Implementing Smokeless Tobacco Instruction into Medical Student Education: Addressing the Gap

Abstract

Background

Despite the unique health and epidemiological aspects of smokeless tobacco use, medical education regarding this topic is virtually lacking.

Methods

Using a National Cancer Institute cancer education grant, we have developed a model curriculum for medical schools that includes specific instruction in basic and clinical sciences as they relate to both smoked and smokeless tobacco. The curriculum was informed by a thorough review of the literature and includes eight modules in basic and clinical sciences that are evaluated by pre-test/post-test increases in knowledge as well as standardized patient encounters and process evaluation. We report preliminary data analysis.

Results

Pre-test/posttest data indicate that students increased knowledge on specific smokeless tobacco questions (e.g, correct answers on prevalence of smokeless, nicotine dosage in smokeless tobacco, cancer risk, and carcinogen components; all increased at p<0.001) Students also scored well on interactions with standardized patients using the Tobacco Intervention Risk Factor Interview Scale, a validated instrument to assess medical students’ tobacco counseling skills. Process evaluation data indicate that modules were generally well received.

Conclusion

This Web-based, comprehensive curriculum—the only curriculum we are aware of treating the topic of smokeless tobacco use—appears to be effective and well-received. Medical education must devote more attention to instruction in smokeless tobacco use, given its adverse health effects including cancer and cardiovascular disease.

Background

Smokeless tobacco (ST) use is often overlooked in research on tobacco control and in medical student education.¹ This highly addictive substance^{2, 3} contains many known carcinogens.^{4, 5} Smokeless tobacco also generally contains a higher concentration of nicotine relative to cigarettes. The typical single dose of nicotine in snuff is almost twice that of cigarettes, while the single dose of nicotine in chewing tobacco can be over 15 times greater.⁶ Because of these nicotine levels, the addictive potential for ST use is likely greater than for cigarette smoking.⁶ The two most common forms of smokeless tobacco are chewing tobacco (plug or loose-leaf) and snuff (dry or moist powder and powder in small tea bag-like sachets). Although most tobacco-related cancer studies have focused on cigarette smoking, ST use also has carcinogenic potential, particularly for oral cancer and a number of other cancers as well (See Table 1).^7–9

Table 1.

Cancers associated with smokeless tobacco use.

Oral

Esophageal

Renal Cell

Pancreatic

Penile

Cervical

A number of studies^10–16 indicate that ST has a unique epidemiology, different in many respects than cigarette smoking. For example, in 2005, approximately 21% of US adults were current smokers; men (24%) and American Indian and Alaskan Natives (32%) had the highest prevalence of use. By contrast, the prevalence of current smokeless tobacco use was 2.3%.¹⁵ Smokeless tobacco use in the United States is higher among young white males (6%) and American Indians/Alaska Natives (9%). Rates are also above the national average for people living in southern and north central states; and people who are employed in blue collar occupations, service/laborer jobs, or who are unemployed.¹⁶ ST users tend to be older than cigarette smokers and tend to live in rural areas. A higher percentage of ST users are women compared to cigarette smokers, particularly older, minority women.^10–16 ST use is associated with oral lesions, such as leukoplakia, gum recession, periodontal disease, and tooth abrasion.⁵ There is strong evidence in the literature for other health effects associated with smokeless tobacco use including cardiovascular disease.⁹ Combined with its unique epidemiology, nicotine pharmacology, and carcinogenic and health effects, specific training by clinicians in both ST cessation and smoking cessation is extremely important.

In 2002, we reported on the dearth of studies that have evaluated smokeless tobacco cessation educational efforts in US medical schools.¹ Since that report, no additional studies on this topic have emerged. Indeed, in 2005, the tobacco control competencies promulgated by the Prevention and Cessation Education Consortium—a group of 12 US medical schools—did not list training in basic and clinical sciences of ST control.¹⁷

Methods

Description of the Program

In 2003, Wake Forest University School of Medicine was awarded a cancer education grant from the National Cancer Institute specifically to develop a Web-based tobacco control curriculum for the nation’s medical schools that included both smoked and smokeless tobacco. Briefly, this curriculum is modular in design and made up of eight modules in basic and clinical sciences regarding smoking and smokeless tobacco use. Web-based education has the potential to realize more efficient and effective learning by students and can lessen the teaching burden of faculty.¹⁸ In addition, Web-based learning can provide immediate access to the most up-to-date information on a given topic, and can ensure that students have a standardized, measurable and reproducible educational experience. Furthermore, students perceive Web-based instruction positively, and it is one favored method of learning by students^{19, 20}

Module Design

Curriculum content was designed based on an extensive review of the literature related to the basic and clinical aspects of tobacco use. Special attention was given to the inclusion of smokeless tobacco in modules when relevant. Each module also contains a resource page that includes salient points from the module and offers Web links for viewers who desire further information. Students must take a pretest before viewing a module, and a posttest at its completion.

Modules were designed using Macromedia (now Adobe) Director software to produce a Shockwave Web-based presentation. Shockwave was selected because it has powerful media-handling capabilities, which includes programmable animation effects, audio, and video so that modules can take full advantage of these effects. Each module was pilot tested individually among 4 medical students and extensively reviewed and revised by the grant team prior to full implementation. This revision regarded such factors as ease of use, level of interest generated, and quality of the Web instruction. Both qualitative and quantitative measures were used in this pilot testing phase.

To complement Web learning, a didactic lecture devoted exclusively to ST use and cessation was developed in PowerPoint format and delivered during a Family Medicine Clerkship rotation. Students then practiced their smokeless tobacco counseling skills during a standardized patient encounter. Table 2 demonstrates the inclusion of ST information in the Web curriculum. Participation in completing modules was voluntary, but added extra credit to students’ grades within the courses in which the each module was inserted. Since the intent of developing this grant was to develop a curriculum inserted school-wide, there was no simultaneous control groups for each module; nonetheless, data were collected on counseling skills for classes preceding implementation of this curriculum which served as historical controls. Given the preliminary nature of those data, this comparative information is not included in this analysis. The total curriculum consisted of seven hours, three of which were intensively embedded in the Family Medicine Clerkship.

Table 2.

Smokeless tobacco topics inserted in a Web-Based Comprehensive Tobacco Curriculum for Medical Students.

Epidemiology of Tobacco use

Prevalence of smokeless tobacco use

Risk factors associated with smokeless tobacco use

Cultural aspects of smokeless tobacco use

Types of smokeless tobacco

Nicotine addiction and smokeless tobacco

Health Effects of Tobacco Use

Carcinogens in smokeless tobacco

Cancers related to smokeless tobacco use

Other health effects related to smokeless tobacco use (e.g., cardiovascular disease)

Cancer Risk and Tobacco Use:

Carcinogens in smokeless tobacco

Genetic susceptibility to cancer in smokeless tobacco use

Nicotine Addiction:

Epidemiology and cultural aspects of smokeless tobacco use

Assessment of nicotine addiction among smokeless tobacco users

Nicotine delivery by smokeless tobacco

Pharmacology and Toxicology of Nicotine:

Pharmacokinetics of nicotine delivery by smokeless tobacco

Nicotine replacement therapy and smokeless tobacco

Pharmacologic Agents in Tobacco Cessation:

Effective smokeless tobacco cessation medications

Standardized Patient Encounter

In order to assess the clinical significance of the smokeless tobacco medical education, medical students interacted with standardized patients, who portrayed smokeless tobacco users. The Tobacco Intervention Risk Factor Interview Scale (TIRFIS) was used to assess students’ counseling skills. The TIRFIS is a slightly modified version of the Smoking Cessation Risk Factor Interview Scale (SCRFIS) designed for the WFUSM smoking cessation training program.²¹ The only modification to the original SCRFIS was to replace “smoking cessation” with “tobacco use”. This total scale has demonstrated very good internal reliability (α = .85).

The TIRFIS has four subscales of three items each. Each item is scored from 1–5, with a total possible score of 60. A higher score indicates better counseling skills. Subscales measure the following:

Relationship

The relationship subscale measures the extent to which the medical student confidently conveys that tobacco cessation is needed and can be effectively achieved (Confidence); the ability to relay that tobacco cessation is a shared responsibility between the patient and health care provider (Joining); and the ability change is conveyed in an empathic manner (Empathy).

Positive Focus

The positive focus subscale includes praise and reinforcement for past, present and future attempts to quit using tobacco (Reinforce Effort); the extent to which the student explicitly highlights the immediate and long-term benefits of behavior change (Highlight Positive Consequences); and the student’s ability to respond to the patient’s report of failure or fear of failure by reframing prior quit attempts as positive (Reframing Failure).

Instigating Behavior Change

This subscale measures the student’s ability to assess the patient’s willingness to quit using tobacco and tailor counseling according to the SPIs stage of readiness (Stages of Change); the extent to which the student evaluates nicotine dependence (Nicotine Dependence) and introduces explicitly at least one of the following behavior change techniques: self-monitoring, contingency contracting/self-reinforcement, or stimulus/cue-control (Behavior Change Technique).

General Interview Techniques

This subscale measures the student’s interview techniques by evaluating how well s/he structures and organizes the interview (Organization); how well s/he uses positive non-verbal communication and verbal facilitation (Rapport/Eye Contact/Nonverbal Facilitation/Body Language/Verbal Facilitation); and how well the student summarizes the agreed upon steps for behavior change (Closure and Follow-up). To date, 97 medical students have interacted with smokeless tobacco using standardized patients.

Evaluation

For each Web module, students answer 5 identical pre- and posttest questions to assess their improvements in tobacco knowledge after viewing the Web curricula. Each module also contains an additional 5 posttest only questions to reduce the likelihood that students will move too quickly through the Web material focusing only on the pretest evaluation questions (i.e., “teaching to the test” phenomenon). Pre- and post-test data are analyzed using paired t-tests. Students who fail to complete the post-test are dropped from all analyses. In addition, descriptive statistics (e.g., frequencies) are calculated for questions that pertain to the instructional design and quality.

Implementation and evaluation of the curriculum began in 2004 and will continue through 2008. Implementation at Wake Forest University School of Medicine required the approval of the Dean of Medical Education, the Committee of Undergraduate Medical Education, and course directors for two courses (Epidemiology and Neuroscience) and one third year clerkship (family medicine). Modules were constructed so that they are “stand-alone”, i.e. they can be used by themselves without the need of viewing the entire set. This facilitated insertion of modules in specific places within the Wake Forest curriculum, minimizing the number of individuals needed to approve insertion of any specific module. This also facilitated instruction within a specific subject area (for example, Web-based module on the epidemiology of tobacco use facilitated instruction of tobacco use during the first year Epidemiology course, obviating the need for didactic instruction).

Data reported here include results of 6 questions that specifically address smokeless tobacco. These questions were taken from the following modules: epidemiology of tobacco use, health effects of tobacco use, and cancer risk and tobacco use. In addition, we provide process data (e.g., Web quality) for these modules, as well as scores on the TIRFIS.

Results

The numbers of students participating was 95% of the two classes that received the curriculum (data not shown).Table 3 shows the results of the ST evaluation questions after initial implementation of the Epidemiology, Health Effects, and Cancer Risk modules. Preliminary data demonstrate that students increase their understanding of ST use through Web instruction. For example, only 20% of students correctly indicated that a single dose of nicotine in chewing tobacco has 15 times the nicotine contained in a single cigarette at pretest. At posttest, however, the percentage who answered correctly rose to 92% (p<.001). The posttest only questions also demonstrated that students watched the entire video without focusing solely on the pretest evaluation questions. Eighty-one percent correctly indicated that smokeless tobacco use has increased 3 times in the past 20 years, and 90% indicated that individuals between ages 18 and 24 and those in poverty are at increased risk for using smokeless tobacco. Students also faired well on the questions pertaining to health effects of ST use and cancer risk and ST use.

Table 3.

Medical Students Knowledge of Smokeless Tobacco Epidemiology and Cancer Risk Before and After Viewing Web-Based Tobacco Curricula¹,²

Question		Correct Answer	n=	% Correct Pre-	% Correct Post-	p3
1.	The prevalence of ST use is highest among adults residing in which US region? (EPI)	Southern States	99	82.8	97.0	.001
2.	A typical single dose of nicotine in chewing tobacco can have approximately ____ time(s) the nicotine contained in a single cigarette. (EPI)	15	99	20.2	91.9	<.001
3.	Smokeless tobacco use has increased how much in 20 years? (EPI)	3 Times	99	n/a	80.81	n/a
4.	Which risk factors for smokeless tobacco use? (EPI)	Between ages 18–24 and Poverty	99	n/a	89.9	n/a
5.	Who is at highest risk for pancreatic cancer? (Health Effects)	Smokeless tobacco users and cigar smokers	171	14.0	90.6	<.001
6.	The most common functional group found in both smoked and smokeless tobacco is____. (Cancer Risk)	Aldehydes	110	46.4	77.3	<.001

¹The epidemiology module was implemented in 2005 with all first year medical students in Population Epidemiology. The Health Effects and Cancer Risk modules were implemented in 2006 with third year medical students during the Family Medicine Clerkship. Data for Health Effects and Cancer Risk questions include one rotation of students; thus results should be considered preliminary.

²Questions without pre-test scores represent only those administered at post-test to reduce the likelihood of “teaching to the test” associated with the pre-test.

³Statistical analysis=paired t-test

The students scored an average of 49 (range 32–58) on their counseling skills during the SPI-student encounter as measured by the TIRFIS. Scores were similar across subscales, although SPIs rated students most favorably on general interviewing techniques and least favorably on positive focus.

Process data also demonstrate that students are generally positive about the Web-based curriculum, particularly regarding the health effects and epidemiology modules. (Table 5). Students were not as favorable about the “entertaining” value of the curriculum; only about half indicated that the modules were entertaining. The process data are being used to redesign graphic quality as well as to increase the “entertainment” value of each module.

Table 5.

Process Evaluation of Tobacco Web-Based Tutorials⁴

	Tobacco Epidemiology (n=98)	Health Effects of Cancer (n=169)	Cancer Risk (n=111)
	% Who Agree or Strongly Agree
Clearly Organized	79	80	71
Quality of Graphics Good	59	60	71
Quality of Audio Good	67	72	75
Tutorial Entertaining	47	47	55
Overall Quality Good	72	74	72

⁴The epidemiology module was implemented in 2005 with all first year medical students in Population Epidemiology. The Health Effects and Cancer Risk modules were implemented in 2006–7 with third year medical students during the Family Medicine Clerkship.

Conclusion

Smokeless tobacco use is often neglected in discussions about tobacco control or in research related to tobacco use. Nonetheless, ST use is associated with specific cancers and health effects;^7–9 has its own epidemiologic patterns of use;^10–16 and is highly addictive.^{2, 3} Furthermore, medical education has largely neglected instruction on smokeless tobacco.¹

We have designed a Web-based model curriculum for the nation’s medical schools that attempts to address this shortcoming in undergraduate medical education. This curriculum is the only one we are aware of that specifically addresses smokeless tobacco use. Our curriculum has increased medical student knowledge regarding ST, and has been generally well-received. Although modules scored less favorably on their “entertaining” value, this is likely to be expected since the material was designed more for education than entertainment. Nonetheless, modules are in the process of being redesigned with this concept in mind, and, in addition, about half of students still thought that the modules were entertaining. We are also in the process of submitting our modules on the open-access online journal sponsored by the American Association of Medical Colleges, MedED Portal. This next step will allow national dissemination of our curriculum.

Due to the adverse health consequences of smokeless tobacco, increased instruction such as ours that is evidence-based and rigorously tested for impact is essential. Specifically, this education should focus on basic and clinical sciences related to the epidemiology and cultural aspects of ST use, its unique delivery of nicotine, health effects associated with its use and medications which are effective in its treatment.

Table 4.

Item-by-Item Analysis of the SPI-Student Encounter for Smokeless Tobacco Cessation Counseling Using the Tobacco Intervention Risk Factor Interview Scale (TIRFIS; n=97)

	Descriptive Statistics
Variable	Mean (sd)	Range
Total Score	49.3 (5.70)	32–58
Relationship	12.3 (1.76)	8–15
Confidence	4.1 (0.71)	3–5
Joining	4.2 (0.75)	2–5
Empathy	4.0 (0.77)	2–5
Positive Focus	11.1 (2.18)	4–15
Reinforce Effort	3.8 (0.93)	1–5
Highlight Positive Consequences	3.5 (0.87)	1–5
Reframing Failure	3.8 (0.90)	1–5
Instigating Behavior Change	12.5 (1.74)	6–15
Stages of Change	4.5 (0.82)	2–5
Nicotine Dependence	4.1 (0.93)	2–5
Behavior Change Technique	3.9 (0.77)	2–5
General Interview Techniques	13.4 (1.85)	8–15
Organization	4.5 (0.71)	2–5
Rapport/Eye Contact/Body Language	4.6 (0.62)	3–5
Closure and Follow-up	4.2 (0.89)	2–5