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Re: Teaching Medical Students to take tobacco use seriously

I always enjoy new research describing how medical students are not taught about tobacco use and smoking cessation. I teach medical students about tobacco use. One of the first things I teach students about tobacco use is that it is best considered a disease, not a risk factor. In the American Society of Addiction Medicine's Public Policy Statement on Nicotine Dependence and Tobacco in the Journal of Addictive Disease, 1993;12(1), it states: "Although the medical profession has traditionally viewed tobacco use as a risk factor for other diseases, and not as a primary problem in itself, this approach has impeded, rather than promoted, the development of optimal treatment methods for patients addicted to nicotine. Nicotine dependence is best regarded as a primary medical problem, with tobacco- related diseases viewed as direct consequences of nicotine dependence." Recently I have been helping a student medical doctor study for the Clinical Skills Assessment required as part of the USMLE process for medical residency qualification to study in the United States. Materials prepared for such study indicate patients should be told about smoking cessation when the medical case indicates smoking is a risk factor. Yet, smoking is not included as a "vital sign" to be asked about, nor is there much recognition that nicotine dependence requires any kind of rigorous response from doctors presented with patient conditions. So, in the case of a patient with pneumonia, the doctor is to "discuss tobacco cessation with the patient."

Sadly, I get little support from clinicians with my emphasis that tobacco use is a primary condition. Generally, they all see tobacco use as a distant "risk factor," far from their focus on strictly curative concerns. With no understanding of tobacco use as a primary medical problem and little reward for counseling/caring for patients to overcome it, I see little prospect for change in physician training or practice in this area.

Physicians wonder why patients increasingly seek help from unqualified healers, counselors, but seem to continue to put preventive and promotive care of primary medical conditions aside because their profession does not support such action. I hope somewhere along the line, the disease and death effects of tobacco use begin to register. Until then, I shall continue teaching my two hours of unorthodoxy.

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Re: Minimal Training in Tobacco-Control May be Epidemic

The findings presented by Roddy et al. [1] paint a dim picture of tobacco training in the UK, but rosier than that in U.S. schools of public health (SPH).

As part of the Association of Schools of Public Health(ASPH)/American Legacy Foundation “STEP UP” initiative, we administered an ASPH survey to the 27 faculty members of the San Diego State University Graduate School of Public Health (SDSU GSPH) and also to 13 members of other departments. We also reviewed the course catalog, and extramural research records.

Of the 76 classes offered by the GSPH, only 10 addressed tobacco in any form. Most of the 10 used tobacco only as illustrations of other content, such as research methods. None emphasized tobacco as a serious risk factor, or control methods. Only two courses offered to the university’s 32,000 undergraduate students included tobacco content, one in health education and one in psychology. Psychology and nursing had two and three graduate classes, respectively, that mentioned tobacco. It is unlikely non- responders provided tobacco education, and department chairs confirmed this conclusion.

With over 1,069 full-time equivalent faculty at SDSU, only 11 are conducting tobacco research. The GSPH has nine tobacco grants. Two full time faculty teach most of the classes that include tobacco content, reaching about 35 students/year.

Undergraduate and graduate students have little exposure to tobacco content and little opportunity for tobacco-related research training. Similar to Roddy et al. [1], the ASPH survey of member schools indicated that about half included some form of tobacco-related content [2], but few had a strong tobacco control program.

Physicians leaving medical school feel unprepared to provide tobacco- related assistance to patients [3,4,5]. Dental schools may be the exception, yet leave considerable room for improvement [6]. Lack of tobacco control training may be true of schools of law, business, social sciences, biology and liberal arts programs. If so, the vast majority of students are not obtaining basic education about the risks of or means of controlling tobacco.

The NIH spends about 1% of its research funds on tobacco-related research, possibly due to under-representation of tobacco control proposals [7] or to under-promotion by NIH. A search of NIH websites produced zero current RFP/RFAs and zero training opportunities specific to tobacco.

Efforts are under way to increase professional education about tobacco [8,9], but extramurally supported programs may not be sustainable without support from intramural sources. In the face of an industry that actively undermines tobacco control efforts and that funds legislators, academic administrators, and investigators in schools of medicine, dentistry, public health and basic science departments [10], we challenge university faculty and academic administrators to dramatically increase the emphasis on tobacco-control. We challenge tobacco control investigators to more actively promote research assistantships, and to make better use of available pre- and post-doctoral fellowships as a means to recruit and support future investigators. For one of the greatest public health crises, this is a tragedy of academic planning and government support.

References

1 Roddy E, Rubin P, Britton J, on behalf of the Tobacco Advisory Group of the Royal College of Physicians. A study of smoking and smoking cessation on the curricula of UK medical schools. Tobacco Control 2004;13:74–77.

2 ASPH Tobacco Studies Survey 2001-2002. Association of Schools of Public Health/American Legacy Foundation. Available online: http://www.asph.org/ document.cfm?page=788. Accessed March 1, 2004.

3 Ferry LH, Grissino LM, Runfola PS. Tobacco dependence curricula in US undergraduate medical education. Journal of the American Medical Association 1999;282:825-9.

4 Khurana S, Batra V, Kim V, Patkar A, Leone FT. Attitudes and beliefs of physicians-in-training regarding nicotine addiction and treatment. Chest 2002;122:S9.

5 Teaching Smoking Cessation: An Expert Interview With Vikas Batra, MD, and Frank T. Leone, MD. Medscape 12/30/2002. Available online: http:// www.medscape.com/viewarticle/446283?mpid=8129. Accessed April 3, 2003.

6 Weaver RG, Whittaker L, Valachovic RW, Broom A. Tobacco control and prevention effort in dental education. Journal of Dental Education 2002;66: 426-9.

7 Hughes J, Liguori A. A critical review of past NIH research funding on tobacco and nicotine. Nicotine and Tobacco Research 2000;2:117-20.

8 Tobacco Control in the 21st Century. University of Sydney, Australia. Available online: http://www.health.usyd.edu.au/tob21c. Accessed April 3, 2003.

9 Curricular innovation grant abstracts. Association of Schools of Public Health/American Legacy Foundation. Available online: http://www.asph.org/ document.cfm?page=791. Accessed March 1, 2004.

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Re: Smoking cessation in curricula- the challenges are linked to health promotion

I have recently completed a doctoral thesis exploring the epistemological challenges associated with the inclusion of health promotion in medical undergraduate education.

Those challenges reflect the dilemmas associated with teaching about smoking cessation. It is in fact only recently that the UK NHS plan has suggested a consistent approach for the delivery of smoking cessation services and previous to that there had been a lack of consensus about not only about how to respond to and support the smoker who wants to stop but also whether or not such a provision should be part of the clinicians’ role.

Intervention is the essence of health promotion activity but its evidence base has been contested, the theories underpinning and informing activity are eclectic and few clinicians will have engaged with this discipline in any depth.

For educationalists the inclusion of health promotion, and specifically smoking cessation, in curricular content has been fraught with difficulties and your findings reflect this. However based on my ethnographic research findings I have constructed a new working definition of health promotion which should assist both medical educators and medical teachers in the development of the learning outcomes and objectives as well as the approaches to assessment. The definition is as follows; Health promotion is the study of, and the study of the response to, the modifiable determinants of health. By using this definition, exploring what is arguably modifiable as well the evidence base for response or intervention, medical educators can progress in the generic field of health promotion teaching as well as the specific field of smoking cessation (1).

I would argue, however, that those medical teachers, who will be charged with the responsibility to teach medical students the current approaches to smoking cessation will need to have the opportunities to familiarise themselves with, and engage with, the debates associated with health promotion theories, evidence and practice.

At this medical school we intent to look at the needs of our medical teachers in this regard and hope to be able to have pragmatic approaches to assessment by 2007 for senior medical students.

Reference List