Tobacco Education and Counseling in Obstetrics and GynecologyClerkships: A Survey of Medical School Program Directors

Catherine A. Powers Jane Zapka

Sharon Phelan Tulin Ozcan Katie Brooks Biello

Joseph ODonnell Alan Geller

Published online: 15 September 2010

Springer Science+Business Media, LLC 2010

Abstract The 16,000 medical students completing

OB/GYN clerkship programs each year provide a unique

opportunity to motivate and mentor students in facilitating

tobacco cessation. To determine the scope of current

tobacco teaching in obstetrics/gynecology (OB/GYN)

education at US medical schools and to assess opportuni-

ties for including new tobacco teaching, a 28-question

survey was administered to directors and assistant directors

at US medical school OB/GYN clerkship programs. Sur-

veys were completed at 71% of schools. Only 9% reported

having at least 15 min of dedicated teaching time for

improving tobacco cessation skills. Nearly three-fourths of

respondents reported teaching students how to intervene to

reduce smoking during a work-up in the OB/GYN clinic,

but only 43% reported that students would know where to

refer someone wishing to quit. Only a third of respondents

reported teaching students both to intervene with and refer

OB/GYN patients who smoke. These findings suggest that

although medical students see many OB and GYN patients

who smoke, they have few opportunities to learn compre-

hensive cessation skills during their clerkships.

Keywords Tobacco Counseling Medical education OBGYN Clerkship education

Introduction

An estimated 18% of pregnant women ages 1844 in the

US smoke [1]. The US Surgeon General and the American

College of Obstetricians and Gynecologists (ACOG) have

determined that smoking during pregnancy is the most

modifiable risk factor for poor birth outcomes [2], and

ACOG includes tobacco use on its list of gender-specific

risks [3]. The impact of smoking during pregnancy,

including increased rates of fetal mortality and morbidity,

has been well documented [4]. Intrauterine exposure to

maternal smoking accounts for 20% of low birth-weight

babies, 8% of pre-term deliveries, and 5% of prenatal

deaths nationwide [5]. Women who use tobacco are also

twice as likely to be diagnosed with cervical cancer and

40% more likely to be diagnosed with breast cancer [69].

Smoking rates during pregnancy are estimated as high as

25% overall, with rates exceeding 35% for women on

Medicaid [10, 11]. Relapse rates range from 70 to 85%

C. A. Powers

Division of Pharmacoepidemiology and Pharmacoeconomics,

Brigham and Womens Hospital, Boston, MA, USA

J. Zapka

Department of Biostatistics, Bioinformatics and Epidemiology,

Medical University of South Carolina, Charleston, SC, USA

S. Phelan

Department of OB/GYN, University of New

Mexico-Albuquerque, Albuquerque, NM, USA

T. Ozcan

Department of OB/GYN, University of Rochester Medical

Center, Rochester, NY, USA

K. B. Biello

Department of Epidemiology and Public Health,

Yale University, New Haven, CT, USA

J. ODonnell

Department of Medicine, Dartmouth Medical School,

Hanover, NH, USA

A. Geller (&)Division of Public Health Practice, Harvard School of Public

Health, Landmark Center, 401 Park Drive, Third Floor East,

Boston, MA 02115, USA

e-mail: ageller@hsph.harvard.edu

123

Matern Child Health J (2011) 15:11531159

DOI 10.1007/s10995-010-0679-3

among women who smoke but quit at some time during

their pregnancy [12].

With an estimated 23.3 million prenatal visits being

made annually, there are ample opportunities for providers

to intervene and counsel pregnant patients who smoke [13].

The epidemiologic evidence correlating smoking with

increased risk for cervical and breast cancer is a compel-

ling reason to include tobacco cessation counseling and

education in standard care, especially since obstetric and

gynecologic (OB/GYN) specialists often serve as the pri-

mary healthcare provider for women. Because nearly all

pregnant smokers in the US will see an obstetric health care

provider during their pregnancy, and many women receive

primary care screening from their OB/GYN practitioners

[9], ACOG recommends that obstetric health care provid-

ers screen all patients for tobacco dependence [3]. In

addition, several professional organizations associated with

womens health, including ACOG and Association of

Professors of Gynecology and Obstetrics (APGO) have

made tobacco treatment a top priority [3, 14].

ACOG has identified three key foci for tobacco cessa-

tion, including medical school curricula.

In addition, ACOG and APGO are collaborating to revise

the learning objective on tobacco use during pregnancy for

graduating medical students [9]. In response to the Healthy

People 2010 goals, moreover, several national organiza-

tions have collaborated to form the National Partnership to

Help Pregnant Smokers Quit, which has influenced research

as well as state and federal funding policies and has fostered

strategies to utilize the health care system, media, and

communities to encourage cessation [15].

Numerous tobacco training curricula are also available

for integration into OB/GYN clerkship programs. For

example, The US Public Health Services updated Clinical

Practice Guidelines, available via the internet provide both

clinician and consumer materials [16], and ACOG offers an

evidence-based clinicians guide that includes information

on integrating tobacco cessation into routine prenatal care

[17]. In addition, Dartmouth Medical Schools on-line

virtual practicum features interactive virtual patient

tobacco cessation counseling [18], and The Legacy Foun-

dations internet-based program for pregnant and post-

partum smokers, although created for smokers, provides

clinicians with tools for motivating smokers to quit [19].

Practice, however, has been suboptimal [20]. In partic-

ular, despite widespread calls to integrate tobacco cessation

and referral skills into the OB/GYN medical school

clerkship, efforts to include tobacco education in OB/GYN

medical clerkships have generally been minimal. Many

physicians do not consistently counsel OB/GYN patients

about smoking cessation, with rates ranging from 19 to

83% [2125]. Providers treating pregnant patients have

cited a lack of time and training among the reasons for not

providing cessation counseling [26, 27]. Furthermore,

despite general consensus that successful tobacco cessation

interventions for the public include patient, education,

pharmacotherapy, and behavioral intervention [2830],

tobacco training in medical schools is limited [30], par-

ticularly in OB/GYN clerkships where in one recent study

only 41% of the students reported receiving instruction for

assisting patients with smoking cessation [10].

OB/GYN rotations are an excellent clinical setting to

learn smoking cessation skills given that the obstetric

population is generally a motivated receptive population

for such education, thus the student may commonly

experience a positive impact with their intervention.

To elucidate the nature and extent of tobacco teaching in

US OB/GYN clerkship programs, we administered a sur-

vey to US medical school clerkship directors and assistant

directors. This survey was designed to assess the current

status of tobacco cessation teaching in OB/GYN clerkships

and identify co-existing conditions that might be conducive

to comprehensive educational interventions.

Methods

Participants

We obtained a list of current clerkship directors and

assistant directors from the Association of Professors of

Gynecology and Obstetrics (hereafter directors and assis-

tant directors will be referred to as directors).

Procedure

In 2007, we mailed a 28-question survey to directors at US

medical school OB/GYN clerkship programs. Initial sur-

veys were sent via mail. Non-respondents received email

surveys. We made a maximum of four attempts via mail

and email to reach participants. The research procedures

and survey were approved by Institutional Review Boards

at Boston University and the Harvard School of Public

Health.

Instruments and Measures

After ascertaining the respondents current position (e.g.,

clerkship director or assistant clerkship director), years of

service, duration of each OB/GYN clerkship block (in

weeks), number of clerkship sites, and number of OB/GYN

patients seen by medical students during a rotation, we

divided the survey into sections representing five domains

traditionally used to assess and plan for new programs in

substance abuse and tobacco for physicians-in-training,

including medical students and residents [3135].

1154 Matern Child Health J (2011) 15:11531159

123

Tobacco Cessation Teaching and Tobacco Control Policies

Tobacco curriculum questions included whether there was

dedicated teaching time of at least 15 min for improving

tobacco cessation skills, and if so, what methods were

used: didactic, skills training (role-plays, etc.), applied

(supervised clinical training), or web-based. We queried if

curricula included: the 5As (Ask, Advise, Assess, Assist,

Arrange), the high rate of post-partum recidivism, and a list

of expected skills to be learned during clinical rotations as

well as whether that list included smoking cessation skills.

Respondents were also asked if there were institutional

tobacco policies such as a smoke-free campus, restriction

on tobacco industry-funding for research, designated

smoking areas on campus, or prohibition on the sale of

tobacco products on campus.

Office Systems and Clinic Environment

Respondents estimated the smoking rate for OB/GYN

patients as \10%, 1120%, or 21?%, and estimated thenumber of OB/ GYN patients students typically see during

a rotation using a scale of \10, 1120 and 21?. Weassumed that students saw one patient per day, seven days

per week, so that at the end of 6 weeks they would have

seen 42 patients (21 OB and 21 GYN). Referring to the

hospital or clinic in which most students clerked, respon-

dents were asked if there were reminders (e.g., vital signs,

chart stickers, and checklists) to encourage patients not to

smoke and if these reminders asked if smoking history was

assessed, follow-up arranged, and hospitals had tobacco

cessation clinics for patient referral.

Professional Development and Training

Respondents indicated if their hospital had ever offered any

in-service training, workshop or continuing medical edu-

cation for tobacco cessation, or related pharmacotherapy.

They also rated level of faculty support for tobacco

workshops and for integrating tobacco cessation into the

clerkship.

Medical Student Skills

We used a four-point Likert scale to assess students skill

level after completing the OB/GYN clerkship in the fol-

lowing areas: counseling patients about environmental

tobacco smoke; asking about smoking at every visit;

advising all smokers to quit; assessing patient willingness

to quit; assisting patients with quit plans; arranging follow-

up contact; recommending nicotine replacement therapy

(NRT); talking with pregnant patients about smoking

effects, and, the major outcome, having learned to

intervene to reduce smoking or where to refer patients

wishing to quit.

Clerkship Director/Assistant Director Practice

Using a 4-point Likert scale, respondents described their

own practice in convincing patients to quit smoking, dis-

cussing smoking when patients have multiple health

problems, advising OB/GYN patients about NRT, and

demonstrating familiarity with state reimbursement/

Medicaid options for cessation counseling.

Data Management and Analysis

We de-identified survey data and entered it into a secure

project database. Using SAS and Excel, we analyzed the

data by calculating the proportion of students who had been

taught to intervene with patients and knew how to make a

referral from other students who did not have these clinical

experiences. We then analyzed all other study variables to

determine predictors related to students who had been

taught to intervene with patients and to make a referral.

Results

Of the 129 US medical schools with an OB/GYN clerkship

program, surveys were completed by OB/GYN clerkship

directors at 70% (90/129) of the schools, with 57 returned

via regular mail and 33 via e-mail. Eighty-eight percent of

respondents were clerkship directors and the rest were

assistant clerkship directors.

Respondents Position and Years of Service

On average, respondents had served 5 years in their current

capacity with a range of \123 years.

Clerkship Program Structure and Setting

Sixty-one percent of the clerkships lasted 6 weeks, 26%

8 weeks, 7% 4 weeks and 6 % other. Seventy-three

percent of programs had at least 24 clinical rotation sites.

Respondents reported that 74% of students see at least 21

gynecology patients and 88% see at least 21 obstetrics

patients during a rotation.

Tobacco Cessation Teaching and Tobacco Control

Policies

Nine percent (8/90) of directors reported having at least

15 min of dedicated teaching time for improving tobacco

cessation skills. Of these, only one program used role plays

for skills training while the remainder (n = 7) used didactic

Matern Child Health J (2011) 15:11531159 1155

123

presentations. The 5As were included as part of teaching in

only 20% of all programs, and only 12% of all programs

included teaching about the high rate of post-partum recid-

ivism. Nearly three-fourths of respondents reported that

students are taught how to intervene to reduce smoking

during a work-up in the OB/GYN clinic, but only 43% report

that their students would know where to refer someone who

wishes to quit. In all, only a third of respondents reported that

students were taught both to intervene and refer (Table 1).

Having specific and dedicated teaching time of at least

15 min on improving tobacco cessation skills was the only

variable associated with students who had been taught both

skills: how to intervene with patients who smoke and how to

refer them for follow-up. While 69% of the programs pro-

vided students with a list of expected skills to be learned

during the clinical rotation, only 14% included smoking

cessation skills on the list.

Two-thirds of the medical campuses were smoke-free,

and more than one-third had restrictions on tobacco

industry-funding for research. Sixteen of the universities

prohibited the sale of tobacco products on campus.

Office Systems and Clinic Environment

Clerkship directors estimated the following rates of

smoking at their clinic: less than 10% (36%), between 11

and 20% (42%), and over 20% (21%). Fifty-six percent

noted that vital signs, chart stickers, and checklists

prompting providers to encourage patients not to smoke

were available in the hospital or clinic for which the largest

number of students completed clerkships. Seventy-three

percent of respondents noted that their charts assessed

smoking history, while 52% noted that follow-up was

arranged, and 48% reported that their hospitals had tobacco

cessation clinics for patient referral.

Professional Development and Training

Less than one-third of respondents reported that their fac-

ulty had ever offered an in-service training on tobacco

cessation; 23% provided continuing medical education

credits (CME) for tobacco education, and only 8% had

workshops on pharmacotherapy. Forty-eight percent of

respondents felt that there was a high level of support for

faculty workshops on integrating tobacco cessation into the

OB/GYN clerkship.

Medical Students Skills

Clerkship directors rated their students as moderately or

very skilled for the following: talking with pregnant

patients about effects of smoking (74%), advising smokers

to quit (74%), asking about smoking at every visit (56%),

assessing patient willingness to quit (45%), arranging

follow-up contact (35%), assisting with quit plans (34%),

counseling about Environmental Tobacco Smoke (ETS)

(33%), and recommending NRT (32%) (see Fig. 1).

Smoking Cessation Practices of Clerkship Directors

Ninety-three percent of clerkship directors reported that they

were able to convince some patients to quit smoking, and 74

and 72%, respectively, reported that they routinely advise

OB/GYN patients about the use of NRT. However, while most

respondents reported that they routinely advise GYN patients

about the use of nicotine replacement (70%), significantly

fewer clerkship directors routinely advise OB patients about

nicotine replacement (31%). Sixty-eight percent of respon-

dents also reported that they were unfamiliar with state

reimbursement/Medicaid options for cessation counseling,

and 12% reported that they were less inclined to talk about

smoking with a patient who has multiple health problems.

Discussion

With 16,000 medical students completing OB/GYN

clerkship programs each year, a unique opportunity exists

Table 1 Students trained to intervene with and/or refer smokers

Refer

Yes (%) No (%) Total (%)

Intervene

Yes 32.9 39.0 72.0

No 9.8 18.3 28.0

Total 42.7 57.3 100.0

Percentage of Total (excluding no response responses)

74 74

56

45

35 34 33 32

0

10

20

30

40

50

60

70

Per

cent

age

of M

edic

al S

choo

ls

Medical Student Skills

Fig. 1 Medical student current skill level as reported by clerkshipdirector

1156 Matern Child Health J (2011) 15:11531159

123

to motivate students to become skilled in facilitating

tobacco cessation in the OB/GYN setting. This survey of

over 70% of US OB/GYN clerkship directors indicates that

although medical students appear to have many OB/GYN

patients who smoke, they have few opportunities to learn

comprehensive cessation skills during their clerkships. In

fact, fewer than 10% of clerkship programs provided at

least 15 min of cessation teaching during the entire clerk-

ship, and only 20% provided training in the US Public

Health Services 5As for tobacco cessation. The fact that

only 43% of clerkship directors felt that students would

know where to refer patients who smoke is distressing,

although it is consistent with other studies that show

arranging follow-up care as the least commonly

employed of the basic 5As [36].

Clerkship directors in our survey also reported that only

33% of medical students are taught both to intervene with a

smoker and provide information about referrals for smok-

ers who wish to quit. One disincentive for timely referrals

can be attributed to the fact that nearly half of the reporting

sites did not have cessation clinics on campus. In fact, lack

of cessation clinics are oft-cited reasons for sub-optimal

cessation counseling during the clinical encounter [6].

Physician referrals to tobacco quit lines have improved

patient quit rates, suggesting that medical students should

be routinely provided with quit line numbers as part of their

educational packets [37].

While we found that nearly 70% of programs have an

expected list of clerkship competencies, only 14% of these

programs included tobacco counseling on their list. This

omission undermines the importance of the skill. With the

ever competing demands of undergraduate medical edu-

cation, a skill that is not formally graded or observed will

be marginalized or omitted altogether. To remedy this,

clerkship directors should formally include tobacco coun-

seling among the expected clinical skills and observe

students as they do with clinical examination skills. Suc-

cessfully integrating tobacco teaching in the clerkship

experience requires preceptor participation. The need for

curricular change related to tobacco teaching in OB/GYN

clerkships provides APGO and ACOG, who have already

developed many relevant materials of instruction, with an

opportunity to take on a leadership role in the effort.

Interestingly, our findings about clerkship directors less

than optimal use of NRT for pregnant smokers may reflect

their own lack of training in tobacco cessation in medical

school and continuing medical education. ACOG recom-

mends using NRT if all other therapies fail, and OB/GYNs

have been shown to recommend NRT when they believe it

is safe and effective for use in pregnancy, and if colleagues

are prescribing it [38]. Periodic CME training in smoking

cessation and the use of NRT would provide practicing

OB/GYNs with current clinical guidelines and best

practices and, presumably, increase exposure of medical

students to these practices. Formally integrating smoking

cessation training, including the safe usage of NRT, in

clerkship programs would ensure that the next generation

of obstetricians and gynecologists has the necessary train-

ing to provide optimal care to their patients who smoke.

Continuing medical education (CME) about Medicaid

reimbursement may also be useful, since lack of awareness

of reimbursements for tobacco cessation treatment pro-

grams for pregnant smokers may hinder physicians

decisions to recommend cessation treatments as well.

According to a 2008 report on Medicaid coverage for

tobacco cessation, 39 states, including the District of

Columbia, provided at least some coverage for smoking-

cessation treatments [39].

On a more encouraging note, our results suggest that the

environmental context of the medical school and clerkship

sites already contain numerous opportunities for promoting

policy and systems change conducive to promoting effec-

tive counseling. Although only 18% of respondents said

their schools prohibited the sale of cigarettes on campus,

two-thirds of campuses were smoke-free. Furthermore,

most clerkship directors routinely advise their own patients

about the use of nicotine replacement, more than half of

clinics had prompts to remind faculty and students to

counsel patients, and 73% had smoking history assess-

ments. These characteristics represent opportunities for

mentoring, role-modeling, and education.

At the same time, our findings confirm the need for

further research, both on the current state of cessation

training and on the most effective methods for teaching

tobacco cessation in OB/GYN clerkship settings. In par-

ticular, because responses on student skill level provided

by clerkship directors are subjective, they should be cor-

roborated with objective evaluations of student perfor-

mance. That nearly 30% of clerkship directors did not

respond to our survey despite numerous attempts to reach

them also suggests some degree of non-response bias,

although this particular concern is mitigated by the sub-

optimal rates of cessation teaching reported by respon-

dents. To better understand effective approaches, short case

studies on the evolution of formal cessation teaching dur-

ing the clerkship in the eight programs that already offer at

least 15 min of instruction in this subject might be fruitful.

Future studies might also investigate factors influencing

both the integration and retention of tobacco cessation

training, such as dedicated funding, influential faculty

members, or a department-wide commitment to preventive

teaching.

In conclusion, given the convincing need and potential

opportunity for intervention, it is imperative that medical

students understand the importance of timely intervention

for smokers in the OB/GYN setting. In fact, most patients

Matern Child Health J (2011) 15:11531159 1157

123

report that they are expecting providers to intervene, and

there is evidence that these interventions are successful

[38]. Our findings confirm ample opportunities within the

OB/GYN clerkship for students to provide counseling and

referrals to patients who smoke. Emerging literature as well

as the support, new resources and practical tools already

available from organizations such as ACOG and APGO

suggests that integrating tobacco education into the

OB/GYN clerkship need not require an entire curricular

overhaul. Individuals interested in integrating preventive

education, such as tobacco education, into the OB/GYN

curriculum can already learn from successful models used

with physicians-in-training [2125]. They can also draw on

suggestions from this study about the potential efficacy of a

series of small but concrete tasks. These include adding

smoking cessation skills to the expected skill set, periodic

CME training or in-service teaching for smoking cessation

skills, and chart space for arranging follow-up care and

providing information to students on where to refer patients

who wish to quit.

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Tobacco Education and Counseling in Obstetrics and Gynecology Clerkships: A Survey of Medical School Program DirectorsAbstractIntroductionMethodsParticipantsProcedureInstruments and MeasuresTobacco Cessation Teaching and Tobacco Control PoliciesOffice Systems and Clinic EnvironmentProfessional Development and TrainingMedical Student SkillsClerkship Director/Assistant Director PracticeData Management and AnalysisResultsRespondents Position and Years of ServiceClerkship Program Structure and SettingTobacco Cessation Teaching and Tobacco Control PoliciesOffice Systems and Clinic EnvironmentProfessional Development and TrainingMedical Students SkillsSmoking Cessation Practices of Clerkship DirectorsDiscussionReferences