Background

In this review, entry-level education programs or program components are those that prepare beginning students (including medical resident trainees and advanced practice nursing students) for entry into a regulated discipline and for key, direct patient care roles within respective health professions. Tobacco dependence education includes teaching students how to offer psychosocial interventions, including brief advice and clinical skills in counseling for smoking prevention and cessation, and pharmaceutical interventions such as recommending or prescribing nicotine replacement therapy.1-2 Such types of health-provider interventions are designed to help clients reduce or overcome tobacco dependence.

Theoretical framework and outcomes

Social Cognitive Theory provides the theoretical framework for this systematic review. This theory has relevance to interventions focussed on individuals and provides a basis for understanding the acquisition and maintenance of certain behavioral patterns.3 Health professional students are expected to become knowledgeable and confident in providing clients with a variety of health promotion advice. However, practicing healthcare professionals report a lack of sufficient education and doubt their own effectiveness in promoting client behavior change when it relates to tobacco use.4-6

Emerging research across several disciplines reveals considerable curricular variation in the content, time spent and teaching strategies used with regard to treating tobacco use and dependence.7-22 Despite reported curricular variation, a central theme is reported. Students should have knowledge and skills in asking all clients if they use tobacco, advising them not to start smoking or to quit and informing them of the health risks associated with tobacco use, assessing clients for interest in quitting if they smoke and assisting them to quit using interventions appropriate to the discipline, for example, assisting activities could be psychosocial interventions, providing a motivational message to encourage future quit attempts, or prescribing nicotine replacement therapies. A brief intervention of less than 10 minutes includes arranging for a follow-up meeting or referring a client to available self-help or community resources. This brief intervention approach has been coined the 5As model for treating tobacco use and dependence,2 and has been incorporated into clinical practice guidelines (CPGs)2,23 and into educational curricula.13,14 Entry-level education aims to prepare health professionals for an espoused standard of practice in which all providers would intervene with tobacco users and offer a brief intervention at each health visit.1,2,20-22,24 This review will summarize tobacco dependence education interventions and their effect on student knowledge and skills.

A second commonly reported barrier by practicing clinicians is lack of confidence or doubt in their own effectiveness in promoting client behavior change relating to tobacco use. Lack of confidence or self-doubt refers to perceived self-efficacy and is the most important prerequisite for behavioral change in Social Cognitive Theory.25 Unless people believe they can produce the desired effects by their actions, they have little incentive to act. Efficacy belief is a major basis of action.26 Self-efficacy refers to beliefs in one's capabilities to perform a particular behavior, including confidence and commitment in overcoming barriers to performing that behavior.25,27,28 Entry-level education programs are well positioned to build health professional student self-efficacy and to promote student behavioral change in regard to smoking prevention and cessation interventions with clients.

A high sense of efficacy in one activity domain is not necessarily accompanied by high self-efficacy in other activities.25 Bandura explains that efficacy beliefs may involve regulating one's own motivation, thought processes, affective states and actions, or it may involve changing environmental conditions.25 An individual's learning performance is enhanced through one of the four mechanisms noted above and when excessive emotional arousal is minimized.25-28 The Social Cognitive Theory posits that enhancing perceived self-efficacy and behavioral capability through the previously stated mechanisms will contribute to actual behavioral change. The self-efficacy concept is important in skill development and encompasses the premise that if a person is to perform a particular behavior, one must know what the behavior is (knowledge of the behavior) and how to perform it.29 Strategies to minimize emotional arousal and anxiety make it easier for individuals to attend to learning.3 Feedback regarding successful performance also enhances behavioral capability.3 As self-efficacy in one activity domain that does not always transfer across domains of learning, this systematic review is designed to summarize the assessment of an important educational outcome: the educational interventions and their effect on student self-efficacy or confidence to perform client prevention and cessation interventions.

A third important student learning outcome is the clinical performance of client tobacco prevention or cessation interventions. Entry-level education programs employ a variety of strategies to promote and maintain desired student clinical performance in treating tobacco use and dependence. Lectures, case studies, problem-based exercises, role play, simulated patients and role modeling by faculty in clinical settings have been reported.7-22,30 There is a growing body of evidence demonstrating the effect of entry-level education on treating tobacco use and dependence in a variety of health disciplines and the effects on students' practice within their programs. Studies in dentistry and dental hygiene,31-33 nursing,34-37 pharmacy,38 medicine,30,39-43 advanced practice nursing,15 chiropractic interns44,45 and medical residents46-49 demonstrate the positive impact of curricular content on student knowledge, self-efficacy (confidence) and intervention skills for providing tobacco-dependence treatment to patients. This evidence lends support for entry-level education programs as appropriate to enhance health professional capacity to address tobacco use.14,18,19,50 This review will summarize the educational interventions reported for theoretical underpinnings, models or CPGs used, the dose, frequency and duration of the intervention, the nature of delivery and student performance of client prevention and cessation interventions.

A fourth outcome relates to providing further evidence of the effectiveness of entry-level health professional student tobacco-dependence education. This systematic review is designed to summarize client smoking cessation behaviors. Fiore et al.2 remind us that health professionals who have received training are far more likely to integrate interventions, and when health professionals address their clients' tobacco use, the odds of successful quitting increase.

Importance of cessation interventions

The importance of educating health professionals in addressing tobacco use and dependence has been endorsed in Canada4,51 and globally.1,21,24 The World Health Organization (WHO) Framework Convention on Tobacco Control, Articles 12 (a) and (d) describe the responsibility for comprehensive education programs for health professionals, social workers and others on the health risks and addictive characteristics of tobacco consumption and exposure to environmental tobacco smoke. The WHO Framework Article 14 outlines tobacco dependence and cessation expectations: health professionals are role models, educators, clinicians and leaders in helping patients address their tobacco use.24

Cessation interventions by health professionals are important to help tobacco users quit and prevent relapses.2 A Cochrane systematic review52 and other studies53 demonstrate that training health professionals in smoking cessation does have a measureable effect on professional performance. Health professionals who receive training in smoking cessation counseling are one-and-a-half to two times more likely to offer smoking cessation interventions to clients.46 Client quit rates increase when counseling is delivered by a variety of healthcare providers.2,54 Therefore, entry-level education, specific to preventing and treating tobacco use and dependence, would enhance healthcare system responsiveness by increasing the capacity among health professionals to effectively address tobacco use. Brief cessation counseling is effective and low cost and is one recognized way to strengthen health systems globally.2,55

Clinical practice guidelines are now available that provide evidence of the effectiveness of training healthcare providers to treat client tobacco use.2,56 Since 1996, three versions of the CPG Treating Tobacco Use and Dependence have been published by the Agency for Healthcare Research and Quality in the United States.2,57 Over 8000 primary studies included in the 2008 guideline demonstrate that healthcare provider interventions do enhance client engagement in quitting and increase client cessation rates. The CPGs highlight the chronic nature of tobacco use and dependence and emphasize the importance of repeated clinical interventions. The CPGs emphasize the effectiveness of a broad scope of clinicians (physicians, nurses, dentists and respiratory therapists) in a wide array of healthcare settings (e.g. clinic, hospital). Although these CPGs are most relevant to primary-care clinicians, brief clinical interventions can be provided effectively by any clinician, and interventions as brief as three minutes can increase client cessation rates significantly.57 Despite existing evidence-based guidelines and frequent direct access to clients who smoke, surveyed health professionals continue to report a lack of training in how to treat client tobacco use and dependence as a barrier to providing these client services.52,58-63

Tobacco use is the leading cause of morbidity and mortality worldwide.64-66 Tobacco use is a major preventable risk factor for most non-communicable diseases including vascular disease, cancer and chronic respiratory disease.65 Mathers and Loncar66 estimate tobacco use may account for 150 million deaths by 2030, with over 80% in low- and middle-income countries. Serious health consequences linked to tobacco use have been documented: cancer, heart diseases, cerebrovascular diseases, chronic obstructive pulmonary diseases, diabetes mellitus, nephritis and chronic liver diseases.67-72 Tobacco use is also linked to poor surgical outcomes,73-78 poor oral health79 and untoward pregnancy outcomes.80-82 If entry-level education addressed both the health risks and diseases associated with tobacco use, and how to assess and treat nicotine dependence, health professionals would be equipped to address client tobacco use. Moreover, health professionals would be better prepared to fulfill patients' expectations that their tobacco use would be addressed during health visits.83-90 An understanding of the effects of educational programing on health professional student performance in treating client tobacco use and dependence would enhance health professional schools' capacity to equip graduates with the knowledge, skills and abilities to address an identified global health priority.

An examination of the Cochrane Library of Systematic Reviews, the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports, and the PROSPERO database indicates that no systematic reviews have been completed (or proposed) on this topic. This pre-search strategy establishes that no other systematic reviews regarding health professional students and treating tobacco use and dependence exist and that no protocols were identified as being under development. An ongoing search for systematic reviews was conducted in 2011, 2012, 2014 and 2015. From 2011 to 2015, Prospero was included; in July 2015, CINAHL and Epistemonikos were added to the search. This ongoing review establishes that no other systematic reviews regarding health professional students and their respective education in treating tobacco use and dependence exist and no protocols were identified as being under development.

Inclusion criteria

Types of participants

This review will consider studies that include health professional students undertaking the following programs of study: nursing (registered nurses, registered psychiatric nurses, advanced practice nurses/nurse practitioners and licensed practical nurses), midwifery, medicine, dentistry, dental hygiene, dental therapy, pharmacy, respiratory therapy, occupational therapy, physical therapy, speech language therapy, optometry, social work, psychology, chiropractic therapy and naturopathic medicine. Studies that evaluate practicing healthcare providers who are not students in entry-level educational programs will be excluded. Health professional student programs whose graduates can practice without qualifying for a license (non-regulated disciplines) will be excluded. Programs in which graduates do not have daily, direct interactions with clients will be excluded.

Advanced practice nurses and medical residents provide specialized care to patients with health concerns commonly linked to tobacco use. Studies reporting evaluations of curricula among the following postgraduate medical speciality programs will be included in the review: anesthesia, cardiac surgery, cardiology, community medicine, critical care medicine, dermatology, endocrinology and metabolism, family medicine, general medicine, emergency medicine, medical oncology, nephrology, neurology, obstetrics/gynecology, ophthalmology, orthopedic surgery, otolaryngology, pediatrics, plastic surgery, psychiatry, radiation oncology, respiratory medicine, surgery and vascular surgery.

Types of intervention(s)

This review will consider studies that report on the implementation and evaluation of an entry-level program, curricular activity or component in smoking prevention or smoking cessation, and its impact on student practice in promoting client health. The comparator will include different approaches to the educational intervention (including pre- and post-training results) to usual or no educational program. The settings will include post-secondary institutions such as universities or colleges and will include undergraduate or pre-licensure training, postgraduate medical speciality training and advanced practice nursing programs at the master's level. The educational intervention and its impact on student practice must have occurred during the entry-level program.

Outcomes

This review will consider studies that report on evaluations of health professional student outcomes in treating tobacco use and dependence during the course of their studies: knowledge/skills, self-efficacy (confidence), and clinical performance of tobacco prevention and cessation interventions. We anticipate that student knowledge and skills will be measured and reported as scores on exams and questionnaires. Because self-efficacy is not easily observable, student self-reports of efficacy in treating tobacco use and dependence will be accepted. The self-report data are expected to be reported as scores on instruments designed to assess self-efficacy in treating tobacco use and dependence. Student clinical performance may be evaluated from faculty observations, standardized patients and client reports. For example, data from skills checklists documenting the number of smoking cessation activities may be used in evaluating clinical performance. Client outcomes, in terms of smoking cessation or behaviors such as following up with referrals, will be recorded to provide further evidence of the effectiveness of the educational intervention.

Types of studies

This review will include all randomized controlled trials (RCTs) that evaluate the effectiveness of educational programing on student knowledge and skills, student self-efficacy and practice in tobacco use prevention and treatment for tobacco use. Evaluation means that studies must report on pre- and post-training results and compare the findings with a control or comparison group experiencing usual care or another educational intervention. In the absence of RCTs, other research designs that minimize the risk of bias (i.e. have some form of randomization or control), including quasi-experimental studies, will be included. In the absence of experimental and quasi-experimental designs, controlled before and after studies, cohort studies (with control), case-controlled and observational will be reviewed to create a comprehensive description of effects of educational programing. Editorials and opinion pieces regarding curricula will be excluded.

Search strategy

A pre-search of review databases was conducted in 2010 to determine whether other reviews existed or protocols were under development. The Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews (including the Tobacco Addiction Group Reviews), the Campbell Collaboration library, the National Health Centre Reviews and Dissemination databases (Database of Systematic Reviews - DARE, Health Technology Assessment - HTA, Economic Evaluation database-NHS-EED), Health Technology Assessment International - HTAi, Evidence of Policy and Practice Information (EPPI-Centre), Physiotherapy Evidence Database-PEDro, Occupational Therapy Systematic Evaluation of Evidence-OT Seeker and Medline were searched using keyword and index search terms: health profession students AND tobacco use prevention or treatment AND education programs. This pre-search and ongoing search strategy described earlier established that no other systematic reviews regarding health professional students and treating tobacco use and dependence existed and that no protocols were identified as being under development.

A three-step search strategy will be used to locate published and unpublished studies. The search will include published articles, books and relevant government documents. First, an initial limited search of Medline and CINAHL will be undertaken followed by analysis of text words contained in the title and abstract and of the index terms used to describe the articles. A second extensive search will be undertaken using all the identified keywords and index terms across all included databases, information sources and health professional student programs. Books and book chapters will be accessed through World Cat. Third, the reference lists of all identified reports and articles will be searched for additional studies that may have been missed in the electronic search. Studies identified from reference list searches will be assessed for relevance based on the study title. Web of Science will be used for citation tracking.

All studies identified in the database, book and website search will be assessed for relevance to the review based on the information in the title and descriptor terms. An abstract and full report will be retrieved for studies that meet the inclusion criteria. All studies that evaluate a program or curricular activity in papers published from 1990 to 2015 will be included. Beginning in the early 1990s, innovative, evidence-based and comprehensive CPGs on treating tobacco use and dependence signaled the importance and effectiveness of brief intervention counseling by a broad array of health professionals in a variety of clinical settings.2,23,56,89-93

Initial keywords will include but not be limited to the following: tobacco or smoking or nicotine; cessation or prevention or intervention or addiction or counseling or counseling; education or programs or curriculum or curricula or training; and health professionals or nurses or pharmacists or dental hygienists or physicians or doctors. All of the health professional programs will be searched using the preceding rubric. No language limitations will be placed on the published electronic database searches. All databases that return English abstracts will be read and considered. Full articles written in English and French meeting the inclusion criteria will be retrieved. The book search and grey literature search will be limited to the English language.

The databases to be searched for published studies from 1990 to 2015 will include the following: Allied and Complementary Medicine, CINAHL, Medline, EMBASE, Scopus, SocIndex, PsychInfo, Academic Search Premier, Education Resources Information Center (ERIC) and Education Search Complete, Health Source-Nursing/Academic Edition, Translating Research into Practice (TRIP), Google Scholar, Web of Science and Natural Standard (alternative medicine). Journals such as Tobacco Control, Nicotine and Tobacco Research and Preventive Medicine from publishers' websites will be searched.

Gray literature includes papers, reports and government information or other documents that are not published commercially and that are inaccessible via bibliographic databases. Searches for gray literature from 1990 to 2015 will include the following: theses and dissertation abstracts databases (Theses Canada Portal and Dissertation Abstracts International) and relevant sites in the Canadian Agency for Drugs and Technologies in Health database. This database has a listing of national and international health technology websites, drug and device regulatory agencies, clinical trial registries, health economics resources, Canadian health prevalence or incidence databases and drug formulary websites. The Directory of Gray Literature via New York Academy of Medicine website will be reviewed. Other sources of unpublished works will include websites of the Canadian Centre on Substance Abuse, Health Canada and the Canadian Public Health Association.

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument94 (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Data will be extracted from papers included in the review following the standardized data extraction tool from JBI-MAStARI program94 (Appendix II). All results will be subject to double data entry. The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and objectives. The following components will be extracted: population (type of health profession program), location (country and university or college), language (English or French), educational intervention (theoretical underpinnings, models or CPGs used, dose, frequency and duration - hours of content, length of entire intervention including follow-up), and nature of delivery (e.g. lecture, video, tutorial, self-study, lab practice, simulated patients), methods to assess student learning outcomes for all selected papers (e.g. score on exams, self-reported questionnaire), clinical settings used or opportunities for practice of skills, culture or gender specific approach, focus on adults or youth, year(s) of study in program, study design, study methods (method of randomization, blinding) and student learning outcomes - knowledge/skills, self-efficacy and behavioral performance in tobacco use prevention and tobacco cessation counseling. Patient outcomes in terms of smoking cessation or behaviors such as following up with referrals will be extracted as further evidence of the effectiveness of the intervention.

Data synthesis

Quantitative data will, where possible, be pooled in statistical meta-analysis using the JBI-MAStARI. Odds ratio (for categorical data) and weighted mean differences (for continuous data), and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard chi-square and also explored using subgroup analyses based on the different study designs included in this review. In cases in which statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

Appendix I: Appraisal instruments

MAStARI appraisal instruments

Appendix II: Data extraction instruments

MAStARI data extraction instrument

References