Abstract:

Objective:

To examine the association between tobacco-related risk factors and smoking among third-year dental students in Latin American countries.

Materials and methods:

Logistic regression models were used to analyze Global Health Professions Student Survey (GHPSS) data.

Results:

Of 5 605 respondents, 33% smoked and 45% had been exposed to secondhand smoke during the previous month, 34% smoked in school buildings during the past year, and 85% had never received formal training in smoking cessation. Smoking was significantly associated with male sex; Bolivian, Chilean, or Mexican nationality; exposure to secondhand smoke; lacking self-perception of being a “role model” for patients; and not believing that health professionals who smoke are less likely to advise patients to quit smoking.

Conclusions:

All dental schools should encourage tobacco-free policies and offer cessation services. Cessation training must be incorporated into dental curricula to include dental professionals in the battle against the tobacco epidemic.

Keywords:
smoking; tobacco; prevalence; student; dentistry

Resumen:

Objetivo:

Analizar la asociación entre ciertos factores de riesgo relacionados con el tabaquismo en estudiantes de tercer año de odontología de países latinoamericanos.

Material y métodos:

Se analizaron los datos de la Encuesta Mundial de Estudiantes de Profesiones de la Salud (GHPSS, por sus siglas en inglés) mediante la aplicación de modelos de regresión logística.

Resultados.

De los 5 605 encuestados, 33% fumó y 45% estuvo expuesto al humo de segunda mano durante el mes pasado; 34% fumó en los edificios de las escuelas dentales durante el pasado año y 85% nunca recibió entrenamiento formal en cesación de tabaquismo. Ser boliviano, chileno o mexicano; estar expuestos al humo de segunda mano; no auto-percibirse como un “modelo a seguir” para los pacientes; y no creer que un profesional de salud que fuma es menos propenso a aconsejar a sus pacientes para dejar de fumar fueron factores asociados significativamente con el tabaquismo.

Conclusiones:

Todas las escuelas dentales deben fomentar las políticas contra el consumo de tabaco y ofrecer servicios de cesación de tabaquismo. La formación sobre cesación debe incorporarse a los planes de estudio con el fin de incluir a los profesionales dentales en la batalla contra la epidemia de tabaquismo.

Palabras clave:
fumar; tabaco; prevalencia; estudiante; odontología

Introducción

Tobacco use is considered one of the largest epidemics of a preventable threat to public health worldwide, killing nearly six million people each year.¹1. Organización Mundial de la Salud. Nota descriptiva nº 339. Junio 2014. accessed on 2014 Oct 31. Available at: http://www.who.int/mediacentre/factsheets/fs339/es
http://www.who.int/mediacentre/factsheet... Besides being the main cause of lung cancer, it is also a cause of other types of cancers, including oral, esophageal, laryngeal, and pancreatic cancers, and is a major risk factor for cardiovascular disease, aortic aneurysm, peripheral arterial disease, chronic obstructive pulmonary disease, and stroke.²2. Chang CM, Corey CG, Rostron BL, Apelberg BJ. Systematic review of cigar smoking and all cause and smoking related mortality. BMC Public Health 2015;15(1):390. http://dx.doi.org/10.1186/s12889-015-1617-5
https://doi.org/10.1186/s12889-015-1617-... ^,33. Von Eyben FE, Zeeman G. Riesgos para la salud derivados del consumo voluntario e involuntario del tabaco. Rev Esp Salud Publica 2003;77(1):11-36. http://dx.doi.org/10.1590/S1135-57272003000100004
https://doi.org/10.1590/S1135-5727200300... Tobacco use is also associated with oral leukoplakia, oral erythroplakia, tobacco-related pigmentation of the mucosa or dental restorations, periodontal disease, halitosis, and failure of dental implants and bone regeneration.⁴4. Villarroel-Dorrego M, Bascones-Martínez A, Pérez González E, Lauritano D. Conocimiento y actitud del odontólogo frente al manejo del tabaquismo: estudio comparativo entre Espa-a, Italia y Venezuela. Av Odontoestomatol 2009;25(4):209-213. https://doi.org/10.4321/S0213-12852009000400006
https://doi.org/10.4321/S0213-1285200900...

In 2005, the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) came into force.⁵5. Organización Mundial de la Salud. Convenio Marco de la OMS para el Control de Tabaco. Internet. Ginebra: Organización Mundial de la Salud, 2003 accessed on December 2014. Available at: http://www.who.int/tobacco/framework/WHO_fctc_spanish.pdf
http://www.who.int/tobacco/framework/WHO... This internationally binding treaty has been signed by 168 countries, 29 of which belong to the Americas region.⁶6. The Framework Convention Alliance for Tobacco Control.Internet Status of the WHO Framework Convention On Tobacco Control (FCTC).The Framework Convention Alliance for Tobacco Control accessed February 2015. Available at: http://www.fctc.org/about-fca/tobacco-control-treaty/latest-ratifications/parties-ratifications-accessions#signed
http://www.fctc.org/about-fca/tobacco-co... ^,77. Organización Panamericana de la Salud. Informe sobre control del tabaco para la región de las Américas. Organización Panamericana de la Salud. Centros para el Control y la Prevención de Enfermedades CDC. 2011 accessed on May 2014. Available at: http://www.paho.org/par/index2.php?option=com_docman&task=doc_view&gid=358&Itemid=239
http://www.paho.org/par/index2.php?optio... ^,88. Organización Panamericana de la Salud. Informe sobre Control del Tabaco para la Región de las Américas. Organización Panamericana de la Salud. Washington, DC: OPS, 2013. accessed on May 2014. Available at: http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=23415&Itemid
http://www.paho.org/hq/index.php?option=... However, only a few of these countries have been able to fully execute the FCTC through the implementation of effective tobacco prevention and control policies.⁹9. Sandoval RC, Blanco A. Estado de la implementación del Convenio Marco para el Control del Tabaco en la región de las Américas. Salud Publica Mex 2010;52(Suppl 2):S270-S276. http://dx.doi.org/10.1590/S0036-36342010000800023
https://doi.org/10.1590/S0036-3634201000... Some nations, such as Argentina, Cuba, Haiti, and the United States (US), have signed the FCTC but have not yet ratified it. Surprisingly, Dominican Republic is the only country in the region that has not yet signed the treaty.⁶6. The Framework Convention Alliance for Tobacco Control.Internet Status of the WHO Framework Convention On Tobacco Control (FCTC).The Framework Convention Alliance for Tobacco Control accessed February 2015. Available at: http://www.fctc.org/about-fca/tobacco-control-treaty/latest-ratifications/parties-ratifications-accessions#signed
http://www.fctc.org/about-fca/tobacco-co... According to the 2011 WHO report on tobacco control for the Americas region, the prevalence of tobacco use among adults in Latin America is 15 to 40%. Tobacco use prevalence is highest in Chile (35%), Bolivia (30%), the US (29%), Argentina (27%), and Uruguay (27%). The prevalence of tobacco use is higher (21%) among females in Venezuela than in other countries of the region, while in Chile (35%), Brazil (30%), Jamaica (29%), Barbados (29%), Ecuador (29%), Mexico (29%), Colombia (28%), and Argentina (27%), tobacco use prevalence is high among youth.⁷7. Organización Panamericana de la Salud. Informe sobre control del tabaco para la región de las Américas. Organización Panamericana de la Salud. Centros para el Control y la Prevención de Enfermedades CDC. 2011 accessed on May 2014. Available at: http://www.paho.org/par/index2.php?option=com_docman&task=doc_view&gid=358&Itemid=239
http://www.paho.org/par/index2.php?optio...

Isolated reports¹⁰10. Cuesta A, Kuster F, Lluberas R. Tabaquismo en el personal y usuarios de un hospital universitario: consumo y recomendación de abandono. Rev Urug Cardiol 2005;20(2):77-85.^,1111. Zárate M, Zavaleta A, Danjoy D, Chanamé E, Prochazka R, Salas M, et al. Prácticas de consumo de tabaco y otras drogas en estudiantes de ciencias de la salud de una universidad privada de Lima, Perú. Invest Educ Enferm 2006;24(2):72-81.^,1212. Casta-o-Castrillón JJ, Páez-Cala ML, Pinzón-Montes JH, Rojo-Bustamante E, Sánchez-Castrillón GA, Torres-Ríos JM, et al. Estudio descriptivo sobre tabaquismo en la comunidad estudiantil de la Universidad de Manizales 2007. Rev Fac Med Univ Nac Colomb 2008;56(4):302-317.of an alarming prevalence of tobacco use among healthcare providers and students of health professions in Latin America led, in 2004, to the development of the Global Health Professions Students Survey (GHPSS) by the WHO, the US Centers for Disease Control and Prevention, and the Canadian Public Health Association. The GHPSS is a school-based, self-administered survey that captures information from third-year students who are pursuing advanced degrees in dentistry, medicine, nursing, or pharmacy. It collects data on demographics, tobacco use, secondhand smoke exposure, and intention to quit, as well as attitudes and perceptions about tobacco use and smoking cessation technique training.¹³13. Reynales-Shigematsu LM, Vázquez-Grameix JH, Lazcano-Ponce E. Encuesta mundial de tabaquismo en estudiantes de la salud, México 2006. Salud Publica Mex 2007;49(Suppl 2):s194-s204. http://dx.doi.org/10.1590/S0036-36342010000800023
https://doi.org/10.1590/S0036-3634201000... ^,1414. Warren CW, Sinha DN, Lee J, Lea V, Jones N, Asma S. Tobacco use, exposure to secondhand smoke, and cessation counseling training of dental students around the world. J Dent Educ 2011;75(3):385-405.^,1515. Gualano MR, Bontempi C, Saulle R, Ricciardi W, La Torre G. Validation of the global health professions students survey questionnaire in Italy. Ital J Public Health 2012;8(4):392-398.^,1616. Organización Panamericana de la Salud. Encuesta Mundial de Estudiantes de Profesiones de la Salud (EMEPS) document on the Internet. Washington DC: Organización Panamericana de la Salud; 2011 Febrero accessed on April 2015. Available at: http://www.paho.org/hq/index.php?option=com_content&view=article&id=1750:global-health-professions-student-survey-ghpss&Itemid=2036&lang=es
http://www.paho.org/hq/index.php?option=... The GHPSS has a standardized method for the selection of schools and uniform procedures for data processing.¹⁷17. The GTSS Collaborative Group. Tobacco use and cessation counselling: Global health professionals survey pilot study, 10 countries, 2005. Tobacco Control 2006;15(Suppl 2):ii31-ii4. Since 2005, the GHPSS has been administered in 21 countries;¹⁸18. Bryant L, Bowman L. Smoking out a deadly threat: Tobacco use in the LGBT community. New York, NY: American Lung Association, 2010.^,1919. Organización Panamericana de la Salud. Encuesta Mundial de Estudiantes de Profesiones de la Salud (EMEPS). Información resumida por país (fact sheets). 2010 accessed on April 2015. Available at: http://www.paho.org/hq/index.php?option=com_content&view=article&id=3199&Itemid=2001&lang=es
http://www.paho.org/hq/index.php?option=... its ultimate purpose is to provide baseline and continuous tobacco use assessments that can be instrumental in incorporating tobacco prevention and cessation training in the curricula of health professional programs at universities and colleges and in developing strategies for assisting students and patients with quitting their addiction.

Industrialized countries have developed a wide spectrum of tobacco prevention and cessation interventions based on educational strategies, counseling techniques, pharmacological treatments, and tobacco regulatory efforts, all with the sole intention of discouraging smoking among the general population, including adolescents and young adults.²⁰20. Thurgood SL, McNeill A, Clark-Carter D, Brose LS. A Systematic Review of Smoking Cessation Interventions for Adults in Substance Abuse Treatment or Recovery. Nicotine Tob Res 2016;18(5):993-1001. https://doi.org/10.1093/ntr/ntv127
https://doi.org/10.1093/ntr/ntv127... ^,2121. West R, Raw M, McNeill A, Stead L, Aveyard P, Britton J, et al. Healthcare interventions to promote and assist tobacco cessation: a review of efficacy, effectiveness and affordability for use in national guideline development. Addiction 2015;110(9):1388-1403. http://dx.doi.org/10.1111/add.12998
https://doi.org/10.1111/add.12998... For instance, the US Department of Public Health has developed two intervention models: the 5 As (Ask about tobacco use, Advise to quit, Assess willingness to make a quit attempt, Assist in the quitting attempt, and Arrange follow-ups) and the AAR (Ask, Advise, and Refer).²²22. Gonzalez M, Sanders-Jackson A, Glantz SA. Association of Strong Smoke-Free Laws With Dentists’ Advice to Quit Smoking, 2006-2007. Am J Public Health 2014;104(4):e88-e94. http://dx.doi.org/10.2105/AJPH.2013.301714
https://doi.org/10.2105/AJPH.2013.301714... Both have been proven to provide positive results when used by dental practitioners to help their patients quit tobacco use. However, these efforts need to be disseminated more effectively in low- and middle-resource settings, and even more importantly, they must be culturally adapted to the existing socio-economic and cultural contexts of each country.²³23. US Department of Health and Human Services. Reducing tobacco use: A report of the surgeon general. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000.^,2424. Warren CW, Lee J, Lea V, Goding A, O’Hara B, Carlberg M, et al. Evolution of the Global Tobacco Surveillance System (GTSS) 1998-2008. Glob Health Promot 2009;16(2):4-37. http://dx.doi.org/10.1177/1757975909342181
https://doi.org/10.1177/1757975909342181...

Healthcare providers are positioned to offer unique and efficient tobacco prevention and treatment.²⁵25. Winn DM. Tobacco use and oral disease. J Dent Educ 2001;65(4):306-312. In particular, dentists have an important role in the battle against the tobacco epidemic since most of the early signs of tobacco use are observed in the oral cavity.²⁶26. Johnson NW. The role of the dental team in tobacco cessation. Eur J Dent Educ 2004;8(s4):18-24. http://dx.doi.org/10.1111/j.1399-5863.2004.00318.x
https://doi.org/10.1111/j.1399-5863.2004... ^,2727. Fried JL, Rubinstein-DeVore L. Tobacco use cessation curricula in the US dental schools and dental hygiene programs. J Dent Educ 1990;54(12):730-735.^,2828. Ramseier CA, Christen A, McGowan J, McCartan B, Minenna L, Ohrn K, et al. Tobacco use prevention and cassation in dental and dental hyglene undergraduate education. Oral Health Prev Dent 2006;4:49-60. Furthermore, scientific evidence has shown that behavioral interventions, in addition to oral examinations in dental settings, increase the abstinence rate among patients who are current smokers.²⁹29. Carr AB, Ebbert J. Interventions for tobacco cessation in the dental setting. A systematic review. The Cochrane Database Syst Rev 2012, Issue 6. Art No:CD005084. http://dx.doi.org/10.1002/14651858.CD005084
https://doi.org/10.1002/14651858.CD00508... However, the lack of sufficient opportunities for tobacco prevention and cessation training in many Latin American dental schools is hampering the opportunities for dental professionals to become fully committed in the fight against tobacco use in the region.³⁰30. Tamí-Maury I, Aigner CJ, Hong J, Strom S, Chambers MS, Gritz ER. Perception of tobacco use prevention and cessation among faculty members in Latin American and Caribbean dental schools. J Cancer Educ 2014;29(4):634-641. http://dx.doi.org/10.1007/s13187-013-0597-3
https://doi.org/10.1007/s13187-013-0597-... Even more, studies conducted in other regions have shown that smoking among health care providers has a negative impact on their beliefs and attitudes towards tobacco control measures.³¹31. Ravara SB, Calheiros JM, Aguiar P, Barata LT. Smoking behaviour predicts tobacco control attitudes in a high smoking prevalence hospital: A cross-sectional study in a Portuguese teaching hospital prior to the national smoking ban. BMC Public Health 2011;11(1):720. http://dx.doi.org/10.1186/1471-2458-11-720
https://doi.org/10.1186/1471-2458-11-720... Also, little is known about dental students’ tobacco use prevalence and knowledge on this topic. Therefore, the objective of this study was to examine the association between tobacco-related risk factors (e.g., knowledge and attitudes) and smoking among third-year dental students in Central and South America.

Materials and methods

Study design and population

In this cross-sectional study, we analyzed GHPSS data, collected between 2001 and 2012, on tobacco use and cessation counseling among undergraduate dental students from Argentina (2007), Bolivia (2007), Chile (2008), Costa Rica (2012), Guatemala (2008), Mexico (2006), Panama (2008), Paraguay (2008), Uruguay (2008), and Venezuela (2001). We used the latest wave of GHPSS data for each country.

For the purpose of this manuscript, all data analyses were restricted to third-year dental students aged 15 years or older (n=5 605 individuals) since students in Latin American dental schools begin to function as dental practitioners during their third year. This study was approved by the Institutional Review Board of The University of Texas MD Anderson Cancer Center (Protocol # PA15-0741).

Main outcome

Dental students who responded “Yes” to the question “Have you ever tried or experimented with cigarette smoking, (even one or two puffs)?” and who also smoked for at least 1 day after being asked “During the past 30 days, on how many days did you smoke cigarettes?” were classified as current smokers. This categorical variable was dichotomized as Yes or No. Non-current cigarette smokers were those participants who had never tried or experimented with cigarette smoking (never smokers) as well as those who had tried or experimented with cigarette smoking but did not smoke cigarettes during the previous month (former smokers).

Statistical analysis

Both descriptive and inferential data analyses were performed using SPSS version 22 software, with 0.05 as the level of significance. The frequency distribution, mean, standard deviation, and proportions were calculated, and current smokers and non-current smokers were compared using chi-squared and independent t-test analyses.

Bivariable and multivariable logistic regression model analyses were performed to determine the association between independent variables (e.g., sex, age, country, secondhand smoke exposure, self-perception as a “role model” for patients, belief that health care providers have a role in advising patients or informing them about smoking cessation, belief that health care providers who smoke are less likely to advise patients to quit, and formal training in smoking cessation approaches to use with patients) and current cigarette-smoking. A multiple logistic regression model for estimating the probability of being a current smoker was constructed using a stepwise selection algorithm, with entry and exit p-value criteria of 0.05 and 0.10, respectively. Unfortunately, the question on the enforcement of tobacco-free policies in dental schools was absent from the GHPSS version used in Chile. Therefore, this variable was excluded for this particular analysis.

Results

The study sample consisted primarily of women (64%), the majority of whom (81%) ranged in age from 19 to 24 years. Table I summarizes the descriptive statistics of the study population.

Among the 5 488 undergraduate dental students who responded to the questions related to current smoking, 1 808 (33%) reported smoking cigarettes at least one day during the past 30 days, while 2 457 (45%) had been exposed to secondhand smoke during the previous month. Among both former and current cigarette smokers, 67% had smoked in a school building during the previous year. Among the students in our study sample, only 15% had received formal training in smoking cessation.

One finding of particular interest was that, among current cigarette smokers, 42% responded “Yes” to the question “Do you want to stop smoking now?” In addition, 65% of the cigarette smokers indicated that they had made attempts to stop smoking during the previous year. Sixty four percent of these dental students had not received help or advice to assist them in their quitting attempts. These results are not shown in the tables.

The association between cigarette smoking and specific independent variables was examined in a multivariable logistic regression model. The tolerance and variance inflation factor were examined for each variable included in the model; all were > 0.2 and < 3.0, respectively, indicating no concerns with multicollinearity.

Being male (OR adj=1.85; CI=1.600-2.145; p<0.01); Bolivian (OR adj=1.78; CI=1.026-3.085; p<0.05), Chilean (OR adj=2.19; CI=1.273-3.779; p<0.01), or Mexican (OR adj=1.89; CI=1.084-3.294; p<0.05); being exposed to secondhand smoke (OR adj=2.55; CI=2.253-2.896; p<0.01); lacked self-perception of being a “role model” for patients (OR adj=1.42; CI=1.227-1.638; p<0.01); and not believing that health professionals who smoke are less likely to advise patients to quit smoking (OR adj=2.05; CI=1.772-2.367; p<0.01) were factors that were significantly associated with current cigarette smoking (table II).

Discussion

The findings from this cross-sectional study provide a unique opportunity to assess not only tobacco use prevalence but also perceptions and risk factors associated with tobacco consumption among third-year students pursuing an advanced dental degree in several Latin America countries (Argentina, Bolivia, Chile, Costa Rica, Guatemala, Mexico, Panama, Paraguay, Uruguay, and Venezuela).¹⁶16. Organización Panamericana de la Salud. Encuesta Mundial de Estudiantes de Profesiones de la Salud (EMEPS) document on the Internet. Washington DC: Organización Panamericana de la Salud; 2011 Febrero accessed on April 2015. Available at: http://www.paho.org/hq/index.php?option=com_content&view=article&id=1750:global-health-professions-student-survey-ghpss&Itemid=2036&lang=es
http://www.paho.org/hq/index.php?option=... Like the findings of Warren and colleagues¹⁴14. Warren CW, Sinha DN, Lee J, Lea V, Jones N, Asma S. Tobacco use, exposure to secondhand smoke, and cessation counseling training of dental students around the world. J Dent Educ 2011;75(3):385-405. in their analysis of 2005-2007 GHPSS data from countries around the world, our results show a high prevalence of tobacco use among dental students from several Latin American countries (33%). Contrary to the results of previous reports¹³13. Reynales-Shigematsu LM, Vázquez-Grameix JH, Lazcano-Ponce E. Encuesta mundial de tabaquismo en estudiantes de la salud, México 2006. Salud Publica Mex 2007;49(Suppl 2):s194-s204. http://dx.doi.org/10.1590/S0036-36342010000800023
https://doi.org/10.1590/S0036-3634201000... ^,3232. Barbouni A, Hadjichristodoulou C, Merakou K, Antoniadou E, Kourea K, Miloni E, et al. Tobacco use, exposure to secondhand smoke, and cessation counseling among health professions students: Greek data from the Global Health Professions Student Survey (GHPSS). Int J Environ Res Public Health 2012;9(1):331-342. http://dx.doi.org/10.3390/ijerph9010331
https://doi.org/10.3390/ijerph9010331... ^,3333. Ferrante M, Saulle R, Ledda C, Pappalardo R, Fallico R, La Torre G, et al. Prevalence of smoking habits, attitudes, knowledge and beliefs among Health Professional School students: a cross-sectional study. Ann Ist Super Sanità 2013;49(2):143-149.^,3434. Tafur LA, Ordó-ez GO, Millán JC, Valera JM, Rebellón P. Prevalencia de tabaquismo en estudiantes recién ingresados a la Universidad Santiago de Cali. Colomb Med 2006;37(2):126-132.the overall prevalence of tobacco consumption was higher among female than male dental students in our study sample. However, this sex difference varied by country according to the prevalent beliefs and norms around tobacco use.³⁵35. Jradi H, Wewers M, Pirie P, Binkley P, Ferketich A. Cigarette and waterpipe smoking associated knowledge and behaviour among medical students in Lebanon. EMHJ 2013;19(10):861-868.

The highest frequency of tobacco consumption among dental students was observed in the group aged 19 to 24 years. Many of the respondents reported trying their first cigarette before age 17. This is consistent with the results of previous reports that indicate that freshman college students who smoke have already begun smoking before they arrive on campus.³⁴34. Tafur LA, Ordó-ez GO, Millán JC, Valera JM, Rebellón P. Prevalencia de tabaquismo en estudiantes recién ingresados a la Universidad Santiago de Cali. Colomb Med 2006;37(2):126-132. Cigarette smoking was predominant compared to other types of tobacco consumption, which is consistent with the results of previous reports from this region²⁴24. Warren CW, Lee J, Lea V, Goding A, O’Hara B, Carlberg M, et al. Evolution of the Global Tobacco Surveillance System (GTSS) 1998-2008. Glob Health Promot 2009;16(2):4-37. http://dx.doi.org/10.1177/1757975909342181
https://doi.org/10.1177/1757975909342181... but differs from what is observed in other countries, particularly those in the Middle East.¹⁴14. Warren CW, Sinha DN, Lee J, Lea V, Jones N, Asma S. Tobacco use, exposure to secondhand smoke, and cessation counseling training of dental students around the world. J Dent Educ 2011;75(3):385-405.

As in previous studies, we found evidence of a significant association between exposure to secondhand smoke and current smoking status.³⁶36. Keshavarz H, Jafari A, Khami MR, Ilmari J. Passive smoking and attitudes towards tobacco control programs among Iranian dental students. Asian Pacific J Cancer Prev 2013;14(6):3635-3639. http://dx.doi.org/10.7314/APJCP.2013.14.6.3635
https://doi.org/10.7314/APJCP.2013.14.6.... ^,3737. Cauchi D, Mamo J. Smoking health professional student: An attitudinal challenge for health promotion? Int J Environ Res Public Health 2012;9(7):2550-2561. http://dx.doi.org/10.3390/ijerph9072550
https://doi.org/10.3390/ijerph9072550... While many countries have existing policies that prohibit smoking in public and in work places,⁶6. The Framework Convention Alliance for Tobacco Control.Internet Status of the WHO Framework Convention On Tobacco Control (FCTC).The Framework Convention Alliance for Tobacco Control accessed February 2015. Available at: http://www.fctc.org/about-fca/tobacco-control-treaty/latest-ratifications/parties-ratifications-accessions#signed
http://www.fctc.org/about-fca/tobacco-co... ^,3838. Sinha D, Singh G, Gupta P, Pednekar M, Warrn CW, Asma S, et al. Linking India global health professions student survey data to the world health organization framework convention on tobacco control. Indian J Cancer 2010;47(5):30-34. http://dx.doi.org/10.4103/0019-509X.65177
https://doi.org/10.4103/0019-509X.65177... ^,3939. Calleja N. Medidas para el control del tabaco en México y en el Mundo. Enseñanza e Investig en Psicol 2012;17(1):83-99.^,4040. World Health Organization. Country profile Colombia. In: World Health Organization. WHO report on the global tobacco epidemic,2015: raising taxes on tobacco. Geneva: WHO, 2015. Available in: http://www.who.int/tobacco/global_report/2015/en/
http://www.who.int/tobacco/global_report... these laws are not always enforced with rigor.⁴¹41. Surani NS, Pednekar MS, Sinha DN, Singh G, Warren CW, Asma S, et al. Tobacco use and cessation counseling in India-data from the Global Health Professions Students Survey, 2005-09. Indian J Cancer 2012;49(4):425-430. http://dx.doi.org/10.4103/0019-509X.107751
https://doi.org/10.4103/0019-509X.107751... Unfortunately, a trend toward the relaxation of antismoking rule enforcement is occurring, even in academic institutions where health-related careers are offered.¹³13. Reynales-Shigematsu LM, Vázquez-Grameix JH, Lazcano-Ponce E. Encuesta mundial de tabaquismo en estudiantes de la salud, México 2006. Salud Publica Mex 2007;49(Suppl 2):s194-s204. http://dx.doi.org/10.1590/S0036-36342010000800023
https://doi.org/10.1590/S0036-3634201000... ^,4242. Inandi T, Caman OK, Aydin N, Onal AE, Kaypmaz A, Turhan E, et al. Global Health Professions Student Survey--Turkey: second-hand smoke exposure and opinions of medical students on anti-tobacco law. Cent Eur J Public Healt 2013;21(3):134-139.^,4343. Navas-Acien A, Peruga A, Breysse P, Zavaleta A, Blanco-Marquizo A, Pitarque R, et al. Secondhand tobacco smoke in public places in Latin America, 2002-2003. JAMA 2004;291(22):2741-2745. http://dx.doi.org/10.1001/jama.291.22.2741
https://doi.org/10.1001/jama.291.22.2741... Adherence to these regulations, asserted Muñoz Escobedo and colleagues,⁴⁴44. Mu-oz-Escobedo JJ, Pasillas-Macias DE, Rivas-Gutiérrez J, Reveles-Hernández G, Moreno-García A. Tabaquismo en la población del área de salud de la Universidad Autónoma de Zacatecas, México. Acta Med Per 2009;26(2):78-82. must be mandatory in any healthcare institution and followed by everyone involved, including administrative and teaching personnel, students, and patients.

According to Cauchi and Mamo, student smoking adversely affects the beliefs and attitudes of students toward tobacco control policies.³⁷37. Cauchi D, Mamo J. Smoking health professional student: An attitudinal challenge for health promotion? Int J Environ Res Public Health 2012;9(7):2550-2561. http://dx.doi.org/10.3390/ijerph9072550
https://doi.org/10.3390/ijerph9072550... In this study, we observed that dental students who smoke or have smoked within educational buildings do not consider themselves to be role models for society. Therefore, it is increasingly important for dental education institutions to provide not only training opportunities in tobacco prevention and cessation but also tobacco treatment services for dental students and faculty members who use tobacco products.

According to Weaver and colleagues,⁴⁵45. Weaver RG, Whittaker L, Valachovic RW, Broom A. Tobacco control and prevention effort in dental education. J Dent Educ 2002;66(3):426-429. a high percentage of smokers report having seen a dentist at least 1 time in the previous year. This suggests that dentists are well positioned to play an important role in public health strategies to reduce the morbidity and mortality associated with tobacco use.⁴⁶46. Rocha-Buelvas A, Hidalgo-Patino C, Collela G, Angelillo I. Oral cancer and dentists: knowledge, attitudes and practices in a South Colombian context. Acta Odontolol Latinoam 2012;25(2):155-162.

A new generation of dentists in Latin America should be aware of the key role they can play in intervention strategies aimed at battling tobacco consumption, creating awareness among these practitioners about the health risks associated with tobacco use and its impact on the quality of life of their patients.⁶6. The Framework Convention Alliance for Tobacco Control.Internet Status of the WHO Framework Convention On Tobacco Control (FCTC).The Framework Convention Alliance for Tobacco Control accessed February 2015. Available at: http://www.fctc.org/about-fca/tobacco-control-treaty/latest-ratifications/parties-ratifications-accessions#signed
http://www.fctc.org/about-fca/tobacco-co... ^,4747. World Health Organization. WHO Framework Convention on Tobacco Control. Implementation database [internet] accessed on December 2015. Available at: http://apps.who.int/fctc/implementation/database/
http://apps.who.int/fctc/implementation/... Previous findings¹³13. Reynales-Shigematsu LM, Vázquez-Grameix JH, Lazcano-Ponce E. Encuesta mundial de tabaquismo en estudiantes de la salud, México 2006. Salud Publica Mex 2007;49(Suppl 2):s194-s204. http://dx.doi.org/10.1590/S0036-36342010000800023
https://doi.org/10.1590/S0036-3634201000... ^,2424. Warren CW, Lee J, Lea V, Goding A, O’Hara B, Carlberg M, et al. Evolution of the Global Tobacco Surveillance System (GTSS) 1998-2008. Glob Health Promot 2009;16(2):4-37. http://dx.doi.org/10.1177/1757975909342181
https://doi.org/10.1177/1757975909342181... ^,4848. Fotedar S, Sogi GM, Fotedar V, Bhushan B, Singh B, Dahiya P, et al. Knowledge of, attitude towards, and prevalence of tobacco use among dental students in Himachal Pradesh State, India. Oral Health Dent Manag 2013;12:73-79.and the evidence shown in the present study clearly indicate a lack of training for dental students on how to provide effective anti-tobacco counseling as well as successful pharmacological and non-pharmacological strategies to help their patients with smoking cessation.⁴⁹49. Warren CW, Sinha DN, Lee J, Lea V, Jones NR. Tobacco use, exposure to secondhand smoke, and training on cessation counseling among nursing students: cross-country data from the Global Health Professions Student Survey (GHPSS), 2005-2009. Int J Environ Res Public Health 2009;6(10):2534-2549. http://dx.doi,org/10.3390/ijerph6102534
https://doi.org/10.3390/ijerph6102534... ^,5050. Warren CW, Sinha DN, Lee J, Lea V, Jones NR. Tobacco use, exposure to secondhand smoke, and cessation counseling among medical students: cross-country data from the Global Health Professions Student Survey (GHPSS), 2005-2008. BMC Public Health 2011;11(1):1. http://dx.doi.org/10.1186/1471-2458-11-72
https://doi.org/10.1186/1471-2458-11-72... ^,5151. Saulle R, Bontempi C, Baldo V, Boccia G, Bonaccorsi G, Brusaferro S, et al. GHPSS multicenter Italian survey: smoking prevalence, knowledge and attitudes, and tobacco cessation training among third-year medical students. Tumori 2013;99(1):17-22.We believe that undergraduate and graduate dental programs in the region should adopt a tobacco control strategy that involves the adoption of tobacco prevention and cessation training into their curricula and the inclusion of tobacco prevention and cessation training in the portfolio offered by their continuing education programs. Approaches such as the 5A and 5R models have already been proposed for this purpose.⁵²52. Bello S. Tratamiento del tabaquismo. Chil Cardiol 2011; 30(3): 230-239. http://dx.doi.org/10.4067/S0718-85602011000300007
https://doi.org/10.4067/S0718-8560201100...

Four important caveats should be mentioned as limitations of this study. First, not all of the dental schools and programs in Latin America participated in each wave in which the GHPSS survey was conducted. Second, data from each of the countries participating in this study were collected in different years which, together with variations in national trends of tobacco consumption and the implementation of anti-tobacco policies, make it extremely difficult to compare dental students and the general population or the countries in our sample. Third, this study only included third-year dental students. This could result in a selection bias because for some dental schools, formal training in tobacco prevention and cessation could have taken place in later years. However, we firmly believe that by the third year, dental students should be exposed to this special training to allow subsequent opportunities for increasing levels of self-efficacy. Finally, the number of responses varied considerably by country, and Bolivia (1 546 students), Mexico (1 257 students), and Venezuela (1 182 students) were overrepresented in our study sample. In this sense, dental schools in all Latin American countries should be encouraged to repeatedly participate in future waves of the GHPSS survey so a uniformed and homogenous representation can be obtained. This will make it possible for each country to track changes in tobacco use and associated risk perceptions among dental students over time and to evaluate the impact that any anti-tobacco policy implemented at the institutional or national level has on the performance of these future health professionals.

Dental associations, oral health societies, and other organizations or institutions sponsoring and promoting scientific meetings should include tobacco prevention and control as an important topic for discussion. This exchange of research ideas and practice experiences will undoubtedly benefit dental care professionals who may be facing similar challenges around tobacco prevention and cessation in their dental offices or academic institutions.

We believe that the findings of this cross-sectional study will encourage dental schools in the region to design and implement new tobacco prevention and cessation training programs for dental students. In institutions where these programs already exist, developing continuing education programs for dental practitioners and specialists will guarantee the positive impact of dental professionals in the battle against the tobacco epidemic.

Acknowledgements

The authors thank Dr. Roberta Caixeta from the Tobacco Program at the Pan American Health Organization for facilitating the GHPSS datasets and for her support and constructive criticism during the writing process of this manuscript. This work was partially supported by the generous philanthropic contributions to The University of Texas MD Anderson Lung Cancer Moon Shots Program and the MD Anderson Cancer Center Support Grant P30 CA01667

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