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

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1 Smoking Cessation in Family Medicine: Effects of an Area Health Education Center Training Program Tracy L. Johns, PharmD Elizabeth Lawrence, MD Leila E. Martini, MPH, MLS Grace E. Dunn, MD Zachary J. Thompson, MS Kira Zwygart, MD Abstract Background and Objectives Many clinicians have not received adequate training in smoking cessation. We examined the effects of a tobacco training program on clinician behavior, attitudes, knowledge, and comfort related to smoking cessation. Methods In a prospective cohort study, family medicine residents and faculty completed a pretest, followed by an educational intervention that encompassed presentations on smoking cessation resources, motivational interviewing, and the neurobiology of addiction and pharmacotherapy. After 3 months, participants completed a postintervention survey. Results were analyzed using chisquare tests to examine the effects of training. Results Thirty-three residents and faculty completed the pretraining survey and 25 completed the posttraining survey. Following training, participants were more familiar and comfortable with Public Health Service Clinical Practice Guidelines (P,.0001). No significant differences were found in performance of the 5 As (Ask, Advise, Assess, Assist, and Arrange) or other behaviors, including providing assistance with counseling, cessation plans, resources, or pharmacotherapy. There were no improvements in knowledge of specific intervention plans or attitudes related to identifying and counseling smokers. Conclusion A multidisciplinary tobacco training program increases clinician familiarity and comfort with practice guidelines, and may contribute to improving care activities that promote a healthy lifestyle. Future research should explore other interventions that have the potential of changing practice patterns on a larger scale. Future studies should also assess the effect of training programs on patient-oriented outcomes. Editor s Note: The online version of this article includes the survey instrument used in this study. Introduction 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 Tracy L. Johns, PharmD, and Elizabeth Lawrence, MD, are faculty in the University of South Florida Family Medicine Residency; Leila E. Martini, MPH, MLS, is Assistant Director of the Tobacco Program at the University of South Florida Area Health Education Center; Grace E. Dunn, MD, is a second-year medical resident in the University of South Florida Family Medicine Residency; Zachary J. Thompson, MS, is a Statistical Consultant in the University of South Florida Biostatistics and Epidemiology Center for Collaborative Research; Kira Zwygart, MD, is Assistant Professor, University of South Florida College of Medicine, Department of Family Medicine. Financial support for this study was provided by the Florida Department of Health. Corresponding author: Tracy L. Johns, PharmD, University of South Florida Family Medicine Residency, Morton Plant Mease Health Care, Turley Family Health Center, 807 N Myrtle Avenue, Clearwater, FL 33755, , tracy.johns@baycare.org Received March 8, 2010; revision received March 23, 2010; accepted April 29, DOI: /JGME-D 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, 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 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 Journal of Graduate Medical Education, June

2 TABLE 1 Overview of the Tobacco Training Program Element Time, min Description Introduction 15 Materials and instruction on how to use tobacco cessation resources in everyday practice Motivational interviewing 60 Basic components of motivational interviewing Neurobiology of addiction, complications, and pharmacotherapy 60 Physiological actions of nicotine, the process of addiction, and medical complications arising from tobacco use; effectiveness and safety of pharmacotherapy 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 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 evidencebased 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. Methods Participants and Setting 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 patient visits at the clinic in 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. Interventions 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 explaining the study, which included a link to an online pretraining survey. A reminder 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 ) and USF (No 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- 284 Journal of Graduate Medical Education, June 2010

3 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 nicotinereplacement therapy (over-the-counter and prescription formulations), bupropion SR, varenicline, and combination therapy. Extended use of pharmacotherapy, costeffectiveness 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 with a link to the posttraining survey, which was identical to the pretraining survey. Reminder s were sent and a reminder flyer was placed in each participant s administrative mailbox. Statistical Analysis 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. Results 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. Discussion 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 Journal of Graduate Medical Education, June

4 TABLE 2 Behaviors Related To Smoking Cessation Behavior Survey Time a Never, n (%) Sometimes, n (%) Often, n (%) Always, n (%) P Value Ask Pre 3 (9.1) 19 (57.6) 11 (33.3).8718 Post 2 (8) 13 (52) 10 (40) Advise Pre 1 (3) 8 (24.2) 24 (72.7).5425 Post 9 (36) 16 (64) Assess Pre 1 (3) 7 (21.2) 13 (39.4) 12 (86.4).234 Post 2 (8) 15 (60) 8 (32) Assist Pre 7 (21.2) 17 (51.5) 9 (27.3).2479 Post 2 (8) 12 (48) 11 (44) Arrange Pre 1 (3) 7 (21.2) 9 (27.3) 16 (48.5).1293 Post 2 (8) 13 (52) 10 (40) Counseling Pre 1 (3) 6 (18.2) 9 (27.3) 17 (51.5).7818 Post 6 (24) 8 (32) 11 (44) Cessation Plan Pre 4 (12.1) 17 (51.5) 11 (33.3) 1 (3.0).7506 Post 1 (4) 14 (56) 9 (36) 1 (4) Resources Pre 5 (15.2) 14 (42.4) 9 (27.3) 5 (15.2).3457 Post 5 (20) 5 (20) 9 (36) 6 (24) Pharmacotherapy Pre 7 (21.2) 22 (66.7) 4 (12.1).0174 Post 5 (20) 9 (36) 11 (44) a Survey questions asked before (Pre) or after (Post) training. 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 TABLE 3 Comfort Related To Caring for Patients Who Smoke Comfort Survey Time a Very Uncomfortable, n(%) Uncomfortable, n (%) Comfortable, n (%) Very Comfortable, n (%) P Value Counseling Pre 2 (6.1) 18 (54.5) 13 (39.4).7870 Post 1 (4) 12 (48) 12 (48) Guidelines Pre 5 (15.2) 20 (60.6) 6 (18.2) 2 (6.1),.0001 Post 4 (16) 17 (68) 4 (16) Pharmacotherapy Pre 4 (12.1) 15 (45.5) 14 (42.4).1964 Post 13 (52) 12 (48) Monitoring Pre 2 (6.1) 1 (3) 21 (63.6) 9 (27.3).3125 Post 14 (56) 11 (44) a Survey questions asked before (Pre) or after (Post) training. 286 Journal of Graduate Medical Education, June 2010

5 FIGURE Percent Change After Training Versus Before Training in Comfort Related To Caring for Patients Who Smoke 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 realtime 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. References 1 Centers for Disease Control. Reducing the Health Consequences of Smoking: 25 Years of Progress: a Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Public Health Service; Centers for Disease Control. Smoking-attributable mortality, years of potential life lost, and productivity losses: United States, MMWR Morb Mortal Wkly Rep. 2008;57(45): Centers for Disease Control. Surgeon General s reports on smoking and tobacco use. 2006: the health consequences of involuntary exposure to tobacco smoke. Available at: index.htm. Accessed April 17, Collins BN, Levin KP, Bryant-Stephens T. Pediatricians practices and attitudes about environmental tobacco smoke and parental smoking. J Pediatr. 2007;150(5): Centers for Disease Control. Cigarette smoking among adults: United States, MMWR Morb Mortal Wkly Rep. 2008;57(45): Hatsukami DK, Stead LF, Gupta PC. Tobacco addiction. Lancet. 2008;371(9629): Okuyemi KS, Nollen NL, Ahluwalia JS. Interventions to facilitate smoking cessation. Am Fam Physician. 2006;74(2): National Quality Measures Clearinghouse. Smoking cessation: percentage of members 18 years of age and older who are current smokers, who were seen by a health plan practitioner during the measurement year for whom smoking cessation medications were recommended or discussed. Available at: aspx?doc_id Accessed April 29, Gorin SS, Heck JE. Meta-analysis of the efficacy of tobacco counseling by health care providers. Cancer Epidemiol Biomarkers Prev. 2004;13(12): Katz DA, Muehlenbruch DR, Brown RL, Fiore MC, Baker TB. Effectiveness of implementing the agency for healthcare research and quality smoking cessation clinical practice guideline: a randomized, controlled trial. J Natl Cancer Inst. 2004;96(8): Journal of Graduate Medical Education, June

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