Tobacco education in North American medical school curricula.

Abstract: Studies indicate the role of physicians in smoking cessation is critical but less than half of tobacco users received smoking advice from their physicians. This study attempted to reveal medical school academic deans' attitudes toward and status of tobacco education in medical school curricula in the United States, Canada, and Mexico. Of 199 copies of the questionnaire mailed, 47% responded. Findings indicated medical school academic deans were overwhelmingly supportive of tobacco education in medical school curricula. There was disagreement, however, regarding how medical schools should educate physicians about their role in providing smoking cessation interventions for their patients.

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In many developed and developing countries, tobacco use is the most preventable cause of premature mortality and morbidity and is viewed as the number one public health enemy. Tobacco related mortality is currently estimated to be four million lives per year and is expected to increase to 10 million lives per year by the year 2030 (World Health Organization, 1999). Strong relationships exist between tobacco use and the development of numerous diseases including cardiovascular diseases, lung cancer, chronic obstructive pulmonary disease, and tumors of the mouth, larynx, esophagus, lip, and bladder (Lopez & Peto, 1996). While tobacco use is a worldwide public health concern, it is especially so on the North American continent where men and women have the second leading and leading rates, respectively, of lung cancer incidence in the world (Parkin, Pisani, & Ferlay; 1999). In North America, state-of-the art smoking cessation is not routinely provided to patients (Coultas, 1991; Glynn, 1988; Montner, Bennett, & Brown, 1994). Numerous studies indicate the clinician's role in smoking cessation is critical but fewer than half of tobacco users receive smoking advice from their physicians (United States Department of Health and Human Services [USDHSS], 1998). If physicians systematically counseled each patient to quit smoking, there would be a 5% to 10% reduction in the rate of smoking in the United States (Kottke, Batisita, DeFriese, & Brekke, 1988; Parkin et al., 1999). The question which naturally follows is: "Why don't more physicians advise their patients to stop smoking?" In part, this can be attributed to the lack of emphasis on tobacco education in medical school curricula (Ferry, Grissino, & Runfola, 1999; Richmond, 1999; Siegal, Cole, Li, & Eddy, 2000). Researchers and educators trying to address this issue encounter a lack of data with regard to tobacco education curricula components and even less information about current attitudes toward tobacco education in medical schools (Ferry et al., 1999).

The purpose of this paper is to examine trends related to tobacco education in medical school curricula in the United States, Canada, and Mexico. Demographic information regarding the respondents and medical schools, attitudes of academic officers toward tobacco education in medical school curricula, and the presence of curricula components related to tobacco education are presented.

PHYSICIANS' ROLE IN SMOKING CESSATION

There is clear evidence that doctors play an important role in assisting patients with smoking cessation (Godshall, 1993; Richmond, 1999; Roche, Eccleston, & Sanson-Fisher, 1996). Physicians are in the unique position to have both influence on and access to the smoking population (Coultas, 1991). For example, in the United States, physicians have access annually to an estimated 70% of the smoking population (USDHHS, 1998). Physicians who intervene with patients that smoke have an impact on smoking behavior (Coultas, 1991; Glynn, 1988; Seim & Verhoye, 1995). Brief, office-based, smoking-cessation interventions by doctors can reduce rates of smoking among their patients. The evidence of the increased quit-rate owing to physicians' advice implies that physicians alone could be responsible for millions of people quitting smoking in a given year (Montner et al., 1994). Physicians often do not take advantage of office visits to encourage tobacco users to quit. For example, among Whites who had seen a physician in the previous year, 50.4% reported receiving advice on quitting smoking. In the same study, racial and ethnic minorities were even less likely to receive similar advice with 45.4% African Americans and 42.4% Hispanics reporting their doctor provided advice on quitting smoking. If the smoking epidemic is to be curbed, it is crucial that doctors are equipped with the knowledge and skills to understand the effects of tobacco on health, encourage their patients to stop smoking, and support them as non-smokers (Richmond, 1996,1999).

Coultas (1991) identified several barriers for physicians to counsel their patients on smoking cessation such as misperceptions about smokers' attitudes toward cessation and efficacy of the physician in smoking cessation. Many doctors rate themselves as ineffective smoking cessation counselors (Boehlecke, Sperber, Kowlowitz, Becker, Contreras, & McGahie, 1996). They feel that they lack the skills and self-efficacy necessary to act in this capacity. Studies that support these feelings of inadequacy have demonstrated that many physicians have never learned smoking-cessation counseling and management techniques (Papadakis, Croughan-Minihane, Fromm, Wilkie, & Ernster, 1997; Siegal et al., 2000). It is plausible that each barrier could be addressed in medical school curricula.

To identify and understand these barriers more completely, the Tobacco Section of the International Union Against Tuberculosis and Lung Disease (IUATLD) conducted a worldwide survey in 1992 (Richmond, 1999). This important study raised awareness regarding tobacco education in medical school curricula. Findings showed there were knowledge deficiencies of smoking related diseases, including lung cancer, pulmonary emphysema, peripheral vascular disease, bladder cancer, and neonatal mortality among medical students around the world. This study also reported deficiencies in medical school students' knowledge and skills related to smoking cessation counseling. The IUALTD study design did not allow easy comparison of responses to survey questions among respondent countries. Researchers grouped all countries of North America into one category, therefore examination of individual country differences was difficult (Richmond, 1999). Other recent studies of tobacco curricula in medical schools have been limited to one country (Horton, 1986; Ferry et al., 1999; Richmond & Kehoe, 1997). Therefore, the present study was designed to provide descriptive information regarding the attitudes of academic administrators toward tobacco education in medical school curricula and the current contents of tobacco education curricula in the United States, Canada, and Mexico.

METHODS

INSTRUMENT

This study utilized a 36-item questionnaire derived from Educating Medical Students About Tobacco: Planning and Implementation published by the International Union Against Tuberculosis and Lung Disease (Crofton & Tessier, 1996). The instrument covered basic demographic information, attitudes toward tobacco education in undergraduate medical education, and content areas of tobacco education included in the medical school curricula. The first seven questions covered demographic information about both respondent and institutional characteristics including: country of the medical school, administrative position of respondent, number of years as a faculty member in the medical school, race of respondent, race of predominant majority and minority patients served by institution, and the community background of patients served by the institution. An attitude scale was adapted from McCartan and Shanley's (1995) survey on the policies and practices of European dental schools related to smoking. Respondents were asked to designate their attitudes toward tobacco education in medical school curricula using a Likert type 5-point scale format ranging from 1 (strongly agree) to 5 (strongly disagree). The development of the remaining 22 items for the content areas was based on IUATLD's Aspects of Tobacco Which Should be Covered in the Curriculum (Crofton, Tessier, Freour, & Piha, 1996). Respondents were asked to indicate whether or not a particular area of content was covered with a yes-or-no response.

The major areas of content covered by the survey included:

[] Basics--harmful components of tobacco smoke, tobacco as an addictive substance, oral tobacco, and why children/people take up smoking.

[] Tobacco-related diseases--major morbidity and mortality, cancers, cardiovascular disease, respiratory diseases, gastrointestinal diseases, reproductive system diseases, diseases of children and young people.

[] Passive smoking--effects on the fetus, children, and adults.

[] Benefits of quitting smoking--reducing the risk of developing tobacco-related diseases, reducing severity of adverse effects due to tobacco-related diseases.

[] Preventive measures--political measures and advocacy for tobacco issues, action by doctors.

[] Administrative actions by medical school--having a coordinator of tobacco education at school, having a written policy regarding a smoke-free medical school environment, and enforcing a smoke-free environment.

SUBJECTS

The chief academic officers (usually held the title Dean of Medical Education or Dean of Academics) of all medical schools in the United States, Canada, and Mexico were targeted for this study. Their names and mailing addresses were obtained from the 1997-98 Directory of American Medical Education (American Association of Medical Colleges, 1997) for the United States and Canada. The chief academic officers for medical schools located in Mexico were identified using the Panamanian World Health Organization's listing of international medical schools (Pan American World Health Organization, 1998). Each chief academic officer of the 199 medical schools in the United States, Canada, and Mexico was invited to complete a survey that assessed demographics, attitudes, and current practices with respect to tobacco education in medical school curricula. All mailings were sent and responses received during the 1998-1999 academic year.

RESULTS

All data were analyzed using the Statistical Package for the Social Sciences (SPSS) 10.0 software package. The initial response rate in November of 1998 was 36% (n=71). A second mailing was conducted to increase response rates. By January of 1999, the overall survey response rate increased to 47% (n=94). The individual country's response rates were United States, 67% (n=72); Canada, 58% (n=11); and Mexico, 19% (n=11).

The demographics portion of the instrument provided descriptive information about both the respondent and the institution with which they were affiliated (see Table 1). The majority of persons who completed the survey were White (80% of the respondents), either the dean or academic administrator of their institutions (76%), with at least 16 years of experience (67%). Most of the institutions (66%) were located in urban communities and had Whites as the majority of their patients (71%).

ATTITUDES

An overall score for attitude (0 to 35) was calculated based on 7-items. Higher values on the attitude scale were associated with a more positive attitude toward tobacco education in the medical school curricula. The average score on this portion of the instrument was 29.7 [+ or -] 3.3. Reliability estimates indicated a Cronbach's alpha of .70. A One-way Analysis of Variance at the .05 level of significance showed no significant difference in attitudes between the three countries surveyed in this study. Individual items within the scale were also examined.

Key findings for attitudes were presented in Table 2. Deans' and administrators' attitudes toward tobacco education in medical school were similar across

three countries. Almost all (99%) respondents agreed or strongly agreed that tobacco-use education should be part of formal medical education. However, when they were asked whether a specific teaching module of tobacco education should be used in medical schools, less than half (42%) had positive attitudes. Most deans/ administrators not only expected medical students to give anti-smoking advice to their patients (79% of the respondents) but also believed that physicians should be active in anti-tobacco campaigns (78%).

CURRICULA COMPONENTS

An overall score (from 0 to 22) was calculated for curricula components. A higher score indicated the inclusion of more current components associated with a comprehensive tobacco education curriculum. The average score was 18.4 [+ or -] 3.1. Reliability estimates revealed a Cronbach's alpha of .82. One-way Analysis of Variance showed a significant difference in curricula components among the three countries surveyed in this study ([F.sub.(2,91)] = 6.64, p = .002). The Tukey's Honestly Significant Difference Post Hoc Test further showed that the differences existed between the United States and Mexico curricular components with the United States having a significantly higher score on the curricula components scale.

Individual items within the scale were also examined and summarized in Table 3. Two content areas of tobacco education, including environmental tobacco smoke (ETS) and oral tobacco education, were less often included as a part of tobacco education curricula. Results showed 6%, 27%, and 35% of the institutions in the United States, Canada, and Mexico, respectively, did not teach their students the impacts of ETS on adults. Similarly, 13%, 45%, and 64% of the respondents from the United States, Canada, and Mexico, respectively, indicated that their institution did not include basic oral tobacco education. Nearly one out of five (18%) institutions did not explain why people use tobacco in their education programs. Furthermore, one-half (50%) of the medical schools did not teach their students preventive measures related to tobacco. While the importance of tobacco education had become a consensus, few (only 5%) had an individual as a coordinator of tobacco education at their schools.

DISCUSSION AND CONCLUSIONS

The results of this study indicated that medical school academic deans in North America who responded to this survey reflected attitudes that were overwhelmingly supportive of tobacco education in medical school curricula. There was a disagreement, however, regarding how medical schools should educate physicians about their role in providing smoking cessation treatment for their patients. Only 42% of the respondents agreed that a specific teaching module of tobacco education should be used in medical schools. Recent data suggested, however, that major components of tobacco curricula were often not included in medical school curricula. Ferry et al. (1999) studied the inclusion of 12 content areas (as recommended by the Agency for Health Care Policy Research and the National Cancer Institute) in basic and clinical science curricula in American medical schools. Results showed that of the six recommended components in the basic science curriculum, only 55% of medical schools included all of the suggested tobacco related topics. Further, only 4% of the schools covered the recommended tobacco related topics in the clinical science curricula.

In the present study, we found that one-fifth (20%) of the survey respondents indicated they had no opinion or disagreed that medical students should be expected to give anti-smoking advice to their patients. When questioned as to whether physicians should be active in anti-tobacco campaigns, more than one-fifth (21%) of the respondents either had no opinion or disagreed with this question. If academic deans, who have the potential to affect medical school curricula, hold this attitude, it may result in missed opportunities for medical students to be trained in effective smoking cessation and tobacco control techniques.

There was variation in responses to questions regarding specific components of tobacco curriculum in the areas of oral tobacco and environmental tobacco smoke. Oral tobacco use is an important part of tobacco education in view of the well-established relationship between its use and upper digestive track cancers and periodontal disease. However, less than 50% of the respondents from Canada and Mexico indicated that the basics of oral tobacco were taught within the current curriculum. Environmental tobacco smoke is the third leading preventable cause of premature mortality in the U.S. and a well-established environmental health hazard worldwide (Glantz & Parmley, 1991). Yet, 15% of the respondents indicated this topic was not currently a part of their curricula. The IUALTD also considers the administrative appointment of a coordinator of tobacco education an important step in supporting the inclusion of the tobacco related curricula components assessed in this survey. Only 5% of all responding institutions currently had a coordinator of tobacco education.

Limitations of this study include the low response rates from Mexico. Although a second mailing did increase the sample size, it would have been desirable to have a higher number of surveys returned to ensure results representative of all North American medical schools. Additionally, the inclusion of tobacco education in the medical school curricula was based on the opinion and self-report of the respondents. A worthwhile future direction would be to conduct a content analysis of the medical school curricula to measure more directly what medical students are taught with regard to tobacco education.

The results of this study are consistent with the findings of other researchers who have investigated tobacco education in medical school curricula. The international study conducted by the International Union Against Tuberculosis and Lung Disease (IUATLD) found major deficits in knowledge among medical students with regard to the diseases less commonly associated with tobacco as well as skills related to tobacco dependence counseling (Richmond, 1999). These deficits may be in part associated with the short comings with regard to attitude and curriculum components identified in this study.

Tobacco is a leading preventable cause of death in North America. Physicians possess the important combination of both access to and influence over the smoking population. As a result, an effective strategy to decrease tobacco related mortality would be to equip physicians with the skills and self-efficacy to encourage patients to stop smoking. Medical school provides an excellent opportunity for giving future physicians these skills and confidence. More research is needed to identify barriers to the introduction of tobacco education into medical school curricula. In addition, studies that evaluate the effectiveness of various learning strategies for tobacco curricula are needed. Competency-based assessments of medical students' skills in smoking cessation are critically needed.

Table 1. Demographic Information of Responding Medical School Personnel

                                    USA *     Canada *    Mexico *
                                    (n=72)     (n=11)      (n=11)
Position of Respondent
  Dean/Academic Administrator         86         82          64
  Faculty Member                      10         18          18
  Staff Person                         3          0          18
  Other                                1          0           0
Experience of Respondent
  1 to 5 years                         6          0          27
  6 to 10 years                       11          9          18
  11 to 15 years                      15          9           9

  16 to 20 years                      17         27          36
  21 to 25 years                      35         36           0
  26 or more years                    17         18           9
Race of Respondent
  Caucasian                           88        100           9
  African American                     3          0           0
Hispanic American                      3          0          91
  Asian American                       2          0           0
  Other                                2          0           0
Predominant Majority of Patients
  Caucasian                           81         82           0
  African American                    10          0           0
  Hispanic American                    3          0          91
  Other                                7          0           9
  Missing Data                         0         18           0
Community
  Rural                               17          0           0
  Urban                               63         91          64
  Suburban                            11          9          27
  Other                               10          0           9

* Percent of Respondents

Table 2. Summary of Findings for Deans' Attitudes Toward Tobacco
Education

Question    Response    Overall *    USA *     Canada *    Mexico *
                         (n=94)      (n=72)     (n=11)      (n=11)

Tobacco use (smoking/smokeless) education should be part of formal
  medical education
               SA          73          75         64          73
                A          26          25         27          27
                N           1           0          9           0
                D           0           0          0           0
               SD           0           0          0           0
A specific teaching module of tobacco education should be used in
  medical schools.
               SA          21          18         36          27
                A          21          10         46          73
                N          38          49          9           0
                D          13          18          9           0
               SD           5           6          0           0
Students are expected to give anti-smoking advice to patients.
               SA          39          36         46          55
                A          40          43         36          27
                N          24          25          9           9
                D           5           4          9           9
               SD           1           1          0           0
Physicians should be active in anti-tobacco campaigns.
               SA          38          39         27          46
                A          40          38         46          55
                N          18          22          9           0
                D           2           1          9           0
               SD           1           0          9           0

* Percent of respondents

SA=Strongly Agree

A=Agree

N=No Opinion

D=Disagree

SD=Strongly Disagree

Table 3. Key Findings for Curricula Components Related to Tobacco
Education

Question    Response    Overall *    USA *     Canada *    Mexico *
                         (n=94)      (n=72)     (n=11)      (n=11)

Are students taught the basics with respect to oral (smokeless)
tobacco?
               Y           75          85         45          36
               N           22          13         45          64
               D            3           3          9           0
Are students taught the basics with respect to why people take up
smoking or use of smokeless tobacco?
               Y           78          83         64          55
               N           18          13         27          46
               D            4           4          9           0
Are students taught about environmental tobacco smoke (passive or
second-hand) with respect to effects on children?
               Y           88          92         73          82
               N            7           3         27          18
               D            4           6          0           0
Are students taught about environmental tobacco smoke (passive or
second-hand) with respect to effects on adolescents and teens?
               Y           84          86         73          82
               N           11           7         27          18
               D            5           7          0           0
Are students taught about environmental tobacco smoke (passive or
second-hand) with respect to effects on adults?
               Y           84          89         73          64
               N           50          54         36          36
               D            4           4          0           9
Are students taught preventive measures related to tobacco with respect
to political measures and advocacy related to tobacco issues
               Y           46          42         64          55
               N           50          54         36          36
               D            4           4          0           9
Does your medical school have a coordinator of tobacco education?
               Y            5           6          9           0
               N           95          94         91         100
               D            0           0          0           0

* Percent of respondents

Y=Yes

N=No

D=Don't Know

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Susan S. Thomas, Ph.D. is a Cancer Prevention Fellow in the Division of Cancer Prevention at the National Cancer Institute in Rockville, Maryland. Mohammad R. Torabi, Ph.D., MPH is the Chancellor's Professor and Chairperson in the Department of Applied Health Science at Indiana University. Stephen J. Jay, M.D. is a Professor of Medicine and Public Health in the Department of Public Health at the Indiana University School of Medicine. Joseph Capparo, B.A. is a Staff Member Emeritus from the American Lung Association of Indiana. Ifeng Jeng; MS is a Doctoral Candidate and Research Assistant with the Department of Instructional Systems Technology in the School of Education at Indiana University. Address all correspondence to Mohammad R. Torabi, Ph.D., MPH, Chancellor's Professor & Chairperson, Department of Applied Health Science, HPER 116, Indiana University, Bloomington, Indiana 47405; PHONE: [phone]; FAX [phone]; E-MAIL: [e-mail].