Pediatric Residency Training on Tobacco: Review and ... - NCBI - NIH

Pediatric Residency Training on Tobacco: Review and Critique of the Literature Norman Hymowitz, PhD Newark, New Jersey

Financial support: Preparation of this manuscript was supported in part by NICHHD/NIH grant #ROI HD40683.

Objective: To review and critique the reseorch literature on training pediatric residents to address tobacco. Methods: A Medline search was conducted to identify studies that specifically addressed pediatric residency training on tobacco, and Google. Scholar was used to identify articles in which the referenced study was cited. Results: Eight studies that specifically addressed training pediatric residents to intervene on tobacco were identified. Most used active as well as passive approaches to training. Baseline data underscored the importance of training future pediatricians to address tobacco. Although the studies differed in size, scope and rigor, they showed that training pediatric residents to address tobacco enhanced residents' ability and likelihood to address tobacco. Conclusion: The review documents the importance and value of training pediatric residents to address tobacco, provides suggestions for future research and underscores the need to incorporate training on tobacco into pediatric residency training curmculum. Key words: pediatric research U education * tobacco smoke * smoking cessation © 2006. From the Department of Psychiatry, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ. Send correspondence and repnnt requests for J NatI Med Assoc. 2006;98:1489-1497 to: Dr. Norman Hymowitz, Professor of Psychiatry, Department of Psychiatry, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Behavioral Health Sciences Building, F-1510, 183 S. Orange Ave., Newark, NJ 07103; phone: (973) 972-5425; fax: (973) 972-8305; e-mail: [email protected]

C igarette smoking, use of other forms of tobacco, and environmental tobacco smoke (ETS) play a significant etiologic role in four of the five leading causes of death in the United States.' For the years 1997-2001, tobacco use and smoke exposure resulted in approximately 438,000 premature deaths, 5.5 million years of potential life lost, and $92 billion in productivity losses annually.2 The harm caused by tobacco is not JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

limited to the United States. Peto and Lopez3 estimate that use of tobacco will cause nearly 450 million deaths worldwide during the next 50 years. Effects of ETS and tobacco use on the young are of particular concern to pediatricians. Smoking by pregnant women may lead to low birthweight, preterm delivery, birth defects and death of the fetus. Exposure to ETS following birth increases the risk of sudden infant death, respiratory distress, ear infections and asthma.4-6 Twenty-seven percent of the children in the United States live in a household with >1 smoker,7 and >5,000 children die each year from tobacco-related exposure.8 Youths who smoke or use other tobacco products face a lifetime of addiction and tobacco-related disease,5'9"0 and, of the 322,423 American youths who became regular smokers in 2005, 103,175 will die prematurely." Statements from the AAP Committee on Substance Abuse5" 2"13 call upon pediatricians to address tobacco. Unfortunately, surveys of practicing pediatricians, 14-20 pediatric residents,2",22 pediatric patients23-25 and parents of pediatric patients26-29 show that pediatricians are less likely to address tobacco than other primary care physicians, miss opportunities to intervene on tobacco and often fail to provide active assistance for modifying exposure to tobacco smoke, preventing smoking onset and helping smokers quit. Missed opportunities to address tobacco in pediatric settings represent a gap in our nation's antismoking armamentarium30 and are not consistent with the pediatrician's traditional role in disease prevention and health promotion.3' Reasons pediatricians give for not addressing tobacco include lack of time, competing priorities, questions concerning reimbursement and efficacy of treatment, and lack of preparation and training.'5 While patient loads may cause pediatricians to give tobacco short shrift, useful models for addressing tobacco in busy clinical settings exist.32-38 When pediatricians and residents receive training, they become more confident in their ability to intervene effectively,'5'39 more skillful in their approach35 40 and more effective in their impact.4"42 If pediatricians were exposed to effective role models and opportunities to acquire knowledge and skills necesVOL. 98, NO. 9, SEPTEMBER 2006 1489

RESIDENT TRAINING ON TOBACCO

sary to intervene on tobacco during residency, they would be more likely to assume a leadership role in the antismoking arena when they enter clinical practice.43 Unfortunately, a survey of pediatric residency training directors showed that most programs do not include tobacco prevention and control in their curriculum,"4 and the most frequently used formats for teaching about tobacco were lectures and reading material, with little emphasis on active learning. While passive learning is appropriate for didactic information, active learning, such as the use of role-playing and simulated patients (SPs), is necessary for teaching clinical skills.45-7 It is also important to note that many pediatric residency training programs are housed in hospitals located in large, urban communities. Many serve large, mostly poor, minority populations,40 for whom resident physicians serve as the main avenue for assistance in managing tobacco and other health behaviors. Failure to prepare residents to address the tobacco challenges not only short changes the resident but also the community in which they serve. Clearly, pediatric residency training programs can and must do more to prepare residents to address tobacco, and it is not necessary to reinvent the wheel. Programs in other primary care specialties45'4748-5' are applicable to pediatric residents; and person-centered interviewing-a cornerstone for effective physician-patient communication,

counseling and intervention on tobacCo_48 52-54 has a long history ofuse in medical settings.55-59 A number of studies specifically dealt with training pediatric residents to address tobacco, and they provide a foundation for progress in this area. The present review describes and critiques the studies in order to gain insight into the current state of research on pediatric residency training on tobacco and to provide direction for the future. Among other factors, the review focuses on design and outcome, training venue, nature of the training, and the role of pediatric faculty. Implications for future studies and application are discussed.

METHODS The literature search was conducted with the use of Medline and Google" Scholar. Key search terms were "pediatric residency training," "residency training," "pediatricians," "tobacco," "ETS," "smoking prevention" and "smoking cessation." A Google search was used to identify articles that cited the referenced studies. Eight studies that specifically addressed pediatric residents were identified. Studies of residents from other medical disciplines and physicians in practice were not included.

Review of Studies Tables 1 and 2 show key characteristics of the eight

Table 1. Study characteristics: design

Study Strecher, et al. (1 991 )60

Design Factorial

Control Group Yes

Random Assignment

Klein, et al. (1995)61

Between group

Yes

Kosower, et al.62

Pre-posttest

Study Duration 6 months

Number of Programs 11 (2 pediatric sites)

Unit of Analysis

No

1

Residents Parents

6 months

No

No

1

Residents

6 months

Hymowitz, et al. Between (200 1)41 group

Yes

No

3 (1 pediatric site)

Residents Patients Parents

4 years

Lee, et al.

Cross-over

Yes

Yes

1

Residents

4 months

Pre-posttest

No

No

1

Residents

3 months

Between group

Yes

Yes

1

Residents Parents

6 months

Hymowitz, et al. Between (2006)40 group

Yes

Yes

16

Training site

2 years*

Yes

Residents Patients Parents

(1995)

(2004)63 Scal, et al.

(2004)65 Collins, et al. (2005)67

* Study still in progress. Total duration: four years

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studies. With three exceptions,404'60 the studies were of relatively limited size, scope and duration, focusing on residents from a single program. Two studies62'65 did not utilize control or comparison groups, while others used quasiexperimental methods to obtain comparison groups.41'61'63'67 Only one study40 used the training site as the unit of analysis (Table 1), and only a few of the studies addressed the effects of resident intervention on behavior change in patients and/or parents (Tables 1 and 2). While it is commendable that many of these firstgeneration studies took advantage of naturally occurring opportunities to study the effects of training pediatric residents to address tobacco, it is apparent that future studies must attend more to design, method and scope. Typically, resident knowledge, beliefs and intervention practices were measured prior to and after introducing the training program on tobacco, and a variety of approaches were used to corroborate resident self-report data (see below). The nature of training used in the various studies often was innovative and comprehensive, employing active as well as passive approaches to learning. Hence, the studies provide considerable food for thought for training directors who wish to implement training on tobacco in the immediate future. It is also noteworthy that each of the studies described in Tables 1 and 2 employed the continuity clinic (CC) as the venue for training. As noted below, CC is uniquely suited for teaching about health

behaviors, such as tobacco prevention and control, providing residents with precious opportunities for intervention with patients and their families as well as opportunities for long-term follow-up. Strecher, O'Malley, Villagra et al.60 studied the effects of a tutorial on smoking cessation and use of prompts to remind physicians to address tobacco. Subjects were 250 residents associated with 11 different residency training programs (six in internal medicine, three in family medicine and two in pediatrics). Faculty members conducted the tutorials. Residents were assigned randomly to one of four experimental conditions, comprising a 2-x-2 factorial design (Al: tutorial, A2: no tutorial, B 1: prompt, B2: no prompt). Changes in resident performance and knowledge were determined by pre- and posttraining resident questionnaires and parent exit interviews. Six months after the initial exit interview, telephone interviewers obtained parent reports on current smoking status. Parents who stopped smoking were asked to return to the clinic for measurement of expired air carbon monoxide. The tutorial focused on brief interventions that could be carried out within a busy clinical setting (setting a quit date, writing a quit date prescription, distributing self-help materials, prescribing nicotine gum and scheduling a follow-up visit) and motivational techniques (determining when the first cigarette of the day is smoked, determining whether

Table 2. Study characteristics: training

Training Venue

?

Pediatric Faculty Involved Yes

Yes

Yes

Kosower, et al. (1995)62

Yes

Hymowitz, et al. (2001)41

CC

Focus of Training Cessation

Focus ofInterv. Parents

Yes

CC

Cessation

Parents

?

Yes

CC

Cessation Prevention ETS

Patients Parents

Yes

Yes

Yes

CC


Patients Parents

Lee, et al. (2004)63

Yes

Yes

Yes

CC

Cessation

Patients Parents

Scal, et al.

Yes

Yes

Yes

CC

Cessation

Patient Parents

Passive

Active

Learning

Learning

Strecher, et al. (1991)60

Yes

Klein, et al. (1995)61

Study

(2004)65

Prevention ETS

Collins, et al. (2005)67

Yes

Yes

Yes

CC

Cessation

Parents

Hymowitz, et al.

Yes

Yes

Yes

CC


Patients Parents

(2006)40

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smokers want to quit, discussing benefits of quitting, fostering self-confidence, relating smoking to current illness and warning offuture health risks). A one-hour session included presentations on smoking cessation and counseling, a videotaped counseling demonstration, discussion and evaluation. Two weeks later, residents attended small-group or individual sessions to discuss initial attempts to counsel patients. The pediatrics tutorial was identical to those for internal and family medicine, except pediatric residents were taught to counsel the patient's parents. Ninety percent of the residents in each discipline completed all phases of the study. Prior to training, all four experimental groups were similar with respect to study outcomes and other selected characteristics. The tutorial (A) led to significant and comparable increases in the frequency of counseling and use of counseling and motivational techniques by residents in each discipline. The effects of the prompt (B) and the interaction between the tutorial and prompt (AxB) failed to achieve statistical significance. Although parent interviews confirmed the self-reported changes in resident counseling behaviors, significant changes in parent smoking behavior were not observed.60 Klein, Portilla and Goldstein61 assessed the effects of incorporating National Cancer Institute (NCI) guidelines32 into pediatric training (e.g., anticipate the risk for tobacco use at each developmental stage, ask about exposure to tobacco smoke and tobacco use at each visit, advise all smoking parents to stop and all children not to use tobacco products, assist children in resisting tobacco use and tobacco users in quitting, and arrange follow-up visits as required. Klein et al.6' developed content modules and role-playing exercises based on time slots available in residency training settings. Curricular presentations were scheduled during the course of six weeks. Fifty-five percent (31/56) of the residents were trained. Residents on rotations in intensive care units or distant sites were not exposed to the training and served as a nonintervention comparison group. Knowledge, attitudes and counseling behaviors were measured using questionnaires, and exit interviews with parents after well-child visits served to corroborate resident selfreport data. Eighty-five percent of trained participants reported using some or most of the information presented, 96% reported feeling more knowledgeable and 63% reported feeling more able to help smokers quit. At baseline (BL), 16% of the residents in both experimental condition reported that they asked parents who smoke to set a quit date and/or discussed obstacles to cessation. The proportions increased to 50% at follow-up for residents in the training condition and 38% (quit date) and 8% (obstacles) for controls. Residents reported providing counseling 3 times more than parents reported receiving it.6' Kosower, Ernst, Taub et al.'s62 training program fea1492 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

tured a pediatric grand rounds; a one-hour workshop on how to use the "5 As,"32 and small-group discussion sessions. Residents were given background readings, patient education brochures and referral lists were available in CC examining rooms; and self-help, behaviorchange materials for smokers were placed on display in CC waiting areas. It is not clear whether active learning approaches to tobacco intervention were employed. Thirty-one healthcare professionals (21 residents and 10 faculty) completed pre- and posttraining surveys. The self-reported frequency of the following behaviors increased significantly after training: 1) asking patients/parents whether they smoked, 2) asking whether others in the home smoked, 3) offering information about the consequences of smoking, 4) advising smokers to quit, 5) offering referrals to smoking cessation programs, and 6) advising parents to protect their children from passive smoke. Confidence to address tobacco and awareness about referral sources also increased significantly from pre- to postsurveys, while three specific barriers to counseling (lack of expertise, lack oftime, and doubts about the effectiveness of counseling) significantly decreased in strength.62 Hymowitz, Schwab and Eckholdt4' studied the effects of tobacco education on resident, patient and parent behavior (Tables 1 and 2). The program was presented annually for three successive years and was evaluated by BL and follow-up surveys of residents, patients and parents. Residents in medicine and psychiatry served as no-treatment controls, completing surveys at BL and year 4 but not participating in the educational program. One-hour training sessions were held during lunch once every two months on an annual basis. Topics and content (e.g., ETS, cessation, prevention) varied from year to year, and residents participated on an annual basis. Additional sessions were held for role-playing and skill-building.4' At BL, most of the residents in each discipline reported that they routinely asked patients/parents about smoking (>85%), advised cessation (>70%) and informed them about the hazards of smoking (>60%). Residents in medicine (50%) and psychiatry (48%) were significantly more likely than residents in pediatrics (18%) to provide assistance for stopping smoking or encourage use of nicotine replacement therapy (11%, 33% and 78% for residents in pediatrics, internal medicine and psychiatry, respectively). Less than 10% of residents in either discipline provided smoking and health brochures or self-help quit-smoking materials. The proportion of pediatric residents who reported that they assisted cessation increased significantly from BL to year 4 (18-54%) while remaining unchanged for residents in medicine and psychiatry. Significant increases from BL also were observed for pediatric residents but not for residents in medicine or psychiatry, for advising patients/parVOL. 98, NO. 9, SEPTEMBER 2006


ents to stop smoking, informing them about the hazards of smoking, providing educational brochures and pamphlets on how to stop smoking, and counseling smokers to quit. The proportion ofpediatric residents who reported that they informed patients/parents about the hazard of ETS, advised parents to create a smoke-free household, advised parents not to expose their children to ETS, and helped parents modify ETS also increased significantly from year 2 to year 4 (data on ETS not collected from residents at BL).4' Parent and patient reports of resident intervention activities were congruent with the resident reports, although the number of adolescents seen in CC was quite low, and few of them smoked. The prevalence of parent/guardian cigarette smoking declined from 36% at BL to 31% at year 4. Although the decline (13.8%) was in the expected direction, the decrease failed to achieve statistical significance. Logistic regression showed that variables that decreased the likelihood of parental smoking at year 4 included duration of time attending the clinic, doctor advice about quitting and doctor offering to help them quit.4' The proportion of parents/guardians who reported creating a smoke-free household and asking visitors to smoke outside the home also increased significantly.4' Logistic regression showed that the number of household members who smoked decreased the likelihood of creating a smoke-free household, while an affirmative answer to the question, "Did your child's doctor offer to help you stop exposing your child to ETS?," was significantly and independently associated with creating a smoke-free household at year 4.41 Lee, Hishinuma, Derauf et al.63 employed a crossover design where the study group (SG, n=15) residents at one CC site served as the initial SG and received the intervention, while the control group (CG, n=1 8) residents at the other CC received no intervention (Table 1). After the completion of SG training, the intervention was crossed and implemented for CG residents. Both groups were tested at BL (time 1), after SG training (time 2) and after CG training (time 3). Residents receiving the intervention completed a series of eight weekly teaching sessions during the first 30 minutes of CC. Four sessions targeted smoking cessation counseling as part of a larger preventive health counseling curriculum. Residents learned principles of motivational interviewing and the NCI "5 As" model.64 The curriculum was taught by CC preceptors, each trained to deliver standardized PowerPoint® presentations, show a smoking cessation training video, facilitate role-playing sessions and provide feedback on resident counseling skills. Each preceptor was assigned to train a group of 1-3 residents. SPs evaluated the residents' counseling skills. Nine SPs underwent training to portray a healthy teen smoker presenting to CC for a routine health maintenance visit. Clinic staff was instructed not to disclose to the resiJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

dents that the SPs were actors. One SP per test period evaluated each resident, and scheduling was coordinated so that a different SP rated each resident's counseling skills at each test period. Twenty-six residents provided complete outcome data, 14 CG residents and 12 SG residents. Residents significantly improved their performance across time periods. SG residents improved performance (counseling skills, knowledge, confidence) from time 1 to time 2, whereas CG residents improved performance from time 2 to time 3. The investigators reported statistically significant differences between pre- and postintervention for each of the four outcome measures: provision of counseling, counseling skills, confidence and knowledge.'4 Scal, Hennrikus, Ehrlich et al.65 evaluated the effects of an educational program on residents' attitudes and self-reported tobacco use prevention and cessation practices (Tables 1 and 2). The subjects were 46 residents (44% of the total number of residents) in the pediatrics and combined medicine/pediatrics training programs that attended the educational intervention. Thirty-two residents (70% of the attendees) completed both BL and follow-up surveys. Training consisted of a three-hour multicomponent program, the principal goal of which was to teach residents to prevent tobacco use and counsel smoking cessation. The curriculum covered epidemiology, consequences of tobacco use and exposure to ETS, factors influencing tobacco use, locating and using community smoking. prevention and cessation resources, and developing clinical skills. The educational program was presented during the Primary Care Symposium (PCS), a quarterly event that is part of the standard residency curriculum.65 Following the program, small groups of 2-5 residents, with a faculty preceptor, practiced counseling in different scenarios using SPs. After each scenario, other residents, faculty and SPs provided feedback. A onehour "booster" session was held during a noon conference six weeks later for review and support. Pre- and posttraining surveys showed that residents felt more confident in their ability to counsel patients and parents about prevention of tobacco use and smoking cessation, and they were significantly less likely to endorse statements concerning inadequate training in tobacco prevention and control. The frequency of counseling to prevent tobacco use and encourage smoking cessation increased significantly, as did residents' use of motivational interviewing principles.66 Collins, D'Angelo, Stearns et al.67 assessed the effects of an educational program on smoking cessation counseling for pediatric residents in a university-based CC. Residents (n=12) who attended CC on Mondays and Wednesdays were assigned to an educational intervention (which had nothing to do with smoking cessation), while those attending on the other days (n=2 1) were given training on smoking cessation counseling. VOL. 98, NO. 9, SEPTEMBER 2006 1493


The residents saw a total of 656 caretakers of pediatric patients over the next six months (Tables 1 and 2). Prior to training, all participating residents completed a BL survey that assessed demographic information as well as knowledge, attitudes and behaviors with regard to smoking cessation counseling. The same survey was readministered six months later. To validate self-reported changes in resident counseling, a telephone survey of caretakers was performed 1-2 weeks following the pediatric visit. Chart reviews also were completed on all patients whose caretakers identified themselves as current smokers to monitor documentation of an elicited smoking history, smoking cessation counseling and distribution of smoking cessation literature. Residents assigned to the intervention group received a multidimensional educational intervention, including a didactic presentation based on the NCI Smoking Cessation Training Program with an accompanying written manual, a small-group problem-solving session, written reminders about counseling that were placed in the patient rooms and general work areas on clinic days, and provision of written educational and self-help materials for distribution to caretakers. Lectures and small-group sessions were conducted by a member of the pediatric faculty and occurred at two required preclinic conferences over a 1.5-hour period. At six months, residents who received training in smoking cessation counseling reported statistically significant increases in smoking cessation counseling behaviors, conducting smoking histories at both the first and subsequent visits, and asking whether there were other smokers in the home. Residents in the intervention condition were more likely than controls to record the family's smoking history on the child's problem list, follow up counseling advice at a later visit, provide selfhelp literature and advise caretakers to modify their smoking behavior. Intervention residents reported significant gains in confidence in smoking cessation counseling skills and significant declines in two barriers to counseling (fear of alienating caretakers and limitations in counseling expertise). Residents assigned to the control group did not report changes in attitudes towards counseling or perception of barriers. They did report a statistically significant increase in the frequency of counseling parents about the risks of passive smoking.67 Hymowitz, Schwab, Haddock et al.40 reported twoyear results from a four-year randomized prospective study of the efficacy of training pediatric residents to address tobacco (Tables 1 and 2). Sixteen pediatric residency training programs were assigned randomly to one of two treatment conditions-special training (ST) and usual training (UT).40 All first-, second- and third-year residents at each site participated in the training, while BL and outcome data were collected for second- and third-year residents only. The interim results paper presented data for sepa1494 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

rate waves of third-year residents at BL and year 2. Annual resident tobacco surveys and observed structured clinical examinations (OSCEs), BL and end-ofstudy patient and parent/guardian tobacco surveys, and a survey of program graduates who enter clinical practice were used to measure study outcomes. Only data from the resident tobacco surveys and OSCEs were available for report at year 2.40 Solutions for Smoking, a hybrid CD-ROM/website distance-learning program, served as the main teaching tool for the ST condition.40 The website contains chapters on background material, and the CD-ROM consists of audio/visual vignettes that model state-of-the-art motivational interviewing, counseling and tobacco intervention skills.40 ST sites also received assistance with clinic mobilization (i.e., take-home educational material and behavior-change material available in CC waiting areas, antitobacco posters, marking charts of smokers, etc.). Residents associated with ST used companion intervention material (packets of educational and behavior-change materials designed for mothers of newborns, adolescent smokers, parents who smoke, etc.) to support tobacco modification efforts. Residents at sites associated with UT received standard background reading material and health education brochures and behavior-change pamphlets to facilitate intervention on tobacco. Residents at UT and ST sites also participated in four one-hour seminars each year. The seminars provided opportunities to utilize roleplaying to help residents acquire interviewing, counseling and intervention skills. Seminar content varied from year to year, and residents attended annually. All of the residents were encouraged to address tobacco in patients and parents seen in CC. Training sessions also were held with faculty and nursing staff. Third-year residents associated with ST and UT were similar to one another at BL. They shared similar demographic characteristics and tobacco attitudes, beliefs and behaviors. They readily endorsed statements about the value and importance of intervention on tobacco, although they doubted the efficacy of doing so. At year 2, third-year residents in ST, but not in UT, were significantly more likely than at BL to agree that effective interventions were available, more likely to indicate that they helped parents create a smoke-free household (30% at BL, 62% at year 2) and helped patients who smoke to quit (37 at BL, 73% at year 2). The change in the proportion of ST residents who stated that they helped parents quit was in the expected direction but failed to achieve statistical

significance (34-50%).4 At BL, 78% of residents in each condition indicated that they tried to prevent a young person from starting smoking or using other forms of tobacco, and >90% stated that they talked with young people about the dangers Of tobacco use.40 Relatively few residents in either condition addressed tobacco advertising, engaged in VOL. 98, NO. 9, SEPTEMBER 2006


role-playing to encourage acquisition ofresistance skills or provided educational material for prevention of tobacco use. At year 2, ST residents, but not those in UT, were significantly more likely to provide material on tobacco use prevention (10% at BL, 64% at year 2), and they were more likely to report that they addressed tobacco advertising (35-52%), discussed peer pressure (74-90%) and engaged in role-playing (19-33%), although the latter increases failed to achieve statistical significance. Additional increases in the frequency of engaging in these important intervention activities are anticipated at year 4. Performance on OSCEs at BL and year 2 was consistent with resident self-reports. Residents in ST, but not those in UT, revealed significant increases in assessing readiness for change (75-98%), discussing obstacles to creating a smoke-free household (61-91%) and giving take-home materials (28-73%). At year 2, >90% of the ST residents assessed knowledge of the health effects of ETS, engaged the parent in creating a treatment plan and arranged follow-up to discuss ETS.

DISCUSSION Pediatricians have a unique and important role to play in the antitobacco arena. To fulfill their role, they must be properly prepared. Preparation may begin during medical school68-7' and continue through residency training45'47 and beyond.35,46,64,72 Indeed, surveys of practicing pediatricians show that tobacco education has a positive impact on confidence and likelihood of intervening on tobacco throughout their careers.39 The pediatric residency training years are ideal times for training future pediatricians to address tobacco. Residents come face to face with pediatric tobacco-related illnesses, such as sudden infant death, asthma, respiratory distress and ear infections. While they rarely see the "end-stage" consequences of tobacco abuse, such as heart disease, lung cancer, and emphysema, residents do have an important role to play in their prevention.43 CC provides unique opportunities for addressing tobacco in youths and parents. All residents are required to treat and follow the same patients in CC for each of the three years of their residency, providing important clinical opportunities for long-term intervention and follow-up. Ideally, each resident should gain experience in protecting infants from ETS, helping women who quit smoking during pregnancy to remain cigarette free during the postpartum year, preventing the onset of smoking in young people, and helping adolescents and adults who smoke or use other tobacco products to quit. To the extent that residents have the opportunity to treat patients and families from diverse backgrounds and cultures, the residents will be that much more prepared to meet the tobacco challenge when they enter clinical practice. While each ofthe studies reviewed above used CC as the venue for training, it is important to consider other JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

venues as well. For example, access to adolescents and young adults in CC may be somewhat limited.4' Other venues such as inpatient and emergency room settings and clinical rotations in preventive and environmental cardiology73 provide additional opportunities to intervene with adolescents, young adults and their families. At the same time, residents learn firsthand about the importance of addressing tobacco in diverse clinical settings and the kinds of issues that arise. It is also important to consider ways of incorporating training on tobacco into the formal core pediatric residency training curriculum. Each of the eight studies reviewed above wrestled with problems of incorporating training on tobacco into an already busy curriculum, and many residents failed to participate because of scheduling conflicts, off-site assignments and other priorities. Solutions employed included preclinic conferences, lunch-hour sessions, use of a distance-learning tool, and building upon standard curriculum activities. To ensure that training on tobacco will be sustained over time and viewed by residents as an essential feature of their clinical preparation, it is necessary to explore ways of incorporating training on tobacco into the three-year core curriculum. This will require attention to other training venues in addition to CC, appreciation of the fact that communication and intervention skills necessary to address tobacco are equally applicable to other health behaviors of concern to pediatricians, and support of program administration and faculty. Whatever forms the nature of training take, the eight studies reviewed above underscore the importance of preparing pediatric residents to address tobacco. Prior to training, residents lacked the skills necessary to intervene effectively on tobacco and failed to take advantage of opportunities to help patients and parents modify their behavior. Surveys of residents,22 patients25 and parents26 conducted at the start of the Pediatric Resident Training on Tobacco Project,40 for example, showed that the proportion of residents who assisted patients or parents to stop smoking or using other forms of tobacco was only 33%, 23% or 13%, depending on whether residents, patients and parents, respectively, were surveyed. In view of the adverse health impact of ETS, cigarette smoking and other forms of tobacco use, these percentages should approach 100%. Despite differences in design, method and scope, each of the studies reviewed above showed that when training on tobacco was introduced, pediatric residents' confidence, skill level and use of state-of-the-art techniques to address tobacco increased. In most ofthe studies, patient and parent interviews and surveys, chart reviews, OSCEs, and/or use of SPs corroborated, to some degree, the residents' self-report data. Factors that may have contributed to the positive changes in resident behavior were: 1) the richness of the training programs, 2) use of active as well passive approaches to learning, VOL. 98, NO. 9, SEPTEMBER 2006 1495


3) use of CC as a venue for training, and 4) use of faculty as role models and educators. Additional research and demonstration projects are warranted. Attention to adequacy of design, evaluation and duration are essential. These issues are particularly important if one wishes to demonstrate the impact that resident intervention has on the behavior of patients and parents. Given the short duration (s6 months) and limited opportunity for intervention of many of the studies conducted to date, it is not surprising that betweengroup differences in changes in patient/parent smoking behavior proved elusive. Hymowitz et al.4' followed residents, patients and parents for a much longer period of time and documented significant changes in behavior. It is anticipated that the four-year outcome data from the Pediatric Residency Training on Tobacco Project40 also will show that resident intervention leads to positive changes in exposure to ETS and use of tobacco products in patients and parents. Such positive feedback may encourage residents to continue tobacco intervention activities when they enter clinical practice and encourage training directors and faculty to stress the importance of preparing residents to play a leadership role in the antismoking arena.

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