An important barrier to smoking-cessation counseling for physicians is a lack of education at the undergraduate level. Interactive methods such as peer role-play (RP) or modules utilizing standardized patients (SPs) may be effective for medical students to enhance their performance on tobacco cessation counseling. This study compared the effectiveness of a module using SPs to that of a RP module for undergraduate medical students on tobacco cessation counseling. This study was conducted over a single week of the family medicine clerkship. One hundred and thirteen fourth-year medical students were randomized into either the SP group or the RP group. A RP module involved a ten-minute encounter between the student doctor and the student patient followed by five minutes of feedback from the observer student using a group developed checklist. In a SP module, each student was asked to interview a SP portraying a smoker with willingness to quit. After the encounter, the SP provided five minutes of direct oral feedback to the student. In both modules, the total intervention lasted three-and-half hours and was supervised by faculty staff. Students’ objective structured clinical examination (OSCE) scores were evaluated to determine their tobacco cessation counseling skills. Four evaluation periods were conducted at baseline, postintervention, post-clerkship, and before receiving the Korean medical licensing examination (KMLE). Students’ smoking knowledge test scores and counseling self-confidence levels at pre- and post-intervention were also compared. In both groups, post-intervention OSCE scores increased significantly compared to baseline (Cohen’s d 0.87, p < 0.001 in SP group; d 0.77, p < 0.001 in RP group). However, there were no differences between the two groups. Students achieved the highest OSCE score for smoking-cessation counseling before the KMLE. After training, student self-confidence and smoking-knowledge test scores increased significantly, regardless of the type of module. Self-confidence was higher in the SP group compared with the RP group (d 0.37, p = 0.01). Peer role-play may be equivalent to the SP method with regard to knowledge and skills reported during smoking-cessation counseling and SP method may be better in self-confidence. Cost and student self-confidence may be important factors when choosing among the teaching methods for smoking-cessation counseling.

/pdf/group-randomized-trial-of-teaching-tobacco-cessation-38bx613ng6.pdf

Group randomized trial of teaching tobacco-cessation counseling to senior medical students: a peer role-play module versus a standardized patient module

Background Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials). Objectives To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers. Search methods We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020. Selection criteria We included randomized controlled trials (RCTs) and cluster‐RCTs (cRCTs) carried out in primary care, including non‐pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician‐delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow‐up or longer. Data collection and analysis We followed standard Cochrane methods. Our primary outcome ‐ smoking abstinence ‐ was measured using the most rigorous intention‐to‐treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow‐up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta‐analyses using Mantel‐Haenszel random‐effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs). Main results We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate‐certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I2 = 44%; 22 studies, 18,150 participants), and provision of cost‐free medications (RR 1.36, 95% CI 1.05 to 1.76; I2 = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate‐certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow‐up or more (RR 1.29, 95% CI 1.04 to 1.59; I2 = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I2 = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I2 = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I2 = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost‐free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty‐four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta‐analyses in most cases. Meta‐analyses provided some evidence that adjunctive counseling combined with either cost‐free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision‐making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation. Authors' conclusions There is moderate‐certainty evidence that providing adjunctive counseling by an allied health professional, cost‐free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster‐randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta‐analysis to investigate this further.

Strategies to improve smoking cessation rates in primary care

Background: Training health care professionals is associated with increased capacity to deliver evidence-based smoking cessation interventions and increased quit rates among their patients. Online training programs hold promise to provide training but questions remain regarding the quality and usability of available programs. Objective: The aim was to assess the quality of English-language online courses in tobacco dependence treatment using a validated instrument. Methods: An environmental scan was conducted using the Google search engine to identify available online tobacco dependence treatment courses. The identified courses were then evaluated using the Peer Review Rubric for Online Learning, which was selected based on its ability to evaluate instructional design. It also has clear and concise criteria descriptions to ensure uniformity of evaluations by trained experts. Results: A total of 39 courses were identified, of which 24 unique courses were assessed based on their accessibility and functionality during the period of evaluation. Overall, the course ratings indicated that 17 of 24 courses evaluated failed to meet minimal quality standards and none of the courses evaluated could be ranked as superior. However, many excelled in providing effective navigation, course rationale, and content. Many were weak in the use of instructional design elements, such as teaching effectiveness, learning strategies, instructor’s role, and assessment and evaluation. Evaluation results and suggestions for improvement were shared with course administrators. Conclusions: Based on the courses evaluated in this review, course developers are encouraged to employ best practices in instructional design, such as cohesiveness of material, linearity of design, practice exercises, problem solving, and ongoing evaluation to improve existing courses and in the design of new online learning opportunities. [J Med Internet Res 2015;17(4):e97]

Review and Evaluation of Online Tobacco Dependence Treatment Training Programs for Health Care Practitioners

INTRODUCTION Smoking cessation pharmacotherapy is underutilized by people with mental illnesses, who smoke at high rates and die prematurely of smoking-related diseases. Educational outreach can improve prescribing, but distances impede widespread use of this practice. Little research has assessed whether videoconference can effectively deliver educational outreach. We conducted a randomized, controlled trial of in-person versus videoconference educational outreach for smoking cessation pharmacotherapy across a state mental health system. METHODS We randomly assigned clinics to receive in-person or videoconference educational outreach with audit and feedback for cessation pharmacotherapy. Prescribers completed brief questionnaires before and after the intervention. With segmented regression analysis of interrupted time series, we evaluated prescribing trends in Medicaid pharmacy claims for nicotine replacement therapy (NRT) and varenicline, with interaction terms for the effect of intervention type (in-person vs. videoconference). RESULTS With interaction terms in the model, filled NRT prescriptions increased after the intervention compared to before (p < .01). The pattern of fills after the intervention were different at centers receiving in-person compared to videoconference educational outreach (p < .02) without clearly favoring one over the other. Additionally, filled varenicline prescriptions increased after the intervention compared to before (p = .04), but type of intervention delivery did not influence varenicline fills. Prescriber satisfaction with the educational intervention was high and prescriber attitudes became more positive in both groups. CONCLUSION This study suggests that single session educational outreach with audit and feedback can increase cessation pharmacotherapy utilization, and that videoconference delivery could be an effective, scalable approach to improve workforce capacity in systems serving mentally ill smokers.

/pdf/expanding-cessation-pharmacotherapy-via-videoconference-ttcy16nb9v.pdf

Expanding Cessation Pharmacotherapy Via Videoconference Educational Outreach to Prescribers

Introduction In line with Article 14 guidelines for the WHO Framework Convention on Tobacco Control, we aimed to assess the progress in training individuals to deliver tobacco cessation treatment. Methods Cross-sectional web-based survey in May-September 2013 among 122 experts in tobacco control and training from 84 countries (73% response rate among 115 countries surveyed). We measured training program prevalence, participants, and challenges faced. Results Overall, 21% (n = 18/84) of countries, mostly low and middle-income countries (LMICs; P = .002), reported no training program. Among 66 countries reporting at least one training program, most (84%) trained healthcare professionals but 54% also trained other individuals including community health workers, teachers, and religious leaders. Most programs (54%) cited funding challenges, although stability of funding varied by income level. Government funding was more commonly reported in higher income countries (high 56%, upper middle 50%, lower middle 27%, low 25%; P = .03) while programs in LMICs relied more on nongovernmental organizations (high 11%, upper middle 37%, lower middle 27%, low 38%; P = .02). Conclusions One in five countries reported having no tobacco treatment training program representing little progress in terms of training individuals to deliver tobacco treatment in LMICs. Without more trained tobacco treatment providers, one of the tenets of Article 14 is not yet being met and health inequalities are likely to widen. More effort and resources are needed to ensure that healthcare worker educational programs include training to assess tobacco use and deliver brief advice and that training is available for individuals outside the healthcare system in areas with limited healthcare access.

Tobacco Dependence Treatment Training Programs: An International Survey.

Introduction Advice can have a small but clinically important effect in promoting smoking cessation. Where studied, the rate of delivery has been found to be low. Training has been found to increases this rates, but there is little research on effectiveness in terms of smoking cessation rates. This study aimed to assess the effectiveness and cost-effectiveness of an health professionals educational program to increase long-term rates of nicotine abstinence in smoking outpatients. Methods We conducted a pragmatic cluster-randomized, controlled trial in 35 primary health care centers in Spain. Participants were all 830 health professionals who attended 5,970 smokers during recruiting period. After that we measured continuous abstinence 6 months after the intervention and biochemically validated (saliva cotinine test) 1 year following intervention. Cost-effectiveness was measured in terms of cost per life year gained. Results After 6 months, the rate of continuous abstinence was significantly higher in the intervention group (2.1% vs. 0.3%, p > .0001) with an odds ratio of 6.5 (95% CI = 3.3-12.7). After 1 year, biochemical validation was performed on 31 of the 67 patients previously registered as abstinent. All of them were abstinent and belonged to intervention group. The incremental cost per life year gained after 6 months was €969. Conclusions A primary care training program on smoking cessation based on scientific evidence, behavioral theory, and active learning methods increases long-term continuous nicotine abstinence rate among outpatients in a significant way. These may be relevant for planning training of professionals, clinical assistance, and public health programs.

Effectiveness of a health professional training program for treatment of tobacco addiction.

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Effectiveness of a health professional training program for treatment of tobacco addiction.