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Physicians can play a key role in smoking cessation but often fail to advise smokers effectively, mainly because they lack counseling skills. We need effective training programs starting during residency to improve physicians' smoking cessation interventions and smokers' quit rates. To achieve this goal, we developed a curriculum using active learning methods and the stages-of-change model. A randomized trial demonstrated that this program increased the quality of physician's counseling and smokers' quit rates at 1 year. This paper describes the educational content and methods of this program. Participants learn to assess smokers' stage of change, to use counseling strategies matching the smoker's stage, and to prescribe pharmacological therapy. This 2 half-day training program includes observation of video-clips, interactive workshops, role plays, practice with standardized patients, and written material for physicians and patients. Participants reached learning objectives and appreciated the content and active methods of the program.
Medical advice and pharmacological therapy are effective and cost-effective smoking cessation interventions in clinical practice.1 However, physicians lack the skills for smoking cessation counseling and often fail to advise smokers with effective strategies.2
Skills training and organizational change are the key features of effective educational programs improving patient outcomes.3 Role plays and practice with standardized patients are active methods enabling physicians and students to learn “by doing” the skills they need to apply in clinical practice.3,4 Organizational change strategies include reminder systems, flow sheets, patient education material, and staff involvement to reinforce application of new skills in clinical practice.3 The single smoking cessation training program that applied these strategies is the only effective curriculum showing a significant increase in quit rates at 1 year.5 Other programs based on didactic teaching improved physicians' practices in smoking interventions but had no impact on patients' smoking cessation.6,7
Smoking cessation is viewed as a process of change through successive stages with increasing motivation to quit, the stages-of-change model.8 Two programs applied this framework to teach physicians how to provide tailored counseling to smokers; both improved physicians' practices but obtained conflicting results on patients' smoking cessation.9,10
We developed and tested a new curriculum for residents based on active methods and the stages-of-change model to teach smoking cessation counseling skills that match the patient's motivation and appropriate use of pharmacological therapy. This paper aims to describe the innovative educational approach of this program, which has been shown to be effective in increasing smoking cessation.11 We hope it may be useful for those considering starting a similar program at their institution.
This project was initiated by its main sponsors, the Swiss Office for Public Health and the Swiss Medical Association. They contracted with both authors to develop and evaluate this new curriculum independently in 2 general internal medicine clinics in university hospitals of Geneva and Lausanne, Switzerland. Four factors facilitated the integration of this curriculum in the busy residency programs of both centers: 1) The recent transfer in both institutions of the existing general internal medicine clinic to a newly created department of community medicine, of which it is the main component. 2) The interest of these departments to include prevention and health promotion in primary care and to integrate public health with clinical practice. 3) The change in educational methods in both residency programs, with a shift from didactic teaching to interactive learning methods. 4) The availability of attending physicians (i.e., both authors) trained in general internal medicine and public health, with major interests in clinical prevention, smoking cessation, and medical education.
This training program is based on 5 principles: 1) Recent evidence-based content on tobacco use and cessation.1 2) Behavioral theory: applying the stages-of-change model to interventions which match the smoker's motivation to quit.8 3) Pharmacological therapy: teaching the appropriate use of nicotine replacement and bupropion for smoking cessation.1 4) Educational methods focusing on active skills training.3,4 5) Tobacco control context: use of national data on the burden of smoking-related diseases and adaptation of content to Swiss tobacco control policies.12
This training program is primarily designed for postgraduate education of residents. Teachers are the 2 authors, who are experienced physicians active in clinical practice and teaching. Teachers were previously trained in smoking cessation counseling during a Master of Public Health course, currently provide these interventions in clinical practice, and are considered as national experts in smoking cessation. Both sessions are run by 2 teachers.
At the end of the program, residents should have reached 8 major objectives. They will: 1) Systematically identify all patients who smoke and assess their level of nicotine addiction. 2) Clearly recommend smoking cessation to all smokers. 3) Assess each smoker's motivation about smoking cessation, using the stages-of-change model to synthesize the smoking cessation process along a continuum: 3.1) “Precontemplation”: no intention to quit smoking within 6 months. 3.2) “Contemplation”: serious intention to quit smoking in 1–6 months. 3.3) “Preparation”: plan to quit smoking within 30 days. 3.4) “Action”: smoking cessation for less than 6 months. 4) Counsel all smokers with strategies matching their motivation stage. 4.1) Minimal advice (<3 min) to inform and sensitize smokers in “precontemplation” with personalized messages: benefits of cessation, risks of smoking, and challenging beliefs. 4.2) Brief advice (3–10 min) to motivate smokers in “contemplation” to quit: balancing pros and cons of smoking, discussing personal barriers to cessation and their solutions, and presenting cessation methods. 4.3) Intensive counseling (>10 min) to help all smokers in “preparation” and “action” to quit and remain abstinent: showing support, setting a quit date, and planning behavioral strategies to prevent relapse in high-risk situations. 5) Prescribe nicotine replacement therapy or bupropion to addicted smokers in “preparation” or “action” with adequate instructions; second-line therapies are not detailed, as they are not registered for smoking cessation in Switzerland. 6) Offer written material matching patient's readiness to quit. 7) Follow-up smokers in the short and long term. 8) Organize and facilitate smoking cessation interventions in routine clinical practice.
The program is designed for 10 to 20 participants and includes two 4-hour sessions scheduled 2 weeks apart to allow practice between sessions. Educational activities include various methods emphasizing active skills training but also providing basic knowledge about tobacco use and cessation. Activities change in a specific order with increasing complexity: observation, analysis, role plays, and practice with standardized patients.
After an initial self-assessment of current smoking cessation practices, the first session has 3 parts focusing each on a patient successively in precontemplation, contemplation, and preparation stages. Each part includes an observation of a videotaped encounter between a smoker and a physician, an interactive workshop, and a role play between participants.
Participants observe 3 video-clips showing smoking cessation interventions by a primary care physician in 3 consultations with the same smoker who is successively in precontemplation, contemplation, and preparation stages. Using a checklist (Appendix I, available online at http://www.jgim.org), participants identify the smoker's motivation stage and the different smoking cessation strategies used by the physician, and then report their observations to the group.
After each video-clip, teachers use the clinical case and learners' observations to conduct a short interactive workshop; using a standard presentation, they provide concepts and evidence about stages of change, nicotine addiction, counseling strategies matching the smoker's motivation, and pharmacological therapy. In the third interactive workshop about smokers in the preparation stage, nicotine replacement products and bupropion are presented and their correct use demonstrated; second-line therapies are only briefly mentioned as they are not available for smoking cessation in Switzerland.
After each interactive workshop, participants group in trios to perform a role play based on a new scenario with a smoker who is successively at the precontemplation, contemplation, and preparation stages. Learners alternatively play the role of the patient, the physician, and the observer who analyzes the role play with the checklist (Appendix I, available online at http://www.jgim.org). After a brief report by all observers, role plays are debriefed with the whole group.
The second session is dedicated to the practice of smoking cessation interventions with standardized patients in small groups. Each participant plays once the role of the physician according to a scenario (Fig. 1) and observes others' interventions with the checklist (Appendix I, available online at http://www.jgim.org). The content and the style of each encounter are then discussed in the large group with input from standardized patients, observers, and “physicians.” Teachers comment on each encounter, answer questions, and support their comments with evidence.
Standardized patients, 2 women and 2 men, all former smokers, were recruited from a university program13 and were trained in four 1-hour sessions by 1 investigator (J-PH). Using written scenarios (example in Fig. 1), each standardized patient was trained to portray a smoker in precontemplation, contemplation, preparation, and action stages. Each has a different profile in terms of age, gender, social situation, cardiovascular risk factors, and smoking-related diseases.
At the end of the first session, participants receive a set of documents developed for this program to reinforce the physician's knowledge and skills in smoking cessation, to facilitate their implementation in clinical practice, and to provide appropriate information to patients. These documents include: 1) A reference manual summarizing the current knowledge on tobacco use and cessation in clinical practice and including a self-assessment before and after training.14 2) Two algorithms summarizing counseling strategies and pharmacological therapy designed for the physician's pocket or desk.14 3) A record sheet for consultations with smokers facilitating recording of information on tobacco use and smoking cessation interventions.14 4) A set of 6 brochures for patients matching the 6 stages of change: “precontemplation,” “contemplation,” “preparation,” “action,” “maintenance,” and “relapse”; these brochures were developed in conjunction with a computer-tailored program for smoking cessation.15,16 5) A set of patient instructions for use of each nicotine replacement product and bupropion.14
These documents were initially written in French and then translated into German, and will soon be available in English, Italian, and Spanish.
The participants attending the pilot phase evaluated this training program with a self-administered questionnaire (Appendix II, available online at http://www.jgim.org). Their mean (SD) ratings on a 4-point Likert scale show that they reached the major learning objectives: counseling smokers with strategies matching the stage of change (3.65 [0.49]), prescribing pharmacological therapy (3.60 [0.50]), and increasing their skills (3.70 [0.47]) and self-efficacy (3.53 [0.61]) in smoking cessation interventions. With their high mean (SD) ratings on a 5-point Likert scale, they valued the learning of skills applicable in their practice (4.68 [0.48]), their active involvement in learning activities (4.95 [0.23]), and their high global satisfaction (4.84 [0.37]).
We tested this program in both of our general internal medicine clinics with a cluster randomized trial, of which methods and results were already reported.11 Compared to the control group, trained residents used all smoking cessation strategies more often and provided counseling of higher quality, even after adjustment for clustering (mean overall score 4.0 vs 2.7; P = .001). Patients' smoking abstinence at 1 year was significantly higher in the intervention group (13% vs 5%; P = .005), corresponding to a cluster-adjusted odds ratio of 2.8 (95% confidence interval (CI), 1.4 to 5.5).
This paper describes an innovative evidence-based program using the stages-of-change model to teach residents how to provide counseling matching the smoker's motivation to stop and to prescribe pharmacological therapy. This program uses various active educational methods, particularly standardized patients to enhance the learning of counseling skills, and includes material facilitating implementation in clinical practice. This training program pleases most participants who achieve the educational objectives. A randomized trial showed that this training program is feasible and effective as it significantly increases the quality of residents' counseling, and most importantly, patients' smoking abstinence at 1 year.11
Our experience and results reflect the impact of the whole program and we cannot determine which components made it successful. We believe that active skills training, the stages-of-change conceptual framework, and its inclusion in the residency programs are the key elements that contribute to the effectiveness of this curriculum.
Our program emphasizes active learning of counseling skills with video-clip observations, role plays, and practice with standardized patients. It confirms that effective training programs must go beyond transmission of information and include skills training to change physicians' behavior and to improve patients' outcomes.3–5 Therefore, it is essential that educational programs define learning objectives in terms of physician's behavior and select appropriate learning methods enabling physicians to apply new knowledge and to practice new skills.
The use of the stages-of-change model as a conceptual framework probably contributes to the effectiveness of this program. Although application of this model in previous smoking cessation training programs resulted in conflicting results,9,10 it probably helps residents to understand the process of smoking cessation, to structure their interventions, and to have more realistic expectations of the effect of counseling.
Our experience shows that residency provides a unique opportunity for intensive training in smoking cessation. Residents appreciate active learning methods enabling them to reach learning objectives and to enhance their self-efficacy. They may then have the basic knowledge and skills in smoking cessation for their professional career. Three prerequisites are necessary to integrate successfully a smoking cessation curriculum in residency programs: program including learning objectives in preventive care, use of interactive educational methods, and availability of an expert trained in smoking cessation.
Like any medical service, training in smoking cessation should occur not only during postgraduate training, but also in medical school and continuing education programs. We must therefore develop a coherent and global approach to recognize smoking cessation as a routine clinical activity and to implement training during all phases of medical education. The feasibility and effectiveness of this program should ideally be tested in undergraduate and continuing education and its content and format eventually adapted. For 2 years, we have included practicing physicians in this program with the choice to attend either the first or both sessions; from our experience, this program is applicable for this audience who provided very positive feedback.
The next challenge is to promote and disseminate this program to train and involve more physicians.1 The dissemination process includes training future trainers, building networks with existing training institutions, medical associations, and health care services, reproducing printed material, and planning sessions that fit institutional needs. The extension of training programs to a large scale is a critical step in having a significant public health impact. If we want to reduce the harmful effects of tobacco smoking and bring significant long-term health benefits to a population, we need many trained physicians able to provide effective smoking cessation interventions.
We thank Alan Rubin, Associate Professor, University of Vermont, Burlington, VT, for his valuable reading and comments on the final version of this article. Grant support: Swiss Office for Public Health, Swiss Medical Association, and Swiss Foundation for Health Promotion.