional stu-dents in all WHO member states. Questionnaires are translated into local languages as needed. GHPSS has a standardized methodology for selecting participating schools and classes and uniform data processing procedures.

MAterIAls And Methods

The current study was conducted in 4 regions of Ukraine during 2010 in the framework of the Global Health Professional Student Survey (GHPSS) in 49 countries under the egis of WHO and the Center for Disease Control and Prevention, the USA (CDC). It is a school-based survey of 3rd year students pursuing advanced degrees in dentistry, medicine, pharmacy, and nursing. The GHPSS uses a core questionnaire on demo-graphics, prevalence of cigarette smoking and use of other tobacco products, exposure to second-hand smoke (SHS), desire to quit smoking, and training received to provide patient counseling on cessation techniques. The GHPSS has a stand-ardized methodology for selecting participating schools and uniform data processing procedures.12

The Medical GHPSS in Ukraine included a sample of students and a sample of schools. The sample was selected with probability proportional to size from all medical schools in Ukraine and a census of students in the selected schools were surveyed. The Ukraine GHPSS was conducted in schools during regular lectures and class ses-sions. Anonymous, self-administered data collec-tion procedures were used. The final question-naire was translated into Ukrainian and back-translated into English to check for accuracy.

The medical school response rate for the Ukraine GHPSS was 80.0%. The medical stu-dents response rates for the Ukrainian GHPSS were 95%.

A software package for statistical analy-sis of complex survey data SUDAAN was used to calculate weighted prevalence estimates and standard errors (SE) of the estimates and 95% confidence intervals (CI).13

results

The percentage of medical students who were females was 70.8% and 95.6% were less than age 25. Among medical students, 72.0% reported that they have ever smoked cigarettes (table 1). A total of 33.1% are currently smoked cigarettes. Over 20% of medical students currently use tobacco products other than cigarettes.

The proportion of medical students report-ing their schools have an official policy banning smoking in school buildings and clinics was 80.0% (table 2). However, only 56.9% reported that their school enforced the ban on smoking in school buildings and clinics.

Among medical students, 47.8% reported that they had been exposed to SHS in their home in the past 7 days. Nearly 75% answered that they had been exposed to SHS in public places in the past week.

Almost seven in 10 of current smokers indi-cated that they want to quit. Similarly, among other tobacco products users 46.6% of medical students reported that they want to stop using tobacco. However, only 49.3% of current smokers ever received help/advice to stop smoking ciga-rettes. Over 67% of the medical students thought health professionals have a role in giving advice about smoking cessation to patients (table 3). Over four in five medical students think health profes-sionals should get specific training on cessation techniques. The percentage of health professions students reporting that they had ever received some kind of formal training in their professional school on cessation approaches to use with their patients was 24.8%.

Smoking prevalence among medical students in Ukraine

12 Warren C W, Jones N R, Chauvin J, Peruga A. Tobacco use and cessation counseling: Cross-country data from the Global Health Professions Student Survey (GHPSS). 2005-2007. Tobacco Control (17). 2008: 238-247.

13 Shah B V, Barnwell B G, Bieler G S. Software for the statistical analysis of correlated data (SUDAAN): User’s Manual. Release 7.5. 1997 (software documentation). Research Triangle Park, NC: Research Triangle Institute. 1997; Hinkle D E, Wiersma W, Jurs S G. Applied statistics for the behavioral sciences. 5th ed. Boston. Houghton Mifflin Co. 2003.

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All Respondents Current Use

Ever smoked cigarettes

Ever smokers who initiated daily

cigarette smoking before age 16 years

Ever used any form of tobacco other than cigarettes

Currently use cigarettes

Currently use any form of tobacco

other than cigarettes

%(95% CI)

%(95% CI)

%(95% CI)

% 95% CI)

%(95% CI)

Discipline (Medicine)

Total 72.0(53.2 - 85.4)

51.3(47.7- 55.0)

53.7(49.1- 58.3)

33.1(26.2-40.9)

20.8(15.1- 28.0)

Women 68.7(47.2- 84.3)

48.0(40.9 -55.2)

50.1(44.7 -55.5)

28.5(21.7- 36.5)

16.8(13.4- 20.9)

Men 79.9(70.5- 86.9)

58.2(39.6 -74.7)

62.6(60.7 -64.4)

44.0(32.1-56.5)

30.4(16.1- 49.9)

Table 1. Lifetime and Current Prevalence of Tobacco Use among Third-Year Medical Students in Ukraine

Table 2. Policy and Exposure to Secondhand Smoke among Third-Year Medical students in Ukraine

Table 3. Cessation, Education and Perception of Responsibility to Counsel Patients among Ever Smokers, Third-Year Medical Students in Ukraine GHPSS, 2010

Source: GHPSS. 2010

Source: GHPSS. 2010

Source: GHPSS. 2010

Ever Cigarette Smokers All Respondents

Smoked on college

premises/prop-erty during the

past year

Smoked in college

buildings dur-ing the past

year

Colleges with an official

policy banning smoking in college

buildings and clinics

Colleges that had an official

policy ban-ning smoking

in school buildings and

clinics that enforced the

ban

Exposure to smoke

at home during the past week

Exposure to smoke

in public places during the past

week

%(95% CI)

%(95% CI)

%(95% CI)

%(95% CI)

%(95% CI)

%(95% CI)

Discipline (Medicine)

42.6(27.1–59.8)

14.8(2.5-4.1)

80.0(67.2-8.7)

56.9 (42.2-70.6)

47.8(27.2-69.1)

74.6(64.8-82.4)

Current Cigarette Smokers who want

to quit smoking cigarettes now

Current Users of Other Tobacco

Products who want to quit using

other tobacco products now

Percentage Answering “Yes”Learned cessation

approaches to use

with patients

Do health pro-fessionals serve

as role models for their patients and

the public?

Should health professionals get specific training

on cessation techniques?

%(95% CI)

%(95% CI)

%(95% CI)

%(95% CI)

%(95% CI)

Discipline (Medicine)

68.3(50.9-81.8)

46.6(38.2-55.3)

67.1(57.8-75.3)

77.7(61.9-88.2)

24.8(12.6-43.2)

Olena Gruzieva

Journal of Health Policy, Insurance and Management – Polityka Zdrowotna 111

dIscussIon

Findings from the Ukraine GHPSS show that the prevalence of current cigarette smoking among medical students was 33.1%. Prevalence of use of tobacco products other than cigarettes was 20.8%. Tobacco use endangers the health of health professions students and negatively influences the future health professions workforce to deliver effective anti-tobacco counseling when they start seeing patients.14 The tobacco control community should target tobacco users among health professions students to overcome this situ-ation. Educational institutions training health pro-fessions students should help their students quit using tobacco by providing encouragement and information to students who are considering quit-ting and providing assistance to students who are motivated to quit.

Over 74.6% of health professions students in Ukraine reported they were exposed to SHS in public places. In addition, about 80% of the students reported their schools have an official policy banning smoking in school buildings and clinics. Educational institutions training health professions students should be encouraged to pro-vide smoke free work and study areas by ban-ning smoking in their buildings and clinics. A smoke free work environment has been shown to improve air quality, reduce health problems associated with exposure to tobacco smoke, sup-port and encourage cessation attempts among smokers trying to quit, and receive high levels of public support from people who spend time in the area.15 Furthermore, the creation of smoke free areas by health education institutions sends a clear message to educators, students, patients,

and clinicians about negative impact of tobacco.16

Health professions students should be trained to provide effective, accurate, and accessible advice to patients on all aspects of health. The Ukraine GHPSS data show that over 67% of stu-dents recognize that they are role models in soci-ety. Over 77% of medical students think they should receive training on counseling and treat-ing patients to quit using tobacco. However, only 24.8% of medical students have received formal training.

The Ukraine GHPSS surveyed 3rd year stu-dents, so it is possible that students receive training on patient cessation techniques during the latter years of their programs. To address this possibility, the GHPSS research coordinators raised this ques-tion to the school administrators and found that, in the majority of the countries, there is no formal training at any time. Of the countries with some training, the type of training included: problem-based learning, included in generic counseling curricula; or included in curricula as part of com-munity medicine or public health courses.

This study did not make an effort to evaluate the adequacy of cessation training in the coun-tries reporting this type of instruction. However, professional training for health professions stu-dents should include courses detailing the harm-ful health effects of tobacco use and exposure to secondhand smoke, and training in counseling on tobacco cessation techniques.17 Curricula should include a course or supplements to exist-ing courses specifically relevant to tobacco issues.

The results of this GHPSS are critical for gaug-ing progress toward WHO FCTC and MPOWER implementation and uptake.

Smoking prevalence among medical students in Ukraine

14 Lenz B K. Beliefs, knowledge, and self-efficacy of nursing students regarding tobacco cessation. American Jour-nal of Preventive Medicine (35) suppl. 6 2008: 494-500.

15 U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Office on Smoking and Health (1996). Making your Workplace Smoke-Free: A Decision Maker's Guide. Atlanta, GA: U.S. Depart-ment of Health and Human Services, Centers for Disease Control and Prevention, Office on Smoking and Health.

16 U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Division of Nutri-tion, Physical Activity, and Obesity. Implementing a Tobacco-Free Campus Initiative in Your Workplace. Avail-able at www.cdc.gov/nccdphp/dnpa/hwi/toolkits/tobacco/index.htm

17 Sarna L, Danao L L, Chan S S, Shin S R, Baldago L A, Endo E, Minegishi H, Wewers M E. Tobacco control cur-ricula content in baccalaureate nursing programs in four Asian nations. Nurs Outlook (6) 54. 2006:334-344; Preecha-wong S. Thai Nurses and Tobacco Cessation Activities in Clinical Practice. Thai Journal of Nursing Research (1) 11. 2007: 62-71; Chan S S, Sarna L, Danao L L. Are nurses prepared to curb the tobacco epidemic in China? A question-naire survey of schools of nursing. International Journal of Nursing Studies (5) 45; 2008:706-713; Barta S, Richard D. The effects of a theory-based training program on nurses’ self-efficacy and behavior for smoking cessation through counseling. The Journal of Continuing Education in Nursing (36). 2005: 117–23; Fiore M C, Jaén C R, Baker T B, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville. MD: U.S. Depart-ment of Health and Human Services. Public Health Service. May 2008; Lancaster T, Stread L, Silagy C. et al. Effec-tiveness of interventions to help people stop smoking: findings from the Cochrane Library (321). BMJ 2000: 355-358.

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Ukraine’s participation in GHPSS addresses the first element of MPOWER (Monitor tobacco use and prevention policies). And GHPSS asks students a range of questions that spans many of the remain-ing elements of MPOWER. The resulting data are critical for gauging Ukraine’s progress toward fully implementing the elements of MPOWER among its youth. The information provided by GHPSS can address several provisions of the FCTC that relate to the role of school personnel and the comprehen-sive school tobacco control policy.

Some of the key MPOWER elements include:A) Protect people from tobacco smoke

The GHPSS data show that 47.8% of medical stu-dents were exposed to second-hand smoke at home in the past week and 74.6% were exposed to second-hand smoke in public places in the past week.B) Offer help to quit tobacco use

Results from GHPSS show that health profes-sions students who currently smoke are interested in quitting. Of students who currently smoke:

- 33.1% are current cigarette smokers who want to quit smoking cigarettes now

- 68.3% are current Users of Other Tobacco Products who want to quit using other tobacco products now

C) Warn about the dangers of tobaccoThe GHPSS showed that 67.1% of medical

students believed that health professionals serve as role models for their patients and the public and 77.7% believed that health professionals should get specific training on cessation techniques. Despite this fact, only 24.8% learned cessation approaches to use with patients.

GHPSS methodology provides an excellent framework for monitoring and guiding the imple-mentation of school tobacco control programs while making it compliant with the requirements of FCTC.

The results of this survey will be disseminated broadly and, ideally, used to adopt and implement effective legislative measures for preventing and reducing tobacco consumption, nicotine addic-tion, and exposure to tobacco smoke.

proposed InterventIons/further studIes

1) The health professions GHPSS has shown sig-nificant unmet need for cessation assistance among health professions students as well as gaps in professional training to provide simi-lar effective assistance to their future patients.

The health professions GHPSS is helpful in evaluating the behavior and attitudes regard-ing tobacco among health professions students, but additional research is necessary to improve the evidence base for effective tobacco-related curricula, especially materials that are appro-priate for a range of cultural and economic settings.

2) Assess and share the content of tobacco con-trol components within the formal training curricula and continuing education courses for health professions students

3) Further research should be carried out to assess the impact of existing tobacco control-related materials and training provided in health pro-fessions schools in a variety of cultural and economic environments.

4) Utilize research above to form a compendium of “best practices” of patient counseling for training health professions students relevant to countries with a broad spectrum of health resources and infrastructures.

recoMMendAtIons

1) Educational institutions, public health organi-zations, and education officials should dis-courage tobacco use among health professions students and work together to design and implement programs that train health profes-sions students in effective cessation-coun-seling techniques.

2) To substantially reduce the use of tobac-co products, resources should be invested in improving the quality of education of health professions students with respect to tobacco control.

3) Training materials, curriculum, and evidence-based programs need to be developed, imple-mented, and evaluated in all schools for health professionals.

4) Smoking bans should be instituted on all health professions schools campuses

AcknoWledgeMent

We acknowledge the support of the World Health Organization’s European Region, and the United States Centers for Disease Control and Prevention (CDC) for providing technical and financial support.

Olena Gruzieva

Journal of Health Policy, Insurance and Management – Polityka Zdrowotna 113

references

1. Jha P, Chaloupka FJ. Tobacco control in developing countries. Oxford University Press. Oxford. UK 2000.

2. World Health Organization. MPOWER: A policy package to reverse the tobacco epidemic. World Health Organization. Geneva 2008.

3. South-Eastern Europe Health Network. Reversing the Tobacco Epidemic. Saving lives in south-east-ern Europe. WHO. 2008: 90.

4. Empower Women - Combating Tobacco Industry Marketing in the WHO European Region. Copenhagen. Denmark 2010.

5. Kills when used as prescribed – tobacco indus-try successfully targets girls with new marketing tactics / Information for the media, WHO ER. Copenhagen. Denmark 30 May 2012.

6. Edwards R. et al. Low and declining cigarette smoking rates among doctors and nurses. New Zealand Medical Journal (121) 1284. 2008.

7. Blumenthal D S. Barriers to the provision of smoking cessation services. J Am Board Family Medicine (20) 3. 2007: 272-279.

8. Ceraso M. et al. Smoking, barriers to quitting, and smoking-related knowledge, attitudes, and patient practices among male physicians in China. Preventing Chronic Disease (6) 1. 2009: A06.

9. Thomas K, Yaphe J, Matalon A. Current primary care physician interventions to promote smoking cessation in Israel. The Israel Medical Association Journal (9). 2007: 645-648.

10. Han Zao Li et al. Cigarette smoking status and smok-ing cessation counseling of Chinese physicians. Asia-Pacific Journal of Public Health (20) 3. 2008: 183-192.

11. Tobacco control in Ukraine. National Report. 2009: 127.

12. Global survey of adult tobacco use (GATS). Reporting of study results. Ukraine. 2010: 160.

13. Chaban T I, Turansky A I. Tobacco smoking among Medical Students. Ukrainian Medical Almanac (4). 2003: 171-172.

14. Andreeva T, Krasovskyy K. Smoking among health pro-fessionals .Vascular disease of the brain (6). 2007: 23 -25.

15. Rice V H, Stead L F Nursing interventions for smoking cessation. Cochrane Database of Systematic Reviews (1) Jan 23. 2008: CD001188.

16. Sarna L, Danao L L, Chan S S, Shin S R, Baldago L A, Endo E, Minegishi H, Wewers M E. Tobacco control curricula content in baccalaureate nursing programs in four Asian nations. Nurs Outlook (6) 54. 2006:334-344.

17. Preechawong S. Thai Nurses and Tobacco Cessation Activities in Clinical Practice. Thai Journal of Nursing Research (1) 11. 2007: 62-71.

18. Chan S S, Sarna L, Danao L L. Are nurses pre-pared to curb the tobacco epidemic in China? A questionnaire survey of schools of nursing. International Journal of Nursing Studies (5) 45. 2008:706-713.

19. Barta S, Richard D. The effects of a theory-based training program on nurses’ self-efficacy and behavior for smoking cessation through coun-seling. The Journal of Continuing Education in Nursing (36). 2005: 117-23.

20. Jenkins K, Ahijevych K. Nursing students’ beliefs about smoking, their own smoking behaviors, and use of professional tobacco treatment intervention. Applied Nursing Research (3) 6. 2003:164-172.

21. Lenz B K. Beliefs, knowledge, and self-efficacy of nursing students regarding tobacco cessation. American Journal of Preventive Medicine (35) suppl. 6 2008: 494-500.

22. Durkin A. Promoting smoking cessation among nursing students: how faculty can help. Nursing Education Perspectives (3) 28. 2007: 150-154.

23. Warren C W, Jones N R, Chauvin J, Peruga A. Tobacco use and cessation counseling: Cross-country data from the Global Health Professions Student Survey (GHPSS). 2005-2007. Tobacco Control (17). 2008 :238-247.

24. Shah B V, Barnwell B G, Bieler G S. Software for the statistical analysis of correlated data (SUDAAN): User’s Manual. Release 7.5. 1997 (software documentation). Research Triangle Park, NC: Research Triangle Institute. 1997.

25. Hinkle D E, Wiersma W, Jurs S G. Applied sta-tistics for the behavioral sciences. 5th ed. Boston. Houghton Mifflin Co. 2003.

26. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Office on Smoking and Health (1996). Making your Workplace Smoke-Free: A Decision Maker’s Guide. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Office on Smoking and Health.

27. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity, and Obesity. Implementing a Tobacco-Free Campus Initiative in Your Workplace. Available at www.cdc.gov/nccdphp/dnpa/hwi/toolkits/tobacco/index.htm

28. Fiore M C, Jaén C R, Baker T B, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville. MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

29. Lancaster T, Stread L, Silagy C. et al. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library (321). BMJ 2000: 355-358.

Smoking prevalence among medical students in Ukraine