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.