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Introduction

Smoking remains the single largest preventablecause of illness and death in Australia.1 Familyphysicians (FPs) are uniquely placed to promote

smoking cessation as they have contact with over80% of the population each year2 and can achievehigh quit rates among patients who smoke.3 Briefsmoking cessation advice from a physician is

The Journal of Continuing Education in the Health Professions, Volume 22, pp. 84–93. Printed in the U.S.A. Copyright © 2002 The Alliancefor Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association forHospital Medical Education. All rights reserved.

Original Article

Can Distance Learning Improve Smoking Cessation Advice in Family Practice? A Randomized Trial

Jane M. Young, MBBS, MPH, PhD, FAFPHM, and Jeanette Ward, MBBS, MHPEd, PhD, FAFPHM

Abstract

Introduction: Family physicians (FPs) underuse opportunities to provide smoking cessationadvice during routine consultations with patients who smoke. Distance learning is a promis-ing approach to continuing medical education, particularly for FPs practicing in rural andremote areas. We developed a distance learning module, conducting a randomized trial toassess its educational impact on knowledge, attitudes and skills (“competence”), self-ratedcompetence, confidence, and readiness to change.

Methods: Volunteer FPs were randomly allocated to receive either a distance learning moduleor a preventive care guideline. Self-administered questionnaires were completed at baselineand post-test.

Results: Fifty-three FPs enrolled in the study. There were no changes in knowledge or atti-tudes. Change in skills was limited to a reduction in use of one ineffective technique, namely“nicotine fading.” Change in self-rated competence between baseline and post-test was sig-nificantly greater for the intervention than for the control group, however (p = .03). Althoughself-ratings of confidence increased significantly between baseline and post-test in both groups,the magnitude of change was no greater in the intervention than the control group (p = .3).Both groups demonstrated only nonsignificant shifts in readiness to change.

Discussion: These modest changes are of uncertain educational value, inviting caution beforerecommending distance learning approaches to promote smoking cessation advice in familypractice.

Key Words: Competence, continuing medical education (CME), distance learning, familypractice, randomized trial, smoking cessation advice

Dr. Young: National Health and Medical Research Council(NHMRC) Postdoctoral Research Fellow, Centre forHealth Services Research, The University of WesternAustralia, Honorary Research Fellow, Needs Assessmentand Health Outcomes Unit, Central Sydney Area HealthService, Camperdown, New South Wales; Dr. Ward:Director, Division of Population Health, South WesternSydney Area Health Service, Liverpool, New South Wales,Australia.

At the time of the study, JY was supported by NHMRCPhD Scholarship No. 974925 and is currently supported atthe University of Western Australia by NHMRC PublicHealth (Australia) Research Fellowship No. 007024.

Reprint requests: Jane M. Young, MBBS, MPH, PhD,FAFPHM, Surgical Outcomes Research Centre, CentralSydney Area Health Service, Level 9, E Block, RoyalPrince Alfred Hospital, Camperdown, NSW 2050,Australia.

effective3; yet, FPs in Australia underuse oppor-tunities to give advice to smokers.4–8

Competence in new clinical behavior requiresknowledge, attitudes, and skills. Although com-petence does not necessarily equate with perfor-mance, educational objectives are typically con-ceptualized using such a framework.9 To learnnew behaviors, FPs also must be predisposed tochange.10 According to the transtheoretical modelof Prochaska and DiClemente, an individual’smotivation to change falls along a continuum,from precontemplation through contemplationand preparation to action and then maintenance ofchange.11 Readiness to change has been proposedas a useful concept for designing interventions toimprove physicians’ provision of smoking cessa-tion advice.12,13

Because approximately one-quarter of FPs inAustralia practice in rural and remote areas,2 andbecause one in four FPs ranked distance learninghigh as a strategy for improving smoking cessa-tion advice,14 in this article, we report a random-ized trial to evaluate a distance learning moduledeveloped especially for FPs. Our aim was todetermine whether there was a significantimprovement in knowledge, attitudes, and skillsas objective components of competence amongFPs who received the distance learning modulecompared with controls. Confidence and readinessto change were measured with participants’ self-assessed levels of competence before and after theintervention.

Method

Development of a Distance LearningModule in Smoking Cessation Advice

We developed a distance learning module com-prising six units (Appendix). To engage FPs inactive learning,15 each section within these unitscommenced with initial “challenge” questionsdesigned to stimulate interest and reflection. Fullyreferenced information then followed. At the endof each section, participants completed questions

to monitor learning. Further, the sixth unit requiredparticipants to develop a plan of action for theirown practice. Our distance learning module wasaccredited by the Quality Assurance and Contin-uing Education Unit of the Royal Australian Col-lege of General Practitioners (RACGP) for con-tinuing medical education (CME) points.16

Study Design

Developed from existing instruments,8,13,14,17–19

our self-administered questionnaire examined thefollowing:

1. Competence• Knowledge of health effects of smoking

(10 true/false questions)• Attitudes toward smoking cessation

advice (Likert scale from “strongly agree”to “strongly disagree” for five attitudinalstatements)

• Skills (Likert scale from “always” to“never” for self-reported use of each of11 smoking cessation techniques)

2. Self-assessed competence in smoking ces-sation advice (visual analog scale)

3. Confidence in specific techniques andhypothetical patients (visual analog scales)

4. Readiness to change (scale comprisingfive statements about FP interest in chang-ing current practice)8,13,19

Selected demographic information also wascollected at baseline.

FPs were notified about the module vianational advertisements. FPs who indicated inter-est were then mailed an introductory letter and con-sent form. On receipt of their completed consentform, participants were randomly allocated tointervention or control groups and mailed baselinequestionnaires to complete and return. On receiptof their completed nine-page baseline question-

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naire, FPs allocated to the intervention group weremailed the distance learning module. Those inthe control group were mailed preventive careguidelines.20 Participants were mailed a post-testquestionnaire on return of the completed distancelearning module (intervention group) or 10 weeksafter mailing the guidelines (control group).

Data were entered by research assistants blindto the participants’ group allocation.

Statistical Analyses

We compared personal and professional charac-teristics of FPs allocated to intervention and con-trol groups using t-tests and chi-square tests.

To assess knowledge, a score was calculatedby summing correct answers to each of 10 knowl-edge questions. A change score was then calculatedby subtracting the baseline score from the post-testscore for each participant. To assess attitudes,ordinal responses to attitudinal statements werecompared. For skills, responses of “always” and“frequently” for use of specific smoking cessationtechniques were combined and proportions com-pared between baseline and post-test and betweengroups. Change in self-rated competence was cal-culated as the difference between baseline andpost-test ratings for each participant. For confi-dence, differences in baseline and post-test ratingsfor each FP for each of eight items were calculated.Also, a summary confidence score was calculatedby summing the responses to each of eight items.To assess positive movement in FP readiness tochange, responses were scored from 1 to 5 acrossthe scale. Then a change score was calculated bysubtracting the baseline score from the post-testscore.

We applied “intention to treat” principles forall analyses. Where data were missing from non-responders at post-test, responses were assumednot to have changed from baseline. For each out-come, independent chi-square tests or Wilcoxonrank sum tests were used to compare interventionand control groups. Also, paired analyses were con-ducted using McNemar test or Wilcoxon signed

rank test to assess change from baseline to post-test within each group.

Results

Of 53 FPs agreeing to participate, 26 were allo-cated to the intervention group and 27 to the con-trol group. Personal and professional characteris-tics of FPs in each group were comparable.Completed post-test questionnaires were receivedfrom 23 (88%) participants in the interventiongroup and 26 (96%) in the control group. Therewas no significant difference in post-test com-pletion rates (�2

1 = 2.1, p = .1).

Competence

Knowledge of health effects of smoking.Between baseline and post-test, there was no sig-nificant improvement in knowledge in either group(Table 1).

Attitudes to smoking cessation advice. Therewere no significant changes between baseline andpost-test for responses to any attitudinal state-ments by participants in either group.

Skills in smoking cessation advice. There wasonly one change in 11 skills (Table 2). Specifically,this change comprised a significant reduction inself-reported use of an ineffective technique,namely “nicotine fading,” among participants inthe intervention group (p = .03) (see Table 2).

Self-Assessed Competence in Smoking Cessation Advice

Change in self-assessed competence between base-line and post-test was significantly greater amongparticipants in the intervention than in the controlgroup (Wilcoxon rank sum test: z = 2.19, p = .03)(see Table 1).

Confidence

Self-ratings of confidence improved significantlybetween baseline and post-test among FPs in both

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intervention and control groups for four of fivetasks of smoking cessation advice, namely assess-ing a patient’s readiness to quit (p = .02 andp = .005, respectively), giving antismoking advicewithout offending or alienating patients (p = .01and p = .02), negotiating a “quit date” (p = .007and p = .005), and advising about nicotine replace-ment therapy (NRT) (p = .02 and p = .004). At post-test, there was no significant difference betweengroups in confidence scores for each of these fourtasks. For a fifth task, namely using evidence-based methods to improve quit rates amongpatients who smoke, confidence improved only

among FPs in the intervention group (p < .001),whereas the control group did not change (p = .1).For this task at post-test, confidence was signifi-cantly higher among FPs in the intervention thanin the control group (p = .009).

For three scenarios representing groups atincreased risk of smoking-related diseases, con-fidence increased in both intervention and con-trol groups for giving effective advice toteenagers (p = .02 and p = .03, respectively) butremained no different between groups at post-test (p = .6). Confidence in giving effectiveadvice to patients from non–English-speaking

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Table 1 Family Physicians’ Knowledge, Self-Rated Competence, and Confidence at Baseline and Post-test, by Group

Intervention Control p Value (Intervention versus Group Group Control Group at Post-test)

KnowledgeMedian knowledge score

Baseline 7.5 7.0Post-test 8.0 7.0

Change (post-test—baseline)Mean –0.2 0.2Median 1 0Range –8 to 4 –4 to 5 .5

Self-rated competenceMedian competence score

Baseline 6 6Post-test 8 8

Change in competence scoreMean 1.9 0.9Median 2.0 0Range –5 to 6 –1 to 4 .03

Confidence (summed score)Median response

Baseline 50 51.5Post-test 62.5 60

Change (post-test—baseline)Mean 10.1 8.6Median 7.5* 6*Range –10 to 28 –11 to 24 0.3

*Wilcoxon signed rank test (post-test versus baseline), p < .001.

backgrounds increased significantly among FPsin both intervention (p < .001) and control groups(p < .001) but remained significantly higher inthe control group at post-test (p = .005). Confi-

dence in giving effective cessation advice towomen improved significantly only among FPsin the control group (p < .001), whereas theimprovement in the intervention group failed

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Table 2 Family Physicians’ Skills at Baseline and Post-test, by Group

Intervention Control p Value Group Group (Intervention versus n (%) n (%) Control at Post-test)

Negotiate a “quit date”Baseline 10 (38) 9 (33)Post-test 11 (42) 14 (52) .5

Give advice about triggers for smokingBaseline 17 (65) 22 (81)Post-test 14 (54) 21 (78) .06

Assess nicotine dependenceBaseline 18 (69) 19 (70)Post-test 19 (73) 19 (70) .8

Arrange follow-upBaseline 11 (42) 15 (56)Post-test 11 (42) 14 (52) .5

Provide written materials with verbal adviceBaseline 13 (50) 18 (67)Post-test 13 (50) 16 (59) .5

Provide written materials without verbal adviceBaseline 0 0Post-test 0 3 (11) .2

Assess stage of changeBaseline 16 (62) 15 (56)Post-test 18 (70) 16 (59) .4

Recommend NRTBaseline 20 (77) 20 (74)Post-test 16 (62) 20 (74) .3

Encourage patient to discuss concerns about quittingBaseline 19 (73) 18 (67)Post-test 21 (81) 20 (74) .6

Advise patient to cut down (“nicotine fading”)Baseline 12 (46) 17 (63)Post-test 6 (23)* 13 (48) .06

Advise patient to quit completelyBaseline 25 (96) 25 (93)Post-test 23 (88) 25 (93) .7

NRT = nicotine replacement therapy.*p (post-test versus baseline) = .03.Providing firm advice to quit, providing behavioral advice about how to quit, recommending nicotine replacement therapyfor appropriate smokers, providing written materials to reinforce verbal advice, and follow-up are effective techniques.Acupuncture, hypnosis, and “nicotine fading” are ineffective.

to reach statistical significance (p = .06). Therewas no difference between groups at post-test forthis scenario (p = .1).

Although improvement in summary confi-dence scores between baseline and post-test wasgreater for participants in the intervention than inthe control group, the difference was not statisti-cally significant (p = .3) (see Table 1).

Readiness to Change

Responses at baseline and post-test for each groupare shown in Table 3. At post-test, the mean changein readiness to change score for the interventiongroup was 0.35 (median zero, range –2 to 2), indi-cating a very small positive shift in willingness toincrease smoking cessation advice. There was an

identical mean shift of 0.27 for the control group(median zero, range –2 to 2). There was no sig-nificant difference in readiness to change betweengroups at post-test (Wilcoxon rank sum test:z = –0.5, p = .6).

Discussion

Our distance learning module achieved minimalimpact on educational outcomes. There were nosignificant improvements in knowledge or attitudesfor FPs in either group. Only one skill improved:participants in the intervention group were sig-nificantly less likely at post-test to recommendnicotine fading, an ineffective technique. Therewere no significant changes in other skills for theintervention group and none for the control group.

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Table 3 Family Physicians’ Readiness to Change at Baseline and Post-test, by Group*

Intervention ControlGroup Groupn (%) n (%)

I do not presently initiate a discussion about smoking with smokers during routine consultations and do not intend to do so.Baseline 0 0Post-test 0 0

I sometimes initiate a discussion about smoking with smokers during routine consultations but do not intend to do this more frequently.Baseline 1 (4) 1 (4)Post-test 0 0

I sometimes initiate a discussion about smoking with smokers during routine consultations and intend to do this more frequently.Baseline 16 (62) 16 (59)Post-test 9 (41) 13 (50)

I have recently started initiating a discussion about smoking during most consultations with smokers.Baseline 0 1 (4)Post-test 5 (23) 1 (4)

I have been initiating a discussion about smoking during most routine consultations with smokers for some time.Baseline 9 (35) 9 (33)Post-test 9 (39) 12 (46)

*Family physicians selected one statement to represent their readiness to change.

Although there was significant improvement inself-rated competence among FPs in the inter-vention group, the value of this finding remainsunclear given absence of improvement in mostother educational outcomes.

Nonetheless, it is encouraging that confidencein the use of evidence-based methods to improvequit rates improved significantly between baselineand post-test for FPs in the intervention group.Summed confidence scores increased in bothgroups but were no different between groups atpost-test however, suggesting that the module wasno more effective than passive distribution ofguidelines in improving FPs’ confidence.

Neither module nor guidelines appear to havemotivated FPs’ willingness to increase smokingcessation advice during routine consultations(“readiness to change”). Although the conceptof readiness to change may hold promise for tai-loring educational strategies,8,19 the predictivevalidity of this scale to reflect actual behavior cer-tainly remains untested. Unfortunately, lack of anysubstantive change of FP knowledge, attitudes, orskills in our study precluded more detailed inves-tigation of whether readiness to change modi-fied or filtered the effect of the distance learningmodule.

FP uptake of the distance learning modulewas disappointing. Despite national advertising,fewer than 1% of FPs across Australia expressedinterest. Although the present study suggests thatthere is limited demand among Australian FPsfor distance learning about smoking cessationadvice, it is unclear whether this was related to thespecific topic or a general dislike of distance learn-ing when offered.

There is little published literature reporting rig-orous evaluations of distance learning in CME.Systematic reviews of the effectiveness of CMEstrategies have not specifically addressed distancelearning approaches as a separate subgroup ofeducational interventions.21–24 A Cochrane Reviewof printed educational materials to improve pro-fessional practice25 identified only two studiesthat involved mailing of self-study materials to

FPs.26,27 Although this review concluded thatprinted educational materials have a small impacton professional practice,25 a distinction was notmade between passive dissemination and strate-gies requiring active participation of recipients.Recently, a randomized trial involving 50 Cana-dian FPs found no difference between distancelearning and workshop formats for CME aboutbreast disease.28 Other approaches to distancelearning CME have involved identification and tar-geting of clinicians considered to be influential bytheir peers,29 problem-based learning,30 clinicalaudit,31 and audiovisual or computer-basedresources.32–34 Clearly, further research is neededto evaluate these and other innovative CME for-mats to improve smoking cessation advice in gen-eral practice.

We conclude with four methodologic caveats.First, although our sample size was comparablewith other evaluations of distance learning,28,35–37

our study may not have had sufficient power todetect important changes in educational outcomeshad they occurred. Second, our assumption thatthose who did not complete the post-test ques-tionnaire had not changed from baseline also mayhave biased the findings toward a null result.Third, the validity of self-assessment using globalrating scales has not been assessed. Indeed, self-

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Lessons for Practice

• Never assume that continuing medicaleducation works.

• A distance learning module aboutsmoking cessation advice may be nomore effective than guidelines inchanging competence, confidence, orreadiness to change.

• Better theoretical perspectives areimportant to improve the design andeducational impact of distance learn-ing for physicians.

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reported measures as reported in this study maynot reflect actual clinical behavior. Finally, weacknowledge that our outcome measures wouldbenefit from further methodologic refinement.

Acknowledgments

We thank the FPs who participated in our trial. Wealso thank Anne Taylor-Vaisey for searching theResearch and Development Resource Base inContinuing Medical Education at the Universityof Toronto, Canada; Peter Hopkins and BrettRobinson for independently reviewing the mod-ule; Tracey Bruce, Leonie Cambage, and NancyHarding for research assistance; and the NHMRCfor providing guidelines distributed to the controlgroup free of charge. This study was approved bythe institutional ethics committees of the CentralSydney Area Health Service and the University ofSydney.

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Appendix Contents of the Distance Learning Module in Smoking Cessation Advice

Unit I Why is smoking a health problem? (pp. 1–19)Section 1: Prevalence of smoking in AustraliaSection 2: Smoking as a cause of cancer and disease

Unit II Why should general practitioners do anything? (pp. 1–14)Section 1: Health benefits of smoking cessationSection 2: Community, practitioner, and professional opinion

Unit III How do I best identify smokers? (pp. 1–12)Section 1: How good are GPs at detecting smokers?Section 2: Strategies to increase rates of detection

Unit IV How effective is advice from GPs? (pp. 1–29)Section 1: Evaluating the evidence for effectiveness of health care interventionsSection 2: Review of the effectiveness of advice from GPsSection 3: Barriers to smoking cessation advice in general practice

Unit V What advice should I give? (pp. 1–26)Section 1: Recommended strategies for smoking cessation

Unit VI How do I monitor my progress? (pp. 1–11)Section 1: A plan for use in general practiceSection 2: Evaluate your detection, advice, and referral ratesSection 3: Further resources and programs for referral

GP = general practitioner.