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Statewide evaluation of a tobacco cessation curriculum for pharmacy students
Preventive Medicine 40 (2005) 888 – 895 www.elsevier.com/locate/ypmed
Statewide evaluation of a tobacco cessation curriculum for pharmacy students Robin L. Corelli, Pharm.D.a, Lisa A. Kroon, Pharm.D.a, Eunice P. Chung, Pharm.D.b, Leanne M. Sakamoto, Pharm.D.c, Berit Gundersen, Pharm.D.d, Christine M. Fenlon, B.F.A.e, Karen Suchanek Hudmon, Dr.P.H., M.S., R.Ph.a,e,* a
Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, USA Department of Pharmacy Practice, Western University of Health Sciences College of Pharmacy, USA c Department of Clinical Pharmacy, University of Southern California School of Pharmacy, USA d Department of Pharmacy Practice, University of the Pacific Thomas J. Long School of Pharmacy and Health Sciences, USA e Department of Epidemiology and Public Health, Yale University School of Medicine, 60 College Street, 4th Floor, New Haven, CT 06520, USA b
Available online 8 December 2004
Abstract Background. Previous studies suggest that healthcare professionals are inadequately trained to treat tobacco use and dependence. Because even brief interventions from clinicians improve patient quit rates, widespread implementation of effective tobacco cessation training programs for health professional students is needed. Methods. Pharmacy students received 7–8 h of comprehensive tobacco cessation training. Participants completed pre- and post-program surveys assessing perceived overall abilities for cessation counseling, skills for key facets of cessation counseling (Ask, Advise, Assess, Assist, Arrange), and self-efficacy for counseling. Results. A total of 493 students (82.3%) completed linkable pre- and post-training evaluations. Self-reported abilities, measured on a fivepoint scale, increased significantly from 1.89 F 0.89 to 3.53 F 0.72 ( P b 0.001). Twenty-two percent of students rated their overall counseling abilities as good, very good, or excellent before the training versus 94% of students after the training. Eighty-seven percent of students indicated the training will increase the number of patients that they counsel; 97% believed it will increase the quality of their cessation counseling. Conclusions. Comprehensive training significantly improved pharmacy students’ perceived confidence and ability to provide tobacco cessation counseling. The curriculum is applicable to other health professional training programs and currently is being used to train pharmacy, medical, nursing, and dental students. D 2004 Elsevier Inc. All rights reserved. Keywords: Tobacco dependence; Curriculum; Education, pharmacy; Schools, pharmacy; Smoking cessation; Health personnel, education
Introduction Tobacco use is a major cause of morbidity and mortality worldwide. Globally, an estimated 1.3 billion individuals currently smoke cigarettes or other forms of tobacco [1]. If current usage patterns remain unchanged, this number will increase to 1.7 billion smokers by the year 2025 [1]. * Corresponding author. Fax: +1 203 785 6279. E-mail address: [email protected] (K.S. Hudmon). 0091-7435/$ - see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2004.10.003
Tobacco-attributable diseases are responsible for an estimated 4.8 million premature deaths worldwide [2]. The World Health Organization (WHO) predicts this figure will double within the next 20 years in the absence of aggressive and effective tobacco control interventions on a global scale [3]. Because even brief interventions from clinicians positively impact the cessation rates of tobacco users [4,5], widespread implementation of effective tobacco cessation training programs for current and future health care providers should be an international priority.
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In a meta-analysis of 10 studies, Lancaster et al. [6] concluded that healthcare providers who have received smoking cessation training are significantly more likely to intervene with patients who use tobacco than those who are not trained. Guidelines issued by the WHO and the United States Public Health Service (USPHS) recommend that all healthcare professionals, including students in healthcare professional training programs, receive education in the treatment of tobacco use and dependence [4,7]. Despite these recommendations and the knowledge that tobacco use is a significant public health problem affecting persons of all ages, numerous studies have shown that students in the health professions receive inadequate training for treating tobacco use and dependence [8–19]. In an international survey assessing the tobacco-related content in medical school curricula, Richmond et al. [13] found that only 34% of schools provided smoking cessation training. Similarly, in a survey of medical schools conducted between 1996 and 1998 in the United States, Ferry et al. [14] reported that nearly 70% of schools did not require any clinical training for tobacco cessation. Nearly one third of the programs averaged fewer than 1 h of tobacco cessation instruction per year of medical school. More recently, Wewers et al. [18] surveyed 631 U.S. nursing programs and estimated that only 46% of baccalaureate and 67% of graduate nursing programs include tobacco cessation skills training as a part of required coursework. In response to this documented need for tobacco intervention training, a comprehensive tobacco cessation curriculum was developed for students in the health professions. Originally designed to train pharmacy students, the Rx for Change: Clinician-Assisted Tobacco Cessation program has been integrated into the required curricula of each school of pharmacy in California since 2000. Because Rx for Change adheres to recommendations outlined in the USPHS Clinical Practice Guideline for Treating Tobacco Use and Dependence [4], its applicability is broad and adapted versions of the program have been incorporated into the required coursework in the schools of medicine, dentistry, and nursing at the University of California, San Francisco. Recently, through grants funded by the National Cancer Institute and the American Legacy Foundation, the Rx for Change curriculum is being disseminated through train-the-trainer programs to schools of pharmacy and schools of nursing, respectively, in the U.S. [20,21]. Here, we present the initial statewide evaluation results of the Rx for Change curriculum obtained during the third year of implementation for pharmacy students in California.
Methods Participants and curriculum content Study participants were Doctor of Pharmacy (Pharm.D.) students attending the University of California San Fran-
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cisco (UCSF), the University of the Pacific (UOP), the University of Southern California (USC), or Western University of Health Sciences (WU) who received comprehensive tobacco cessation training (the Rx for Change curriculum) as part of their required pharmacy coursework. Students were either in their first or second year of professional school. The Rx for Change curriculum, which has been described in greater detail elsewhere, [22] and is available to registered users at http://rxforchange.ucsf.edu, is a series of independent, but complementary modules that equip students with the skills necessary to treat tobacco use and dependence. Six core modules considered essential include: epidemiology of tobacco use, nicotine pharmacology and principles of addiction, drug interactions with smoking, assisting patients with quitting, aids for cessation, and role playing with case scenarios. Optional modules include: forms of tobacco, pathophysiology of tobacco-related disease, genes and smoking, post-cessation weight maintenance, how to get involved, and a history of tobacco control. At a minimum, the core modules can be administered in 6 h. Seven to 8 h provide a more desirable pace and allows more time for hands-on pharmacotherapy counseling and role-playing exercises. The materials heavily emphasize methods for behavior modification that can be applied in a wide range of clinical settings. Students are trained to apply the 5 A’s (ask, advise, assess, assist, arrange) [4,23] when delivering patient-specific behavioral interventions that, when appropriate, also include pharmacotherapy. As part of the aids for cessation module, students are given the opportunity to handle nonprescription nicotine replacement therapy formulations and placebo samples of the nicotine nasal spray and the nicotine oral inhaler. Participants learn key counseling points for each medication, as well as proper dosing regimens and drug administration techniques. Nonpharmacologic cessation aids also are discussed and students gain hands-on experience with a hand-held computer for scheduled, gradual reduction of smoking. A minimum of 2 h of role-playing with case studies enable students to gain first-hand experience in applying their newly acquired knowledge and skills. Case studies illustrate a wide variety of realistic counseling interactions; these vary by practice environment (ambulatory or acute care setting) and patient characteristics (demographics, stage of readiness to quit, history of tobacco use, preferences for methods of cessation, coping difficulties, etc.). During the study period, students were exposed to the six core modules and the optional forms of tobacco module from the Rx for Change curriculum. While the modules presented during the trainings were standardized, the format and total hours of instruction varied by school: University of California San Francisco, 8 h taught over 2 days (Spring 2002); Western University of Health Sciences, 8 h taught over 2 days (Spring 2002); University of Southern California, 7 h taught over 4 days (Spring 2002); and University of the Pacific, 7 h taught over 5 days (Fall 2002).
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Study measures To assess the effects of the training program, a 2-page anonymous pre-training survey was administered immediately prior to the first Rx for Change module, and a threepage anonymous post-training survey was administered immediately following the final module. The surveys, which included mostly parallel measures, were linked using the following information: the last three digits of the student’s home telephone number, the numerical day of the month the student was born, and the first two letters of the high school from which the student graduated. Participation was voluntary, and because of the anonymous nature of the data, a waiver of written informed consent was obtained. Students were provided with a onepage information sheet describing the study and its procedures, risks, and benefits. The survey instruments and study procedures were approved by the institutional review board for the protection of human research subjects at each study site. Prior to this study, all measures were extensively pilot tested with more than 1,100 pharmacy students who participated in Rx for Change trainings during 2000 and 2001. The measures focused on assessing student perceptions of the training and its impact on confidence for counseling and perceived counseling abilities. Students were asked to estimate the percentage of the curriculum that (1) was completely new, (2) they had been taught before but needed to review, and (3) had been taught before and was an unnecessary review (summing to 100%). Students also estimated the percentage of the material that would be used when working with patients and indicated whether they had previously counseled any patients for tobacco cessation. Both surveys evaluated students’ self-rated abilities for cessation counseling, including (a) overall ability, (b) five key competency facets of tobacco cessation counseling (the 5 A’s), and (c) self-efficacy (i.e., confidence) for counseling, using a 12-item scale. Responses for assessments of overall ability and the 5 A’s were scored using a five-point scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). Self-efficacy items also were scored using a 5-point scale (1 = not at all confident, 2 = not very confident, 3 = moderately confident, 4 = very confident, 5 = extremely confident). Sociodemographic variables (assessed posttraining) included sex, age, race/ethnicity, and tobacco use status. Finally, we assessed impressions of curriculum content and its applicability, general attitudes concerning the role of the pharmacy profession in tobacco control activities, and opinions about tobacco sales in pharmacies (1 = strongly against it, 2 = against it, 3 = neither for it nor against it, 4 = in favor of it, 5 = strongly in favor of it). Analysis Responses were summarized using standard descriptive statistics. Scale scores were computed as the average of
constituent items for (a) a tobacco cessation counseling competency scale, composed of the 5 A’s items, and (b) self-efficacy for counseling, composed of 12 items. The statistical significance of change scores were assessed using paired t tests. Because our evaluation was designed to assess program impact, our analyses included only students who completed linkable pre- and post-training surveys. As such, because the surveys were administered in class, immediately prior to the first session and immediately following the last session, students who were absent from class on either day were unable to provide linkable surveys.
Results Student population During the study period (March 2002 to November 2002), a total of 599 Pharm.D. students were enrolled in the classes participating in the program. Of these students, 493 (82.3%) had linkable pre- and post-training surveys. Participants at UCSF (n = 118; 96.7% participation), UOP (n = 164; 80.4% participation), and USC (n = 120; 66.3% participation) were in their first-year of professional school; participants at WU (n = 91, 98.9% participation) were second-year students. For two of these schools (UCSF and WU), class attendance was mandatory, thus participation rates were higher. Seventy-four percent were female, and ethnicity was distributed as follows: 65.1% Asian or Pacific Islander, 22.4% Caucasian, 6.1% Hispanic or Latino, 0.6% African American and 5.8% other. The average age was 24.3 years (standard deviation, 3.4; range 19–41), and 11.0% disclosed that they had smoked 100 or more cigarettes in their life. Overall, 2.5% of students used tobacco (cigarettes, cigars, pipes, snuff, or chew) every day, 4.3% used tobacco some days, and 4.9% previously used tobacco but had quit. Eight percent had previously counseled one or more patients for tobacco cessation. Program evaluation results On average, students reported that 77.4% of the material was completely new, 16.2% had been taught before but needed to be reviewed, and 6.4% was an unnecessary review. Students estimated that 80.8% of the material would be used when providing patient care. The self-reported pre- and post-training overall ability to help patients quit using tobacco (Fig. 1) increased significantly ( P b 0.001), from an average of 1.89 (SD, 0.89) to 3.53 (SD, 0.72). Post-training assessments of pre-training abilities (mean, 1.50; SD, 0.71; bBefore attending this class, how would you have rated your overall ability to help patients quit using tobacco?Q) were significantly lower than were pre-training assessments of the same ability ( P b
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Fig. 1. Students’ self-ratings of overall ability a to help patients quit using tobacco (n = 493). P b 0.001 for all comparisons. a bHow do you rate your overall ability to help patients quit using tobacco? Q bbBefore the training, how would you have rated your overall ability to help patients quit using tobacco?Q c Responses were scored using a five-point scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent).
0.001). The proportion of students who rated their overall ability to help patients quit tobacco as good, very good or excellent increased from 22.1% (assessed pre-training) to 94.1% (assessed post-training). Post-training assessments of pre-training abilities were lower, with 9.5% of students rating their overall ability to help patients quit using tobacco as good, very good or excellent. Students’ pre- and post-training ratings of the 5 A’s are shown in Fig. 2; for each of these, at least 92.3% described their post-training skills as good, very good, or excellent. For the post-training tobacco cessation counseling compe-
tency scale (Cronbach alpha estimate of internal consistency in this sample, 0.85; one factor accounting for 63.2% of the variance), the mean score was 3.74 (SD, 0.65) and this differed significantly ( P b 0.001) from the pre-training scores (mean, 2.10; SD, 0.81). For the 12-item self-efficacy for counseling scale (Cronbach alpha estimate of internal consistency in this sample, 0.92; one factor accounting for 52.9% of the variance), the post-training overall scale scores (mean, 3.62; SD, 0.57) were significantly higher ( P b 0.001) than were pre-training scores (mean, 1.94; SD, 0.74). Post-training
Fig. 2. Students’ pre- and post-training self-ratings for five components of comprehensive tobacco cessation counseling: Ask, Advise, Assess, Assist, and Arrange (n = 493). aAll P values for paired t tests comparing pre- and post-training ratings b 0.001.
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responses to the 12 scale items are presented in Table 1; for each constituent item, we observed a significant difference from pre- to post-training ( P b 0.001). Eighty-seven percent of students indicated that participating in the training would increase the number of patients whom they counsel in the future; 97% believed it would increase the quality of the counseling that they provide. Approximately 96% and 89% of students believe the pharmacy profession should be more active in helping patients to quit using tobacco and in preventing the onset of tobacco use, respectively. Ninety-nine percent believed that students at other schools of pharmacy in the United States would benefit from receiving the same, or similar tobacco cessation training. On the issue of tobacco sales in pharmacies, post-training assessments indicated that 53.4% of students were strongly against it, 28.5% were against it, 16.9% were neutral, 0.8% were in favor of it, and 0.4% were strongly in favor of it. Exposure to the Rx for Change training strengthened opposition toward tobacco sales in pharmacies, from an average score of 1.89 (SD, 1.29) pretraining to 1.67 (SD, 0.82) post-training ( P b 0.001).
Discussion Previous studies of tobacco cessation curricula in health professional schools have been evaluations of programs developed and implemented at a single institution [24–32]. To our knowledge, this is the first multi-site evaluation of a standardized tobacco cessation training program for health professional students. In this state-wide evaluation, we
observed a significant improvement in pharmacy students’ self-rated confidence and ability for providing cessation counseling following exposure to a 7- to 8-h comprehensive tobacco cessation training program. The vast majority (N94%) of students rated their overall tobacco cessation counseling abilities as good, very good, or excellent following completion of the training. Students’ self-efficacy for providing counseling was similarly high, with more than 84% of students reporting being moderately, very, or extremely confident for each of the 12 facets of counseling embedded within the self-efficacy scale. This finding is notable given that most (81.5%) of the participants were first-year students with limited professional training or direct patient care experience. Students felt most confident in their abilities to motivate patients who are trying to quit, intervene in the bask,Q bassess,Q and bassistQ facets of cessation counseling, and recognize the need for referral. Students were less likely to feel confident in their abilities to provide cessation counseling when patients were not interested in quitting or when there were time constraints. Although the format for program implementation varied among the schools, we observed no between-school differences for the pre- versus post-training scores for overall ability or the tobacco cessation counseling competency scale (the 5 A’s). As the Rx for Change program is disseminated across the United States, a larger sampling of pharmacy schools and formats for implementation (e.g., the total number of hours taught, the amount of time elapsed between the first and last modules, and the year of pharmacy school in which the students receive the training) will be examined in an attempt to determine the most effective methods for implementation.
Table 1 Post-training self-efficacy for tobacco cessation counseling: distribution of responses (n = 493) ITEM
Post-training student responses (%) Not at all confident
Can provide motivation to patients who are trying to quit Know when a referral to a physician is appropriate Have sufficient therapeutic knowledge of the pharmaceutical products for tobacco cessation Can sensitively suggest tobacco cessation to patients who use tobacco Can create consumer awareness of why pharmacists should ask questions about tobacco use Have the skills to monitor and assist patients throughout their quit attempt Know the appropriate questions to ask patients when providing counseling Can help recent quitters learn how to cope with situations or triggers that might lead them to relapse back to smoking Have the skills needed to counsel for an addiction Are able to provide adequate counseling when time is limited Can counsel patients who are not interested in quitting Have the skills to assist patients who seem to be in a hurry Average item score (post-training)b a b
Not very confident
Moderately confident
Very confident
Extremely confident
Meana (SD)
0.0 0.4 0.2
3.9 4.3 5.1
27.0 35.5 32.9
50.5 41.0 45.2
18.7 18.8 16.6
3.84 (0.77) 3.73 (0.83) 3.73 (0.80)
0.6
2.4
35.3
46.2
15.4
3.73 (0.77)
0.4
5.1
34.9
42.4
17.2
3.71 (0.82)
0.0
3.3
34.8
50.3
11.6
3.70 (0.71)
0.0
3.0
34.5
52.5
9.9
3.69 (0.69)
0.4
3.0
38.1
45.4
13.0
3.68 (0.75)
0.6 0.6 1.8 1.8
6.5 11.8 13.2 14.8
44.4 42.8 41.2 43.3
40.0 36.9 34.3 31.7
8.5 7.9 9.5 8.3
All P values for paired t tests comparing pre- and post-training item responses b 0.001. Computed as average of constituent items; significantly different than pre-training overall scale score (mean, 1.94; SD, 0.74), P b 0.001.
3.49 3.40 3.37 3.30 3.62
(0.77) (0.82) (0.89) (0.89) (0.57)
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An interesting finding from our study was the difference between students’ pre-training versus post-training (retrospective) assessments of their baseline ability to help patients quit using tobacco. While standard evaluations of educational interventions include a pre- and post-training design, we included this additional retrospective measure because we hypothesized that untrained students generally underestimate the level of skills required to provide tobacco cessation counseling. Prior to the training, one of every five pharmacy students rated their overall ability to help patients quit using tobacco as good (17.5%), very good (3.5%), or excellent (1.1%). After exposure to the Rx for Change curriculum, fewer than one of every 10 students rated their baseline counseling abilities as good (8.1%) or very good (1.4%), and none rated their pre-training skills as excellent. This change suggests that the training itself leads students to gain an enhanced understanding and appreciation for the diverse set of skills necessary to provide comprehensive tobacco cessation counseling, but further studies in this area are warranted. Although many schools of pharmacy across the country are in the process of enhancing the tobacco education component of their curricula, it is paradoxical that the majority of community pharmacies, particularly chain pharmacies, sell tobacco. As part of the Rx for Change program, students are challenged to consider the ethical dilemma imposed by the sales of tobacco in a practice environment that otherwise is bmarketedQ to promote health. While our evaluations over the past several years have consistently demonstrated that very few future pharmacists are in favor of tobacco sales in pharmacies, the impact of a tobacco education program on these perceptions has never been evaluated. The Rx for Change program significantly strengthened opposition to tobacco sales in pharmacies. As we continue to raise awareness of this issue within the profession, we can only hope that owners and employees of pharmacies that sell tobacco products will revisit the ethics of a practice that is incongruent with the pharmacist’s code of ethics (http://www.aphanet.org/pharmcare/ethics.html). Although our findings suggest that the Rx for Change curriculum improves student confidence and ability to provide tobacco cessation counseling, our study is not without limitations. Our study was conducted in schools of pharmacy in California, which tend to have a disproportionately high number of students of Asian/Pacific Islander descent; as such, our results might not be generalizable to other training programs throughout the U.S. Although we did include a 10-item post-training knowledge assessment in our surveys, we do not report these data because the items were changed throughout the period of study and varied across the sites (e.g., different items and response options were tested), in preparation for our nationwide dissemination study (currently ongoing). Our short-term pre-post design does not afford the opportunity to estimate the sustainability of the program’s effects on student confidence or its impact on actual counseling activities during clinical
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rotations or after graduation. Additionally, our study did not include a control group, and our measures relied on students’ self-report of abilities. Evaluations of student performance using an objective structured clinical examination (OSCE) would better assess the participants’ tobacco cessation counseling competencies. We were unable to incorporate OSCE measures because this examination format was not used in the courses in which the Rx for Change program was taught, and we lacked funding to develop and implement an OSCE specifically designed to evaluate the curriculum outside of the scheduled class time. In the future, we hope to incorporate OSCE evaluations, as others have done [24–29], to further evaluate the impact of Rx for Change on counseling skills. Finally, while our program is applicable to students in all health professions, our study evaluated the impact of the Rx for Change curriculum only on students enrolled in a doctor of pharmacy program. While formal evaluations of the impact of the Rx for Change program on other disciplines have not been conducted, the program has been adapted and disseminated to 84 nursing programs, one dental school, and one medical school in the US [21]. The program also has been used to train licensed providers including tobacco cessation counselors in a research study of smoking cessation in patients with schizophrenia (Michael Smith, Principal Investigator) and community pharmacists in a large National Cancer Institute-funded smoking cessation program in sixteen communities Texas (Alexander Prokhorov, Principal Investigator). Because the Rx for Change curriculum is based on the USPHS Clinical Practice Guideline and incorporates enhanced instructional techniques (e.g., role playing and hands-on demonstration exercises; our more recent additions to the program include the viewing of videotaped counseling sessions and engaging students in trigger tape discussions) that have been found in previous studies to be effective in training medical students, [33] residents, [34], and practicing physicians [35], we anticipate that our results would be applicable to students in other disciplines. Our data suggest that students completing the training attain a high degree of self-confidence for providing comprehensive tobacco cessation assistance. Moreover, the vast majority of students perceive that participation in the training will increase both the frequency and quality of their intervention efforts with tobacco users. Given the prevalence of tobacco-related morbidity and mortality, it is imperative that practicing clinicians and students in health professional schools receive evidence-based training in the treatment of tobacco use and dependence. Ideally, comprehensive tobacco cessation training would be a core requirement in the curricula of all health care professional schools, and this training would be further augmented through continuing education and certification programs for licensed providers. While further studies are necessary to document the impact of these training programs on long-term cessation rates with tobacco users, it is logical to conclude that
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providing patients with widespread access to a multidisciplinary team of providers trained in tobacco cessation is an important step toward reducing the future burden of tobacco-induced disease. In summary, we have developed, implemented, and conducted a statewide evaluation of a comprehensive, 7 to 8 h modular tobacco cessation curriculum designed for students in the health professions. With funding from the National Cancer Institute, the Rx for Change curriculum is currently being disseminated through train-the-trainer programs to schools of pharmacy nationwide (currently faculty members from 85 of the 89 schools have been trained), thereby ensuring that future pharmacists will have received comprehensive training to assist patients with quitting. In this time of limited resources, particularly among academic institutions, we believe that it is particularly important that health professional schools work together in sharing expertise and curricular materials toward the common goal of enhancing patient care and improving medical outcomes.
Acknowledgments We would like to thank the pharmacy students at UCSF, USC, UOP, and WU who completed our surveys and have provided thoughtful feedback toward the refinement of the Rx for Change curriculum since 2000. The evaluation of this program was made possible through funding from the University of California Tobacco-Related Disease Research Program (grant 10ST0339 to K Hudmon). Preparation of the manuscript was supported in part by the National Cancer Institute (grant R25 90720 to K Hudmon). The hands-on portion of the aids for cessation module was made possible in part through product donations to the schools from Pharmacia Corporation (now Pfizer, Inc.) and PICS Inc.
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Statewide evaluation of a tobacco cessation curriculum for pharmacy students Robin L. Corelli, Pharm.D.a, Lisa A. Kroon, Pharm.D.a, Eunice P. Chung, Pharm.D.b, Leanne M. Sakamoto, Pharm.D.c, Berit Gundersen, Pharm.D.d, Christine M. Fenlon, B.F.A.e, Karen Suchanek Hudmon, Dr.P.H., M.S., R.Ph.a,e,* a
Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, USA Department of Pharmacy Practice, Western University of Health Sciences College of Pharmacy, USA c Department of Clinical Pharmacy, University of Southern California School of Pharmacy, USA d Department of Pharmacy Practice, University of the Pacific Thomas J. Long School of Pharmacy and Health Sciences, USA e Department of Epidemiology and Public Health, Yale University School of Medicine, 60 College Street, 4th Floor, New Haven, CT 06520, USA b
Available online 8 December 2004
Abstract Background. Previous studies suggest that healthcare professionals are inadequately trained to treat tobacco use and dependence. Because even brief interventions from clinicians improve patient quit rates, widespread implementation of effective tobacco cessation training programs for health professional students is needed. Methods. Pharmacy students received 7–8 h of comprehensive tobacco cessation training. Participants completed pre- and post-program surveys assessing perceived overall abilities for cessation counseling, skills for key facets of cessation counseling (Ask, Advise, Assess, Assist, Arrange), and self-efficacy for counseling. Results. A total of 493 students (82.3%) completed linkable pre- and post-training evaluations. Self-reported abilities, measured on a fivepoint scale, increased significantly from 1.89 F 0.89 to 3.53 F 0.72 ( P b 0.001). Twenty-two percent of students rated their overall counseling abilities as good, very good, or excellent before the training versus 94% of students after the training. Eighty-seven percent of students indicated the training will increase the number of patients that they counsel; 97% believed it will increase the quality of their cessation counseling. Conclusions. Comprehensive training significantly improved pharmacy students’ perceived confidence and ability to provide tobacco cessation counseling. The curriculum is applicable to other health professional training programs and currently is being used to train pharmacy, medical, nursing, and dental students. D 2004 Elsevier Inc. All rights reserved. Keywords: Tobacco dependence; Curriculum; Education, pharmacy; Schools, pharmacy; Smoking cessation; Health personnel, education
Introduction Tobacco use is a major cause of morbidity and mortality worldwide. Globally, an estimated 1.3 billion individuals currently smoke cigarettes or other forms of tobacco [1]. If current usage patterns remain unchanged, this number will increase to 1.7 billion smokers by the year 2025 [1]. * Corresponding author. Fax: +1 203 785 6279. E-mail address: [email protected] (K.S. Hudmon). 0091-7435/$ - see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2004.10.003
Tobacco-attributable diseases are responsible for an estimated 4.8 million premature deaths worldwide [2]. The World Health Organization (WHO) predicts this figure will double within the next 20 years in the absence of aggressive and effective tobacco control interventions on a global scale [3]. Because even brief interventions from clinicians positively impact the cessation rates of tobacco users [4,5], widespread implementation of effective tobacco cessation training programs for current and future health care providers should be an international priority.
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In a meta-analysis of 10 studies, Lancaster et al. [6] concluded that healthcare providers who have received smoking cessation training are significantly more likely to intervene with patients who use tobacco than those who are not trained. Guidelines issued by the WHO and the United States Public Health Service (USPHS) recommend that all healthcare professionals, including students in healthcare professional training programs, receive education in the treatment of tobacco use and dependence [4,7]. Despite these recommendations and the knowledge that tobacco use is a significant public health problem affecting persons of all ages, numerous studies have shown that students in the health professions receive inadequate training for treating tobacco use and dependence [8–19]. In an international survey assessing the tobacco-related content in medical school curricula, Richmond et al. [13] found that only 34% of schools provided smoking cessation training. Similarly, in a survey of medical schools conducted between 1996 and 1998 in the United States, Ferry et al. [14] reported that nearly 70% of schools did not require any clinical training for tobacco cessation. Nearly one third of the programs averaged fewer than 1 h of tobacco cessation instruction per year of medical school. More recently, Wewers et al. [18] surveyed 631 U.S. nursing programs and estimated that only 46% of baccalaureate and 67% of graduate nursing programs include tobacco cessation skills training as a part of required coursework. In response to this documented need for tobacco intervention training, a comprehensive tobacco cessation curriculum was developed for students in the health professions. Originally designed to train pharmacy students, the Rx for Change: Clinician-Assisted Tobacco Cessation program has been integrated into the required curricula of each school of pharmacy in California since 2000. Because Rx for Change adheres to recommendations outlined in the USPHS Clinical Practice Guideline for Treating Tobacco Use and Dependence [4], its applicability is broad and adapted versions of the program have been incorporated into the required coursework in the schools of medicine, dentistry, and nursing at the University of California, San Francisco. Recently, through grants funded by the National Cancer Institute and the American Legacy Foundation, the Rx for Change curriculum is being disseminated through train-the-trainer programs to schools of pharmacy and schools of nursing, respectively, in the U.S. [20,21]. Here, we present the initial statewide evaluation results of the Rx for Change curriculum obtained during the third year of implementation for pharmacy students in California.
Methods Participants and curriculum content Study participants were Doctor of Pharmacy (Pharm.D.) students attending the University of California San Fran-
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cisco (UCSF), the University of the Pacific (UOP), the University of Southern California (USC), or Western University of Health Sciences (WU) who received comprehensive tobacco cessation training (the Rx for Change curriculum) as part of their required pharmacy coursework. Students were either in their first or second year of professional school. The Rx for Change curriculum, which has been described in greater detail elsewhere, [22] and is available to registered users at http://rxforchange.ucsf.edu, is a series of independent, but complementary modules that equip students with the skills necessary to treat tobacco use and dependence. Six core modules considered essential include: epidemiology of tobacco use, nicotine pharmacology and principles of addiction, drug interactions with smoking, assisting patients with quitting, aids for cessation, and role playing with case scenarios. Optional modules include: forms of tobacco, pathophysiology of tobacco-related disease, genes and smoking, post-cessation weight maintenance, how to get involved, and a history of tobacco control. At a minimum, the core modules can be administered in 6 h. Seven to 8 h provide a more desirable pace and allows more time for hands-on pharmacotherapy counseling and role-playing exercises. The materials heavily emphasize methods for behavior modification that can be applied in a wide range of clinical settings. Students are trained to apply the 5 A’s (ask, advise, assess, assist, arrange) [4,23] when delivering patient-specific behavioral interventions that, when appropriate, also include pharmacotherapy. As part of the aids for cessation module, students are given the opportunity to handle nonprescription nicotine replacement therapy formulations and placebo samples of the nicotine nasal spray and the nicotine oral inhaler. Participants learn key counseling points for each medication, as well as proper dosing regimens and drug administration techniques. Nonpharmacologic cessation aids also are discussed and students gain hands-on experience with a hand-held computer for scheduled, gradual reduction of smoking. A minimum of 2 h of role-playing with case studies enable students to gain first-hand experience in applying their newly acquired knowledge and skills. Case studies illustrate a wide variety of realistic counseling interactions; these vary by practice environment (ambulatory or acute care setting) and patient characteristics (demographics, stage of readiness to quit, history of tobacco use, preferences for methods of cessation, coping difficulties, etc.). During the study period, students were exposed to the six core modules and the optional forms of tobacco module from the Rx for Change curriculum. While the modules presented during the trainings were standardized, the format and total hours of instruction varied by school: University of California San Francisco, 8 h taught over 2 days (Spring 2002); Western University of Health Sciences, 8 h taught over 2 days (Spring 2002); University of Southern California, 7 h taught over 4 days (Spring 2002); and University of the Pacific, 7 h taught over 5 days (Fall 2002).
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Study measures To assess the effects of the training program, a 2-page anonymous pre-training survey was administered immediately prior to the first Rx for Change module, and a threepage anonymous post-training survey was administered immediately following the final module. The surveys, which included mostly parallel measures, were linked using the following information: the last three digits of the student’s home telephone number, the numerical day of the month the student was born, and the first two letters of the high school from which the student graduated. Participation was voluntary, and because of the anonymous nature of the data, a waiver of written informed consent was obtained. Students were provided with a onepage information sheet describing the study and its procedures, risks, and benefits. The survey instruments and study procedures were approved by the institutional review board for the protection of human research subjects at each study site. Prior to this study, all measures were extensively pilot tested with more than 1,100 pharmacy students who participated in Rx for Change trainings during 2000 and 2001. The measures focused on assessing student perceptions of the training and its impact on confidence for counseling and perceived counseling abilities. Students were asked to estimate the percentage of the curriculum that (1) was completely new, (2) they had been taught before but needed to review, and (3) had been taught before and was an unnecessary review (summing to 100%). Students also estimated the percentage of the material that would be used when working with patients and indicated whether they had previously counseled any patients for tobacco cessation. Both surveys evaluated students’ self-rated abilities for cessation counseling, including (a) overall ability, (b) five key competency facets of tobacco cessation counseling (the 5 A’s), and (c) self-efficacy (i.e., confidence) for counseling, using a 12-item scale. Responses for assessments of overall ability and the 5 A’s were scored using a five-point scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). Self-efficacy items also were scored using a 5-point scale (1 = not at all confident, 2 = not very confident, 3 = moderately confident, 4 = very confident, 5 = extremely confident). Sociodemographic variables (assessed posttraining) included sex, age, race/ethnicity, and tobacco use status. Finally, we assessed impressions of curriculum content and its applicability, general attitudes concerning the role of the pharmacy profession in tobacco control activities, and opinions about tobacco sales in pharmacies (1 = strongly against it, 2 = against it, 3 = neither for it nor against it, 4 = in favor of it, 5 = strongly in favor of it). Analysis Responses were summarized using standard descriptive statistics. Scale scores were computed as the average of
constituent items for (a) a tobacco cessation counseling competency scale, composed of the 5 A’s items, and (b) self-efficacy for counseling, composed of 12 items. The statistical significance of change scores were assessed using paired t tests. Because our evaluation was designed to assess program impact, our analyses included only students who completed linkable pre- and post-training surveys. As such, because the surveys were administered in class, immediately prior to the first session and immediately following the last session, students who were absent from class on either day were unable to provide linkable surveys.
Results Student population During the study period (March 2002 to November 2002), a total of 599 Pharm.D. students were enrolled in the classes participating in the program. Of these students, 493 (82.3%) had linkable pre- and post-training surveys. Participants at UCSF (n = 118; 96.7% participation), UOP (n = 164; 80.4% participation), and USC (n = 120; 66.3% participation) were in their first-year of professional school; participants at WU (n = 91, 98.9% participation) were second-year students. For two of these schools (UCSF and WU), class attendance was mandatory, thus participation rates were higher. Seventy-four percent were female, and ethnicity was distributed as follows: 65.1% Asian or Pacific Islander, 22.4% Caucasian, 6.1% Hispanic or Latino, 0.6% African American and 5.8% other. The average age was 24.3 years (standard deviation, 3.4; range 19–41), and 11.0% disclosed that they had smoked 100 or more cigarettes in their life. Overall, 2.5% of students used tobacco (cigarettes, cigars, pipes, snuff, or chew) every day, 4.3% used tobacco some days, and 4.9% previously used tobacco but had quit. Eight percent had previously counseled one or more patients for tobacco cessation. Program evaluation results On average, students reported that 77.4% of the material was completely new, 16.2% had been taught before but needed to be reviewed, and 6.4% was an unnecessary review. Students estimated that 80.8% of the material would be used when providing patient care. The self-reported pre- and post-training overall ability to help patients quit using tobacco (Fig. 1) increased significantly ( P b 0.001), from an average of 1.89 (SD, 0.89) to 3.53 (SD, 0.72). Post-training assessments of pre-training abilities (mean, 1.50; SD, 0.71; bBefore attending this class, how would you have rated your overall ability to help patients quit using tobacco?Q) were significantly lower than were pre-training assessments of the same ability ( P b
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Fig. 1. Students’ self-ratings of overall ability a to help patients quit using tobacco (n = 493). P b 0.001 for all comparisons. a bHow do you rate your overall ability to help patients quit using tobacco? Q bbBefore the training, how would you have rated your overall ability to help patients quit using tobacco?Q c Responses were scored using a five-point scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent).
0.001). The proportion of students who rated their overall ability to help patients quit tobacco as good, very good or excellent increased from 22.1% (assessed pre-training) to 94.1% (assessed post-training). Post-training assessments of pre-training abilities were lower, with 9.5% of students rating their overall ability to help patients quit using tobacco as good, very good or excellent. Students’ pre- and post-training ratings of the 5 A’s are shown in Fig. 2; for each of these, at least 92.3% described their post-training skills as good, very good, or excellent. For the post-training tobacco cessation counseling compe-
tency scale (Cronbach alpha estimate of internal consistency in this sample, 0.85; one factor accounting for 63.2% of the variance), the mean score was 3.74 (SD, 0.65) and this differed significantly ( P b 0.001) from the pre-training scores (mean, 2.10; SD, 0.81). For the 12-item self-efficacy for counseling scale (Cronbach alpha estimate of internal consistency in this sample, 0.92; one factor accounting for 52.9% of the variance), the post-training overall scale scores (mean, 3.62; SD, 0.57) were significantly higher ( P b 0.001) than were pre-training scores (mean, 1.94; SD, 0.74). Post-training
Fig. 2. Students’ pre- and post-training self-ratings for five components of comprehensive tobacco cessation counseling: Ask, Advise, Assess, Assist, and Arrange (n = 493). aAll P values for paired t tests comparing pre- and post-training ratings b 0.001.
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responses to the 12 scale items are presented in Table 1; for each constituent item, we observed a significant difference from pre- to post-training ( P b 0.001). Eighty-seven percent of students indicated that participating in the training would increase the number of patients whom they counsel in the future; 97% believed it would increase the quality of the counseling that they provide. Approximately 96% and 89% of students believe the pharmacy profession should be more active in helping patients to quit using tobacco and in preventing the onset of tobacco use, respectively. Ninety-nine percent believed that students at other schools of pharmacy in the United States would benefit from receiving the same, or similar tobacco cessation training. On the issue of tobacco sales in pharmacies, post-training assessments indicated that 53.4% of students were strongly against it, 28.5% were against it, 16.9% were neutral, 0.8% were in favor of it, and 0.4% were strongly in favor of it. Exposure to the Rx for Change training strengthened opposition toward tobacco sales in pharmacies, from an average score of 1.89 (SD, 1.29) pretraining to 1.67 (SD, 0.82) post-training ( P b 0.001).
Discussion Previous studies of tobacco cessation curricula in health professional schools have been evaluations of programs developed and implemented at a single institution [24–32]. To our knowledge, this is the first multi-site evaluation of a standardized tobacco cessation training program for health professional students. In this state-wide evaluation, we
observed a significant improvement in pharmacy students’ self-rated confidence and ability for providing cessation counseling following exposure to a 7- to 8-h comprehensive tobacco cessation training program. The vast majority (N94%) of students rated their overall tobacco cessation counseling abilities as good, very good, or excellent following completion of the training. Students’ self-efficacy for providing counseling was similarly high, with more than 84% of students reporting being moderately, very, or extremely confident for each of the 12 facets of counseling embedded within the self-efficacy scale. This finding is notable given that most (81.5%) of the participants were first-year students with limited professional training or direct patient care experience. Students felt most confident in their abilities to motivate patients who are trying to quit, intervene in the bask,Q bassess,Q and bassistQ facets of cessation counseling, and recognize the need for referral. Students were less likely to feel confident in their abilities to provide cessation counseling when patients were not interested in quitting or when there were time constraints. Although the format for program implementation varied among the schools, we observed no between-school differences for the pre- versus post-training scores for overall ability or the tobacco cessation counseling competency scale (the 5 A’s). As the Rx for Change program is disseminated across the United States, a larger sampling of pharmacy schools and formats for implementation (e.g., the total number of hours taught, the amount of time elapsed between the first and last modules, and the year of pharmacy school in which the students receive the training) will be examined in an attempt to determine the most effective methods for implementation.
Table 1 Post-training self-efficacy for tobacco cessation counseling: distribution of responses (n = 493) ITEM
Post-training student responses (%) Not at all confident
Can provide motivation to patients who are trying to quit Know when a referral to a physician is appropriate Have sufficient therapeutic knowledge of the pharmaceutical products for tobacco cessation Can sensitively suggest tobacco cessation to patients who use tobacco Can create consumer awareness of why pharmacists should ask questions about tobacco use Have the skills to monitor and assist patients throughout their quit attempt Know the appropriate questions to ask patients when providing counseling Can help recent quitters learn how to cope with situations or triggers that might lead them to relapse back to smoking Have the skills needed to counsel for an addiction Are able to provide adequate counseling when time is limited Can counsel patients who are not interested in quitting Have the skills to assist patients who seem to be in a hurry Average item score (post-training)b a b
Not very confident
Moderately confident
Very confident
Extremely confident
Meana (SD)
0.0 0.4 0.2
3.9 4.3 5.1
27.0 35.5 32.9
50.5 41.0 45.2
18.7 18.8 16.6
3.84 (0.77) 3.73 (0.83) 3.73 (0.80)
0.6
2.4
35.3
46.2
15.4
3.73 (0.77)
0.4
5.1
34.9
42.4
17.2
3.71 (0.82)
0.0
3.3
34.8
50.3
11.6
3.70 (0.71)
0.0
3.0
34.5
52.5
9.9
3.69 (0.69)
0.4
3.0
38.1
45.4
13.0
3.68 (0.75)
0.6 0.6 1.8 1.8
6.5 11.8 13.2 14.8
44.4 42.8 41.2 43.3
40.0 36.9 34.3 31.7
8.5 7.9 9.5 8.3
All P values for paired t tests comparing pre- and post-training item responses b 0.001. Computed as average of constituent items; significantly different than pre-training overall scale score (mean, 1.94; SD, 0.74), P b 0.001.
3.49 3.40 3.37 3.30 3.62
(0.77) (0.82) (0.89) (0.89) (0.57)
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An interesting finding from our study was the difference between students’ pre-training versus post-training (retrospective) assessments of their baseline ability to help patients quit using tobacco. While standard evaluations of educational interventions include a pre- and post-training design, we included this additional retrospective measure because we hypothesized that untrained students generally underestimate the level of skills required to provide tobacco cessation counseling. Prior to the training, one of every five pharmacy students rated their overall ability to help patients quit using tobacco as good (17.5%), very good (3.5%), or excellent (1.1%). After exposure to the Rx for Change curriculum, fewer than one of every 10 students rated their baseline counseling abilities as good (8.1%) or very good (1.4%), and none rated their pre-training skills as excellent. This change suggests that the training itself leads students to gain an enhanced understanding and appreciation for the diverse set of skills necessary to provide comprehensive tobacco cessation counseling, but further studies in this area are warranted. Although many schools of pharmacy across the country are in the process of enhancing the tobacco education component of their curricula, it is paradoxical that the majority of community pharmacies, particularly chain pharmacies, sell tobacco. As part of the Rx for Change program, students are challenged to consider the ethical dilemma imposed by the sales of tobacco in a practice environment that otherwise is bmarketedQ to promote health. While our evaluations over the past several years have consistently demonstrated that very few future pharmacists are in favor of tobacco sales in pharmacies, the impact of a tobacco education program on these perceptions has never been evaluated. The Rx for Change program significantly strengthened opposition to tobacco sales in pharmacies. As we continue to raise awareness of this issue within the profession, we can only hope that owners and employees of pharmacies that sell tobacco products will revisit the ethics of a practice that is incongruent with the pharmacist’s code of ethics (http://www.aphanet.org/pharmcare/ethics.html). Although our findings suggest that the Rx for Change curriculum improves student confidence and ability to provide tobacco cessation counseling, our study is not without limitations. Our study was conducted in schools of pharmacy in California, which tend to have a disproportionately high number of students of Asian/Pacific Islander descent; as such, our results might not be generalizable to other training programs throughout the U.S. Although we did include a 10-item post-training knowledge assessment in our surveys, we do not report these data because the items were changed throughout the period of study and varied across the sites (e.g., different items and response options were tested), in preparation for our nationwide dissemination study (currently ongoing). Our short-term pre-post design does not afford the opportunity to estimate the sustainability of the program’s effects on student confidence or its impact on actual counseling activities during clinical
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rotations or after graduation. Additionally, our study did not include a control group, and our measures relied on students’ self-report of abilities. Evaluations of student performance using an objective structured clinical examination (OSCE) would better assess the participants’ tobacco cessation counseling competencies. We were unable to incorporate OSCE measures because this examination format was not used in the courses in which the Rx for Change program was taught, and we lacked funding to develop and implement an OSCE specifically designed to evaluate the curriculum outside of the scheduled class time. In the future, we hope to incorporate OSCE evaluations, as others have done [24–29], to further evaluate the impact of Rx for Change on counseling skills. Finally, while our program is applicable to students in all health professions, our study evaluated the impact of the Rx for Change curriculum only on students enrolled in a doctor of pharmacy program. While formal evaluations of the impact of the Rx for Change program on other disciplines have not been conducted, the program has been adapted and disseminated to 84 nursing programs, one dental school, and one medical school in the US [21]. The program also has been used to train licensed providers including tobacco cessation counselors in a research study of smoking cessation in patients with schizophrenia (Michael Smith, Principal Investigator) and community pharmacists in a large National Cancer Institute-funded smoking cessation program in sixteen communities Texas (Alexander Prokhorov, Principal Investigator). Because the Rx for Change curriculum is based on the USPHS Clinical Practice Guideline and incorporates enhanced instructional techniques (e.g., role playing and hands-on demonstration exercises; our more recent additions to the program include the viewing of videotaped counseling sessions and engaging students in trigger tape discussions) that have been found in previous studies to be effective in training medical students, [33] residents, [34], and practicing physicians [35], we anticipate that our results would be applicable to students in other disciplines. Our data suggest that students completing the training attain a high degree of self-confidence for providing comprehensive tobacco cessation assistance. Moreover, the vast majority of students perceive that participation in the training will increase both the frequency and quality of their intervention efforts with tobacco users. Given the prevalence of tobacco-related morbidity and mortality, it is imperative that practicing clinicians and students in health professional schools receive evidence-based training in the treatment of tobacco use and dependence. Ideally, comprehensive tobacco cessation training would be a core requirement in the curricula of all health care professional schools, and this training would be further augmented through continuing education and certification programs for licensed providers. While further studies are necessary to document the impact of these training programs on long-term cessation rates with tobacco users, it is logical to conclude that
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providing patients with widespread access to a multidisciplinary team of providers trained in tobacco cessation is an important step toward reducing the future burden of tobacco-induced disease. In summary, we have developed, implemented, and conducted a statewide evaluation of a comprehensive, 7 to 8 h modular tobacco cessation curriculum designed for students in the health professions. With funding from the National Cancer Institute, the Rx for Change curriculum is currently being disseminated through train-the-trainer programs to schools of pharmacy nationwide (currently faculty members from 85 of the 89 schools have been trained), thereby ensuring that future pharmacists will have received comprehensive training to assist patients with quitting. In this time of limited resources, particularly among academic institutions, we believe that it is particularly important that health professional schools work together in sharing expertise and curricular materials toward the common goal of enhancing patient care and improving medical outcomes.
Acknowledgments We would like to thank the pharmacy students at UCSF, USC, UOP, and WU who completed our surveys and have provided thoughtful feedback toward the refinement of the Rx for Change curriculum since 2000. The evaluation of this program was made possible through funding from the University of California Tobacco-Related Disease Research Program (grant 10ST0339 to K Hudmon). Preparation of the manuscript was supported in part by the National Cancer Institute (grant R25 90720 to K Hudmon). The hands-on portion of the aids for cessation module was made possible in part through product donations to the schools from Pharmacia Corporation (now Pfizer, Inc.) and PICS Inc.
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