Our previous research documented a need for formal instruction in treating tobacco use and dependence in psychiatry residency training programs (21
). To address this need, we developed and evaluated an evidence-based 4-hour curriculum with 55 residents in three northern California psychiatry residency training programs. The curriculum resulted in significant changes in residents’ knowledge, attitudes, confidence, and behaviors for treating tobacco dependence among patients with mental illness. Changes pre- to posttraining were sustained at 3-month follow-up. To our knowledge, this is the first comprehensive curriculum that addresses tobacco use among smokers with mental illness, a group that is estimated to account for nearly one in two cigarettes sold in the United States (1
The uniformity of the curriculum’s effects with residents representing different residency programs, training years, smoking histories, and initial levels of interest in tobacco treatment supports the generalizability of the program. The effect of the training also can be conceptualized by the increase in the number of patients seen by residents who received attention to their tobacco use. On average, the 55 residents reported clinical encounters with 36 out-patients during the 3-month follow-up assessment window (1,980 patients in total). Based on the residents’ reported changes in the 5As, if a third of these patients were cigarette smokers (a conservative estimate), we estimate that the training resulted in 177 additional patients being advised to quit smoking, 189 being assessed for their readiness to quit, 157 receiving assistance with quitting, 131 receiving follow-up attention on tobacco, and 105 receiving tobacco treatment referrals. Changes in documented practices mirrored self-reported practice behavior. The chart review, though systematic, comprehensive, and evaluated for coding accuracy, was limited to UCSF because of the intensive nature of the chart review and restricted access to patient records at the other two sites. Generalizability of the study findings beyond residency programs in northern California and when taught by faculty other than study investigators is unknown and needs to be tested.
Dissemination of the curriculum to psychiatry residency training programs at a state or national level provides opportunity for even greater reach and impact. The costs of the training, which averaged $139 per resident, are nominal in light of the financial burden of tobacco use and the costs of psychiatry residency training (31
). The cost of 4 years of psychiatry residency training, inflated to 2006 dollars, is estimated at $400,000 per resident (32
). Based on this estimate, the tobacco treatment training would represent a 0.03% portion of total training costs. To reduce the potential costs of the training for dissemination, the resident and faculty materials are available on the internet as downloadable and printable PDFs (http://rxfor-change.ucsf.edu
). Identifying faculty available to provide the 4-hour training as part of their teaching commitments can lower the costs even further.
In the current study, the 4-hour training was provided in two to four sessions, providing flexibility in curriculum delivery across programs. Of note, better attendance was obtained when the curriculum was delivered in fewer sessions and when it was required. Attendance also was higher among residents in an earlier year of training and among those who endorsed greater interest in tobacco treatment training at pretest.
Although the curriculum resulted in significant changes in residents’ clinical practices, room for improvement remains. In particular, residents did not ask all of their patients about tobacco use. We recommend offering the training each year and working more toward implementing system-level changes to recognize, prioritize, and reinforce tobacco treatment practices at all levels of patient care. The curriculum was very highly rated, and all participants recommended that students at other psychiatry residency training programs would benefit from the tobacco cessation training.
Lastly, in addition to its primary application to tobacco treatment, the current study is offered as a potential model for developing other shared, evidence-based curricular materials for residency training programs. Several benefits of a shared tobacco education program are noteworthy: all programmatic materials can be maintained at a central location, with ease of access to the most current versions via the internet; resource sharing eliminates the need for duplication of efforts in developing and updating lecture materials, thereby saving faculty resources and providing administrative and economic incentive for adoption of tobacco education in general; and the materials benefit from the collective feedback from faculty who utilize the program. Because enhanced training yields increased delivery of cessation interventions in clinical practice (23
) and because clinicians have a proven positive influence on patients’ ability to quit (17
), we believe that efforts toward enhancing the tobacco cessation counseling skills of psychiatric residents will ultimately translate into reductions in tobacco use and improvements in public health among patients with mental illness.