Background
Smoking is the leading single cause of preventable disease [
1] and death in the western world. Smoking-related mortality is estimated to increase from 3 million annually (1995 estimate) to 10 million annually by 2030, with 70% of these deaths occurring in developing countries [
2]. The vast majority of these smokers wish to quit, but find it difficult to do so, in large part because of the addictive effects of nicotine. Smoking cessation treatment represents one of the most cost effective healthcare interventions [
3].
Effective behavioural and pharmacological treatments, coupled with professional counselling and advice, are required to improve smoking cessation rates [
4]. Since smoking duration is the principal risk factor for smoking-related morbidity, the treatment goals should be early cessation and prevention of relapse [
4]. Physicians are uniquely placed to assist in smoking cessation as a crucial preventive medical measure: They are generally accessible to the whole community; are frequently visited; are the preferred source of information on health and lifestyle matters; and have been demonstrated to be effective agents of change [
5]. Furthermore, they act as visible role models and may unintentionally affect the smoking behaviour of others. Developing attitudes of future physicians towards preventive medicine (e.g. smoking, other substance or non-substance abuse cessation, nutrition counselling/education, weight reduction, physical activity) will likely provide a major impetus for the inclusion of preventive medicine content in medical school curricula and in other forms of physician education [
6]. Assuming that physicians’ personal attitude towards the issue of smoking cessation counselling is to a great extent formed during their medical education, any successful tobacco control measures within the medical profession will need to begin prior to graduation from medical school. Teaching modules should focus on the responsibility of physicians in disease prevention and training in specific smoking cessation techniques early in undergraduate curricula [
7].
Despite its importance, few medical students receive formal training in smoking cessation counselling [
7,
8]. Anxiety and feelings of being ill-prepared for practice are common amongst medical students [
9]. Several studies have documented physicians’ failure to advise their patients regarding smoking [
10]. Most smoking patients are not instructed or assisted in their cessation efforts. Given the importance of smoking in practically all aspects of medicine and the role of clinicians in advising and aiding cessation, such competence is needed [
7].
The purpose of this project was to teach students how to work effectively with patients in the area of smoking cessation counselling through an efficient 4-h comprehensive course. The workshop was designed to be easy to implement within the medical school curriculum. Key competences for adequate and successful smoking cessation counselling were intended to be as effective as possible, but still applicable to other health behaviours within daily clinical practice [
11].
Discussion
The study confirms that a compact comprehensive 4-h interactive smoking cessation workshop for medical students is effective in terms of a profound short-term effect on the participants’ counselling abilities. Its design allows easy inclusion in the medical curriculum. As the course was designed, organized and conducted by medical students for their fellow medical students and supported by experts, its low costs makes it feasible for low- and middle income countries, where institutional receptivity for integration of tobacco control education in the medical curricula is frequently limited. The workshop was implemented “by students for students” thus promoting corporate culture and identity among medical students, which may have been part of the particularly high acceptance of the course. Furthermore, in their spontaneous feedback, many students considered this smoking cessation counselling workshop to be “in line with the trend.”
The quality of teaching during medical education is an important predictor of medical students’ learning outcomes [
22]. Observations of community-based faculties indicated strong deficits in the provision for feedback [
23]. In order to motivate students and to leave room for feedback, we offered the course to all medical students in the context of voluntary participation independent of their educational level. Their feedback confirmed that the course had a fundamental effect on “the enhancement of physician-patient communication” in general. Active educational methods, particularly standardized patient-physician role-playing were used in this study to foster “learning by doing” of counselling skills. Whereas the practical parts of the course emphasized brief intervention strategies [
24,
25] using key components of Motivational Interviewing for the range of patients willing to quit - to patients unwilling to quit. The course was intended to form a focused, albeit expandable basis for clinical practice. Students were provided with the knowledge and skills needed to reasonably fill a minimal - but realistic - intervention time of approximately 5 min according to the patient’s individual stage of readiness to quit. The vast majority of students rated the exercises and intervention training educational content as highly important and appropriate for their level of training and for their future clinical work. This is also reflected by the fact that at the 4-week evaluation, 77% of the students had not consulted the hand-outs, underlining that the learning experience was, in effect, the course itself.
When and how to learn smoking cessation counselling?
In our study the “two-half day training program” suggested in Humair and colleagues “new curriculum to train residents in smoking cessation” [
13] was reduced to a 4-h comprehensive course en bloc, and tailored to medical students’ educational needs independent of their academic year. Similar courses at 12 US medical schools [
26] were quite heterogeneous, and lasted 4 to18 h.
By including education about tobacco in the medical curricula early on, students can be alerted to the health effects of tobacco use and learn to assist smokers to quit. This paper describes an efficient and economic setting for a smoking cessation course using the Stages-of-Change model by Prochaska, et al. [
15] to teach medical students how to provide smoking cessation counselling tailored to the smoker’s individual readiness and motivation and to prescribe pharmacological therapy. The Transtheoretical Model is an evidence-based model of behavior change that has been developed and tested during the past decades in the context of smoking cessation [
27]. Antypas and colleagues see the potential to combine the efficacy of health behavior change theory-based interventions with the higher perceived usefulness of interventions designed according to patient input [
28].
In their anonymous feedback most students strongly agreed that the course provided not just the competence to approach and counsel smokers in a specifically scientific way, and overcome theoretical arbitrary dividing lines in order to assign patients to categories by means of a diagnosis and a consecutive treatment plan. They also learned about the physician-patient relationship in general, more or less detached from theoretical assessment tools, thus enabling them to expand and modify their counselling skills according to the individual needs of their future patients. The use of the Stages-of-Change model to behaviours other than tobacco dependence is an advantageous teaching method for promoting behavioural change in addiction in general, such as exercise, sleep hygiene, or nutrition, rather than specific techniques for specific behaviours [
29].
For the purpose of an efficient training methodology and a proper evaluation of the issue of smoking cessation, competence was differentiated into the components “knowledge,” “skills” and “attitude,” which is well established in the literature [
30]. Students demonstrated significant, and considering Cohen’s
d effect size and student feedback, probably highly relevant improvements in key measurements of knowledge, skills and attitude regarding smoking cessation counselling and in the confidence and motivation to apply those competence elements in practice as future physicians. Medical students felt more knowledgeable and confident in following the recommended practices and offering cessation counselling to their future patients, as shown in Additional file
7: Table S1.
The most important outcome of knowledge, skill and attitude results may be the remarkable shift in attitude. Behaviour towards the patient is probably most influenced in the long-term by attitude.
Study limitations
As there are no existing validating tools, therefore the questionnaires have not been validated. The current assessment for physicians and trainees formats reliably test core knowledge and basic skills. However, they may underemphasize some important domains of professional medical practice, including interpersonal skills, lifelong learning, professionalism, and the non-trivial step of integration of core knowledge and skills into clinical practice. In addition to assessments of basic skills, new formats that assess clinical reasoning, expert judgment, management of ambiguity, professionalism, time management, learning strategies, and teamwork would require optimal multidimensional assessments. Institutional support, reflection, and mentoring should accompany their development and change medical school programs and education.
Unfortunately, most program evaluations - ours included - lack long-term follow-up.
Variations in counselling competence between genders were not considered. Empirical findings on gender differences in smoking cessation with focus on 1) nicotine replacement therapy, 2) depression and anxiety factors, 3) post-cessation weight gain and body-shape concerns, 4) post-cessation withdrawal, and 5) the importance of social support during smoking cessation might play a role.
There may exist an important selection bias due to non-randomized selection of the participants. The course took place on a voluntary basis, and students who voluntarily enrolled for this course may be more motivated.
Conclusions
We conclude that the study’s major objectives were achieved as significant and assumed relevant gains in medical students’ dimensions of competence (knowledge, skills, attitude) for successful patient-centred smoking cessation counselling could be measured. The students’ anonymous feedback was an indicator for the courses feasibility and for improved self-efficacy, suggesting that such a course was tailored to their competence needs, and could be implemented into medical school curricula. The course seems highly effective in promoting future physicians’ ability in smoking cessation counselling and thus in the long-term retention of medical students’ preventive medical competence. Although not shown, such trained competences may foster general counselling competences in further areas, such as addiction, nutrition, exercise and weight, stress management, or sleep issuescounselling could be measured.
Acknowledgement
The authors thank the following people for their support of this project: Dr. med. Jean-Paul Humair; Ms. Marianne Habicht-Steppacher; Ms. Christine Smith; all students for their motivation and willingness to be extensively assessed. The authors thank Linda Bolzern for critically reading and correcting the manuscript. Further, the authors thank the organisation “Teach the Teacher” of the Saarland University, Homburg, Germany, where two authors (VK, JH) are active members, for their support in the design and implementation of this teaching project.