0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Review | Clinician's Corner

Tobacco Intervention Training:  Current Efforts and Gaps in US Medical Schools FREE

John G. Spangler, MD, MPH; Geeta George, MPH; Kristie Long Foley, PhD; Sonia J. Crandall, PhD
[+] Author Affiliations

Author Affiliations: Department of Family and Community Medicine (Drs Spangler and Crandall) and Department of Public Health Sciences (Dr Foley), Wake Forest University School of Medicine, Winston-Salem, NC; and Department of Behavioral Science, University of Texas M. D. Anderson Cancer Center, Houston (Ms George).


JAMA. 2002;288(9):1102-1109. doi:10.1001/jama.288.9.1102.
Text Size: A A A
Published online

Context Research has documented that US medical schools inadequately teach tobacco intervention skills.

Objective To examine effective training methods for tobacco intervention in undergraduate medical education.

Data Sources Using indexing terms related to tobacco intervention and medical education, we searched MEDLINE (1966–June 2002) and the Cochrane Database of Systematic Reviews (through issue 2, 2002). Reference lists of relevant articles were also read to identify additional articles. Because of their importance to tobacco intervention, we also reviewed Ockene and colleagues' tobacco education research and the tobacco treatment guidelines of the United States Public Health Service and the United States Preventive Services Task Force.

Study Selection All study designs that incorporated process or outcome evaluation of tobacco intervention educational methods for medical students were included in this review. Of an initial 1241 articles retrieved, 82 included medical students. Reviewing abstracts and references of these articles identified 13 pertinent studies.

Data Extraction Quality criteria for inclusion consisted of explicit evaluation of the educational methods used. Data extraction identified all evaluations and any problems in program implementation.

Data Synthesis Enhanced instructional methods (eg, the use of patient-centered counseling, standardized patient instructors, role playing, or a combination of these) are more effective for teaching tobacco intervention than are traditional didactic methods alone and can be effectively inserted into medical school curricula.

Conclusions Various educational methods have been used to train medical students in tobacco intervention. Nonetheless, gaps still exist within undergraduate medical education, including a lack of integration of tobacco dependence information throughout all 4 years of medical school curricula, specific training in smokeless tobacco intervention, tobacco intervention training that addresses cultural issues, and long-term studies showing that such training is retained.

Tobacco use is the leading cause of preventable death in the United States and is responsible for more than 400 000 deaths annually, largely from cardiovascular disease and cancer.1 Unfortunately, despite nearly 5 decades of research linking tobacco use to ill health, about one quarter of the US adult population still smokes.2 While the prevalence of cigarette smoking has declined over the past few decades, the rate of decline has been slowing.2,3 In fact, cigarette smoking among adolescents appears to be increasing,3,4 and its prevalence remains high among certain minority populations such as Native Americans.5,6 The problem is not limited to cigarettes, since other tobacco products have also recently increased in popularity. Per capita consumption of smokeless tobacco, for example, has tripled in the past 3 decades,7 with use especially common among minority populations, those living in the rural South, and adolescent boys.5,8,9 This addictive product delivers relatively large doses of nicotine10 and has its own array of associated health effects.11,12 The prevalence of cigar smoking is also increasing, particularly among young white men,13 placing these smokers at risk of oral cancer, lung cancer, chronic obstructive pulmonary disease, and other diseases.13,14

Physicians play a critical role in addressing tobacco use.15 Nearly 70% of current smokers would like to quit,16 and an equal number state that they would quit if offered firm advice by their physicians.17 Unfortunately, several studies1820 have documented physicians' failure to counsel their patients to stop smoking, and most smoking patients are not advised or assisted in a cessation attempt.21,22

One reason for this is that physicians often perceive that they are ill-prepared in treating patients addicted to nicotine.23 A 1991 survey showed that only 21% of practicing physicians believed that their formal medical training prepared them to help patients stop smoking.24 More recent data25,26 indicate that a majority of medical school graduates still are not adequately trained to treat nicotine dependence. Using a 13-item questionnaire based on the US Public Health Service's guidelines27 and a National Cancer Institute expert panel,26 Ferry and colleagues25 surveyed 122 of the 126 US medical schools. These investigators found that only 3 schools had a required course devoted specifically to tobacco treatment. About a third of the schools surveyed (31.4%) spent 3 hours or less teaching smoking cessation counseling during the 4 years of medical school education. Moreover, most medical schools (69.2%) did not require clinical training in smoking intervention techniques. A major deficit in medical school education nationally, as Ferry et al suggest,25 is the lack of smoking intervention instruction and evaluation in the clinical years. Unfortunately, no national curricular models exist to guide schools in determining the content of tobacco dependence instruction or how it should be implemented.

Major health care organizations and authorities recommend that physicians provide their patients routine tobacco interventions.15,27 The most explicit and comprehensive tobacco intervention guidelines were recently published by the US Public Health Service27 and have been found to be cost-effective if used intensively. According to these guidelines, the key elements of smoking intervention counseling include providing reinforcement through repeated and consistent advice from a team of practitioners to stop smoking, setting a specific quit date, and scheduling follow-up visits.15,27 With the addition of pharmacotherapy and individual contact using problem solving and social support approaches, cessation rates can be increased by a factor of 2 or more.27

Because physicians often cite lack of time as a barrier to providing tobacco interventions,27 it is important to know if brief tobacco interventions improve patient outcomes. This is especially important before educational resources are devoted to training medical students in brief tobacco interventions. A recent Cochrane review28 of pooled data from 16 studies found evidence that brief tobacco interventions by physicians lead to higher odds of a patient quitting (summary odds ratio [OR], 1.69; 95% confidence interval [CI], 1.45-1.98).

A meta-analysis of 7 studies by the US Public Health Service27 found that brief physician advice (eg, ≤3 minutes) resulted in a small but statistically significant increase in cessation rates (summary OR, 1.3; 95% CI, 1.1-1.6). Additionally, a 43-study meta-analysis by this group27 indicated that minimal counseling (≤3 minutes) by clinicians increases patient abstinence rates (summary OR, 1.3; 95% CI, 1.01-1.6). Finally, a 35-study meta-analysis by the US Public Health Service27 indicated that a total contact time of 1 to 3 minutes focused on tobacco intervention increased abstinence rates (summary OR, 1.4; 95% CI, 1.1-1.8). The cumulative effects of providing at least brief advice to all patients who smoke could result in thousands of additional US citizens quitting smoking each year.27

The US Public Health Service guidelines do not emphasize smokeless tobacco intervention to the same extent as that for smoking intervention, given the greater prevalence of cigarette smoking.27 Nonetheless, smokeless tobacco use is increasing within certain populations.4,7 Thus, these guidelines suggest that smokeless tobacco users should also be identified, strongly urged to quit, and provided the same treatment as smokers.27 Brief advice to quit has also been found to increase smokeless tobacco abstinence rates.27,29

We systematically searched MEDLINE (1966–June 2002) and the Cochrane Database of Systematic Reviews (through issue 2, 2002) using the following search terms: health promotion, counseling, tobacco, tobacco use, smoking cessation, spit tobacco, and smokeless tobacco. Each of these terms was then separately combined with the following terms: medical education, medical students, residents, standardized patients, simulated patients, role playing, and curriculum. Only studies that involved process or outcome evaluation of medical student educational methods were selected for review. Given the varied nature of education research, all types of study designs were included. Of an initial 1241 articles retrieved, 82 were identified as including medical students. Abstracts and reference lists of these articles were read, identifying 13 studies3042 that evaluated outcomes of medical student tobacco educational activities (Table 1). Because of their importance to tobacco treatment education, we also reviewed tobacco education research by Ockene and colleagues4348 and the tobacco intervention guidelines of the US Public Health Service27 and the US Preventive Services Task Force.15

Table Graphic Jump LocationTable. Studies of Medical Student Education Methods for Tobacco Intervention Training*

Given the barriers to incorporating tobacco curricula into medical schools,49 it is frequently difficult to carry out educational studies with randomized or even prospective designs. With these caveats in mind, we dichotomized tobacco education research into traditional didactic approaches, such as lectures or provision of reading materials alone,32,33,38,39,42 and more "enhanced" methods of teaching that include instruction in patient-centered counseling, critiqued interaction with standardized and real patients, and role playing.30,31,3441

Traditional Didactic Approaches

Lectures and assigned readings are straightforward means of conveying tobacco control information to medical students, and several investigators have evaluated them. At the University of Hong Kong (Hong Kong, China), Chung et al33 provided students with a brochure on tobacco intervention and incorporated a tobacco control lecture, a tobacco epidemiology videotape, and small-group discussions on the health effects of tobacco use into the second-year curriculum for all medical students (n = 151). Changes in tobacco knowledge and attitudes were assessed through a 51-item questionnaire administered before and after the intervention. At the end of the intervention, students demonstrated increased knowledge and more favorable attitudes regarding tobacco intervention among patients.

Wadland and colleagues42 at Michigan State University (East Lansing) incorporated 10 hours of tobacco instruction into the existing medical school curriculum, including all 12 content areas advocated by Ferry et al.25 Next, during the third year, all medical students rotating through family medicine (n = 93) were evaluated by a videotaped encounter with a standardized patient. This videotape was scored by the investigators using a scale based on the US Public Health Service guidelines.27 Of a possible 10 points, students' scores ranged from 6.5 to 10, with 90% of students scoring 8 or better.

Boehlecke et al32 at the University of North Carolina (Chapel Hill) compared the effect of lecture, a 1-page smoking history and counseling guide, and prompts to faculty preceptors on the smoking intervention skills of 2 consecutive classes of second-year medical students. The first class was assigned to the control condition (n = 155), which consisted of a lecture on tobacco history taking and provision of the 1-page tobacco counseling guide to faculty preceptors. The second class (n = 158) received the lecture and the 1-page guide; in addition, about half of their faculty preceptors received a telephone reminder about the 1-page guide. Compared with control students, intervention students performed better on an Objective Structured Clinical Examination station that assessed smoking intervention skills at the end of their second year.

While these traditional educational efforts seemed to be effective, none compared use of lectures or reading materials to patient-centered counseling, critiqued interaction with standardized or real patients, or role playing. Other research,38,39 however, has shown that such enhanced instructional methods for tobacco intervention are more effective than traditional approaches alone.

Patient-Centered Methods

Much of the smoking intervention education research for physicians, residents, and medical students has been based on the work of Ockene and colleagues.4348 These investigators have developed a brief, patient-centered treatment paradigm that uses information sharing, open- and closed-ended questions, and identification of patient motivation for and past experiences with smoking cessation. These factors are utilized by the clinician to increase the patient's self-efficacy by recognizing his or her own skills and resources to quit. This information leads to individualized treatment and follow-up plans. Kristeller and Ockene48 incorporated these materials into the curriculum at the University of Massachusetts School of Medicine to train medical students in patient-centered tobacco intervention. Ockene et al have also used their patient-centered methods to train residents in the internal medicine and family practice residency programs at the University of Massachusetts (Worcester).43,44,47 On completion of the training program, residents showed significant increases in knowledge about and attitudes toward smoking and smoking intervention, patient-centered counseling skills, and ability to affect their patients' smoking behavior.

Using the patient-centered approach of Ockene et al, Allen et al30 studied second-year medical students rotating through the family medicine segment of an introductory clinical medicine course at the University of Minnesota (Minneapolis). Students were randomly assigned by rotation block to the 2-hour intervention workshop training (n = 98 students) or a control condition (n = 90 students) consisting of standard orientation to family medicine. The intervention included lectures, videotaped examples of patient-centered counseling, and patient-centered role playing among students to teach treatment of cigarette smoking. All students were evaluated by an Objective Structured Clinical Examination with a standardized patient who smoked. Compared with students in the control group, students who participated in the intervention were more confident in their smoking intervention skills, asked more open-ended questions about patients' past experiences with cessation attempts, and performed better on the overall process of patient-centered counseling.

Seim and Verhoye39 likewise combined the patient-centered approach with other teaching methods in a study among fourth-year medical students in an ambulatory family medicine elective at the University of Minnesota (Minneapolis). Students were randomly assigned by rotation block to either a formal-training group (n = 37) or a brief-training group that served as the control (n = 33). The formal-training group received lectures and reviewed videotapes on patient-centered counseling, reviewed a smoking cessation algorithm, and role-played among themselves. The brief training group received only a 5-minute overview of patient-centered counseling techniques and the smoking cessation algorithm. Based on review of audiotaped interactions with standardized patients, students in the formal training group scored higher on 3 of 6 smoking intervention content areas (exploring past experiences, determining resources for change, and negotiating a plan) and 2 of 3 patient-centered counseling skills (providing information and eliciting or responding to feelings). Enhanced teaching methods improved medical students' tobacco intervention skills beyond traditional educational approaches.

Standardized Patient Instructors

In addition to the patient-centered approach, standardized patient instructors (SPIs) have been used by many investigators in medical school smoking intervention curricula. Standardized patient instructors are trained lay individuals who act as patients, usually following a standardized script and giving students objective feedback. They have been used frequently to teach medical students, residents, and physicians interviewing and counseling techniques. Stillman et al50 and Levenkron et al51,52 used SPIs to instruct medical students in a variety of health promotion and interview skills. Most pertinent to tobacco treatment is the University of Rochester Risk Factor Interview Scale (URRFIS) of Levenkron et al,5153 on which an SPI experience for medical students can be based. This 12-item scale was originally developed to characterize and quantify the skills required of physicians and medical students for coronary artery disease risk factor counseling but is easily adapted to tobacco intervention.3540 When used by SPIs to evaluate third-year medical students, the URRFIS has demonstrated a high degree of interrater reliability (R = 0.88) and internal consistency (α = .76).52

Levenkron and colleagues53 tested the effectiveness of SPI interactions on cardiovascular risk factor counseling prospectively among 2 consecutive classes of second-year medical students at the University of Rochester (Rochester, NY). The first class of students (n = 92) learned risk factor counseling (which included advice to quit smoking) through lecture and small-group discussion and the second class (n = 91) by interacting with SPIs. Both classes of students were followed up 6 months later with objective testing by SPIs using the URRFIS. Students from the class that interacted with the SPIs had greater improvement from baseline on all subscales of the URRFIS between their first and second SPI interactions. The authors concluded that cardiovascular risk factor counseling for medical students may be taught effectively by SPIs and that the learning appears durable for at least 6 months after instruction. In this study, students did not receive specific instruction or feedback regarding tobacco treatment skills.

A further study by Eyler et al35 found that SPI interactions using URRFIS-based feedback can be used to teach medical students smoking intervention skills. In this nonrandomized study, all third-year medical students (n = 159) rotating through general internal medicine at the University of Michigan (Ann Arbor) were assigned required reading on smoking intervention and spent 1 hour interacting with SPIs. Students assessed themselves using the URRFIS and were also evaluated by the SPIs on the same instrument. Overall, students scored acceptably on the URRFIS. However, compared with SPI assessment, students tended to underemphasize the benefits of quitting smoking and overestimate their competence on a number of smoking intervention skills. Because of the discrepancy between student self-assessment and SPI assessment, this study highlights the additional educational value of SPI feedback.

At the University of Ottawa (Ottawa, Ontario), Bland and colleagues31 incorporated lectures and interaction with SPIs into a required 5-week curriculum on human reproduction for all second-year medical students (n = 84). Although the emphasis of this program focused on interventions for all substance use disorders in pregnancy, tobacco intervention was a prominent component. At end of the program, students achieved a statistically significant increase in their comfort level for tobacco counseling and reported less acceptance of use by pregnant women of even small amounts of tobacco.

Role Playing

Although SPI-student interactions are effective, they can be expensive. A much less expensive teaching method is role playing, in which one medical student acts as a smoker and another acts as the physician. Research examining the outcomes of this technique has produced mixed results. Using a block randomization design, Roche et al38 studied the effect of various tobacco education methods among fifth-year Australian medical students (n = 210), allocating them into 1 of 4 groups: a control group receiving a 3-hour lecture (n = 52); a group receiving a 1-hour lecture and audiotape review of a physician counseling a patient to quit smoking (n = 53); a group receiving a 1-hour lecture and 2 hours of faculty-supervised role playing in small groups (n = 49); and a group receiving a 1-hour lecture and 2 hours of role playing that was videotaped and reviewed with faculty (n = 56). All students were tested before and after the intervention on smoking intervention skills by interacting for 10 minutes with an SPI. This study found that role playing was better than lecture alone but no different from audiotape or videotape review in improving smoking intervention skills. Moreover, role playing is cheaper and often easier to arrange for medical students than SPI interactions.

On the other hand, students appear to enjoy SPI interactions more so than role playing. Papadakis et al37 compared smoking intervention training using SPIs with role playing by randomly assigning first-year medical students at the University of California, San Francisco, to practice smoking intervention skills with SPIs (n = 35) or by role playing with each other (n = 37). Two weeks later, students were followed up with an SPI activity and were evaluated on cognitive, counseling, and overall skills. Costs for the 2 methods were also calculated. Results from this study suggested that having students practice tobacco intervention techniques with other students was cheaper than an SPI interaction ($500 vs $2500 for a typical class of 100 medical students), yet was equally effective. Nonetheless, students enjoyed the SPI experience much more than role playing.

Among second-year medical students at the University of California, Los Angeles, School of Medicine (n = 127), Usatine et al41 compared role playing to counseling encounters with real patients who smoked. While students rated the role-playing activity to be only moderately useful, they stated that the interaction with real patients was very powerful. The authors noted that coordinating student meetings with patients who smoked proved logistically difficult, and the retrospective design of this study was subject to recall bias.

Finally, Geller et al36 evaluated tobacco intervention role playing as part of a required cancer prevention skills workshop among 2 consecutive classes of second-year medical students (n = 226) at Boston University. Students rotated through 6 cancer skills workshops, spending 15 minutes at each station. One of these workshop stations dealt with smoking intervention skills and another with analyzing antitobacco commercials. Students rated their own cancer control skills before and after the workshops. These investigators found a significant increase in medical students' self-rated tobacco intervention skills but acknowledged the need for a more thorough assessment of actual student performance and long-term retention of this material.

Combination of Patient-Centered and SPI Approaches

Several investigators have combined patient-centered methods and SPI interactions to teach medical school students skills in effective smoking intervention. As mentioned above, Eyler et al35 combined the patient-centered approach of Ockene and colleagues45,46 with the SPI interaction of Levenkron et al and URRFIS feedback51,52 to develop a smoking intervention training program for third-year medical students in internal medicine. Based on scores on the URRFIS, the results of this study suggest that combining these methods of instruction is effective in teaching students smoking intervention. Moreover, students highly rated the SPI experience in terms of the reality of the patient simulation, feedback constructiveness and interview scale clarity of the URRFIS, amount learned from the activity, and likelihood that they would use the feedback in future tobacco interventions.35

Coultas et al34 achieved similar outcomes in combining the patient-centered approach with the use of SPIs among first-year medical students during the patient-physician communication course at the University of New Mexico (Albuquerque). In this study, students were randomly assigned to an intervention (n = 35) or control (n = 43) group. Students in the intervention group received lectures on patient-centered counseling as well as 8 hours of small-group time that included interaction with 2 SPIs and role playing. Students in the control group received the traditional course materials. Both groups were evaluated at baseline by videotaped interaction with an SPI and 18 months later during an Objective Structured Clinical Examination with an SPI who smoked. At follow-up, intervention students asked more questions about smoking cessation than control students, shifting their counseling toward greater inquiry into a patient's motivation and past experiences with quit attempts. The study also found that students maintained the learned skills up to 18 months later.49

Spangler and colleagues40 have also adapted the work of Ockene et al and Levonkron et al and incorporated it into an integrated, 4-year tobacco dependence curriculum at Wake Forest University (Winston-Salem, NC). Qualitative evaluation among 2 consecutive classes of third-year medical students (n = 216) found that students were enthusiastic about the program and reported greater self-confidence in their ability to counsel and treat patients who use tobacco.

Unfortunately, gaps exist within these educational efforts. For example, while these methods in some cases have demonstrated near-term retention of smoking intervention skills,34,53 no long-term follow up studies have been performed to evaluate retention of these skills beyond medical school. Additionally, studies have not evaluated whether the intervention skills learned are actually applied during real clinical encounters.

Other gaps also remain in medical student tobacco intervention training. One of these is the absence of research on the best ways of educating medical students in treating smokeless tobacco use. This is despite the highly addictive nature of smokeless tobacco,10 its increasing prevalence and unique epidemiology,5,7,8 and the frequent presence of an oral pathologic state among smokeless tobacco users, providing ideal "teachable moments" in the clinic with patients.12 Although a number of authors27,54,55 have developed smokeless tobacco treatment approaches, no education research has evaluated these approaches in medical student training or their impact on patient outcomes. The same is also true for cigar smoking intervention.

In addition, a paucity of education research has investigated ways to integrate tobacco dependence information throughout all 4 years of medical school curricula,29,40,42,49 and the barriers that might be encountered with such integration.49 In their survey of US medical schools, Ferry and colleagues25 used a variety of guidelines to identify 12 tobacco dependence content areas (6 in basic sciences and 6 in clinical sciences) that should be included in any tobacco curriculum (BOX). Only 55% of schools reported teaching all 6 basic science topics. Furthermore, only 4% of schools reported teaching all 6 clinical science topics and only 3 schools (2.4%) reported a required course devoted specifically to treatment of tobacco use. With these results, Ferry et al25 proposed the development of a body of core teaching materials that all schools could integrate throughout the 4 years of undergraduate medical education.

Box. Tobacco Curriculum Content Area*

Basic Science
Cancer risk from tobacco
Health effects: tobacco-related diseases
Effects of passive smoking
Cigarette smoke contents (nicotine, tar, carbon monoxide)
Nicotine withdrawal symptoms
High-risk groups with most difficulty quitting (eg, teens, pregnancy, psychiatric disorders)

Clinical Science
Clinical intervention (5 a's anticipate, ask, advise, assist, and arrange)
Relapse prevention
Pharmacologic agents: nicotine replacement or antidepressant therapy
Smoking cessation techniques in artificial setting (no patients)
Smoking cessation techniques in clinical setting with patients
Smoking cessation techniques in clinical setting with patients and evaluation of performance

*Wording of the 12 content areas of the survey selected from the Agency for Healthcare Research and Quality and National Cancer Institute panel recommendations. Reprinted from Ferry et al.25

Finally, cultural competency for tobacco intervention training has not been developed to any significant degree in US medical schools, despite the high prevalence of tobacco use among many minority populations5 and the finding that tobacco intervention is best accomplished among these groups through culturally relevant approaches.5,27 While the patient-centered approach to tobacco treatment incorporates aspects of cultural competency, specific instruction in culturally appropriate counseling to specific racial and ethnic groups still is necessary. This is because cultural competency is crucial for risk factor intervention,56,57 especially tobacco intervention.5 Moreover, cultural competency is a distinct clinical skill that can be learned by medical students.5860 Studies have repeatedly demonstrated the efficacy of a variety of smoking treatment approaches in minority populations.6168 For treatment approaches to be effective, however, they must be offered in language that is understood by the tobacco user and provide culturally appropriate models or examples of tobacco cessation.27 Unfortunately, culturally relevant tobacco curriculum materials for undergraduate medical education have not been developed.

 Cigarette smoking—attributable mortality and years of potential life lost—United States, 1990.  MMWR Morb Mortal Wkly Rep.1993;42:645-649.
 Cigarette smoking among adults—US, 1995.  MMWR Morb Mortal Wkly Rep.1997;46:1217.
Smith SS, Fiore MC. The epidemiology of tobacco use, dependence, and cessation in the United States.  Prim Care.1999;26:433-461.
 Tobacco use among high school students—United States, 1997.  MMWR Morb Mortal Wkly Rep.1998;47:229-233.
US Department of Health and Human Services.  Tobacco Use Among US Racial/Ethnic Minority Groups–African American, American Indians and Alaska Natives, Asian Americans, Pacific Islanders, and Hispanics: A Report of the Surgeon GeneralAtlanta, Ga: US Dept of Health and Human Services; 1998.
Welty TK, Lee ET, Yeh J.  et al.  Cardiovascular disease risk factors among American Indians: the Strong Heart Study.  Am J Epidemiol.1995;142:269-287.
Office of Evaluations and Inspections.  Spit Tobacco and Youth. Washington, DC: US Dept of Health and Human Services; 1992. DHHS publication (OEI-06) 92-00500.
 Use of smokeless tobacco among adults—United States, 1991.  MMWR Morb Mortal Wkly Rep.1993;42:263-266.
US Department of Health and Human Services.  Women and Smoking: A Report of the Surgeon General–2001Atlanta, Ga: Centers for Disease Control and Prevention; 2001.
 Pharmacology of smokeless tobacco use: nicotine addiction and nicotine-related health consequences. In: Benowitz NL. Smokeless Tobacco or Health: An International Perspective . Washington, DC: US Dept of Health and Human Services; 1992:219-228.
Winn DM. Epidemiology of cancer and other systemic effects associated with the use of smokeless tobacco.  Adv Dent Res.1997;11:313-321.
NIH Consensus Development Panel.  Health implications of smokeless tobacco use.  Biomed Pharmacother.1988;42:93-98.
National Cancer Institute.  Cigars: Health Effects and TrendsBethesda, Md: National Cancer Institute; 1998. Smoking and Tobacco Monograph No. 9.
Iribarren C, Sidney S, Tekawa IS, Friedman GD. Effects of cigar smoking on the risk of cardiovascular disease, chronic obstructive pulmonary disease and cancer in men.  N Engl J Med.1999;340:1773-1780.
US Preventive Services Task Force.  Counseling to prevent tobacco use. Baltimore, Md: Williams & Wilkins; 1996.
Hatziandreu EJ, Pierce JP, Lefkopoulou M.  et al.  Quitting smoking in the United States in 1986.  J Natl Cancer Inst.1990;82:1402-1406.
Sherin K. Smoking cessation: the physician's role.  Postgrad Med.1982;72:99-102, 104-106.
Eraker SA, Becker MH, Strecher VJ, Kirscht JP. Smoking behavior, cessation techniques, and the health decision model.  Am J Med.1985;78:817-825.
Orleans CT. Understanding and promoting smoking cessation: overview and guidelines for physician intervention.  Annu Rev Med.1985;36:51-61.
Gilpin E, Pierce JP, Lefkopoulou M, Berry C, Burns D. Trends in physicians' giving advice to stop smoking, United States, 1947-1987.  Tob Control.1992;1:31-36.
Ferry LH. Overcoming barriers to nicotine dependence treatment.  Prim Care.1999;26:707-746.
Centers for Disease Control and Prevention.  Physician and other health-care professional counseling of smokers to quit—United States, 1991.  MMWR Morb Mortal Wkly Rep.1993;42:854-857.
Wells KB, Ware Jr JE, Lewis CE. Physicians' attitudes in counseling patients about smoking.  Med Care.1984;22:360-365.
Cantor JC, Baker LC, Hughes RG. Preparedness for practice. Young physicians' views of their professional education.  JAMA.1993;270:1035-1040.
Ferry LH, Grissino LM, Runfola PS. Tobacco dependence curricula in US undergraduate medical education.  JAMA.1999;282:825-829.
Fiore MC, Epps RP, Manley MW. A missed opportunity: teaching medical students to help their patients successfully quit smoking.  JAMA.1994;271:624-626.
Fiore MC, Bailey WC, Cohen SJ.  et al.  Treating Tobacco Use and Dependence. Rockville, Md: US Public Health Service; June 2000.
Silagy C, Stead LF. Physician Advice for Smoking CessationOxford, England: Cochrane Library, Update Software; 2001; issue 2.
Stevens VJ, Severson H, Lichtenstein E, Little SJ, Leben J. Making the most of a teachable moment: a smokeless-tobacco cessation intervention in the dental office.  Am J Public Health.1995;85:231-235.
Allen SS, Bland CJ, Dawson SJ. A mini-workshop to train medical students to use a patient-centered approach to smoking cessation.  Am J Prev Med.1990;6:28-33.
Bland E, Oppenheimer L, Brisson-Carroll G, Morel C, Holmes P, Gruslin A. Influence of an educational program on medical students' attitudes to substance use disorders in pregnancy.  Am J Drug Alcohol Abuse.2001;27:483-490.
Boehlecke B, Sperber AD, Kowlowitz V, Becker M, Contreras A, McGaghie WC. Smoking history-taking skills: a simple guide to teach medical students.  Med Educ.1996;30:283-289.
Chung TW, Lam TH, Cheng YH. Knowledge and attitudes about smoking among medical students before and after a tobacco seminar.  Med Educ.1996;30:290.
Coultas DB, Klecan DA, Whitten RM.  et al.  Training medical students in smoking-cessation counseling.  Acad Med.1994;69:S48-S50.
Eyler AE, Dicken LL, Fitzgerald JT, Oh MS, Wolf FM, Zweifler AJ. Teaching smoking-cessation counseling to medical students using simulated patients.  Am J Prev Med.1997;13:153-158.
Geller AC, Prout MN, Sun T.  et al.  Cancer skills laboratories for medical students: a promising approach for cancer education.  J Cancer Educ.2000;15:196-199.
Papadakis MA, Croughan-Minihane M, Fromm LJ, Wilkie HA, Ernster VL. A comparison of two methods to teach smoking-cessation techniques to medical students.  Acad Med.1997;72:725-727.
Roche AM, Eccleston P, Sanson-Fisher R. Teaching smoking cessation skills to senior medical students: a block-randomized controlled trial of four different approaches.  Prev Med.1996;25:251-258.
Seim HC, Verhoye JR. Comparison of training techniques using a patient-centered approach to smoking cessation.  Med Educ.1995;29:139-143.
Spangler JG, Enarson C, Eldridge C. An integrated approach to a tobacco-dependence curriculum.  Acad Med.2001;76:521-522.
Usatine RP, Wilkes M, Slavin S, Wilkerson L. A model smoking-intervention curriculum for medical school.  Acad Med.1996;71:S96-S98.
Wadland W, Keefe C, Thompson M, Noel M. Tobacco dependence curricula in medical schools.  JAMA.2000;283:1426-1427.
Ockene JK, Kristeller J, Goldberg R.  et al.  Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial.  J Gen Intern Med.1991;6:1-8.
Ockene JK. Smoking intervention: the expanding role of the physician.  Am J Public Health.1987;77:782-783.
Ockene JK. Physician-delivered interventions for smoking cessation: strategies for increasing effectiveness.  Prev Med.1987;16:723-737.
Ockene JK. Smoking intervention: a behavioral, educational and pharmacology perspective. In: Ockene IS, Ockene JK, eds. The Prevention of Coronary Heart Disease. Boston, Mass: Little Brown; 1992.
Ockene JK, Quirk ME, Goldberg RJ.  et al.  A residents' training program for the development of smoking intervention skills.  Arch Intern Med.1988;148:1039-1045.
Kristeller JL, Ockene JK. Tobacco curriculum for medical students, residents and practicing physicians.  Indiana Med.March/April 1996:199-204.
Short GJ, Ricer RE, Filak AT. Overcoming barriers to creating a tobacco use curriculum.  Acad Med.1999;74:1158-1160.
Stillman PL, Burpeau-Di Gregorio MY, Nicholson GI, Sabers DL, Stillman AE. Six years of experience using patient instructors to teach interviewing skills.  J Med Educ.1983;58:941-946.
Levenkron JC, Greenland P, Bowley N. Using patient instructors to teach behavioral counseling skills.  J Med Educ.1987;62:665-672.
Levenkron JC, Greenland P. Validation of the University of Rochester Risk Factor Interview Scale.  Am J Prev Med.1987;3:152-156.
Levenkron JC, Greenland P, Bowley N. Teaching risk-factor counseling skills: a comparison of two instructional methods.  Am J Prev Med.1990;6:29-34.
Severson H. Enough Snuff: A Guide for Quitting Smokeless Tobacco. Eugene, Ore: Rainbow Productions; 1994:50.
Hatsukami DK, Severson HH. Smokeless tobacco: addiction, prevention and treatment.  Nicotine Tob Res.1999;1:21-44.
Loudon RF, Anderson PM, Gill PS, Greenfield SM. Educating medical students for work in culturally diverse societies.  JAMA.1999;282:875-880.
Chin JL. Culturally competent health care.  Public Health Rep.2000;115:25-33.
Welch M. Culturally competent care. In: Concept Papers Commissioned for the Development of Cultural Competence Curricular Modules. Washington, DC: American Institutes for Research; March 12, 2002.
Campinha-Bacote J. A model and instrument for addressing cultural competence in health care.  J Nurs Educ.1999;35:203-205.
Nunez AE. Transforming cultural competence into cultural efficacy in women's health education.  Acad Med.2000;75:1071-1080.
Ahluwalia JS, McNagny SE, Clark WS. Smoking cessation among inner-city African Americans using the nicotine transdermal patch.  J Gen Intern Med.1998;13:1-8.
Lipkus IM, Lyna PR, Rimer BK. Using tailored interventions to enhance smoking cessation among African-Americans at a community health center.  Nicotine Tob Res.1999;1:77-85.
Royce JM, Ashford A, Resnicow K, Freeman HP, Caesar AA, Orlandi MA. Physician- and nurse-assisted smoking cessation in Harlem.  J Natl Med Assoc.1995;87:291-300.
Schorling JB, Roach J, Siegel M.  et al.  A trial of church-based smoking cessation interventions for rural African Americans.  Prev Med.1997;26:92-101.
Leischow SJ, Hill A, Cook G, Muramoto M, Lundergan LL. The effects of transdermal nicotine for the treatment of Hispanic smokers.  Am J Health Behav.1996;20:304-311.
Munoz RF, Marin BV, Posner SF, Perez-Stable EJ. Mood management mail intervention increases abstinence rates for Spanish-speaking Latino smokers.  Am J Community Psychol.1997;25:325-343.
Johnson KM, Lando HA, Schmid LS, Solberg LI. The GAINS project: outcome of smoking cessation strategies in four urban Native American clinics.  Addict Behav.1997;22:207-218.
National Cancer Institute.  Native American Outreach: A Report to American Indian, Alaska Native and Native Hawaiian Communities. Bethesda, Md: National Cancer Institute; 1999.

Figures

Tables

Table Graphic Jump LocationTable. Studies of Medical Student Education Methods for Tobacco Intervention Training*

References

 Cigarette smoking—attributable mortality and years of potential life lost—United States, 1990.  MMWR Morb Mortal Wkly Rep.1993;42:645-649.
 Cigarette smoking among adults—US, 1995.  MMWR Morb Mortal Wkly Rep.1997;46:1217.
Smith SS, Fiore MC. The epidemiology of tobacco use, dependence, and cessation in the United States.  Prim Care.1999;26:433-461.
 Tobacco use among high school students—United States, 1997.  MMWR Morb Mortal Wkly Rep.1998;47:229-233.
US Department of Health and Human Services.  Tobacco Use Among US Racial/Ethnic Minority Groups–African American, American Indians and Alaska Natives, Asian Americans, Pacific Islanders, and Hispanics: A Report of the Surgeon GeneralAtlanta, Ga: US Dept of Health and Human Services; 1998.
Welty TK, Lee ET, Yeh J.  et al.  Cardiovascular disease risk factors among American Indians: the Strong Heart Study.  Am J Epidemiol.1995;142:269-287.
Office of Evaluations and Inspections.  Spit Tobacco and Youth. Washington, DC: US Dept of Health and Human Services; 1992. DHHS publication (OEI-06) 92-00500.
 Use of smokeless tobacco among adults—United States, 1991.  MMWR Morb Mortal Wkly Rep.1993;42:263-266.
US Department of Health and Human Services.  Women and Smoking: A Report of the Surgeon General–2001Atlanta, Ga: Centers for Disease Control and Prevention; 2001.
 Pharmacology of smokeless tobacco use: nicotine addiction and nicotine-related health consequences. In: Benowitz NL. Smokeless Tobacco or Health: An International Perspective . Washington, DC: US Dept of Health and Human Services; 1992:219-228.
Winn DM. Epidemiology of cancer and other systemic effects associated with the use of smokeless tobacco.  Adv Dent Res.1997;11:313-321.
NIH Consensus Development Panel.  Health implications of smokeless tobacco use.  Biomed Pharmacother.1988;42:93-98.
National Cancer Institute.  Cigars: Health Effects and TrendsBethesda, Md: National Cancer Institute; 1998. Smoking and Tobacco Monograph No. 9.
Iribarren C, Sidney S, Tekawa IS, Friedman GD. Effects of cigar smoking on the risk of cardiovascular disease, chronic obstructive pulmonary disease and cancer in men.  N Engl J Med.1999;340:1773-1780.
US Preventive Services Task Force.  Counseling to prevent tobacco use. Baltimore, Md: Williams & Wilkins; 1996.
Hatziandreu EJ, Pierce JP, Lefkopoulou M.  et al.  Quitting smoking in the United States in 1986.  J Natl Cancer Inst.1990;82:1402-1406.
Sherin K. Smoking cessation: the physician's role.  Postgrad Med.1982;72:99-102, 104-106.
Eraker SA, Becker MH, Strecher VJ, Kirscht JP. Smoking behavior, cessation techniques, and the health decision model.  Am J Med.1985;78:817-825.
Orleans CT. Understanding and promoting smoking cessation: overview and guidelines for physician intervention.  Annu Rev Med.1985;36:51-61.
Gilpin E, Pierce JP, Lefkopoulou M, Berry C, Burns D. Trends in physicians' giving advice to stop smoking, United States, 1947-1987.  Tob Control.1992;1:31-36.
Ferry LH. Overcoming barriers to nicotine dependence treatment.  Prim Care.1999;26:707-746.
Centers for Disease Control and Prevention.  Physician and other health-care professional counseling of smokers to quit—United States, 1991.  MMWR Morb Mortal Wkly Rep.1993;42:854-857.
Wells KB, Ware Jr JE, Lewis CE. Physicians' attitudes in counseling patients about smoking.  Med Care.1984;22:360-365.
Cantor JC, Baker LC, Hughes RG. Preparedness for practice. Young physicians' views of their professional education.  JAMA.1993;270:1035-1040.
Ferry LH, Grissino LM, Runfola PS. Tobacco dependence curricula in US undergraduate medical education.  JAMA.1999;282:825-829.
Fiore MC, Epps RP, Manley MW. A missed opportunity: teaching medical students to help their patients successfully quit smoking.  JAMA.1994;271:624-626.
Fiore MC, Bailey WC, Cohen SJ.  et al.  Treating Tobacco Use and Dependence. Rockville, Md: US Public Health Service; June 2000.
Silagy C, Stead LF. Physician Advice for Smoking CessationOxford, England: Cochrane Library, Update Software; 2001; issue 2.
Stevens VJ, Severson H, Lichtenstein E, Little SJ, Leben J. Making the most of a teachable moment: a smokeless-tobacco cessation intervention in the dental office.  Am J Public Health.1995;85:231-235.
Allen SS, Bland CJ, Dawson SJ. A mini-workshop to train medical students to use a patient-centered approach to smoking cessation.  Am J Prev Med.1990;6:28-33.
Bland E, Oppenheimer L, Brisson-Carroll G, Morel C, Holmes P, Gruslin A. Influence of an educational program on medical students' attitudes to substance use disorders in pregnancy.  Am J Drug Alcohol Abuse.2001;27:483-490.
Boehlecke B, Sperber AD, Kowlowitz V, Becker M, Contreras A, McGaghie WC. Smoking history-taking skills: a simple guide to teach medical students.  Med Educ.1996;30:283-289.
Chung TW, Lam TH, Cheng YH. Knowledge and attitudes about smoking among medical students before and after a tobacco seminar.  Med Educ.1996;30:290.
Coultas DB, Klecan DA, Whitten RM.  et al.  Training medical students in smoking-cessation counseling.  Acad Med.1994;69:S48-S50.
Eyler AE, Dicken LL, Fitzgerald JT, Oh MS, Wolf FM, Zweifler AJ. Teaching smoking-cessation counseling to medical students using simulated patients.  Am J Prev Med.1997;13:153-158.
Geller AC, Prout MN, Sun T.  et al.  Cancer skills laboratories for medical students: a promising approach for cancer education.  J Cancer Educ.2000;15:196-199.
Papadakis MA, Croughan-Minihane M, Fromm LJ, Wilkie HA, Ernster VL. A comparison of two methods to teach smoking-cessation techniques to medical students.  Acad Med.1997;72:725-727.
Roche AM, Eccleston P, Sanson-Fisher R. Teaching smoking cessation skills to senior medical students: a block-randomized controlled trial of four different approaches.  Prev Med.1996;25:251-258.
Seim HC, Verhoye JR. Comparison of training techniques using a patient-centered approach to smoking cessation.  Med Educ.1995;29:139-143.
Spangler JG, Enarson C, Eldridge C. An integrated approach to a tobacco-dependence curriculum.  Acad Med.2001;76:521-522.
Usatine RP, Wilkes M, Slavin S, Wilkerson L. A model smoking-intervention curriculum for medical school.  Acad Med.1996;71:S96-S98.
Wadland W, Keefe C, Thompson M, Noel M. Tobacco dependence curricula in medical schools.  JAMA.2000;283:1426-1427.
Ockene JK, Kristeller J, Goldberg R.  et al.  Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial.  J Gen Intern Med.1991;6:1-8.
Ockene JK. Smoking intervention: the expanding role of the physician.  Am J Public Health.1987;77:782-783.
Ockene JK. Physician-delivered interventions for smoking cessation: strategies for increasing effectiveness.  Prev Med.1987;16:723-737.
Ockene JK. Smoking intervention: a behavioral, educational and pharmacology perspective. In: Ockene IS, Ockene JK, eds. The Prevention of Coronary Heart Disease. Boston, Mass: Little Brown; 1992.
Ockene JK, Quirk ME, Goldberg RJ.  et al.  A residents' training program for the development of smoking intervention skills.  Arch Intern Med.1988;148:1039-1045.
Kristeller JL, Ockene JK. Tobacco curriculum for medical students, residents and practicing physicians.  Indiana Med.March/April 1996:199-204.
Short GJ, Ricer RE, Filak AT. Overcoming barriers to creating a tobacco use curriculum.  Acad Med.1999;74:1158-1160.
Stillman PL, Burpeau-Di Gregorio MY, Nicholson GI, Sabers DL, Stillman AE. Six years of experience using patient instructors to teach interviewing skills.  J Med Educ.1983;58:941-946.
Levenkron JC, Greenland P, Bowley N. Using patient instructors to teach behavioral counseling skills.  J Med Educ.1987;62:665-672.
Levenkron JC, Greenland P. Validation of the University of Rochester Risk Factor Interview Scale.  Am J Prev Med.1987;3:152-156.
Levenkron JC, Greenland P, Bowley N. Teaching risk-factor counseling skills: a comparison of two instructional methods.  Am J Prev Med.1990;6:29-34.
Severson H. Enough Snuff: A Guide for Quitting Smokeless Tobacco. Eugene, Ore: Rainbow Productions; 1994:50.
Hatsukami DK, Severson HH. Smokeless tobacco: addiction, prevention and treatment.  Nicotine Tob Res.1999;1:21-44.
Loudon RF, Anderson PM, Gill PS, Greenfield SM. Educating medical students for work in culturally diverse societies.  JAMA.1999;282:875-880.
Chin JL. Culturally competent health care.  Public Health Rep.2000;115:25-33.
Welch M. Culturally competent care. In: Concept Papers Commissioned for the Development of Cultural Competence Curricular Modules. Washington, DC: American Institutes for Research; March 12, 2002.
Campinha-Bacote J. A model and instrument for addressing cultural competence in health care.  J Nurs Educ.1999;35:203-205.
Nunez AE. Transforming cultural competence into cultural efficacy in women's health education.  Acad Med.2000;75:1071-1080.
Ahluwalia JS, McNagny SE, Clark WS. Smoking cessation among inner-city African Americans using the nicotine transdermal patch.  J Gen Intern Med.1998;13:1-8.
Lipkus IM, Lyna PR, Rimer BK. Using tailored interventions to enhance smoking cessation among African-Americans at a community health center.  Nicotine Tob Res.1999;1:77-85.
Royce JM, Ashford A, Resnicow K, Freeman HP, Caesar AA, Orlandi MA. Physician- and nurse-assisted smoking cessation in Harlem.  J Natl Med Assoc.1995;87:291-300.
Schorling JB, Roach J, Siegel M.  et al.  A trial of church-based smoking cessation interventions for rural African Americans.  Prev Med.1997;26:92-101.
Leischow SJ, Hill A, Cook G, Muramoto M, Lundergan LL. The effects of transdermal nicotine for the treatment of Hispanic smokers.  Am J Health Behav.1996;20:304-311.
Munoz RF, Marin BV, Posner SF, Perez-Stable EJ. Mood management mail intervention increases abstinence rates for Spanish-speaking Latino smokers.  Am J Community Psychol.1997;25:325-343.
Johnson KM, Lando HA, Schmid LS, Solberg LI. The GAINS project: outcome of smoking cessation strategies in four urban Native American clinics.  Addict Behav.1997;22:207-218.
National Cancer Institute.  Native American Outreach: A Report to American Indian, Alaska Native and Native Hawaiian Communities. Bethesda, Md: National Cancer Institute; 1999.
CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 76

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles