Smoking Cessation in Family Medicine: Effects of an Area Health Education Center Training Program Open Access

Smoking is the single most preventable cause of death in the United States.1 It harms nearly every organ of the body, causing or contributing to numerous diseases and reducing the health and life expectancy of smokers.2 Nonsmokers are affected as well; almost 60% of children age 3 to 11 years in the United States are exposed to environmental tobacco smoke daily.3,4 Annually, 443 000 people in the United States die prematurely as the result of smoking or exposure to tobacco smoke.2 Even with this significant morbidity and mortality, 19.8% of adults in the United States currently smoke. At least 39.8% of these have made one or more attempts to quit in the preceding year.5 Unfortunately, quitting smoking is extraordinarily difficult. The processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine.6 Almost one third of those who try a cigarette become addicted to nicotine.7 

Despite the difficulty of smoking cessation, 70% of smokers report that they are interested in stopping. They also report being more likely to quit if a doctor advised them to do so. Encouragingly, several clinical trials have demonstrated that even brief advice on smoking cessation is associated with a 30% increase in the number of people who quit smoking.8–10 Clinicians are clearly a vital component in the smoking cessation process. However, physician intervention rates are low.11,12 Potential barriers to physician intervention include a lack of time, knowledge, or confidence in the effectiveness of the activity.4 A 2008 study demonstrated that less than 6% of health care providers know the US Agency for Healthcare Research and Quality treatment guidelines for tobacco dependence. One possible explanation for lack of knowledge among physicians is lack of education in this area. Eighty-seven percent to 93% of doctors and other health care workers receive fewer than 5 hours of training on tobacco dependence and cessation methods.13 A 2002 meta-analysis of articles on tobacco intervention and medical education confirmed that gaps in undergraduate medical education existed, particularly in integration of tobacco-dependence information and specific training in smokeless tobacco intervention. They also found that enhanced instructional methods, such as those demonstrating patient-centered counseling, were more effective than traditional didactic methods alone.14–16 Indeed, recent studies have demonstrated positive behavior changes with special educational programs.17,18 

The University of South Florida (USF) Area Health Education Center Tobacco Program provides education and support services with the goal of strengthening the capacity of Florida's health care system to deliver effective evidence-based tobacco use treatment, cessation, and prevention services. This program, in conjunction with the USF Morton Plant Mease Family Medicine Residency, proposed to examine the current behaviors, attitudes, knowledge, and comfort regarding tobacco-cessation techniques among health care providers at the residency, to provide training for those clinicians, and to examine the effects of the training.

The participants in this study were 25 family medicine residents and 15 faculty at the Turley Family Health Center, located in Clearwater, Florida. The Turley Family Health Center is a community-based clinic that is the main outpatient facility for the USF Morton Plant Mease Family Medicine Residency. There were 22 400 patient visits at the clinic in 2008. The population served is 38% male and 62% female. Fifty-one percent of the patients have Medicaid, 12% have Medicare, 27% have commercial insurance, and 10% are self-pay.

This study used a pretraining and posttraining program survey design. The survey was adapted from one previously published and was used with permission from the authors. One week prior to the training program, eligible participants received an e-mail explaining the study, which included a link to an online pretraining survey. A reminder e-mail was also sent during the course of the week. The opening page of the survey was an informed consent form, which was followed by questions designed to measure the participants' practices related to smoking cessation. The research protocol was approved by the institutional review board for Morton Plant Mease (No. 2009.005) and USF (No. 107642 I).

The Tobacco Training Program was conducted during a monthly 2.5-hour noon symposium, which is part of the usual didactic curriculum for the residency. The program, components of which are outlined in table 1, was presented by a multidisciplinary team consisting of clinicians specializing in public health, psychiatry and behavioral medicine with training in motivational interviewing techniques, and internal medicine.

The program began with an introduction and distribution of resource materials, including presentation slide sets, Area Health Education Center Tobacco Cessation Clinician Resource booklet, Tobacco Treatment Chart, Readiness Ruler, Florida Quit-for-Life Line Referral Form, list of TobaccoCME.com online modules, Patient Quit-Line brochures, Healing Timeline magnet, and a Quit-Line magnet. The US Public Health Service Guidelines on tobacco cessation were reviewed, along with the Fagerström Test for tobacco addiction and the 5 As of smoking cessation counseling (Ask, Advise, Assess, Assist, and Arrange).

The next segment of the training program focused on the basic components of motivational interviewing. A didactic portion described the REDS techniques, including rolling with resistance by acknowledging reluctance and ambivalence but not directly confronting it, expressing empathy by reflective listening, developing discrepancy between the patients' values and their current behavior, and supporting self-efficacy. The OARS technique was also reviewed. Components of this method include asking open-ended questions that address the potential of changing the patients' behavior, affirming, reflecting any change talk, and summarizing key points. These techniques were also demonstrated in previously videotaped role-playing scenarios. After video demonstration, the audience reflected on the content and offered feedback on problems encountered and interventions to improve motivation. The use of an importance or confidence ruler was also explored. This tool asks patients to identify on a scale of 0 to 10 (lowest to highest) how important it is to stop smoking and how confident they are that they could quit. The results are used to set goals for smoking cessation.

The final portion of the training program included education on the physiological actions of nicotine, the process of nicotine addiction, medical complications of tobacco abuse, and nicotine-withdrawal symptoms. The effectiveness, safety, and appropriate use of pharmacotherapy were also reviewed, including nicotine-replacement therapy (over-the-counter and prescription formulations), bupropion SR, varenicline, and combination therapy. Extended use of pharmacotherapy, cost-effectiveness of interventions, and relapse were also discussed.

Any eligible participants who were unable to attend the training program were permitted to view a video recording of the event. They were also provided with a copy of all of the materials distributed. Following a 3-month implementation period, the participants were again sent an e-mail with a link to the posttraining survey, which was identical to the pretraining survey. Reminder e-mails were sent and a reminder flyer was placed in each participant's administrative mailbox.

Descriptive summary statistics were calculated for each item. Chi-square tests were used to analyze differences in distribution of responses to single items before and after the training program. When no participants responded in a pretraining or posttraining survey category, the category was deleted to allow data analysis. Furthermore, if no participants responded in a posttraining survey category, then the pretraining responses for that category were merged with the count in the adjacent category and treated as new category. Because there were multiple hypothesis tests on the survey data, the Bonferroni correction was used to control the family-wise error rate.

The online survey was completed by 33 participants prior to the training program (response rate, 82.5%). Of the 40 eligible participants, 24 attended the live program and 6 received a packet containing the conference video. Approximately 3 months after the program, the same survey was completed by 25 providers (response rate, 62.5%). Overlap between pretraining and posttraining survey participants was 51.5% (17 of 33). There were no significant differences between groups in the percentage of their patients estimated to be smokers before and after training.

Results related to smoking cessation behaviors are summarized in table 2. Participants were asked how often they perform the elements of the 5 As in patient care. No statistically significant differences were found between surveys in the response distributions. All but 1 participant reported these activities at least “sometimes” before and after the training program. No significant differences were found in the percentage of participants providing assistance with counseling, cessation plans, resources, or pharmacotherapy before and after the training program.

Survey questions assessing knowledge before and after training show mixed results. No significant differences were found in the distribution of responses before and after training related to use of specific pharmacotherapy or a specific intervention plan. The survey question related to the Public Health Service Clinical Practice Guidelines revealed a significant difference in the percentage of participants who were familiar with these recommendations. Prior to training, 12% (4 of 33) were familiar with these guidelines, whereas 88% (22 of 25) expressed knowledge of these guidelines after the program (P < .0001).

Significant differences in attitudes toward smoking cessation as a result of the training program were not found. The distribution of responses was similar in the pretraining and posttraining survey related to how important it is to identify patients who smoke. Whether prior to or after training, identifying patients who smoke was listed as at least “important.” Similar results were noted for attitudes toward counseling.

Assessment of comfort in caring for patients who smoke was a major component of the survey. Questions were asked about comfort with counseling, use of the Public Health Service Clinical Practice Guidelines, pharmacotherapy, and following patients to help them sustain their cessation plan. table 3 shows the results for this part of the survey. Only comfort with practice guidelines was significantly improved after training (P < .0001). There was no significant difference in the responses before and after training pertaining to comfort with other elements of this category. The figure illustrates the magnitude of change in individual responses after training relative to before training.

The Tobacco Training Program increased awareness of and comfort in using the Public Health Service Clinical Practice Guidelines to help patients with tobacco cessation. Guidelines were reviewed in didactic format and also provided in enduring printed materials. This is a common intervention in efforts to change practice patterns. Evidence of benefit has been shown in a recent systematic review that demonstrated improved process outcomes (prescribing patterns and other smoking-cessation activities) with printed educational materials compared with no intervention. Unfortunately, patient outcomes were not positively affected by printed materials in that review.19 

Printed educational materials are only one aspect of comprehensive continuing medical education. Evidence-based educational guidelines have been published to give direction on teaching methods that might lead to improved patient care outcomes.20 Recommendations for programming in these guidelines include the use of multiple media, multiple instructional techniques, and multiple exposures. We used printed as well as live media in our training program. We also used several techniques for teaching, including lectures, role playing, group discussion, and reflection.

Even with this multifaceted program, many elements of care to promote smoking cessation did not improve after training, suggesting there are areas of education in smoking cessation needing further study. Innovative teaching methods should be developed and examined for effects on provider behaviors and attitudes. These might include real-time patient case presentations or videotaping with facilitator feedback. There is also the potential for participation in formal smoking-cessation programs as part of the residency curriculum. Perhaps retrospective reviews of patient charts and recommendations for improvement would be helpful. In addition, it is possible that repeated exposures to smoking-cessation interventions will change the culture in our program such that subsequent research will show improvement in process and outcome measures, such as patients receiving counseling or those successfully quitting.

The investment for a training program such as the one in our study is likely minimal. Costs associated with the program include those for printed materials and time. If not available free online, many printed materials can be obtained from local agencies. Time for presentations given in our program may be part of the usual activities of academic faculty. More research is needed to determine if a program such as the one we describe is cost-effective.

Our study has limitations. First, the sample size in our study may not have been large enough to detect significant differences in many of the survey responses. Second, we adapted our survey instrument from one that had been previously validated.21 We omitted several questions related to use of a handheld computer devise as they were not applicable, and changed the Likert scale for assessing attitudes and comfort from a 7-point to a 4-point range. This was done to allow precise description of the label assigned to each number of the scale and enhance consistency in participant interpretation.

In conclusion, we have shown that a multidisciplinary postgraduate tobacco training program can increase health care provider familiarity and comfort with clinical practice guidelines. The multifaceted program used in our study is a reproducible and efficient mechanism to provide education that may improve patient care outcomes. However, other innovative educational methods should be developed and studied for effects on health care provider behaviors, knowledge, and attitudes.