Prevention and Cessation Education
in US Medical Schools
Harvard Tobacco Control
Working Group
March 17, 2004
NCI R25-CA9-1958-02
PACE (August 1, 2002 – July 31st, 2007)
At the end of this five-year grant, we anticipate that
tobacco education modules will be successfully
incorporated into a number of US medical schools
and graduating students at these schools will be
able to skillfully perform tobacco prevention and
cessation counseling for children, adolescents, and
adults.
PACE Study Sites and Number
of Enrolled Students
Dartmouth Medical School – (286)
University of Kentucky – (368)
University of Rochester – (391)
University of South Florida – (397)
University of Massachusetts Medical School – (419)
Case Western Reserve University – (566)
PACE Study Sites and Number
of Enrolled Students (cont.)
University of Iowa – (591)
UCLA – (598)
Boston University – (623)
University of Alabama at Birmingham (UAB) – (643)
Loma Linda University – (653)
Harvard University – (712)
Rationale for selection of sites:
As our long-term objective is inclusion of tobacco control curriculum
in multiple US medical schools, we have selected a representative
sample of these schools. We used the following criteria for choosing
sites:
a.) Public and private schools;
b.) The major geographic sites in the United States;
c.) Inner city and rural areas;
d.) Schools with varying amounts of tobacco education (range of no
current content to multiple modules);
e.) Internet access to students for survey completion.
Evolution of Current NCI R-25 Award
a.) Missed opportunities-"specific curriculum devoted to
smoking cessation and prevention must become a
mandatory component of undergraduate education in
every US school"-JAMA 1994
b.) Work of UMass team
c.) Linda Ferry article-JAMA 1999
d.) BU R25-Preventive Medicine 2002
e.) Collaborations with American Association of
Cancer Education
Percent of Current Smokers Ever Receiving
Advice to Quit from Physicians and Dentists
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
56%
56%
60%
63%
51%
26%
25%
19%
1974
1986
1991
1993
21%
1996
Source: NHIS 1974, 1986, 1991; CPS 1993, 1996, 1999.
1999
Physician
Dentist
Physicians’ Counseling Behavior*
100%
90%
80%
70%
60%
67%
74%
50%
40%
30%
35%
20%
10%
Assist >
80% of
smoking
patients
Advise >
80% of
smoking
patients to
quit
Ask > 80%
of patients
about
smoking
status
Arrange
follow-up
for > 80%
of smoking
patients
8%
0%
*A representative sample of 246 community-based Rhode Island primary care physicians
Source: Goldstein MG, DePue JD, Monroe AD, et al. A population-based survey of physician smoking cessation counseling
practices. Preventive Medicine. 1998;27:720-729.
Percent of Pediatricians Reporting Giving
Advice to Parents of Patients, CA (1997-8)
100%
73%
80%
62%
56%
60%
40%
18%
13%
20%
5%
CESSATION ADVICE
Asking parents
about smoking
in front of their
child outside
the home
Ask parents if
they smoke
inside their
house
Scheduling a
follow-up visit or
telephone call
Prescribing
NRT
Recommending
setting a quit
date
Asking about
smoking status
0%
ETS ADVICE
Source: Perez-Stable EJ, Juarez-Reyes M, Kaplan CP, Fuentes-Afflick E, Gildengorin V, Millstein SG. Counseling smoking parents
of young children: comparison of pediatricians and family physicians. Arch Pediatr Adolesc Med. 2001;155:25-31.
National Cancer Institute panel (1992)
a.) Specific curriculum devoted to smoking cessation
and prevention must become a mandatory
component of undergraduate medical education;
b.) An assessment of tobacco curricula at medical
schools is necessary;
c.) Certain core materials can serve as key
components of different tobacco curricula;
National Cancer Institute panel (1992) (cont.)
d.) The effectiveness of a smoking cessation and prevention
curriculum must be evaluated
e.) Questions on this topic should be included as part of the
USMLE steps 1,2,3;
f.) The AMA and the Association of American Medical Colleges
(AAMC) and other organizations are important vehicles for
promoting discussion and action;
A National Action Plan
for Tobacco Cessation (2004)
‘clinicians feel inadequately prepared to intervene with patients
who smoke and appraisals of medical school curricula reveal
little training in tobacco intervention strategies’
Subcommittee recommended that ‘USDHH provide grants to
medical and other health professional schools to develop,
implement, and evaluate curriculum for treatment of tobacco
dependence’
‘Licensure and certification exams assess knowledge of tobacco
dependence’
‘Ensure that competency in tobacco dependence interventions
is a core graduation requirement for all new physicians’
(AJPH February 2004)
Tobacco Curriculum Boston University
Medical School (BUSM) 2003
Year
Course
Topic
# Hours
1
Essentials of Public Health
Cancer prevention and detection
2
1
Essentials of Public Health
Case-control studies on tobacco and lung cancer
1
1
Introduction to Clinical Medicine
Introduction to substance abuse – Tobacco cessation
1
2
Biology of Disease-Cardiology
Discussion of tobacco effects
0.5
2
Biology of Disease-Pulmonary Diseases Discussion of tobacco effects
0.5
2
Introduction to Clinical Medicine
Cancer skills laboratory
2
3
Pediatric Orientation
Role of pediatrician in smoking prevention
1
3
Introduction to Ambulatory Medicine
Cancer communication skills laboratory
4
Home Medical Service
Cancer detection in the elderly
2
1
Self-Rated Skills Among
BUSM IV by Chronological Year
Smoking
prevention
counseling
Smoking
cessation
counseling
Sun protection
counseling
4.5
4.4
4.3
4.2
4.1
4
3.9
3.8
3.7
3.6
3.5
3.4
3.3
3.2
3.1
3
Skin cancer
examination
Clinical breast
examination
1996
1997
1998
1999
Mean scores with responses ranging from
1(very unskilled) to 5 (very skilled)
Obtaining smears
for Pap test
Proportion of BUSM III (2001-02) completing
assessments as a function of
preceptor reinforcement
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Preceptor made
expectations clear
Observe preceptor talk Preceptor observe you
with family
talking with family
Injury
Prevention
Smoking
Assessment
Injury
Prevention
Smoking
Assessment
Injury
Prevention
Smoking
Assessment
Injury
Prevention
Smoking
Assessment
Yes
No
Preceptor gave you
feedback
Smoking Prevention Activities
Conducted by BUSM III
(average response per six weeks)
70
60
50
40
30
20
10
0
Discourage
parents from
smoking in the
house
Initiate
discussions with
children about
smoking
Discuss nicotine Ask parent if they Offer tips for
replacement
talked with child
parents to
therapy (NRT)
about smoking counsel children
with parents
about smoking
PACE Design (2003-2007)
2003
Education
Evaluation
NA
2004
2005
Course
Development
*
Module
Intervention
I^
SS
Course
Evaluation
2006
2007
Complete
National
Module
dissemination
Intervention +
#
SS/NA
NA = Needs Assessment
SS = Student Surveys (2nd + 4th year students)
* Course development consists of the creation of three separate modules
^ Module Intervention I is the stage in which each school initiates the one course that
the PI took part in developing
+ Complete module intervention is the stage when each of the 12 schools initiates all
modules that were developed
# The national dissemination stage is when the modules are made available to all
medical schools in the United States
PACE Timetable
Aim 1/Year 1-
Assess current curriculum and organize and convene a national
conference
Aim 2/Year 2-
Develop new curriculum, plans for integration, and conduct
faculty training
Aim 3/Year 3-
Conduct trial implementation of new curriculum
Aim 3/Year 4-
Share ‘best content’ across all 12 schools
Aim 4/Years 1-4 Conduct a comprehensive process and
impact evaluation
Aim 5/Year 5-
Disseminate Resource Guides/Tool Kits to other
medical schools
Assessment of Current Curriculum
What is currently being taught?
- Can get to minutes but not quality of teaching
Defining what needs to be taught?
- Educational visioning
Offering means to address the deficit
- Course development, evaluation of sites of
inclusion
Courses and Tobacco Content (12 schools)
YEAR 1
YEAR 2
YEAR 3
Courses
Courses with Tobacco
112 (range =6-11)
41 (range=0-7)
mode=9 mean=9
mode=2,5 mean=3
92 (range =4-17)
39 (range=1-10)
mode=6,7 mean=8
mode=3 mean=3
92 (range =4-10)
26 (range=1-7)
mode=5 mean=6
mode=2 mean=3
Number of Tobacco Hours by School (n=12)
6
5
4
# of Schools
3
2
1
0
< 5 hours
6-9 hours
10-15 hours
Hours
27 hours
Clerkships
Heavy Hitters:
Family Medicine
Internal Medicine
Soft Spots:
Pediatrics
OB GYN
Lack of Faculty Training for Tobacco
Prevention and Cessation (“NO” Responses)
Among 12 US Medical Schools
12
10
8
6
4
2
0
Tobacco CME's
Pre ve ntion/Ce ssation
Guide lne s
Pre ve ntion Course
Workshop
Me ntor/Maste r
Te aching
Instructional
De ve lopme nt Se minar
Pharmacologic
The rapy
Uncovered Impediments to Reform
Time overload-stealth approach
- Advantage-cuts across so many disciplines
Lack of any organized tobacco infrastructure
Far more didactics than skills
Aim 2-Development of New Curriculum Modules, Plans
for Integration, and Faculty Training (Year 2)
a) Formulate graduating competencies for tobacco control
education and related goals and objectives;
b) Construct a formally evaluated series of educational modules
for teaching in all medical school years, both in preclinical and
clinical years.
c) Develop strategies to integrate the educational modules
into existing courses specific for each school;
Why integrate tobacco control curriculum?
Tobacco control should be part of basic skills of
ALL medical students “ what every student
should know”
Core courses are venues for basic skills
Year 2 Tasks Resulting from Initial
PACE Meeting
Major Domains
Adult cessation
Pediatric Prevention
Public Health Approaches
Other – OB/GYN
Tasks
Preceptor education
Clerkship orientations and in-services
Integrate tobacco into community
health programs
Study Design/Timeline
2004-5
Pilot Year
2005-6
PACE School
Dissemination
Preceptor Orientation
Pediatrics Orientation
Community Electives
(4 Schools)
(4 Schools)
(4 Schools)
BU
CWRU
Dartmouth
Harvard
Loma Linda
UAB
UCLA
U.Iowa
U.Kentucky
UMass
U.Rochester
USF
2006-7
U.S. Medical
Schools
Dissemination
All U.S. Medical Schools
Graduating competencies are
organized according to:
a.) Adult cessation and prevention competencies;
b.) Pediatric prevention and cessation competencies;
c.) Public health advocacy/population science
competencies;
d.) Support systems in clinic/medical setting
competencies; and
e.) Professional development/global competencies
All presentations will be tailored
and available as:
Seminar presentations
Audio
CD
Written copies of print-outs
With teacher manuals
Hand-outs for students to give to patients
The Difference Between a
Curriculum and a Pile of Stuff
 Transferability: Contains tools and resources so others can
use it
 Ease of Use: Materials are well organized and complete
 Format: Materials conform to a common format.
 Synergy: Modules fit together coherently
 Coverage: Adequate coverage of a competency area
PRECEPTORSHIP MODULE
Students must practice what they
have learned in the classroom
Students model what they see in
clinical settings
Preceptors have an important role as
teachers and mentors
Will be encouraged to promote
feedback
Community Tobacco Electives
 Teaching and training: First year and fourth
year students
 Tobacco Advocacy: working with national
organizations on policy and legislation
 On-line training in tobacco prevention and
cessation
Exploratory:
OB GYN
National Board of Medical Examiners Step IIb
US Student Organizations
International medical students