Presentation by J. Taylor Hays, M.D., a Global Bridges co-investigator and professor of medicine at Mayo Clinic, at the Global Bridges Preconference at the 15th World Conference on Tobacco OR Health in Singapore.

1. Tobacco Dependence Treatment
Training
What should we teach?
How should we teach it?
J. Taylor Hays, MD
Professor of Medicine
Mayo Clinic
Rochester, MN USA

2. Learning Objectives
 Recognize evidence based treatment
components for tobacco dependence
 Describe the gaps between physician
knowledge and practice regarding
tobacco dependence treatment
 Describe best approaches to
educating health professionals in
tobacco dependence treatment

3. Outline
 Brief background
 Review evidence based treatment
 Knowledge-practice gaps for tobacco
dependence treatment
 Instructional approaches for health
professionals
 Competency-based training

4. 438,000 Deaths Attributable to
Cigarette Smoking
United States
Heart disease
Other
diagnoses
Lung cancer
Stroke
Other Chronic lung
cancers disease
CM862644-4

5. Tobacco Is a Risk Factor for 6 of the World’s 8 Leading
Causes of Death
Hatched areas indicate proportions of deaths related to tobacco use.

6. Tobacco Use: An Escalating Epidemic
8
10
7 By 2030:
•Leading cause of death
millions of deaths
6
•10 million annual deaths
5
due to tobacco
4 •70% of those deaths will
4.9
3 occur in developing
2 countries
1
0
2000 2030
Developed Countries
Developing Countries

7. Evidence Based Treatment

8. Eisenberg MJ, et al. CMAJ 2008; 179:135-144

9. West R, Zatonski W, Cedzynska M, et al. NEJM 2011;365:1193-2000.

10. Combination NRT Compared With Single Agent
NRT
 Nicotine patch + short-acting NRT
Patch provides steady baseline
NG, NL NNS, NI respond to urges
 Withdrawal may be improved
 Overall abstinence rates at 6 mos. better
OR 1.35 (95% CI 1.11-1.63)*
*Cochrane Database of Systematic Reviews 2009
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11. Adherence to NRT Treatment
Balmford J, et al. Nicotine & Tobacco Research 2011;13:94-102
•Only 28.6% of NRT users completed the recommended 8 weeks of
treatment
•Most quit prematurely because they believed the medication was not
working, had unwanted side effects or believed that they no longer needed
treatment.
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12. Nicotine patch 8 vs 24 weeks: RCT of
568 adult smokers
Schnoll R A et al. Ann Intern Med 2010;152:144-151
©2010 by American College of Physicians
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13. Behavioral Treatment
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14. Effect of Contact Intensity
Cessation by intensity of person-to-person
contact
Contact* O.R. Cessation%
None 1.0 10.9
Minimal 1.3 13.4
Brief 1.6 16.0
Counseling 2.3 22.1
*minimal<3mins; brief >3 to <10mins; counseling > 10mins.
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15. Effectiveness Based on Total Contact
Time
Time (min) OR
Abstinence %
None 1.0 11.0
1-3 1.4 14.4
4-30 1.9 18.8
31-90 3.0 26.5
91-300 3.2 28.4
> 300 2.8 25.5
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16. Effect of Providers
Smoking cessation by type of provider
Type O.R.*
Abstinence %
Self-help 1.1 10.9
NonMD 1.7 15.8
M.D. 2.2 19.9
Multiple 2.5 23.6
*odds ratio
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17. Benefits of Counseling
 Boost motivation to quit- Motivational
Interviewing techniques
 Discuss barriers to quitting
 Review coping strategies
 Discuss other big challenges to
quitting
Living with other smokers
Cautions about use of alcohol
Post-cessation weight gain
1

18. Gaps Between Knowing and Doing
1

19. JAMA 2001;285:2643-2648
Smoking prevalence by birth cohort among physicians in Japan
1

20. JAMA 2001;285:2643-2648
Attitude
Action
2

21. •41% of male MD’s are smokers
•Most MD’s believe they should
offer help and advise quitting
•Fewer than 10% take active
steps to help a smoker quit
Am J Prevent Med 2007;33:15-22
2

22. Teaching Health Professionals
2

23. Adult Learners
 Motivated to learn
 Goal directed
•Increase knowledge and skills
•Change attitudes and beliefs
 Self-directed– control nature, timing
and direction of the process
 Build on established foundation– a
“two-edged” issue
2

24. Training Experts
Performance of experts continues to
improve as they engage in more
complex cognitive tasks and deliberate
practice of skills.
•Performance is most closely
related to specialized training
and years in practice.
•Without specialized training
and practice skills decline.
Ericsson KA. Acad Med 2004;79:S70-S81
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25. Competency Based Training
 Competency- a skill performed to a specific
standard
 Competencies clearly identified
 Assessment criteria are clear (knowledge,
skill, attitude, practice)
 Instruction targets each competency
 Learners progress at their own rate
 Varied instructional methods (traditional,
groups, reading, remote, asynchronous)
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26. ATTUD Competencies
1. Tobacco Dependence Knowledge and Education Provide clear and accurate information about tobacco use,
strategies for quitting, the scope of the health impact on the population, the causes and consequences of tobacco
use
2. Counseling Skills Demonstrate effective application of counseling theories and strategies to establish a
collaborative relationship, and to facilitate client involvement in treatment and commitment to change
3. Assessment Interview Conduct an assessment interview to obtain comprehensive and accurate data needed for
treatment planning
4. Treatment Planning Demonstrate the ability to develop an individualized treatment plan using evidence-based
treatment strategies
5. Pharmacotherapy Provide clear and accurate information about pharmacotherapy options available and their
therapeutic use
6. Relapse Prevention Offer methods to reduce relapse and provide ongoing support for tobacco-dependent persons
7. Diversity and Specific Health Issues Demonstrate competence in working with population subgroups and those
who have specific health issues
8. Documentation and Evaluation Describe and use methods for tracking individual progress, record keeping,
program documentation, outcome measurement and reporting
9. Professional Resources Utilize resources available for client support and for professional education or consultation
10. Law and Ethics Consistently use a code of ethics and adhere to government regulations specific to the health
care or work site setting
11. Professional Development Assume responsibility for continued professional development and contributing to the
development of others
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27. Learner Outcomes
 Changed attitudes, values, habits
 Knowledge base enlarged and
enhanced
 Practice skills (information gathering,
counseling skill, treatment planning)
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28. Competency Based Training
Rigotti NA, et al. Addiction 2009; 104:288-296
2

29. Training Capacity
Rigotti NA, et al. Addiction 2009; 104:288-296
2

30. Summary
 Strong evidence base for tobacco
dependence treatment… we know
what works
 There are large gaps between
evidence base and the knowledge
and practice of physicians… we do
not practice what works
 Competency based training using
varied instructional methods must be
widely deployed to build capacity and
expertise 3