Efficacy of Resident Training in Smoking Cessation

Context Training programs for counseling about smoking cessation have seldom shown a significant effect on sustained tobacco abstinence, possibly because most programs have used didactic teaching techniques. The effect of active learning methods on cessation rates is unknown. Contribution In this study, half the participating physicians were trained in the stages-of-change model and pharmacotherapy techniques. Counseling skills were practiced on standardized patients. The other half received no relevant training. One year later, patients of the trained residents showed a significantly higher smoking cessation rate than those of the untrained residents. Implications Training programs using active learning techniques increase the effectiveness of smoking cessation counseling. The Editors Medical advice and pharmacotherapy are effective interventions in clinical practice to help patients stop smoking (1, 2). Although primary care physicians can play a key role in promoting smoking cessation to their patients who smoke (3), they miss many opportunities to advise smokers (4-7), mainly because they lack skills in counseling about smoking cessation (8). Residency training in ambulatory care is an ideal setting in which to learn the attitudes and skills of preventive medicine, including smoking cessation (9). Training programs in smoking cessation improve the frequency and quality of smoking cessation interventions administered by physicians (10-17). However, training improved rates of smoking cessation at 6 months or 1 year in only two trials (17, 18) and had no significant effect on abstinence from smoking in most studies (10-16, 19). Most training programs mainly use didactic teaching rather than such potentially effective methods as active learning of practical skills (20, 21). A few training programs based on active learning methods effectively improve counseling skills, self-efficacy, and attitudes (22-25), but their effect on rates of smoking cessation remains unknown. Most programs did not consider smoking cessation as a process of change through successive stages that required counseling tailored to smokers' motivation to quit (26, 27). Use of such a model improves physicians' performance, but its effect on rates of smoking cessation at 1 year is unclear (11, 14, 19). New educational and conceptual approaches to improve physicians' skills and effectiveness in smoking cessation, particularly during residency training, should be developed (2, 28). We used active learning methods to train physicians in smoking cessation interventions based on counseling that matched the patient's stage of change and appropriate use of pharmacotherapy. We conducted a cluster, randomized, controlled trial among residents in ambulatory care to assess the effectiveness of this training program on physicians' practices and patients' rate of smoking cessation. Methods Design and Setting We conducted a cluster randomized, controlled trial in two general internal medicine clinics of the university hospitals of Lausanne and Geneva, Switzerland. Both sites are public service clinics that provide adult ambulatory care in approximately 25 000 outpatient visits per year. Patients are assigned to residents who provide care at walk-in and follow-up visits. We randomly assigned all 35 residents at both clinics to an intervention group trained in smoking cessation or a control group trained in management of dyslipidemia. An independent research assistant performed computer randomization stratified by clinic and concealed the result of randomization until 2 weeks before the intervention, when we provided residents with practical details about training sessions. The residents constitute the clusters; the unit of analysis is the patient. We based our sample size calculation on the difference in rates of abstinence from smoking at 1 year (the primary outcome) among patients attended by trained residents and among patients attended by control residents. Using data from a previous local study and the literature (1, 11), we estimated that the 1-year cessation rate would be 4% in the control group and 15% in the intervention group. These estimates seemed realistic for our setting and relevant from clinical and public health perspectives. At an value of 5% or less and a power of 80%, the required sample size was about 130 participants per group. In the sample size evaluation, we did not account for a potential clustering effect because the clinic statistics and previous research (11) showed that physicians cared for similar numbers of patients per month (average of 60 to 80) and that the correlation of patients within physicians would be small. Participants The residents were 18 women and 17 men; their median age was 31 years. Thirty-two were never-smokers or former smokers, and 3 were current smokers. All residents were at the end of postgraduate training in general internal medicine or family medicine (median duration of training, 4 years). None of them had previously received specific training in smoking cessation. We used several strategies to minimize a change in professional behavior induced by the study among the residents (Hawthorne effect). Residents were blinded to the aim of the trial and were informed only that a survey on cardiovascular risk factors and prevention would be conducted among clinic patients. To mask our interest in smoking cessation counseling, we did not inform the residents that patients would be interviewed on smoking cessation interventions. We announced only that a training program in clinical prevention that included sessions on smoking cessation and management of dyslipidemia was being conducted. Residents who were first trained in smoking cessation attended the session on dyslipidemia 4 months later, and vice versa. The second session took place after the 3-month patient recruitment period had ended. To identify smokers and avoid revealing group assignments, we interviewed all patients, regardless of their smoking status. Patients were also blinded to the aim of the study and group allocation of their physician. Figures 1 and 2 show the trial design and patient recruitment. Eligible patients were 16 to 75 years of age, understood French, consulted one of the outpatient clinics for a follow-up or an emergency visit, and had smoked one or more cigarettes daily during the previous week. Full-time research assistants recruited patients, checked their eligibility criteria, and asked them for written informed consent to participate in a study about preventive care. Of the 2430 consecutive patients approached, 1456 met the eligibility criteria; of these 1456 patients, 1277 agreed to be interviewed after the visit. Research assistants interviewed 790 patients after the consultation; 487 patients left before the interview. The sex distribution and mean age of noninterviewed patients did not differ from those of interviewed patients. Of the 790 interviewed patients, 251 (32%) were current regular cigarette smokers; these patients formed the final study sample. Figure 1. Flow of the study. Figure 2. Patient recruitment. The study protocol was approved by the ethics committees of both institutions. Intervention The smoking cessation training program for physicians was based on active learning of counseling skills and interventions that match patients' readiness to quit smoking (29, 30). After training, residents had to reach the following educational objectives: to systematically identify all patients who smoke; to clearly advise all smokers to quit; to assess each smoker's readiness to quit; to use applied counseling strategies and offer a brochure that matched their readiness to quit; to propose an individual smoking cessation program; to follow smokers in the short and long term; and to facilitate implementation of smoking cessation in routine practice. The strategies that residents used to counsel patients about smoking cessation differed according to the patient's stage of change. For patients in the precontemplation stage (no intention to quit smoking in the next 6 months), residents were taught to inform patients about and sensitize them to tobacco use and cessation by personalizing the benefits of quitting and by challenging their beliefs. For smokers in the contemplation stage (intention to quit in the next 6 months but not within 30 days), physicians learned motivational strategies to balance pros and cons of smoking and discuss barriers to cessation and their solutions. Residents learned how to assist patients who were ready to quit smoking by showing support, setting a quit date, prescribing nicotine replacement therapy with instructions for use, and suggesting behavioral hints to prevent relapse. The training program comprised two half-day sessions. The first session included an analysis of three videotaped encounters with a smoking patient at successive stages of motivation, an interactive workshop with theoretical input linked to clinical cases, and role-playing between participants that was based on scenarios of smokers at various stages. The second session involved encounters with four standardized patients (two women and two men, all former smokers) who were recruited from an academic program and portrayed smokers at different stages; some had cardiovascular risk factors or smoking-related diseases. Each resident received a reference document that included algorithms for counseling and pharmacotherapy, a record sheet for smoking patients (29), and stage-matched brochures for patients that were recently developed in conjunction with an expert system program for smoking cessation (31). Control Intervention To ensure equal contact conditions, we chose a traditional didactic training program on management of dyslipidemia as the control intervention. This half-day course taught residents about Swiss guidelines on screening for and diagnosis and management of high blood levels of cholesterol (32). The program comprised