Matern Child Health J (2011) 15:11531159

DOI 10.1007/s10995-010-0679-3

Tobacco Education and Counseling in Obstetrics and Gynecology

Clerkships: A Survey of Medical School Program Directors
Catherine A. Powers Jane Zapka
zcan Katie Brooks Biello
Sharon Phelan Tulin O
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 opportunities for including new tobacco teaching, a 28-question
survey was administered to directors and assistant directors
at US medical school OB/GYN clerkship programs. Surveys 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 comprehensive cessation skills during their clerkships.

C. A. Powers
Division of Pharmacoepidemiology and Pharmacoeconomics,
Brigham and Womens Hospital, Boston, MA, USA

Keywords Tobacco
Counseling
Medical education

OBGYN
Clerkship education

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
zcan
T. O
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

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%

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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 compelling reason to include tobacco cessation counseling and
education in standard care, especially since obstetric and
gynecologic (OB/GYN) specialists often serve as the primary 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 providers 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 cessation, 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 organizations 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 Foundations internet-based program for pregnant and postpartum smokers, although created for smokers, provides
clinicians with tools for motivating smokers to quit [19].
Practice, however, has been suboptimal [20]. In particular, 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

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Matern Child Health J (2011) 15:11531159

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], particularly 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 survey 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 assistant 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 surveys 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].

Matern Child Health J (2011) 15:11531159

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 the
number of OB/ GYN patients students typically see during
a rotation using a scale of \10, 1120 and 21?. We
assumed 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, respondents 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 education 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 following 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 followup contact; recommending nicotine replacement therapy
(NRT); talking with pregnant patients about smoking
effects, and, the major outcome, having learned to

1155

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, discussing 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

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Matern Child Health J (2011) 15:11531159

Medical Student Skills

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)

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 recidivism. 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 provided 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.

Percentage of Medical Schools

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

70

74

74

60
50
40
30

56
45
35

34

33

32

20
10
0

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

director

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).

Office Systems and Clinic Environment

Smoking Cessation Practices of Clerkship Directors

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.

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 respondents 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.

Professional Development and Training

Less than one-third of respondents reported that their faculty had ever offered an in-service training on tobacco
cessation; 23% provided continuing medical education
credits (CME) for tobacco education, and only 8% had

123

Discussion
With 16,000 medical students completing OB/GYN
clerkship programs each year, a unique opportunity exists

Matern Child Health J (2011) 15:11531159

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 clerkship, 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 smokers 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 education, a skill that is not formally graded or observed will
be marginalized or omitted altogether. To remedy this,
clerkship directors should formally include tobacco counseling among the expected clinical skills and observe
students as they do with clinical examination skills. Successfully 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 recommends 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

1157

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 training 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 programs 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 smokingcessation 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 effective 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 assessments. 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 particular, because responses on student skill level provided
by clerkship directors are subjective, they should be corroborated with objective evaluations of student performance. 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 suboptimal rates of cessation teaching reported by respondents. To better understand effective approaches, short case
studies on the evolution of formal cessation teaching during 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

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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.

Matern Child Health J (2011) 15:11531159

11.

12.

13.

14.

15.

16.

17.

18.

References
1. Centers for Disease Control. (2010). Smoking & tobacco use.
Fact sheet women and tobacco. Office on Smoking and Health.
Centers for Disease Control. http://www.cdc.gov/tobacco/
data_statistics/fact_sheets/populations/women/. Accessed 07/15/
2010.
2. Hamilton, B. E., Martin, J. A., & Ventura, S. J. (2010). Births:
Preliminary data for 2008. National vital statistics reports (Vol.
58, No 16). Hyattsville, MD: National Center for Health Statistics. Released 6 April 2010.
3. APGO. (2001). Womens Healthcare competencies sample
learning objectives for UGME. http://www.apgo.org/binary/
Comp.pdf. Accessed 15 July 2010.
4. Melvin, C., Dolan-Mullen, P., Windsor, R., Whiteside, H., &
Goldenberg, R. (2000). Recommended cessation counseling for
pregnant women who smoke: A review of the evidence. Tobacco
Control, 9(Suppl. 3), iii80iii84.
5. US Department of Health and Human Services, Surgeon Generals
Report. (2001). Women and smoking. http://www.surgeongeneral.
gov/library/womenandtobacco/. Accessed 7/15/2010.
6. American Cancer Society (2009) What are the risk factors for
cervical cancer? http://www.cancer.org/Cancer/CervicalCancer/
DetailedGuide/cervical-cancer-risk-factors. Accessed 7/15/2010.
7. Dobson, R. (2002). Risk of breast cancer increases with number
of years smoking. BMJ, 325, 298.
8. Gunnell, A. S., Tran, T. N., Torrang, A., Dickman, P. W., &
Sparen, P. (2006). Synergy between human papilloma virus type
16 in cervical cancer in situ development. Cancer Epidemiology,
Biomarkers and Prevention, 15(11), 21412147.
9. Li, C. I., Malone, K. E., & Daling, J. R. (2005). The relationship
between various measures of cigarette smoking and risk of breast
cancer among older women 6579 years of age (United States).
Cancer Causes and Control, 16(8), 975985.
10. Geller, A. C., Brooks, D. R., Powers, C. A., Brooks, K. R.,
Rigotti, N. A., Bognar, B., et al. (2008). Tobacco cessation and
prevention practices reported by second and fourth year students

123

19.

20.

21.

22.

23.

24.
25.

26.

27.

28.

at US medical schools. Journal of General Internal Medicine,

23(7), 10711076.
Weng, S., & Booker, J. M. (2005). Smoking around the time of
pregnancy New Mexico, 19982002. New Mexico Epidemiology,
2, 14.
Whalen, U., Griffin, M. R., Shintani, A., Mitchel, E., CruzGervishttp, R., Forbes, B. L., et al. (2006). Smoking rates among
women in Tennessee 19902001. Preventive Medicine, 43,
196199.
Schappert, S. M. (1997). Ambulatory care visits of physician
offices, hospital outpatient departments, and emergency departments: United States, 1995. Vital Health Stat, 13, 138.
Chapin, J., & Root, W. (2004). Improving obstetrician-gynecologist implementation of smoking cessation guidelines for pregnant women: An interim report of the American College of
Obstetricians and Gynecologists. Nicotine & Tobacco Research,
6(Suppl 2), S253S257.
The National Partnership to Help Pregnant Smokers Quit. (2010).
http://www.helppregnantsmokersquit.org/. Accessed 15 July
2010.
Treating tobacco use and dependence. (2008). 2008 Update. US
Department of Health and Human Services. http://www.surge
ongeneral.gov/tobacco/. Accessed 15 July 2010.
ACOG Smoking cessation information for providers. (2010). http://
www.acog.org/departments/dept_notice.cfm?recno=13&bulletin=
1863. Accessed 15 July 2010.
Smoking cessation for pregnancy and beyond. (2010). Learn proven strategies to help you patient quit. http://iml.dartmouth.edu/
education/cme/Smoking/index.html. Accessed 15 July 2010.
Become an ex: re-learn life without cigarettes. (2010). http://
www.becomeanex.org/pregnant-smokers.php. Accessed 15 July
2010.
Zapka, J. G., Pbert, L., Stoddard, A. M., Ockene, J. K., Goins,
K. V., & Bonollo, D. (2000). Smoking cessation counseling with
pregnant and postpartum women: A survey of community health
center providers. American Journal of Public Health, 90, 7884.
DePue, J. D., Goldstein, M. G., Schilling, A., Reiss, P., Papandonatos, G., Sciamanna, C., et al. (2002). Dissemination of the
AHCPR clinical practice guideline in community health centers.
Tobacco Control, 11, 329335.
Fang, W. L., Goldstein, A. O., Butzen, A. Y., Hartsock, S. A.,
Hartmann, K. E., Helton, M., et al. (2004). Smoking cessation in
pregnancy: A review of postpartum relapse prevention strategies.
The Journal of the American Board of Family Practice, 17,
264275.
Goldstein, M. G., DePue, J. D., Monroe, A. D., Lessne, C. W.,
Rakowski, W., Prokhorov, A., et al. (1998). Dube CEA population-based survey of physician smoking cessation counseling.
Preventive Medicine, 27(5 Pt 1), 720729.
Sullivan, M. G. (2003). Physician counseling on tobacco often
falls short. Internal Medicine News, 36(1), 13.
Holtrop, J. S., Malouin, R., Weismantel, D., & Wadland, W. C.
(2008). Clinician perceptions of factors influencing referrals to a
smoking cessation program. BMC Family Practice, 9, 18.
Easton, A., Husten, C., Malarcher, A., Elon, L., Caraballo, R.,
Ahluwalia, I., et al. (2001). Smoking cessation counseling by
primary care women physicians: Women physicians health
study. Women Health, 32, 7791.
Park, E. R., Wolfe, T. J., Gokhale, M., Winickoff, J. P., & Rigotti,
N. A. (2005). Perceived preparedness to provide prevention
counseling: Reports of graduating primary care residents at academic health centers. Journal of General Internal Medicine, 20,
386391.
Fiore, M. C., Bailey, W. C., & Cohen, S. J. (2000). Treating
tobacco use and dependence. Rockville, Md: Department of
Health and Human Services, Public Health Service.

Matern Child Health J (2011) 15:11531159

29. Geller, A. C., Zapka, J., Brooks, K. R., Dube, C., Powers, C. A.,
Rigotti, N., et al. (2005). Tobacco control competencies for US
medical students. American Journal of Public Health, 95,
950955.
30. Fiore, M. C., Epps, R. P., & Manley, M. W. (1994). A missed
opportunity: Teaching medical students to help their patients to
successfully quit smoking. JAMA, 271, 624626.
31. Richmond, R. (2004). The process of introducing a tobacco
curriculum in medical school. Respirology, 9, 165172.
32. Potter, B., & Fleming, M. F. (2003). Obstetrics and gynecology
resident education in tobacco, alcohol, and drug use disorders.
Obstetrics and Gynecology Clinics of North America, 30,
583599.
33. Kokotailo, P. K., Fleming, M. F., & Koscik, R. L. (1995). A
model alcohol and other drug use curriculum for pediatric residents. Academic Medicine, 70, 495498.
34. Muramoto, M. L., & Lando, H. (2009). Faculty development in
tobacco cessation: Training health professionals and promoting
tobacco control in developing countries. Drug and Alcohol
Review, 28, 498506.

1159
35. Springer, C. M., Tannert Niang, K. M., Matte, T. D., Miller, N.,
Bassett, M. T., & Frieden, T. R. (2008). Do medical students
know enough about smoking to help their future patients?
Assessment of New York City fourth-year medical students
knowledge of tobacco cessation and treatment for nicotine
addiction. Academic Medicine, 83, 982989.
36. Quinn, V. P., Stevens, V. J., Hollis, J. F., Rigotti, N. A., Solberg,
L. I., Gordon, N., et al. (2005). Tobacco-cessation services and
patient satisfaction in nine nonprofit HMOs. American Journal of
Preventive Medicine, 29, 7784.
37. Jordan, T. R., Dake, J. A., & Price, J. H. (2006). Best practices for
smoking cessation in pregnancy: Do obstetrician/gynecologists
use them in practice? Journal of Womens Health, 15(4),
400441.
38. Stead, L. F., Bergson, G., & Lancaster, T. (2008). Physician
advice for smoking cessation. Cochrane Database of Systematic
Reviews, 16(2), CD000165.
39. State Medicaid coverage for tobacco-dependence treatment
United States, 2006. (2008). MMWR Morb Mortal Wkly Rep,
57(5), 117122.

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