Impact of the ENSP eLearning platform on improving
knowledge, attitudes and self-efficacy for treating tobacco
dependence: An assessment across 15 European countries

INTRODUCTION In 2018, the European Network for Smoking Cessation and Prevention (ENSP) released an update to its Tobacco Treatment Guidelines for healthcare professionals, which was the scientific base for the development of an accredited eLearning curriculum to train healthcare professionals, available in 14 languages. The aim of this study was to evaluate the effectiveness of ENSP eLearning curriculum in increasing healthcare professionals’ knowledge, attitudes, self-efficacy (perceived behavioral control) and intentions in delivering tobacco treatment interventions in their daily clinical routines. METHODS We conducted a quasi-experimental pre-post design study with 444 healthcare professionals, invited by 20 collaborating institutions from 15 countries (Albania, Armenia, Belgium, Italy, France, Georgia, Greece, Kosovo, Romania, North Macedonia, Russia, Serbia, Slovenia, Spain, Ukraine), which completed the eLearning course between December 2018 and July 2019. RESULTS Healthcare professionals’ self-reported knowledge improved after the completion of each module of the eLearning program. Increases in healthcare professionals’ self-efficacy in delivering tobacco treatment interventions (p<0.001) were also documented. Significant improvements were documented in intentions to address tobacco use as a priority, document tobacco use, offer support, provide brief counselling, give written material, discuss available medication, prescribe medication, schedule dedicated appointment to develop a quit plan, and be persistent in addressing tobacco use with the patients (all p<0.001). CONCLUSIONS An evidence-based digital intervention can be effective in improving knowledge, attitudes, self-efficacy and intentions on future delivery of tobacco-treatment interventions.


INTRODUCTION
Tobacco use is the most significant threat to European Public Health and directly associated with morbidity and mortality 1 . More than a quarter (26%) of Europeans still smoke 1 . Smoking cessation is one of the main strategies suggested by the World Health Organization's (WHO) MPOWER package against the tobacco epidemic, presenting the first comprehensive worldwide analysis of tobacco use and control efforts 2 . The WHO Framework Convention on Tobacco Control (WHO FCTC) Article 14 and its implementation guidelines call on its Parties to 'facilitate accessibility and affordability for treatment of tobacco dependence' 2 . Healthcare professionals have a key role to play in supporting tobacco treatment delivery, one of the targets of the WHO MPOWER package and FCTC 3 .
Training is an integral part of supporting tobacco treatment delivery and has been shown to increase the likelihood of healthcare professionals delivering evidence-based tobacco treatment. Despite this, only a fraction of European healthcare professionals have completed training as part of their formal undergraduate education or as part of continuing medical education 4 . Recent reviews show that there is a gap in the use of advanced computer-based medical education approaches on tobacco treatment training for healthcare professionals, and there is a need to support the training/education of healthcare professionals in behavioral change in Europe 4 .
In 2018, the European Network for Smoking Cessation and Prevention (ENSP) released an update to its tobacco treatment guidelines for healthcare professionals 5 . The guidelines summarize the latest evidence and provide recommendations for healthcare professionals (www.elearning-ensp.eu). An eLearning curriculum was developed to train healthcare professionals in the guideline recommendations, available in 14 languages.
This study reports on the effectiveness of an accredited eLearning curriculum that aimed to increase healthcare professionals' knowledge, and to change attitudes, self-efficacy (perceived behavioral control) and intentions in delivering tobaccotreatment interventions in their daily clinical life.

METHODS
In the context of EPACTT-Plus, collaborating institutions from 15 countries (Albania, Armenia, Belgium, Italy, France, Georgia, Greece, Kosovo, Romania, North Macedonia, Russia, Serbia, Slovenia, Spain, Ukraine) worked to develop an accredited eLearning course on Tobacco-Treatment Delivery available at http://elearning-ensp.eu/. This fivemodule eLearning training course was accredited by the European Accreditation Council for Continuing Medical Education (EACCME) for 2 CME credits. Ajzen's Theory of Planned Behavior (TPB) was used to guide intervention design. The TPB incorporates both social influences and personal factors as predictors, specifying a limited number of psychological variables that can influence behavior such as attitude, subjective norms, perceived behavioral control (PBC), and intention 6 .

eLearning curriculum
The curriculum includes five different training modules as well as case studies, quizzes, and

Module 1
This module is entitled 'Nicotine Addiction -Why people smoke?' and discusses why it is so difficult for individuals to quit smoking. The physical and psychological aspects of tobacco use are reviewed, as well as the pathophysiology of nicotine addiction and the associated withdrawal symptoms and cravings that can make quitting challenging. In addition are discussed the connections between daily routines, triggers to smoke and mood in maintaining tobacco use.

Module 2
This module is entitled 'How to help your patients quit smoking'. The important role of health professionals in supporting cessation among patients who smoke as a clinical priority is reviewed as well as a brief overview of the 5As model for integrating tobacco dependence treatment into clinical settings. The 5As include: 'Ask' patients about smoking status; 'Advice' them to quit smoking; 'Assess' their readiness to quit smoking; 'Assist' them with making a quit attempt; and 'Arrange' a follow-up meeting.

Modules 3 and 4
The behavioral counselling content is divided into two parts, Modules 3 and 4. In Module 3, the role of behavioral counselling as a treatment for supporting tobacco users with quitting is discussed as well as evidence-based counselling strategies designed for individuals ready to quit smoking in order to increase their likelihood of successfully quitting. In Module 4, key behavioral strategies used to enhance motivation among patients who are not ready to quit smoking include motivational interviewing and smoking reduction approaches. These two modules also include examples of how to deliver behavioralchange techniques as an active learning method.

Module 5
This module provides training on pharmacological treatment as a fundamental component of treating tobacco use. In this module, first-line quit smoking medications are discussed including Nicotine Replacement Therapy, Bupropion, Varenicline and their appropriate use in clinical practice in order to maximize success with smoking cessation among patients. A brief overview of other quit-smoking medications that are emerging as promising therapies are also presented to learners. Several interactive case studies are embedded in this module as an active learning method.

Adaptation and translation of the material
In order to adapt and translate the eLearning content for each participating country, local champions were engaged. The training program was adapted and translated into 14 different languages (Albanian, Armenian, English, French, Georgian, Greek, Italian, Macedonian, Romanian, Russian, Serbian, Slovenian, Spanish, Ukrainian) and released in 2018.

Evaluation of the training curriculum
During the recruitment period, an email to relevant healthcare professionals was sent from collaborating institutes in each country, to invite them to take the courses. A cut-off of 30 participants per language was set as a limit for the evaluation, while the complete duration of the sessions was about two and a half hours of online training.
A pre-post assessment was embedded in the structure of the eLearning courses. During the pre-assessment, and following the provision of consent, participants reported their demographic characteristics, current practices in delivering tobacco treatment practices (5As delivery with 9 components), their normative beliefs (5 components), attitudes (6 components), selfefficacy in delivering tobacco treatment interventions (5 components), perceived importance in providing these interventions (1 component), and intentions (9 components). During the post-assessment, the same variables were assessed to document changes. In addition to the above, before and after each module, participants completed a knowledge assessment. A score of 80% or higher was required to pass the test. The tools used to evaluate the training curriculum have been previously tested in several studies conducted from members of our team 7-11 .

Statistical analysis
Quantitative variables that followed normal distributions are presented as means and standard

Research Paper Tobacco Induced Diseases
Tob. Induc. Dis. 2020;18(May):40 https://doi.org/10.18332/tid/120188 4 deviations (SD). Quantitative variables that did not follow a normal distribution and ordinal variables are presented as median and interquartile range (non-parametric methods). Qualitative variables are expressed as frequencies and percentages. In the case of related samples (paired comparisons), paired t-test (when the variable was continuous and followed a normal distribution) and Wilcoxon signed-rank test (when the variable did not follow a normal distribution or was an ordinal variable) were used. In this case, results are presented as the median difference, 95 % confidence interval for the difference and IQR 25-75, while a z-test was used for the difference of the median between the pre-test ranks and the post-test ranks. Statistical significance was set at 0.05. All analyses were performed in IBM SPSS statistical software package version 23.0.

RESULTS
From December 2018 to July 2019, a total of 444 healthcare professionals were enrolled and completed the course. Table 1 presents the characteristics of participating healthcare professionals and their practices. The majority of the participants were female (73.4%), under 30 years of age (43.6%), working in the public sector (73.9%) and urban settings (81.9%). Most of the participants (68.9%) had not participated in smoking cessation training in the past, while 32.2% reported being smokers (67.8%). Table 2 depicts the recorded changes in healthcare professionals' self-reported knowledge before and after the completion of each module of the eLearning program. Statistically significant changes were documented for all knowledge questions, except one, of Module 1, Module 2, and behavioral counselling Modules 3 and 4 (p<0.001). A significant increase in participant's knowledge regarding pharmacotherapy (Module 5) was also recorded. For example, there was an increase in knowledge regarding the safety of the NRT (45.7% vs 97.0%; p<0.001) and the most common side effect of Varenicline (68.5% vs 96.2%; p<0.001). Table 3 presents the changes in healthcare professionals' self-reported attitudes, normative beliefs, self-efficacy (perceived behavioral control), intentions of delivering tobacco treatment interventions as well as the importance of smoking cessation interventions, before and after the completion of the eLearning curriculum. Favorable changes were documented for attitudes in five out of six areas assessed. Normative beliefs of the participants also changed after the course with statistically significant results in four out of the five statements. A statistically significant increase in healthcare professionals' self-efficacy to help their patients quit smoking was documented between the pre-and post-intervention assessment (z-score = -13.083; p<0.001).   Counseling by a clinician helps motivate smokers to quit.  An increase was also documented in the intention to address tobacco use as a priority (z-score = -4.414; p<0.001), document tobacco use (z-score = -6.703; p<0.001), offer support (z-score = -7.022; p<0.001), provide brief counseling (z-score = -5.586; p<0.001), give written material (z-score = -4.719; p<0.001), discuss available medication (z-score = -9.726; p<0.001), prescribe medication for smoking cessation (z-score = -8.345; p<0.001), schedule dedicated appointment to develop a quit plan (z-score = -7.327; p<0.001) and be persistent on addressing tobacco use with the patients even if they are not effective the first time (z-score = -5.911; p<0.001).

DISCUSSION
Our study evaluated the effectiveness of an accredited eLearning curriculum in increasing key constructs known to be related to tobacco treatment delivery. Results indicated that the eLearning program improved participants' knowledge, attitudes, beliefs, self-efficacy (perceived behavioral control) and intentions associated with the delivery of evidence-  Smoking is a personal decision which does not concern the healthcare professional. 8 based tobacco treatment interventions. This is important as recent European population-based studies have found that many patients report that they did not receive any advice or support to quit during a healthcare visit 1,12,13 .
Results from a recent systematic review highlighted that digital education was at least as effective as traditional or usual learning, resulting in similar or higher improvement in knowledge and satisfaction, and sometimes in the attitude of the healthcare professionals, following digital education compared with conventional learning 4 . This is an essential aspect as eLearning courses and in general digital education can increase educational opportunities 14 by providing training and new skills to healthcare professionals who want to integrate tobacco-dependence treatment into their daily clinical practice 15,16 and at the same time overcome the barrier of distance in healthcare professionals' education 14 .
Previous results, from our team, also showed that evidence-based training increases healthcare workforce self-efficacy, competence, knowledge and attitudes related to tobacco treatment 7 and improves the rates at which evidence-based tobacco treatment is delivered to patients 8,9 . Additionally, pre-post studies evaluating the impact of the tobacco treatment guidelines and training for patients with multiple morbidities (CVD, diabetes and COPD) also showed significant increases in physicians' knowledge and self-efficacy immediately following and at 6 months after exposure to training sessions 10 . Significant increases were also recorded in knowledge, selfefficacy and rates at which doctors delivered evidencebased tobacco treatment following exposure to a live educational intervention 11 . All the above support the findings of our study. However, a follow-up, preferably at 6 months, after the completion of the eLearning course, would be useful to evaluate the sustainability of our results and also the level of the implementation in the healthcare providers' daily clinical practice.
Previous studies have identified a lack of knowledge and skills among healthcare professionals as a key barrier to the delivery of smoking cessation advice 17 . In addition, due to lack of knowledge, low motivation, perceived low self-efficacy and concerns about inadequate time and workload, many healthcare professionals do not provide effective cessation services 17,18 . However, implementation of tobacco dependence treatment for healthcare professionals has been shown to increase their cessation efforts significantly with their patients and quit attempts 19,20 , as well as improve trainees' attitudes and perceived behavioral control in providing tobacco dependence services 21 . The importance of continuing medical education training programs to address this gap in knowledge and skills has also been acknowledged and can significantly impact healthcare professional competence, future clinical practice and patient outcomes if embedded into the healthcare system [22][23][24][25][26] . Based on all the aforementioned, time and distance saving and cost-effective training programs that provide new knowledge and skills are essential to ensure that healthcare professionals are confident to deliver smoking cessation interventions to all their patients who smoke.

Strengths and limitations
Previous research that has evaluated digital education for smoking cessation until now has mainly focused on patient interventions 27,28 . In contrast, our research has focused on training healthcare professionals. We present a novel approach by using a pre-post design to monitor the change at the participant level for a broad representation of the healthcare professionals from many European countries.
However, as the eLearning course was accredited, there were some restrictions on the procedure of the completion of the course, as participants had to successfully complete each module's test to receive accreditation. In addition, the profile of the participants and the voluntary nature of our course may mean that the participants were more motivated than the general population of healthcare professionals. On the other hand, for the same reasons, the course healthcare professionals may have overperformed in their responses for changing attitude norms, perceived behavioral control and intentions in delivering tobacco treatment interventions with their patients who smoke. For these reasons, the generalizability of our findings requires further investigation.

CONCLUSIONS
The ENSP eLearning intervention, built on evidencebased tobacco treatment eLearning courses, was associated with significant increases in healthcare professional's knowledge, attitudes, normative beliefs, perceived behavioral control and intention to integrate tobacco treatment delivery into daily clinical practice. Future research should examine supplementary methods for supporting the broader dissemination of well-designed digital interventions and eLearning programs, and develop targeted strategies for all healthcare professionals.