Open Journal of Nursing, 2013, 3, 351-357 OJN Published Online August 2013 (
Effectiveness of a course in the control of tobacco use for
university health students: A quasi-experimental
community intervention trial
Daniel Fernandez, Antonio Molina, Vicente Martin, Beatriz Ordas, Jose Manuel De Luis
Leon University Hospital, University of Leon, Leon, Spain
Received 12 March 2013; revised 13 April 2013; accepted 15 May 2013
Copyright © 2013 Daniel Fernandez et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction: The aim of the study was to evaluate
the effectiveness of a tobacco control course in the
reduction of prevalence and the improvement of
knowledge and attitudes among university health
students. Method: Quasi-experimental study on a
community based intervention. Interventional cam-
pus students received a tobacco control course in the
first year of the degree. Data were collected by Self-
Answered Questionnaire during three academic years
in two graduations years among health students in
both campuses. Results: 84.4% of students partici-
pated in the study. In both campuses tobacco use was
reduced, not significantly, above all in those joining
courses from origins other than baccalaureate. In the
intervention and control campus showed an increase
in the nicotine dependency according to Fagerström
test and a little change in motivation according to
Richmond test. The regression model best explaining
the improving of the knowledge included academic
course mainly and campus and academic background
too. With regard to opinions and beliefs tobacco use
was not influenced, being associated in general to the
academic course. Conclusions: A specific tobacco con-
trol course did not change prevalence of tobacco,
nicotine dependence and motivation to give up. The
improvement in knowledge was associated with aca-
demic course in both campuses. We recommend to
commence smoking cessation strategies in university
health students.
Keywords: Tobacco; Students; Nursing; University;
The prevention and control of tobacco consumption is a
major challenge for health science professionals, for it
affects their effectiveness as promoters of health with
regard to, among other things, giving up smoking. Their
period as students is an optimal time to intervene in the
knowledge of these professionals, and in their belief sys-
tems and attitudes regarding tobacco [1-3]. Indeed, the
correct training at university leads to health professionals
developing interventions effective against tobacco use
[4-8]. In Spain, students of health sciences are not nor-
mally the subject of studies on tobacco consumption,
such studies that have been made relying on small popu-
lations [9-15]. In general, the prevalence and distribution
of smokers among students of health sciences vary by
country and the duration of studies [16,17]. Few inter-
ventions, however, have been carried out to establish the
most effective strategies for a positive influence on their
future roles as health promoters and to reduce the to-
bacco use [16,18-20], especially those who smoke [21].
1.1. Purpose
The aim of our study was to assess the effectiveness of a
specific training course on tobacco use on the reduction
of the prevalence of consumption and on the improve-
ment of knowledge and attitudes among health science
students. Thus this is the aim of our study, we hypothe-
sized that the active engagement with the topics of our
specific training course on tobacco addiction would re-
duce the tobacco use and lead to a change in smoking-
related attitudes and behaviors.
Quasi-experimental community intervention trial. The
target population comprised all the students enrolled in
the first year of Nursing and Physiotherapy at the School
of Health Sciences of the University of León at its
campuses in León (Nursing) and Ponferrada (Nursing
D. Fernandez et al. / Open Journal of Nursing 3 (2013) 351-357
and Physiotherapy) in the years 2005-2006 and 2006-
2007. Both courses have a total duration of three years.
The students at Ponferrada (the intervention campus)
attended a specific training course on tobacco addiction,
while those at León (the control campus) did not. Al-
though the impact of Law 28/2005, which came into
effect on the 1st January 2006, was not studied, one of its
articles deals with measures on health education and
assistance in cessation of the smoking habit [22].
The intervention consisted in a free course of 45 hours
carrying 4.5 credits. The aim was to improve knowledge,
belief and attitudes towards tobacco use and to stress
health professionals’ position as role models in its con-
trol, prevention and treatment. The students carried out
related activities like the preparation of leaflets and pos-
ters in groups: some focused on cessation and others on
advice against starting. Role-play was used for diagnos-
ing smokers and for minimal advice.
We used an anonymous questionnaire designed ac-
cording to the European Regional Office of the World
Health Organization [23] and validated in previous
studies [13,14]. collection was performed among all the
students enrolled in Nursing and Physiotherapy at the
University of León during practical laboratory sessions
in October 2005, May 2007 and May 2008 for those
graduating in 2008; and October 2006, May 2008 and
May 2009 for those finishing in 2009. At the time of data
collection, a total of 440 students were enrolled.
A smoker was defined as anyone smoking daily (at
least one cigarette) or occasionally (less than one ciga-
rette per day) at the time of the survey, while those who
had never smoked or who were abstinent were classed as
non-smokers. Factors taken into account for smokers
were age on starting, nicotine dependence as measured
by the Fagerström test (potential range 0 - 10) and moti-
vation for cessation according to the Richmond test (po-
tential range 0-10). Information was also collected on
age, sex, year of study and previous studies.
Knowledge of the consequences of smoking was mea-
sured by means of a question requiring the student to
identify the link between tobacco use and certain health
problems on the following scale:
1) Tobacco use is the main cause of illness.
2) Tobacco use is one of the main causes of illness.
3) There is no link between tobacco use and illness.
4) I don’t know if there is a link.
Likewise, another question with the same scale was
used for the students to identify the link between air pol-
luted with tobacco smoke and a list of health problems.
Those answering 1 or 2 (main cause and one more cause)
scored 1 (positive event), those answering 3 (no link)
scored 1 (negative event) and those answering 4, were
given a 0 (neutral event). The study group considered the
respondent to have “sufficient knowledge” of the first
question for scores of 7 and above, and of the second
question for scores of 5 or above.
Students’ opinions and beliefs were measured on a
scale from 1 - 4, where 1 = totally disagree, 2 = partly
agree, 3 = mostly agree and 4 = totally agree. On the
basis of this, the average was calculated for each of the
items measured.
2.1. Data Analysis
The Epiinfo for Windows program was used for statistic-
cal analysis of the data. On the bivariate level, for cate-
gorical variables we used the Chi-square test while for
continuous variables we applied the T-test in the event of
normality for variances as shown by the Wilcoxon test,
and the Kruskall-Wallis non-parametric test where there
was no such homogeneity. On the multivariate level, we
used a logistic regression model including the variables
associated with tobacco use with a p-value less than 0.20.
Changes in percentages, both in consumption prevalence
and in students with sufficient knowledge, were calcu-
lated from the percentage of difference with regard to the
first year, which was used as base 100.
2.2. Ethical Considerations
Principles of informed consent and confidentiality were
observed during the data collection. The students were
assured that their participation or non-participation would
in no way affect their academic progress. The study, fi-
nanced by the Carlos III Health Research Fund of the
Spanish Ministry of Health and Consumption, was ap-
proved by the Ethics Committee of the University of
3.1. Description of Participants
84.8% (373/440) of the students took part in the study,
whose characteristics as found in the first survey, along
with their distribution by group and intervention, are
shown in Table 1, which also reveals that those in the
intervention group were younger and included more
males than the controls, and that no differences were
observed between the two groups in tobacco consump-
tion prevalence or in the age when they started smoking.
3.2. History of Tobacco Use
On both campuses there was a drop in the prevalence of
smokers from the first to the second year, 8% on the in-
tervention campus and 4% on the control one (Table 2).
These decreases were observed mainly among students
with a background other than the baccalaureate, preva-
lence increasing among those who had studied the bac-
calaureate, in both groups (Table 2).
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D. Fernandez et al. / Open Journal of Nursing 3 (2013) 351-357
Copyright © 2013 SciRes.
Table 1. Distribution of the participants in the first year of the university health science courses.
Control Cam pus (173) Intervention Campus (200) p
Men 10.4% (18) 17.5% (35)
Women 89.6% (155) 82.5% (165)
Baccalaureate 68.2% (118) 63.5% (127)
Academic background
Others 31.8% (55) 36.5% (73)
2005-08 46.8% (81) 48% (96)
Graduation year
2006-09 53.2% (92) 52% (104)
Age Average (SD) 19.9 (3.3) 20.7 (4.3) 0.04
Consumption Smokers 27.2% (47) 28.0% (56) 0.85
Age of smokers Average (SD) 21.8 (4) 21.6 (3.7) 0.61
Age of non smokers Average (SD) 21.1 (4.2) 21.9 (4.3) 0.08
Ageo on starting to smoke Average (SD) 14.7 (1.7) 14.7 (1.9) 0.95
Table 2. Distribution of prevalences by campus, year of study, academic background and total per campus
Baccalaureate Non Baccalaureate TOTAL Baccalaureate Non Baccalaureate TOTAL
% Change % % Change % Change % Change % Change
1˚ 21.2 40 27.2 25.2 32.9 28.0
2˚ 23.9 +12.7 37.1 7.2 28.1+3.3 29.4 +14.2 21.335.2 26.3 6.1
3˚ 21.4 +0.94 35.6 11 26.14.0 28.1 +11.5 21.135.8 25.7 8.2
Of the smokers, 248 (84.6%) had started before begin-
ning their university studies and 45 (15.4%) took up the
habit during their studies, giving an initiation incidence
of 5.1% (45/[1126-248]). In this regard, there were no
statistical differences by campus or year of study, but
there were differences according to academic back-
ground, 33 students (5.5% or 33/[736-144]) with the
baccalaureate taking up the habit in comparison with 12
(4.2% or 12/[390-104]) from other backgrounds (p =
0.05). Differences in nicotine dependence according to
the Fagerström test were found between the campuses,
with the control campus showing an average of 3.6 + 2.2
and the intervention campus 2.6 + 2.1 (p = 0.0001) in the
pre-course survey. Dependence rose on both campuses
(Table 3). No differences were observed in motivation to
stop as measured by the Richmond test either at the be-
ginning of the study or during the students’ time at uni-
versity (Table 3).
3.3. Knowledge
With regard to knowledge of the effects of tobacco on
health, in the pre-intervention survey, more students at
the intervention campus had a sufficient level of knowl-
Table 3. Distribution of averages for the Fagerström nicotine
dependence test and the Richmond test for motivation for
cessation organized by campus and year of study.
Average SD Average SD p
1st 3.4 2.1 2.3 2.2 0.01
2nd 3.4 2.4 2.4 2.2 0.03
3rd 4.1 2.0 3.0 2.1 0.01
1st 5.2 2.4 5.4 2.7 -
2nd 4.4 2.3 4.8 2.5 -
3rd 5 2.6 4.8 3.2 -
edge (64.5% vs 53.8%; p = 0.03, Table 4). On both
campuses the percentage rose as their studies progressed,
although the percentage remained higher on the interven-
tion campus (Table 4). From the logistic regression
analysis, which included all the variables studied, the
model best explaining the prevalence of sufficient
knowledge included the variables of year of study, cam-
pus and academic background. Thus, third-year students,
D. Fernandez et al. / Open Journal of Nursing 3 (2013) 351-357
Table 4. Distribution of the prevalence of “sufficient knowledge” regarding health problems and tobacco use organized by campus
and year of study.
n/N % Change n/N % Change p
1st 93/173 53.8 129/200 64.5 0.03
2nd 153/196 78.1
+45.1 172/194 88.7 +37.5 0.005
3rd 156/176 88.6
+64.7 180/187 96.3 +49.3 0.005
*p ˂ 0.0001.
students on the intervention campus and those from a
non-baccalaureate background registered differences of
9.1, 1.9 and 1.9 with regard respectively to first-year
students, controls and those with a baccalaureate back-
ground (p < 0.001).
Smokers on the control campus with sufficient knowl-
edge increased from 61.7% in the first year to 84.8% in
the third (p < 0.001), with a corresponding increase on
the intervention campus from 75% to 97.9% (p < 0.001).
Among non-smokers, the respective increases were from
50% - 8% to 90% (p < 0.001) and from 60.4% to 95% -
7% (p < 0.001).
Regarding knowledge of the link between environ-
mental smoke and health problems, significant differ-
ences were observed between the two campuses as early
as the first interview, these differences persisting in the
second interview and losing statistical significance in the
third year (Table 5). Logistic regression analysis re-
vealed ORs of 8, 2.2 and 1.5 for the intervention campus,
third year and non-baccalaureate background with regard
to the control campus, first year and baccalaureate back-
3.4. Beliefs Concerning Tobacco Addiction
Table 6 shows students’ average degree of agreement on
opinions concerning tobacco use. Students’ year of study
has a statistically significant influence at both campuses
except regarding the item “Smokers take your recom-
mendations into account”, where there was a statistical
increase on the intervention campus (p < 0.0018), but not
on the control one. For the statements “Students should
receive specific training regarding tobacco use” and
“Topics concerning prevention should be included in the
training” there were statistical differences in the last year,
with a higher average on the control campus. The bivari-
ate analysis revealed no differences in averages concern-
ing consumption, sex or academic background.
The educational intervention carried out reduced the per-
centage of tobacco addiction in comparison with the con-
trol campus, but without statistical significance, to an ex-
tent similar to studies performed in other countries [18-
20]. Among our students the greatest decrease was among
those from non-baccalaureate backgrounds, which sug-
gests a greater effectiveness among this section of the
The intervention had no effect on nicotine dependence
levels, which rose on both campuses in the way de-
scribed by Boccoli [25]. The low initial dependence lev-
els as compared with those recorded in similar studies
concerning health science students [4,21,26-28] may
have hindered the good results of the intervention, to-
gether with the fact that it was not designed for this end.
Likewise, the intervention did not alter motivation to
cease as measured by the Richmond test, which showed
a minimal change on both campuses.
As in previous studies [12,21,28-30], most of the stu-
dents smoked before coming to university and the num-
ber of new smokers was similar on the two campuses.
Follow-up studies would, however, be useful to deter-
mine the exact incidence of new smokers.
Although improved knowledge is significantly associ-
ated with both the intervention and the years of study, the
latter seemed to be the most important factor, with ORs
near to 9.
The effect of the intervention, despite reaching an OR
approaching 2, was weakened by the knowledge acquired
during their studies. Whether students were smokers or
nonsmokers had no significant influence, unlike other
studies, where tobacco use was a determining factor
The year of study had a significant influence on all
items in the section on opinions and beliefs, except num-
ber 2, where there was no modification on the intervene-
tion campus, whereas on the other, probably owing to the
intervention, as students were taught the importance they
would have as future health professionals on the control
of tobacco use.
For Sections 4 and 6, the average degree of agreement
in the third year was higher on the control campus, per-
haps because students on the intervention campus do not
perceive these aspects as necessary. This study revealed
no differences in knowledge, attitudes and beliefs be-
tween smokers and non-smokers on either campus, un-
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D. Fernandez et al. / Open Journal of Nursing 3 (2013) 351-357 355
Table 5. Distribution of students with “sufficient knowledge” of the link between health problems and air polluted by tobacco smoke,
organized by campus and year of study.
n/N % Change n/N % Change P
1st 83/172 48,3 130/199 65,3 <0,0001
2nd 143/196 73 +51.1 172/192 89.6 +37.3 <0.0001
3rd 156/176 88.6 +83.4 174/187 93 +42.4 0.14
*p ˂ 0.0001.
Table 6. Distribution of average of students’ degree of agreement at the beginning and end of the period of study.
1ST 3RD p* 1ST 3RD p* p**
1. Health professionals
should be role models. 2.50 ± 0.83 3.25 ± 0.71 <0.0001 2.37 ± 1 3.27 ± 0.72 <0.0001 1º p = 0.19 3º
p = 0.76
2. Smokers heed our
recommendatioins 2.45 ± 0.78 2.60 ± 0.77 0.15 2.34 ± 0.69 2.60 ± 0.75 0.0018 1º p = 0.14 3º
p = 0.98
3. My knowledge allows me to
give correct information on the
consequences of tobacco use.
2.69 ± 0.86 3.19 ± 0.60 <0.0001 2.52 ± 0.86 3.09 ± 0.66 <0.0001 1º p = 0.06 3º
p = 0.12
4. Students should receive
specific training regarding
tobacco consumption
2.59 ± 1.08 3.60 ± 0.56 <0.0001 2.49 ± 1.14 3.32 ± 0.65 <0.0001 1º p = 0.42 3º
p ˂ 0.0001
5. I know strategies and
methods for helping people
to give up.
2.05 ± 0.76 2.76 ± 0.82 <0.0001 1.92 ± 0.81 2.71 ± 0.85 <0.0001 1º p = 0.12 3º
p = 0.52
6. Topics concerning
prevention should be included
in our courses
2.56 ± 0.95 3.52 ± 0.57 <0.0001 2.47 ± 1 3.21 ± 0.70 <0.0001 1º p = 0.42 3º
p ˂ 0.0001
*p: analysis on comparing 1st & 3rd years; **p: analysis on comparing 1st & 3rd years on the control and intervention campuses.
like most studies carried out among health science stu-
dents [9,10,15,24,29,32-35], where consumption did have
an influence regarding these sections.
The specific training course on tobacco use carried out
does not appear to alter the overall prevalence of con-
sumption among students of nursing and physiotherapy.
Among those with a non-baccalaureate background,
consumption decreased in a statistically significant way,
35% in comparison with the first year. The intervention
did not influence nicotine dependence or motivation to
give up. Improved knowledge of tobacco use is strongly
linked to their education, less to their background and to
the intervention on the intervention campus.
Opinions and beliefs were not affected by tobacco use
or by the specific course, but did improve with year of
study. The results reveal the need to initiate strategies for
cessation of the habit among health science students and
set up anti-smoking programmes in the years immedi-
ately prior to university in order to reduce or delay the
onset of the habit.
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