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Joseph K. Lim, MD

JAMA. 2000;283:2174.

More than a decade has passed since former Surgeon General C. Everett Koop challenged this nation to create a smokeless America by the year 2000. While we have achieved small triumphs in decreasing smoking rates over the last 13 years, tobacco use remains by far the leading cause of preventable deaths in the United States and worldwide. Each year smoking-related disease results in 430,700 deaths and $97.2 billion in health care costs and lost productivity in the United States.¹ The Global Burden of Disease Study group predicts that annual tobacco-related deaths will increase from 3.0 million in 1990 to 8.4 million in 2020.²

Physicians who are in training bear special responsibility to fight tobacco use within their generation. Recent efforts by the American Medical Association Resident and Fellow Section (AMA-RFS), including the Campaign for Tobacco-Free Kids, have focused on prevention among adolescents at an age when intervention can make a critical difference. One strategy deserving greater attention from medical educators is tobacco cessation. Despite adequate clinical knowledge of tobacco-related disease, physicians are often ill equipped to help their patients stop smoking.

More than 70% of smokers visit physicians each year, yet most smokers are not counseled about quitting.³ As late as the 1990s, the majority of physicians reported insufficient preparation for this task.⁴ A more recent survey assessing health care practices related to smoking cessation guidelines, promoted by the Agency for Healthcare Quality and Research, found that 51% of physicians had reviewed the guidelines, and only a minority of this group had fully or partially (9% and 39%, respectively) implemented the recommendations.⁵ These shortcomings stem, in part, from the absence of training in medical school curricula. In 1997, only 30.8% of US medical schools required training in smoking cessation techniques.⁶ Consequently, graduating medical students have generally been deficient in knowledge of tobacco-related disease and poorly trained in cessation techniques. Studies among graduate medical education programs suggest that resident physicians, too, are deficient in cessation training, although short-term training interventions may be beneficial.⁷

The AMA-RFS has the opportunity to improve the training of future physicians by urging residency review committees to require smoking-cessation training, supporting resident initiatives in tobacco cessation education, and promoting behaviors that prioritize tobacco cessation in patient interventions (eg, recognizing tobacco status as a vital sign). Small steps to highlight the importance of cessation and to improve physician counseling in cessation techniques may greatly affect how well the next generation of physicians succeeds in overcoming this nation's greatest public health threat.

Yale University School of Medicine
New Haven, Conn

REFERENCES
1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207-2212. ABSTRACT 2. Murray CL. Alternative projections of mortality and disability by cause, 1990-2020. Lancet. 1997;349:1498-1504. FULL TEXT | ISI | PUBMED 3. Centers for Disease Control and Prevention. Physician and other health-care professional counseling of smokers to quit—United States, 1991. MMWR Morb Mortal Wkly Rep. 1993;42:854-857. PUBMED 4. Cantor JC, Baker LC, Hughes RG. Preparedness for practice: young physicians' views of their professional education. JAMA. 1993;270:1035-1040. ABSTRACT 5. Brunk D. Managed care urged to take on smoking cessation. Intern Med News. 1999;32:14. 6. Ferry LH, Grissino LM, Sieler Runfola P. Tobacco dependence curricula in US undergraduate medical education. JAMA. 1999;282:825-829. FREE FULL TEXT 7. Cornuz J. Smoking cessation counseling by residents in an outpatient clinic. Prev Med. 1997;26:292-296. FULL TEXT | ISI | PUBMED

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