A Survey of the Training of Canadian Health Professionals to Counsel against Smoking
Roger Thomas

Abstract

Canadian schools that train health professionals were asked to evaluate the amount of teaching of counselling skills to prevent clients from starting smoking or to help them quit, the topics covered, the knowledge and counselling skill level of their graduates and whether an integrated smoking counselling program was needed for their school. Responses to a questionnaire were received from the Assistant Dean of Undergraduate Studies, the Assistant Dean of Postgraduate Studies and/or the Postgraduate Program Director of 165 professional schools or departments of 283 contacted (58% response rate). For those schools that replied that they taught counselling about smoking, they devoted more hours in the curriculum (range 1–11 hours) to education about the diseases caused by smoking than to counselling children or adults against smoking or helping smokers to quit. Nursing schools tended to have integrated health education curricula, and it was therefore difficult for them to identify the hours devoted exclusively to counselling about tobacco. Few of the deans or program directors of any of the professional schools estimated the knowledge and counselling skills of their graduates as superior, and a majority felt that an integrated smoking counselling curriculum was needed for their school.

Key words: Canada; counselling; education, professional; smoking; tobacco

Introduction

Smoking remains a key threat to health in Canada. Health Canada's 1994 Survey on Smoking in Canada¹ found that 30% of the Canadian population over age 15 smoked regularly (31% of males, 29% of females). Among those aged 15–19, 28% smoked; among those aged 20–24, 38% smoked; among those aged 25–64, 33% smoked; and among those aged 65 and over, 15% smoked. The average number of cigarettes smoked per day by females was 17, and by males, 20.

By age 10, 30–50% of children will have experimented at least once with a cigarette, with initiation rates accelerating rapidly thereafter.² On average, one cigarette will be smoked each week by 1–3% of 10-year-olds,³ rising to 20–24% at age 15.⁴ Children who begin smoking at age 12 or younger are more likely to be regular and heavy smokers.

Purpose and Methods of the Survey

Since health professionals have an important role to play in their clients' smoking behaviours, a survey was devised to assess how well trained they are to counsel against smoking. Specifically, the purpose of the survey was to ascertain if counselling about smoking was offered in Canadian professional schools; how many hours were offered; what topics were covered; whether a specific counselling program “Guide your Patients to a Smoke-free Future” was used; what level of knowledge and counselling skills graduates had; and whether the respondents thought an integrated counselling curriculum on smoking was needed for their school.

Finance was available only for a mailed survey. Because the survey included all provinces, on-site visits to all professional schools would have increased the costs of the survey substantially. To encourage response, a one-page questionnaire (see Appendix) was designed that could be completed in a few minutes.

After an initial mailing and a further two contacts either by telephone or mail in January and February 1997, responses were received from a total of 165 professional schools or departments of the 283 contacted (58% response rate). Nine schools of undergraduate medicine, 30 departments of postgraduate medicine, 93 schools of nursing, 9 schools of pharmacy and 24 departments of psychology replied. It is a sign of the stringent financial situation of professional education that 15 colleges of nursing wrote that they would not formally reply because they were either in the process of closure or anticipating closure. The administrative arrangements to contact the colleges of dentistry were not completed in time for the survey, and their views will be included in any subsequent survey.

Results

The Provision of Counselling in Canadian Professional Schools

The percentages of schools not able to reply if counselling was provided in their curriculum varied from 55% for undergraduate medicine to 22% for psychology and 11% for some aspects of counselling in pharmacy (Table 1).

The professional schools who replied spent from one to eleven hours over the entire program discussing diseases caused by smoking. However, many schools had no smoking counselling curriculum, and the average number of hours devoted to counselling among those who replied and stated a specific number was only two.

Many nursing schools had integrated health education curricula for which it was not possible to be specific about the number of hours devoted to counselling about smoking. Comments were made regarding this integration into several courses, often problem-based, dealing with general health education and counselling or discussion of the many medical conditions known or believed to be related to smoking. Nevertheless, six schools of nursing reported more than 20 hours of curriculum time in integrated counselling that included smoking; a further two reported 20–30 hours; three, 40–50; and one, 80 hours.

For some nursing schools the counselling on smoking was in elective courses, for example, “15 hours in 1st and 2nd year, as part of elective therapeutic course (45 hours), if area of interest.”

Addiction to smoking is cited as a pathology factor. A healthy lifestyle is recommended, but there are no specific approaches. Intervention as you seem to see it enters into conflict with values and can be perceived as total intervention. The dilemma of training versus indoctrination. [translation]

Only one nursing school commented on the rate of current smoking among nursing students.

Many nursing students continue to smoke. We have a lot of generic health counselling that can be applied to smoking.

Some nursing schools preferred to provide conceptual tools rather than specific counselling skills.

Nursing education does not teach disease-specific content—concepts are the focus instead, i.e. cell aberration, oxygen deprivation, ischemia, etc. Counselling, again, does not tease out content-specific material re smoking/anti-smoking–generic.

We believe in the concept of teaching principles, not a larger number of facts. There are courses in health promotion and principles of teaching in which smoking along with other diseases/habits are included. I believe we include all the principles and basic knowledge.

Specific Approaches to Counselling

Effective counselling against smoking requires at least culture-specific and gender-specific materials to interest the clients. Of those schools that had a curriculum for counselling about smoking, the percentage using a gender-specific approach ranged from 44% for undergraduate medicine to 0% for pharmacy (Table 2). The survey asked whether the counselling program “Guide your Patients to a Smoke-Free Future” (from the Canadian Council on Smoking and Health, the Canadian College of Family Physicians and the Canadian Medical Association) was used: less than 10% of the professional schools used this program.

Opinions about Students' Counselling Skills

One third of the assistant deans of medical schools could not assess their students' counselling abilities (Table 3). About half the assistant deans thought that their students had minimal or basic skills. None of the assistant deans of medicine, francophone nursing or pharmacy thought their students had acquired superior counselling skills, and only 6% of the anglophone nursing schools and 8% of the psychology schools thought their students had superior practice skills.

Opinions about the Need for Integrated Counselling Curricula

The percentage of assistant deans expressing an opinion about the need for an integrated counselling curriculum ranged from 78% of the assistant deans of undergraduate medicine to 100% of the assistant deans of pharmacy (Table 4).

On average, the assistant deans of all schools agreed that there was a need for an integrated counselling curriculum (scores varied from 1.9 to 2.6, where 1 = strong need, 3 = neither agree nor disagree, and 5 = no need), but there was a wide variety of opinion within each discipline.

The assistant deans of two undergraduate medical schools focused on how integrated medical curricula functioned.

I am not sure that the integrated curriculum needs to be specifically aimed at tobacco, but we need to improve our teaching around counselling and behavioural change—addictions, tobacco, other drugs.

We have a problem-based curriculum where discussions about specific problems occur in groups of seven students. The amount of time spent in each tutorial group can vary significantly.

Some assistant deans of postgraduate medicine felt that counselling was most likely to take place in primary care disciplines.

Psychiatry deals with major illnesses and syndromes; this may be more appropriate to primary care settings.

Depends on which program—family medicine very well prepared, surgery less well, since they tend not to be involved in counselling.

The assistant deans of pharmacy noted a specific focus in their programs and preferred a more integrated approach.

We are currently using the “Butting Out for Life Program.” While we “teach” about helping smokers to quit, it is very product-focused (i.e. nicoderm, etc.), not patient-focused. Resources to assist in motivational counselling would be helpful.

Emphasis to date has been on smoking cessation aids, how they work, patient counselling and monitoring. An integrated curriculum would be very useful, especially if it incorporated case work and practice in counselling patients.

Assistant deans of psychology noted the effect that specific educational programs had on the amount of counselling received.

The interns who go through health psychology and perinatal rotations receive more smoking cessation [instruction] than those in other rotations (i.e. adult clinical, neuropsychology).

We are an internship setting, primary work is with children. Some students, if interested, can receive specialized training in area. The role of psychology is better suited to developing prevention and treatment programs.

The assistant deans of psychology also were interested in integrated curricula.

If you have curriculum materials, please send them. I would like to raise this with the instructors, and at least make modules available in our training clinics.

More general strategies and interventions such as cognitive behavioural change procedures are taught and could be applied easily to the problem of smoking.

A workshop on this topic could be integrated into our clinical seminar series.

Our patients are chronic psychiatric patients and very heavy smokers.

Only one assistant dean (of psychology) mentioned ongoing research.

We have a reasonable protocol ongoing to evaluate a cognitive-behavioural, manual-based smoking cessation program. Should prove to be effective.

The comments on the surveys suggest that those schools (such as medicine and nursing) that have moved to problem-based curricula have thereby given their students more freedom to explore issues that interest them, but also rendered the assistant deans less certain of what material is being covered in each tutorial group. Those disciplines (such as psychology) with a structure consisting of courses for which students register indicate more ability to introduce new material into the curriculum via course or module offerings.

Review of the Literature

The Effectiveness of Interventions by Physicians

Interventions by physicians to help patients to quit smoking have been shown to be effective. The American Guide to Clinical Preventive Services⁵ and the Canadian Guide to Clinical Preventive Health Care⁶ both assess the evidence for counselling against smoking as being of “A” (excellent) quality.

A meta-analysis of randomized controlled trials of nicotine replacement therapies (NRTs), which summarized the results for 18,000 patients, showed that for the longest duration of follow-up available (usually 12 months), 19% of those allocated to NRT and 11% of controls were abstinent, a 71% (95% confidence interval [CI] = 56–87%) increase in the odds of abstinence with NRTs.⁷ For trials that provided high-intensity support, the probability of not smoking at 6–12 months was 19.7% (95% CI = 18.7–20.6%), compared to 10.5% (95% CI = 9.9–11.1%) for those that used low-intensity support. However, the trials using transdermal nicotine patches showed no significant difference in abstinence if high-intensity support was provided.

A meta-analysis of 94 randomized controlled trials of programs to prevent adolescent smoking or encourage smokers to quit identified 48 studies with acceptable methodological quality.⁸ Programs with social reinforcement, social norms and developmental orientations had significant positive effects, but those with rational (factual) orientations did not. The number of sessions of counselling was related to larger effect sizes.

Identifying the Smokers in a Practice

For counselling to be effective, studies have shown that several elements must be present. Physicians need to receive training to enquire about the smoking status of their patients and passive smoke; ask about readiness to quit and past quitting attempts; ask about smoking history and Fagerström tolerance level;^9,10 encourage smokers to set a date to quit; offer counselling, self-help materials and nicotine replacement therapy; record the counselling and cessation plan in the chart; set up follow-up appointments; and organize their offices and staff so that patients receive a comprehensive program.

Health professionals need training in regularly identifying the smokers in their practices. A study of family physicians in New Brunswick found that they were aware of only about 20% of the adult smokers in their practices.¹¹

A 1992 survey in Connecticut reported that 48% of family physicians, 38% of pediatricians and 26% of dentists were able to estimate the smoking prevalence in their patients aged 12–18.¹² Their estimates were 30–50% below national rates. In addition, 24% of the family physicians, 20% of the pediatricians and 8% of the dentists reported “always” counselling 10–12-year-olds about smoking; these percentages increased to 51%, 48% and 9%, respectively, for 16–18-year-olds.

A questionnaire survey of 2095 family physicians in Indiana found that 86% asked new patients if they smoked and 23% asked about exposure to passive smoke.¹³ Twenty-eight percent used a formal smoking program, but only eleven percent considered their counselling skills about stopping smoking to be excellent.

In a University of Ottawa family medicine clinic, the smoking status was recorded in the chart for only 12% of the patients aged 15–65. A study found that recording could be increased by 26% with a 15-second enquiry by a physician (at an average cost per percentage point improvement in recording of $7.37 CAN), by 37% with a mailed letter ($61.80) and by 44% when a nurse telephoned ($22.03).¹⁴

Offering Counselling about Smoking

Health professionals also need training in regularly asking smokers if they wish to quit and in offering therapy. Physicians tend to enquire more about smoking with patients who smoke more cigarettes per day or who have more severe health problems, or where smoking affects prescribing (e.g. for contraceptives).

The US Centers for Disease Control and Prevention conducted the National Health Interview Survey—Health Promotion and Disease Prevention Survey in 1991 among people aged 18 or over.¹⁵ Of the estimated 51 million smokers, 36 million reported at least one visit with a physician in the preceding year, and 13 million (37% of smokers) received some advice during that visit to quit smoking. Those who smoked more and made more visits to physicians were more likely to receive advice to quit: 45% of those with 4 or more visits and 41% of those who smoked 15–24 cigarettes per day were advised to quit. The proportion of smokers ever advised to quit was 61%. Physicians reported a higher rate of giving advice to quit (52–97%) than the survey estimate, which may be due to overestimation on their part or to forgetting of advice on the part of survey respondents.

In the Stanford Five-City Project, 51% of smokers in 1989/90 said they had never been advised by a physician to quit, and only 3.6% of ex-smokers said they had been helped by a physician to quit.¹⁶ Thirteen percent of the smokers aged 13–17 were advised to quit, whereas the proportion was sixty-nine percent for smokers aged 50–74. Thirty-five percent of those who had visited the physician once that year and sixty percent of those with more than 6 physician visits said that they had ever been advised to quit.

In a sample of Michigan residents over age 18, 44% reported ever being advised by a physician to quit smoking (30% of the males and 46% of the females aged 18–34). Eighty percent of the males and sixty percent of the females who had suffered a heart attack had been so advised also.¹⁷

A telephone survey of first-year college students in Arizona found that 89% had visited a physician in the past year.¹⁸ Among these, 31% of the females and 21% of the males remembered being asked if they used tobacco (17% of the females and 19% of the males were smokers).

In California, a telephone survey of 24,296 patients revealed that physicians tended to offer advice to those smokers who were older, smoked more and were in worse perceived health.¹⁹

A study of family physicians in Nebraska used the Nebraska Academy of Family Physicians' membership list (comprising 90% of all physicians practising in Nebraska) as a sampling frame. The study planned to choose one practice from each of 12 types, based on practice type (solo versus group), physician's sex and location (frontier, rural, urban).²⁰ Eleven practices were each studied in a 2–3-day site visit, and the conclusions were that little advice was given to prevent the onset of adolescent smoking; the responsibility for identification, documentation, counselling and follow-up of smokers lay solely with the physicians; counselling was basic and consisted of advice to quit, offering NRT and tips for changing habits; no packages such as the American Academy of Family Physicians' smoking cessation kits were used; and none of the physicians were optimistic about change.

Training Physicians to Offer Counselling and Organize Their Offices for a Comprehensive Program

A randomized controlled trial with 97 residents in internal medicine and 15 faculty general internists offered them a one-hour lecture or personal instruction on the consequences of smoking, the benefits of quitting and evidence that NRT and advice by physicians can be helpful in quitting. Those who completed a questionnaire and received a one-hour lecture on cessation asked 41% of their patients about smoking, those with a fluorescent sticker on the chart offering 10 free packets of nicotine gum asked 84%, those with two fluorescent stickers on the chart asking about smoking and a quitting date asked 75%, and those with all three stickers asked 95%.²¹ After one year, 2.7% of the control group had quit smoking, 8.8% of the group offered nicotine gum, 15% of the group who received reminders and 9.6% of the group who received reminders and gum. There were no statistically significantly different results between the three intervention groups, but the differences between the control group and the three experimental groups were significant (p < 0.05).²² The physicians in the intervention groups spent significantly more time counselling against smoking.

In a non-randomized trial in 10 clinics near Minneapolis, Minnesota, nurse-educators made an average of 6 site visits, 24 phone calls and 6 mailings per practice site to offer smoking cessation training and assistance to the practice personnel. One staff member from each practice attended one workshop, and 13 of the 142 primary care physicians attended a workshop. In these 10 clinics, the proportion of patients asked about tobacco rose from 23% to 40%, compared to a change from 22% to 26% in 8 control clinics in Wisconsin (p < 0.05).²³ After the intervention, 41% of the physicians in the experimental clinics asked smokers to quit, compared to 26% in the control clinics.

Another study offered pediatricians a 2-hour seminar (39% of the 28 attended) and a reminder and chart documentation system for enquiring about passive smoke. Interviews with parents and chart reviews ascertained that screening for the presence of passive smoke increased from 17% to 32% (p < 0.03), and counselling to prevent parental smoking rose from 19% to 46% (p < 0.03).²⁴ However, documentation of the enquiry in the chart only increased from 2% to 6%, and of counselling, from 4% to 6%.

By 1995, the BC Doctors' Stop Smoking Program had recruited 655 general practitioners to implement a systematic approach to intervention in tobacco use. Ninety percent of the participating physicians stated that they regularly asked patients who smoked whether they were ready to stop. It was estimated that 4700 smokers had been helped to quit and 135,000 had received counselling and follow-up through the efforts of these physicians and other physicians who implemented part of the program.²⁵ Smokers in a survey in British Columbia said that if they chose assistance to stop smoking (they could choose more than one method), 44% preferred NRT; 33%, a program offered by their physician; 20%, a program by another health professional; 15%, booklets or videotapes; and 23% did not wish to use any of the above methods.²⁵

Orthodontists in Kansas were trained to give prescriptions advising against smoking to their patients aged 10–18. For the first year the average prescribing rate was 66%, and, in a multiple regression analysis, 20% of the variance in prescribing was explained by receiving praise from patients and knowing that the prescriptions were being tracked. In the second period the prescribing rate was 73%, and 23% of the variance was explained by receiving praise and having received instruction on how to apply operant learning theory in counselling patients.²⁶

In the only study located for this article of educating health professionals to give smoking cessation advice that made power computations to assess the sample size required to reduce the probability of Type II error, orthodontic offices in California were randomly assigned to receive 1.5 hours of training based on the National Cancer Institute's tobacco cessation workshops. The effect on initiation of smoking within the next 30 days was non-significant.²⁷ However, for adolescents who received 4–6 prescriptions against smoking, the odds ratio (OR) of beginning smoking within 30 days was 0.76 (95% CI = 0.62–0.94) and for those receiving 7 or more prescriptions, the OR was 0.75 (95% CI = 0.59–0.95).

In a survey of 30 randomly chosen physicians' offices in each of 11 communities, those who responded (48% response rate) said that they offered smokers an intervention 70% of the time.²⁸ However, few had organized their staff to co-ordinate the smoking cessation program and provide reminders.

Physicians at the Kaiser-Permanente health maintenance organization in California were trained to give a 1- or 2-minute message to quit smoking, and nurses were trained to give a 30-minute behavioural counselling session and four 10-minute follow-up phone calls to patients who were hospitalized.²⁹ After 12 months, the patients randomized to the intensive therapy had higher smoking cessation rates (OR = 1.4, 95% CI = 1.1–1.8) than those randomized to usual care.

Training Medical Students and Residents to Offer Counselling about Smoking

A worldwide study of medical students in 1985 reported the following proportions of male students who said that they smoked: 41% in the former USSR, 35% in Japan, 19% in Europe and 0% in the USA (the highest proportions for females were 15% in Chile and 12% in both the former USSR and Europe).³⁰ The percentages of final-year medical students who stated they would “often” advise quitting to a patient with no smoking-related disease or complaint and who had not raised the subject were in these ranges: 19–43% in the former USSR, 15–60% in Europe and Asia, 20–41% in Africa and the Middle East, and 2–9% in Japan.

Training student and resident physicians to offer stop-smoking programs requires the same structure of counselling to ask about smoking status, offer therapy, arrange reminders and organize the office that is helpful for experienced clinicians in practice.

In Australia, a randomized controlled trial of teaching fifth-year medical students to give advice about stopping smoking assessed their performance on an 82-item rating scale. Those receiving audio feedback, peer feedback and video feedback significantly improved their advice giving and the behavioural strategies used compared to a control group.³¹ The effect of giving advice on patients' smoking behaviour was not assessed.

A three-day workshop to improve the preventive health behaviours of general practice trainee doctors in Australia showed that questions about smoking were asked in 22% of consultations before the workshop.³² Although the experimental group asked more questions about smoking status after the workshop (p < 0.01), two thirds of smokers still remained undetected and less than one in five were advised to stop smoking. The authors concluded that skills training needed reinforcement in clinical practice.

A study to ascertain if the US National Cancer Institute (NCI) Guide to Preventing Tobacco Use During Childhood and Adolescence could be incorporated into a pediatric residency found that parents reported that 37% of the residents who had received the classroom training asked about smoking, compared to 17% of those who had not received the training.³³ Of the residents who had received the NCI manual, 12% could not recall receiving it and only 38% said that they had read it.

A study of 15 residents in internal medicine in Lausanne showed that, after receiving a training program, enquiries about smoking increased from 68% to 77%; advice to quit, from 28% to 43%; and counselling about smoking cessation, from 10% to 25%, but provision of self-help materials only increased from 1% to 7% and arranging for follow-up visits only rose from 1% to 5%.³⁴ Although the patients' interest in quitting did increase, there was no actual increase of quitting in the following 12 months.

Thirty-five obstetric and family practice residents at the University of Vermont received training to implement a brief smoking counselling intervention with prenatal patients, which was followed by counselling with a smoking cessation counsellor.³⁵ Residents in the control group did not receive chart prompts to offer counselling. At the first antepartum visit, 96% of the residents in the intervention group advised quitting, as did 94% of the control group residents. The percentages on the second antepartum visit were 91% and 52%, respectively (p < 0.0001).

Health checks given by nurses in five general practices in the Oxford Region were not associated with any changes in smoking behaviour.³⁶

Offers of mailed self-help smoking materials and brief telephone interventions are not effective in stopping patients from smoking. At the University of California in Los Angeles, the Preventive Health Behavior Study of 2786 smokers among 15,004 female members of a health maintenance organization observed that mailing out self-help smoking cessation programs had no effect on readiness to stop smoking at 1, 6, 12 or 18 months.³⁷ A study using two 15-minute telephone calls to counsel against smoking resulted in a reduction in self-reported and cotinine-validated smoking after 6 months, but the effect had disappeared at 18 months.³⁸ There is, therefore, a need to train health professionals to ask about smoking status, identify those interested in quitting, provide NRT and counselling, and to organize their practices to provide materials, follow-up and reminders within an effective structure to maximize smoking cessation.

Conclusions from the Survey in Relation to the Literature Review

Many assistant deans are not able to define the number of hours of specific tobacco-counselling instruction given in their curriculum. For those programs that do state a number of hours, the range is 1–11 hours, and the average is about 2 hours over the entire professional curriculum. Because many nursing schools have integrated health counselling programs, it is not possible for many of them to identify to what extent counselling specifically about smoking is offered.

Of the assistant deans who have an opinion about the level of counselling practice skills among their students, about half rate the skills as minimal or basic. In only two types of school do ratings of superior occur (6% of anglophone nursing, 8% of psychology).

Effective smoking prevention needs to be gender and culture sensitive. This survey only inquired about gender-sensitive counselling, which varied from 44% for undergraduate medicine programs to 0% for pharmacy programs.

The assistant deans and program directors who replied concur that an integrated smoking counselling curriculum is needed.

Although this survey was limited to being one page that could be rapidly completed in order to ensure response, it is clear that those mandated to have an oversight of the educational curricula of their professional schools did not outline an integrated program of instruction to ensure that all their graduates would offer a comprehensive and effective smoking cessation program when in practice. Such a training program would ensure that all practising graduates ask about the smoking status and passive smoking status of all of their clients; ask about past smoking history and Fagerström tolerance levels;^9,10 ask about interest in quitting and past quitting attempts; set a quitting date; offer self-help materials, NRT and counselling; arrange follow-up visits and reminders; record the counselling and the therapy plan in the chart; and organize their offices and staffs to offer a comprehensive smoking therapy program to all patients.

Acknowledgements

Source of funding: Office of Tobacco Reduction Programs, Health Issues Division, Health Promotion and Programs Branch, Health Canada

Sponsor and co-ordinating office for the survey: Physicians for a Smoke-Free Canada

References

1. Health Canada. Survey on smoking in Canada. Ottawa, 1995 Feb.

2. Tucker AW. Elementary school children and cigarette smoking: a review of the literature. Health Education 1987;18(3):18–27.

3. Escobedo LG, Marcus SE, Holtzman D, Giovino GA. Sports participation, age at smoking initiation, and the risk of smoking among US high school students. JAMA 1993;269(11):1391–5.

4. Morgan M, Eiser JR, Budd RJ, Gammage P, Gray E. Patterns of cigarette smoking among Bristol schoolchildren: implications for educational intervention. Health Educ Res 1986;1(2):95–100.

5. US Preventive Services Task Force. Counselling to prevent tobacco use. In: Guide to clinical preventive services: report of the US Preventive Services Task Force. 2nd ed. Baltimore: Williams and Wilkins, 1996.

6. Canadian Task Force on the Periodic Health Examination. Prevention of tobacco-caused disease. In: The Canadian guide to clinical preventive health care. Ottawa, 1994; Health Canada Cat H21-117/1994E: 500–11.

7. Silagy C, Mant D, Fowler G, Lodge M. Meta-analysis on efficacy of nicotine replacement therapies in smoking cessation. Lancet 1994;343:139–42.

8. Bruvold WH. A meta-analysis of adolescent smoking prevention programs. Am J Public Health 1993;83(6):872–80.

9. Fagerström KO. Measuring degree of physical dependence to tobacco smoking with reference to individualization of treatment. Addict Behav 1978;3-4;235–41.

10. Fagerström KO. The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict 1991;86(9):1119–27.

11. Battista RN, Palmer CS, Marchand BM, Spitzer WO. Patterns of preventive practice in New Brunswick. Can Med Assoc J 1986;132:1013–5.

12. Gregorio DI. Counselling adolescents for smoking prevention: a survey of primary care physicians and dentists. Am J Public Health 1994;84(7):1151–3.

13. Saywell RM, Jay SJ, Lukas PJ, Casebeer LL, Mybeck KC, Parchman ML, et al. Indiana family physician attitudes and practices concerning smoking cessation. Indiana Med 1996;89(2):149–56.

14. Rosser W, McDowell I, Newell C. Documenting smoking status. Can Fam Physician 1992;38:1623–8.

15. Centers for Disease Control and Prevention. Physician and other health-care professional counseling of smokers to quit—United States, 1991. MMWR 1993;42(44);854–7.

16. Frank E, Winkleby MA, Altman DG, Rockhill B, Fortmann SP. Predictors of physicians' smoking cessation advice. JAMA 1991;266(22):3139–44.

17. Anda RF, Remington PL, Sienko DG, Davis RM. Are physicians advising smokers to quit? JAMA 1987;257(14):1916–9.

18. Foote JA, Harris RB, Gilles ME, Ahner H, Roice D, Becksted T, et al. Physician advice and tobacco use: a survey of 1st-year college students. J Am Coll Health 1996;45(3):129–32.

19. Gilpin EA, Pierce JP, Johnson M, Bal D. Physician advice to quit smoking: results from the 1990 California Tobacco Survey. J Gen Intern Med 1993;8(10):549–53.

20. McIlvain HE, Crabtree BF, Gilbert C, Havranek R, Backer EL. Current trends in tobacco prevention and cessation in Nebraska physicians' offices. J Fam Pract 1997;44:193–202.

21. Cohen SJ, Christen AG, Katz BP, Drook CA, Davis BJ, Smith DM, et al. Counseling medical and dental patients about cigarette smoking: the impact of nicotine gum and chart reminders. Am J Public Health 1987;77(3):313–6.

22. Cohen SJ, Stookey GK, Katz BP, Drook CA, Smith DM. Encouraging primary care physicians to help smokers quit. A randomized, controlled trial. Ann Intern Med 1989;110(8):648–52.

23. Kottke TE, Solberg LI, Brekke ML, Conn SA, Maxwell P, Brekke MJ. A controlled trial to integrate smoking cessation advice into primary care practice: doctors helping smokers, round III. J Fam Pract 1992;34(6):701–8.

24. Narce-Valente S, Kligman EW. Increasing physician screening and counseling for passive smoking. J Fam Pract 1992;34(6):722–8.

25. Bass F. Mobilizing physicians to conduct clinical intervention in tobacco use through a medical-association program: 5 years' experience in British Columbia. Can Med Assoc J 1996;154(2):159–64.

26. Russos S, Hovell MF, Keating K, Jones JA, Burkham SM, Slymen DJ, et al. Clinician compliance with primary prevention of tobacco use: the impact of social contingencies. Prev Med 1997;26(1):44–52.

27. Hovell MF, Slymen DJ, Jones JA, Hofstetter CR, Burkham-Kreitner S, Conway TL, et al. An adolescent tobacco-use prevention trial in orthodontic offices. Am J Public Health 1996;86(12):1760–6.

28. Lindsay EA, Ockene JK, Hymowitz N, Giffen C, Berger L, Pomrehn P. Physicians and smoking cessation. A survey of
office procedures and practices in the Community Intervention Trial for Smoking Cessation. Arch Fam Med 1994;3(4):341–8.

29. Miller NH, Smith PM, DeBush RF, Sobel DS, Taylor CB. Smoking cessation in hospitalized patients: results of a randomized trial. Arch Intern Med 1997;157:409–15.

30. Crofton JW, Freour PP, Tessier JF. Medical education on tobacco: implications of a worldwide survey. Med Educ 1994;28:187–96.

31. Roche AM, Eccleston P, Sanson-Fisher R. Teaching smoking cessation skills to senior medical students: a block-randomized controlled trial of four different approaches. Prev Med 1996;25:251–8.

32. Ward J, Sanson-Fisher R. Does a 3-day workshop for family medicine trainees improve preventive care? A randomized control trial. Prev Med 1996;25(6):741–7.

33. Klein JD, Portilla A, Goldstein A, Leininger L. Training pediatric residents to prevent tobacco use. Pediatrics 1995;96(2 Pt 1):326–30.

34. Cornuz J, Zellweger JP, Mounoud C, Decrey H, Pecoud A, Burnand B. Smoking cessation counseling by residents in an outpatient clinic. Prev Med 1997;26(3):292–6.

35. Secker-Walker RH, Solomon LJ, Flynn BS, LePage SS, Crammond JE, Worden JK, et al. Training obstetric and family practice residents to give smoking cessation advice during prenatal care. Am J Obstet Gynecol 1992;166:1356–63.

36. Imperial Cancer Research Fund OXCHECK Study Group. Effectiveness of health checks conducted by nurses in primary care: final results of the OXCHECK study. Br Med J 1995;310:1099–1104.

37. Gritz ER, Berman BA, Bastiani R, Wu M. A randomized trial of a self-help smoking cessation intervention in a nonvolunteer female population: testing the limits of the public health model. Health Psychol 1992;11(5):280–9.

38. Lando HA, Hellerstedt WL, Pirie PL, McGovern PG. Brief supportive telephone outreach as a recruitment and intervention strategy for smoking cessation. Am J Public Health 1992;82(1):41–6.

APPENDIX

QUESTIONNAIRE

Teaching Counselling Skills about Smoking

The students during their undergraduate years receive the following number of hours of education about:
(___ = please enter number; DK = don't know)

DK   0   1   2   3   4    5   6   7   8   9   10   ___

2. Counselling children against smoking:

DK   0   1   2   3   4    5   6   7   8   9   10   ___

3. Counselling adults against smoking:

DK   0   1   2   3   4    5   6   7   8   9   10   ___

4. Helping smokers quit:

DK   0   1   2   3   4    5   6   7   8   9   10   ___

5. We use the specific counselling program:

“Guide Your Patients to a Smoke-Free Future”

YES                        NO

Gender-specific approaches are used

YES                        NO

6. After completing their undergraduate years the students' skills in counselling about smoking are:

In our curriculum there is a need for an integrated curriculum about:
(SA = strongly agree; A = agree; N = neither; D = disagree; SD = strongly disagree)

SA     A     N     D     SD

8. Counselling children against smoking

SA     A     N     D     SD

9. Counselling adults against smoking

SA     A     N     D     SD

10. Helping smokers quit

SA     A     N     D     SD