Tobacco Induced Diseases

Research Paper

Impact of tobacco cessation education on behaviors of

nursing undergraduates in helping smokers to quit smoking
Li Zhang1, Xian Long Huang2, Tao Ye Luo3, Li Jiang4, Mei Xue Jiang5, Han Yan Chen1

ABSTRACT
INTRODUCTION Smoking continues to be a significant public health issue, but nursing AFFILIATION
1 College of Nursing,
students do not receive sufficient training on tobacco cessation education. Chongqing Medical University,
Integrating the 5As behaviors for tobacco cessation into a compulsory course Chongqing, China
2 Respiratory Medicine
could improve nursing students’ skills and increase their clinical behaviors for Department, The First Branch
assisting patients in quitting smoking. The aim of this study was to evaluate the of the First Affiliated Hospital
impact of evidence-based tobacco cessation education on the perceptions and of Chongqing Medical
University, Chongqing, China
behaviors of nursing students who are assisting patients to quit smoking. 3 Clinical Epidemiology and
METHODS A prospective single-group design was used to evaluate the perceptions Biostatistics Department,
Children's Hospital of
and behaviors of 626 senior nursing students enrolled in an education program, at Chongqing Medical University,
three time points: baseline, 3 months post education, and 6 months post education. Chongqing, China
4 Respiratory Medicine
Data were collected, before and after the tobacco cessation education, using Department, The First
assessment tools for knowledge, attitudes, and the 5As behaviors for assisting Affiliated Hospital of
Chongqing Medical University,
patients to quit smoking. Chongqing, China
RESULTS A total of 572 senior students completed the baseline survey, 289 students 5 Disease Prevention and
completed the survey 3 months post education, 348 students completed the Healthcare Department
of Healthcare Center of
survey 6 months post education, and 285 students completed all three surveys. Xiejiawan Subdistrict of
Knowledge and self-efficacy of tobacco cessation were improved dramatically Jiulongpo District, Chongqing,
China
(p<0.05) after the education program, compared with the baseline survey. At
6 months post education, compared with at 3 months post education, nursing CORRESPONDENCE TO
Han Yan Chen. College of
students reported more interventions of asking, advising, assessing, assisting, and Nursing, Chongqing Medical
arranging smokers to quit smoking (p<0.05). University, Chongqing
CONCLUSIONS The integration of tobacco cessation education into compulsory courses 400016, China. E-mail:
[email protected]
could improve clinical skills and enhance the behaviors of nursing students for
assisting patients to quit smoking. KEYWORDS
5As, evidence-based practice,
tobacco dependence
treatment, nursing students,
smoking cessation

Received: 11 February 2021

Revised: 22 May 2021
Accepted: 15 June 2021

Tob. Induc. Dis. 2021;19(July):58 https://doi.org/10.18332/tid/139024

INTRODUCTION and Article 14 of its guidelines stresses the need to

The evidence suggests that global tobacco users do improve global medical professionals’ abilities to
not obtain the help they need to quit smoking1. The deliver tobacco dependence treatment through various
Framework Convention on Tobacco Control (FCTC) educational strategies, providing many approaches
developed by the World Health Organization (WHO) to tobacco treatment to members, including China,

Published by European Publishing. © 2021 Zhang L. et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International
License. (https://creativecommons.org/licenses/by/4.0/)

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Research Paper

therefore strengthening their ability to assist patients China6. A survey in Beijing and Hefei found that
in quitting smoking. The International Council of only 63.9% of nurses frequently asked patients about
Nurses and the International Society of Nurses in their smoking history7. The lack of tobacco cessation
Cancer Care both support the WHO FCTC on tobacco behaviors can be attributed to a lack of knowledge
cessation and have asked nurses to implement brief and skills due to the lack of corresponding education
smoking cessation interventions for inpatients 2. in the undergraduate nursing curriculum8,9.
Nursing students are future nurses, and education Tobacco cessation education is an effective approach
about tobacco cessation could promote their for improving the knowledge and skills of medical
responsibility for smoking cessation and improve their professionals 10. Tobacco cessation education for
knowledge and skills for assisting patients in quitting nurses has been shown to increase the 5As behaviors
smoking. However, the Global Health Professions for assisting smokers in quitting smoking 11–14 .
Student Survey (GHPSS) found that no more than Tobacco cessation training as entry-level education
40% of nursing students have received formal tobacco for medical students has been shown to increase the
cessation education3. China, the largest producer and frequency of behaviors for assisting clients to quit
consumer of cigarettes in the world, currently has 316 smoking15. Studies have shown that evidence-based
million smokers, and approximately 1 million smokers tobacco cessation education dramatically improved
die of tobacco-related diseases each year4. If China nursing students' intention to participate in smoking
does not adopt quick and effective tobacco cessation cessation, improved their skills, and enhanced their
interventions to control tobacco prevalence, China confidence16–19. Sohn16 implemented tobacco cessation
could experience a dismally large number of deaths education in an elective nursing course at a South
caused by tobacco. Korean university, including a 2-hour lecture on
To prevent the adverse effects of tobacco on people, cessation strategies and a 3-hour simulation, and
the Chinese government has taken active measures found a significant improvement in the self-efficacy
to control smoking by adopting the WHO FCTC of participants for assisting patients to quit smoking.
and trying to fulfil the obligations to ban smoking Shishani17 adopted the content of a tobacco cessation
in public, establish smoke-free schools and hospitals, program into compulsory courses and improved
publicize the harm of tobacco through media, and the clinical skills of nursing students for assisting
implement a Healthy China Action plan requiring patients to quit smoking through online education
medical professionals to be non-smoker models and and simulation practice in various settings. Schwindt18
actively assist patients in quitting smoking. thought it was important to increase confidence and
The China Clinical Smoking Cessation Guidelines motivation in order to assist patients to quit smoking
(Guidelines) 5 clearly require that all medical and developed a tobacco cessation program which
professionals should practice the following 5A was designed based on the self-determination theory
behaviors for helping patients to quit smoking: 1) (SDT) to integrate tobacco cessation into a course
Ask patients about their smoking history, 2) Advise on Mental Health Nursing/Mental Health Care.
patients who smoke to quit, 3) Assess patients’ This program reported significant improvement
readiness to quit, 4) Assist patients who want to quit in motivation for assisting patients with mental
to stop smoking, 5) Arrange follow-up for smokers health problems to quit smoking. Along with the
who take action to quit smoking and assist with the development of information, the blended learning of
challenges of smoking cessation. traditional face-to-face interaction and e-learning have
However, medical professionals in China do demonstrated flexibility in practical teaching. Choi19
not universally demonstrate the 5As behaviors for administered blended teaching of tobacco cessation
assisting patients in quitting smoking. The first step education for nursing students and enhanced their
to smoking cessation is to ask patients about their self-motivation and self-efficacy for assisting patients
smoking history. At the same time, only 63.1% of to quit smoking.
professionals reported a high frequency of asking The above-mentioned studies have shown that
about smoking status at a tertiary A hospital in Beijing, different formats of tobacco cessation education for
which was one of the first smoke-free hospitals in nursing students can enhance knowledge, attitudes,

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self-efficacy, and skills for smoking cessation. regulations and measures for tobacco cessation,
However, few studies have focused on assessing health-related theories such as the transtheoretical
the 5As behaviors of students for assisting patients model of health behavior change, methods and skills
in quitting smoking post education. According to of health education, and the 5As behaviors and 5Rs
the theory of knowledge, attitude, and practice, for assisting patients to quit smoking.
those skills are the basis but not the necessary and Students were required to study the online
sufficient conditions of behaviors. The impact of resources within one month after the didactic lecture,
tobacco cessation education on the 5As behaviors of including the epidemiology of tobacco use, nicotine
nursing students for assisting patients to quit smoking pharmacology and addiction principles, smoking
is not completely known. As the largest producer and cessation drugs, brief theories of smoking cessation
consumer of cigarettes, China has reported limited intervention, interventions at different stages of
tobacco cessation education for nursing students9,20, smoking cessation, 5As behaviors for assisting
possibly because the disease-centered curriculum patients to quit smoking, and tools for aiding smoking
model has ignored the instruction of this important cessation. The online learning contents were mainly
public health skill21,22. To investigate the impact of from the Guidelines5 and a short intervention manual
tobacco cessation education on the behaviors of for smoking cessation (Manual)23 which was compiled
nursing students, as well as to improve students’ by the Tobacco Control Office of CDC of China with
smoking cessation skills, and to develop more medical the help of the WHO, which were usually employed
professionals for assisting patients in quitting smoking for training and self-study of medical professionals.
in a clinic setting, in this study, we integrated tobacco After 3 years of implementation, the Manual23 was
cessation education into a compulsory course. We revised and improved, and published. It was used
assessed the impact on the knowledge, attitudes, to popularize brief tobacco cessation interventions
and self-efficacy, as well as the behaviors of nursing and to meet the needs of medical professionals and
students for assisting patients in quitting smoking. smokers about tobacco cessation. The Manual 23
involved a PowerPoint for training, demonstration
METHODS videos, teaching cases, test questions, simple tools for
Study design tobacco cessation intervention, and questionnaires for
This study followed a one-group study design and teaching assessment, all free and accessible on the
used an objective sampling method to provide tobacco website of the Tobacco Control Office of CDC (http://
cessation education for 626 senior nursing students. www.notc.org.cn/). The online learning session was
We assessed changes in knowledge, attitudes, self- processed on the e-learning website of the Chongqing
efficacy, and the 5As behaviors for assisting patients in Medical University (http://e-learning.cqmu.edu.
quitting smoking, at 3 and 6 months post-education. cn/meol/index.do) with the functions of learning
This study was approved by the Ethics Committee resource uploading, learning monitoring, questioning
of the First Affiliated Hospital of Chongqing Medical and answering (Q and A), online quiz, and learning
University (No. 2019-157), and students were statistics. Lecturers supervised the learning process
informed that their participation was voluntary. A and provided timely help when problems presented.
total of 572 senior nursing students participated in The students were required to complete an online
the baseline survey, and 285 students completed all test after the learning process. When they passed the
three surveys, i.e. baseline, 3 months post-education, test (grade ≥60), they attended the simulation session.
and 6 months post education. Students were provided with 9 cases for role playing,
which included possible cases in clinical settings at
Course procedure and content different stages of readiness to quit, i.e. ‘unwilling
Students received 6 hours of instruction on tobacco to quit’, ‘willing but not ready to quit’, ‘ready to
cessation, including a 2-hour didactic session, a 2-hour quit’, and ‘quitter’. Those cases involved patients
online self-learning session, and a 2-hour scenario of different ages, with various diseases, as well as
simulation session. The didactic lecture introduced different cultures. Each class was divided into 4
tobacco harm and the importance of tobacco cessation, groups with 4–5 students, i.e. one patient, one to two

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family members, one nurse, and one observer. When 0.944, involving the perceptions of tobacco cessation
the simulation finished, the students summarized importance: 1) nurses should participate in tobacco
their positive and negative learning experiences, cessation; 2) nurses thought it was important or not
by completing a brief report focusing on reflective to take additional training or learn skills for tobacco
learning. cessation, evaluated on a 1–5 scale from ‘not important
at all’ to ‘very important’, and the professional role for
Faculty tobacco cessation was also evaluated; 3) nurses were
Four teachers participated in the study, one senior non-smoker models; and 4) attitude of nurses towards
teacher from the community health service center positive tobacco cessation interventions for patients,
who was engaged in a community smoking control evaluated on a 1–5 scale from ‘strongly disagree’ to
service, two primary teachers of smoking cessation ‘strongly agree’.
in clinical nursing work, and one senior teacher
who administered community nursing education Self-efficacy
and conducted tobacco control research on nursing There were 8 questions with a Cronbach’s alpha of
students. Before the learning process, the teachers 0.923. Students assessed confidence on 8 aspects about
discussed the form and content of teaching, referring tobacco dependence treatment, e.g. confidence to
to the Guidelines5 and the Manual23, to ensure that the accurately assess smokers’ willingness to quit smoking,
students received homogeneous smoking cessation provide tobacco cessation counselling, motivate
education. patients who attempt to quit, and demonstrate the
skills for assisting patients throughout the cessation
Assessment tools process. The responses ranged from 1 (poor) to 5
The knowledge and attitudes of tobacco cessation, (excellent) on a 5-point Likert scale.
as well as self-efficacy of assisting patients to quit
smoking were assessed by surveys completed prior 5As behaviors
to education, 3 months post education, and 6 months There were 5 questions with a Cronbach’s alpha of
post education, as well as the post-education 5As 0.933. The 5As behaviors for assisting patients to
behaviors. The survey was developed with reference quit smoking in the clinical practicum were evaluated
to the Manual23 and some documents20,24. To ensure 3 months post and 6 months post, including the
the effectiveness of the evaluation tool, before the numbers of patients ‘asked about smoking history’,
survey, we randomly selected 65 students to do a ‘advised to quit’, ‘assessed their readiness to quit’,
pre-survey. The Cronbach’s alpha of the survey was ‘assisted to quit’ and ‘arranged for follow-up’. The
0.881, showing good reliability. The survey consisted responses were scored 1–5 with 1 = none, 2 = 1–3
of questions designed to assess the following. patients, 3 = 4–9 patients, 4 = 10–25 patients, and 5
≥25 patients.
Tobacco cessation knowledge In addition, in order to improve the teaching,
There were 30 questions that covered the basic teachers collected students’ assessment of the course
knowledge of effective smoking cessation consultation: post the learning process and their experience of
1) tobacco prevalence and harm; 2) cigarettes and tobacco cessation education through an open question.
nicotine; 3) cigarettes dependence and addiction;
4) adaptive drug therapy for nicotine dependence; Data collection
5) the behavior change model at different stages ofAfter having obtained informed consent and before the
the smoking cessation process; and 6) counseling tobacco cessation education, teachers asked students
strategies about 5As behaviors and 5Rs for smoking to complete a baseline survey in the classroom
cessation. Each correct answer scored 1. The summedafter scanning a QR code. Three months post and 6
score was 1–30. months post education, the students were scattered in
different hospitals taking a clinical practicum, so it was
Attitudes towards tobacco cessation not possible to perform gathered assessments. Links
There were 4 questions, with a Cronbach’s alpha of to Questionnaire Star and informed consent were

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provided to participants through QQ group or WeChat 593 (94.7%) students who provided comments on
group of the internship management. Students were the course after the learning process; 289 students
offered a small payment to encourage participation completed the post education survey at 3 months
to share the 5As behaviors for assisting patients to follow-up ; 348 students completed the post education
quit smoking. survey at 6 months; and 285 students completed all
three surveys. The students were aged 18–24 years
Data analysis with a mean age of 21.47±0.854 years; 90.5% were
The data were analyzed by SPSS version 20.0 female and 2.2% were current smokers.
(IBM Corporation, Armonk, NY, USA). The count
data were represented by the number of cases (n) Attitudes towards tobacco cessation pre- and
and percentage (%). The measurement data were post-education assessment
described by mean and standard deviation. Single-arm Students reported significant improvement in their
repeated ANOVA was used to detect the changes of knowledge of tobacco cessation after the education
students’ tobacco cessation knowledge, attitude, self- and in their perceptions of the importance of
efficacy, and 5As behaviors at different time points ‘nurses should receive or prepare additional tobacco
pre and post education. A p<0.05 was considered cessation training or skills’ (p<0.05). Understanding
to be statistically significant. The differences that of the importance and responsibility of the medical
were statistically significant between two time points professionals’ involvement in tobacco cessation was
were analyzed by paired comparison. The Bonferroni not statistically significant (p>0.05). The details are
method was used for pairwise comparison of the data shown in Table 1.
at two time points for the 285 students who completed
the survey at the baseline, 3 months post education, Self-efficacy pre- and post-education
and 6 months post education. assessment
Compared with the baseline, the nursing students
RESULTS reported dramatic improvements in their self-efficacy
Demographics of the 5As behaviors for assisting smokers to quit
A total of 572 of the 626 students attending the course smoking, 3 months post and 6 months post education.
completed the baseline survey (91.4%). There were There were no significant differences in the paired

Table 1. Knowledge and attitudes pre- and post-education assessments – baseline, 3 months, and 6 months,
post education (N=285)

Items Single-arm repeated ANOVA at differences over time Pairwise comparison

p
Baseline 3 months 6 months F p 3 months/ 6 months/
Mean (SD) Mean (SD) Mean (SD) baseline baseline
Knowledge 14.66 (3.558) 18.42 (4.420) 19.69 (4.110) 135.542 <0.001 <0.001 <0.001
Importance‡
Tobacco cessation involvement, 4.30 (0.982) 4.28 (1.116) 4.34 (1.061) 0.200 0.819 - -
compared to other disease prevention
(nutrition, exercises, etc.)
Nurses obtained additional tobacco 4.08 (1.101) 4.29 (1.108) 4.30 (1.003) 3.836 0.022* 0.063 0.038*
control training/skills
Attitudes†
Nurses were non-smoker models 4.20 (1.101) 4.31 (1.154) 4.39 (1.034) 2.099 0.124 - -
Nurses provided active smoking cessation 4.29 (1.008) 4.34 (1.088) 4.36 (0.956) 0.385 0.681 - -
interventions for patients
P-values were calculated using single-arm repeated (ANOVA) at differences over time. †1–5 = ‘strongly disagree’ to ‘strongly agree’. ‡1–5=‘ least important’ to ‘most important’.
**p<0.001, *p<0.05.

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Table 2. Self-efficacy pre- and post-education assessments – baseline, 3 months, and 6 months post education
(N=285)

Self-efficacy Single-arm repeated ANOVA at differences over time Pairwise comparison

p
Baseline 3 months 6 months F p 3 months/ 6 months/
Mean (SD) Mean (SD) Mean (SD) baseline baseline
I can perform accurate assessment of 3.57 (0.903) 3.91 (0.752) 3.90 (0.749) 14.276 <0.001 <0.001 <0.001
smokers’ tobacco dependence
I can perform accurate assessment of 3.53 (0.829) 3.93 (0.780) 3.95 (0.688) 26.124 <0.001 <0.001 <0.001
smokers’ willingness to quit smoking
I can conclude various risks of smoking 3.56 (0.927) 3.04 (0.721) 3.96 (0.706) 20.527 <0.001 <0.001 <0.001
according to smokers’ characteristics
I can conclude various benefits of 3.79 (0.847) 4.04 (0.718) 4.05 (0.659) 10.096 <0.001 <0.001 <0.001
quit smoking according to smokers’
characteristics
I can offer some brief quit smoking 3.97 (0.738) 4.13 (0.680) 4.05 (0.640) 3.526 0.030 0.024 0.438
instructions for smokers
I can draw up brief quit smoking plans 3.52 (0.914) 3.92 (0.774) 3.84 (0.743) 17.180 <0.001 <0.001 <0.001
for smokers
I can arrange appropriate follow-up for 3.57 (0.876) 3.91 (0.802) 3.83 (0.736) 12.593 <0.001 <0.001 <0.001
smokers
P-values were calculated using single-arm repeated (ANOVA) at differences over time. Likert scale 1–5 = not confident to very confident. SD: standard deviation.

Table 3. Comparison of the self-reported 5As behaviors for assisting patients to quit smoking, 3 and 6 months
post education (N=285)

Delivery of 5As behavior One-way ANOVA at differences over time Pairwise comparison
p
3 months 6 months F 6 months/3 months
Mean (SD) Mean (SD)
Ask about smoking/tobacco use 2.70 (1.453) 3.19 (1.468) 16.114** <0.001
Advise patients to quit smoking 2.42 (1.302) 2.96 (1.362) 23.444** <0.001
Assess readiness to quit smoking 2.21 (1.230) 2.66 (1.392) 16.402** <0.001
Assist with smoking cessation 2.03 (1.087) 2.51 (1.350) 21.926** <0.001
Arrange smoking cessation follow-up 1.83 (1.055) 2.27 (1.295) 19.657** <0.001
The responses were scored 1–5: 1 = none; 2 = 1–3 patients; 3 = 4–9 patients; 4 = 10–25 patients; 5 ≥25 patients. Analyses performed using one-way ANOVA. SD: standard
deviation. **p<0.001.

comparisons between the baseline and 3 months between 3 and 6 months post education was
post education or 6 months post education (p>0.05), statistically significant. The details are shown in
except ‘I can provide some simple smoking cessation Table 3.
suggestions for smokers’ (p<0.05). The details are
shown in Table 2. Students’ assessments of tobacco cessation
education
Behaviors assisting patients to quit smoking The students’ views on the tobacco cessation course
after the tobacco cessation education were collected immediately after the learning process.
The nursing students delivered more 5As behaviors A total of 593 students shared their opinion, 95.2%
for assisting patients to quit smoking during clinical (565/593) of the students thought the content was
practicum. The difference in the 5As behaviors useful and 91.7% (544/593) indicated that the

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simulation helped them to perform better skills for DISCUSSION

assisting patients to quit smoking; 92.4% (548/593) This study suggests that the inclusion of tobacco
of the students perceived the online course materials cessation education, directed by the Guidelines5 and
uploaded by teachers quite suitable for the learning the Manual23, into nursing compulsory courses, in
objectives; 89.0% (528/593) of the students stated the form of a classroom didactic session, online self-
the course resources were helpful for them to prepare learning, and a scenario simulation session, effectively
for the simulation; 85.5% (507/593) of the students increased nursing students’ knowledge, skills, and
reported the simulation scenario was realistic; 84.8% confidence in tobacco cessation, which was consistent
(503/593) of the students were very satisfied with the with the results of previous studies16–19. This study
experience of timely support and instruction from the also found that students performed skills learned in
lecturers; 82.5% (489/593) of the students reported the course to actively assist patients to quit smoking.
well-organized education; 77.1% (457/593) of the These findings indicate that it is feasible and practical
students felt well prepared to provide assessment and to promote tobacco cessation knowledge and skills
counselling for patients who were smokers. for all nursing students and to increase the students’
In addition, the students shared the following behaviors for assisting patients to quit smoking.
experiences about tobacco cessation learning through The tobacco cessation education achieved relatively
an open-ended question, explaining that the training good results, probably because of the traditional
was valuable: ‘I had frequently persuaded my father didactic session with specific instruction on tobacco
to quit smoking but I failed as always. This course cessation health education theories such as the
helped me to know how to make a tailored plan for transtheoretical model of behavior change25, the 5As
my father to attempt to quit’; ‘I believe I can apply and 5Rs theoretical models of tobacco cessation, and
the skills learned here to solve practical problems’; ‘I the provision of the corresponding online resources.
learned how to provide specific assistance for patients Those online resources were about different cases
to quit smoking with the 5As model’; ‘I am confident with assistance from different medical professionals,
to provide help to quit smoking to families, relatives which were easily accessible and could be repeatedly
and friends’. learned17–19. The online Q and A helped students
The students reported that they implemented to solve problems in self-learning. The teachers
smoking cessation skills in practice: ‘I learned a lot supervised and checked the process and results of
of methods and measures of smoking cessation and the self-learning online. Students’ self-learning
used them on families’; ‘I learned the theories better was scored using the formative assessment for the
and can perform the 5As in practice’; ‘I grasped brief quantity, duration, and test result. Additionally, the
tobacco cessation methods and will apply the skills scenario simulations of 5As behaviors provided the
learned in class to future work’. opportunity for experimental learning16,17,19,26,27. The
The students spoke highly of the various resources scenario cases were similar to those encountered by
in the education. They thought: ‘Online resources are nurses during daily work, facilitating nursing students
very helpful to improve knowledge and skills about to apply knowledge into practice and to develop
tobacco cessation’; ‘Especially, the video about 5As their problem-solving competency. The simulation
skills offers direct instructions for scenario simulation, offered students realistic scenarios to role play and
encouraging me to take a good try’; ‘Those scenarios experience real situations, enhancing 5As behavior
are exactly the same as I encounter in real life’; ‘The skills by exploring communication and interaction
scenario simulation helps me to master the 5As with various clients and doing specific practice. This
interventions of smoking cessation. I can draw up brief blended online and offline teaching gave students
plans for smokers to quit and introduce to smokers novel experiences and was favored by students17,19,27.
the harm of smoking and benefits of quitting’; ‘The The tobacco cessation education did not affect
simulation also helps me to apply specific methods to the students’ role identification, likely because of
assist different smokers to quit’. Students said that the positive attitudes before the education. Chinese
they ‘would apply that knowledge and perform the nursing students were mostly female and few were
skills learned here in clinical practicum’. smokers; thus, they had very positive attitudes towards

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smoking cessation28. not serve patients at the time of the baseline survey.
Previous studies have indicated that teaching Fourth, the online self-reported changes instead of
resources for tobacco cessation education have direct observation of 5As behaviors or reading medical
been held back 29. This study designed content records might be incorrect, more or less, which is an
and developed resources from the Guidelines 5 inherent limitation of an online survey. Future studies
and the Manual23, which also provided free online should be conducted on direct tracking of tobacco
resources on their websites. Community Nursing is cessation interventions. Fifth, students’ knowledge
a compulsory course for baccalaureate students. It was less than 70% post education. One reason was
explicitly requires students to master health education that it was tested three months later, rather than
skills and to promote health. All Chinese schools can immediately. Finally, this study was implemented
access these resources and integrate tobacco education only in one university in Chongqing, China, and the
into compulsory courses, and therefore enhance the effectiveness might not be nationally representative.
corresponding knowledge and skills and help more Further studies in more universities and among
patients to quit smoking. It can also help to achieve different education degrees are needed.
the goal of decreasing the current smoking rate of
27.7% to 20% or lower the smoking population aged CONCLUSIONS
>15 years, by 203030. The integration of tobacco cessation education into
To the best of our knowledge, this is the first compulsory courses could enhance and improve
study to integrate tobacco cessation education into nursing students’ clinical knowledge and skills, and
a compulsory course in China. The results indicate also improve clinical skills for assisting patients to
important information for nursing schools, i.e. quit smoking.
smoking cessation skills can be effectively improved in
a clinic setting with no additional class time. Tobacco REFERENCES
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ACKNOWLEDGEMENTS
We thank the teachers and students who were involved in this research,
and also thank all the preceptors who helped us to conduct the survey
and all the students who completed the investigation. We give our
thanks to the directors and managers for their close support from the
nursing departments at the teaching hospitals in Chongqing.

CONFLICTS OF INTEREST
The authors have completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and none was reported.

FUNDING
This work was supported by Humanities and Social Sciences Research
Program 19SKGH024 from Chongqing Education Committee in 2019.

ETHICAL APPROVAL AND INFORMED CONSENT

This study was approved by the Ethics Committee of the First Affiliated
Hospital of Chongqing Medical University (No. 2019-157), and students
were informed that their participation was voluntary. Informed consent
was obtained before the tobacco cessation education.

DATA AVAILABILITY
The data supporting this research is available from the authors on
reasonable request.

AUTHORS’ CONTRIBUTIONS
All authors made substantial contributions to the conception and
design of the study, acquisition of data, analysis and interpretation
of data, drafting the article, revising it, and approved the submitted
version. LZ, XLH, HYC and LJ were involved in the research design.
LZ, MXJ, XLH and LJ conducted the compulsory course Community
Nursing and the tobacco cessation education program. LZ, TYL and
XLH cooperated in collecting and analyzing the data. LZ, HYC and
XLH contributed to the draft of the manuscript. HYC was in charge of
the accuracy of the concepts, the supervision of data collection and
analysis, and the interpretation of the data and manuscript preparation.
All authors have agreed on the final version of the manuscript.

PROVENANCE AND PEER REVIEW

Not commissioned; externally peer reviewed.

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