Background
Complementary and alternative medicine (CAM) therapy use is an increasingly important factor in the health care landscape [
1]. A number of national surveys indicate substantial [
2-
6] and in some cases growing use [
7] of CAM therapies. In the United States (U.S.), between the 2002 and 2007 National Health Interview Survey (NHIS), the proportion of adults reporting use of at least one form of CAM increased from 25.7% to 29.4% - a relative increase of 14.2%. Provider-based CAM (pbCAM, including all those services which require the presence of a practitioner as contrasted with CAM treatments that can be self-administered, such as herbal medicines) use saw a relative increase of 29.6%. The most significant increases in pbCAM use were seen in chiropractic care, acupuncture, massage therapy, and folk medicine [
7]. Harris and colleagues [
6] note in their international review of CAM use studies that more population-based assessment (i.e. through government sponsored health surveys) of CAM use is necessary to provide a more accurate picture of trends in prevalence of CAM use over time.
Context validity of interventions in CAM practices
Growth in CAM use has inspired innovative attempts to offer patients holistic care through integrating CAM into conventional medical practice [
8-
10]. By contrast, there has been much less exploration of how interventions widely used in conventional medicine and behavioral health might be effectively incorporated into pbCAM practice as a means of advancing the preventive and promotive health goals of both CAM and conventional medicine [
11]. CAM practitioners and practices differ markedly from conventional medicine practitioners and practices with respect to professional training, practice patterns, business models, treatment and healing paradigms, philosophical orientation to the patient/client – practitioner relationship and perceptions of treatment effectiveness [
11-
18]. A central question that arises is whether evidence-based health care and/or behavior change interventions widely employed in conventional medical and behavioral health care could be integrated into the CAM practice context in ways that ensure validity within the specific context of a CAM practice while maintaining the conceptual integrity of the evidence-based intervention. In this paper we refer to this concept as
“context validity”. Intervention development to ensure context validity requires addressing such questions as: Will these interventions be acceptable to practitioners in different CAM disciplines? Do the interventions “fit” or make sense within the training and healing traditions, scope of practice, and practice patterns relevant to practitioners of the specific CAM disciplines who would be asked to implement the intervention? In order for integration to be effective, interventions would at once need to be tailored into real world CAM practices; yet maintain their conceptual integrity and be subject to established evaluation criteria.
Project CAM Reach
Context validity of the research intervention is a key aspect of Project CAM Reach (CAMR), a National Cancer Institute (NCI) sponsored study examining the public health potential of tobacco cessation training for chiropractors, acupuncturists and massage therapists (CAM practitioners). The CAMR study has two main aims. First, develop an intervention protocol, a tobacco cessation brief intervention training and practice-system intervention that includes appropriate tobacco cessation best practices from the U.S. Public Health Service Guideline on Treatment of Tobacco Dependence (PHS Guideline) [
19] and is tailored for the needs of CAM practitioners. Second, in the real world of CAM practices, evaluate the impact of the CAMR intervention on CAM practitioners’ knowledge, attitudes and practice behaviors with respect to integration of tobacco cessation practices recommended by the PHS guideline [
19].
The inspiration for CAMR is three-fold. First, the growing burden of chronic disease is at the heart of the US health care crisis. Chronic disease accounts for more than 75% of health care costs in the US and the steady escalation of the nation’s health care bill is driven in large part by the increasing costs of caring for chronic disease [
20-
22]. Globally, chronic diseases are the largest cause of death. The leading chronic diseases share common life-style related major risk factors of tobacco use, unhealthy diet, physical inactivity, and alcohol use [
23,
24]. Second, CAM practitioners have characteristics and practice patterns that make them well suited to addressing lifestyle-related chronic disease risk factors. Third, local CAM practitioners participating in a tobacco-cessation training project for lay community members (described below) requested that tobacco cessation training be made more available to their disciplines [
25].
Tobacco cessation and CAM practitioners
Even after decades of public health tobacco control efforts, tobacco remains the single largest preventable cause of death globally [
26]. In the U.S., where the current work was conducted, tobacco cessation brief interventions (BIs) based on the 5A’s framework (Ask, Advise, Assess, Assist, Arrange) [
27], and that also include intra-treatment social support, continue to form the backbone of practice-based conventional healthcare intervention. More recently, BIs are being evaluated in developing nations [
28,
29]. That said, despite clear evidence from the U.S. that BIs by health care providers result in increased tobacco cessation rates [
19], and that such BIs are the most cost-effective preventive health services [
30], implementation of BIs by biomedical physicians fall far short of the ideal [
31]. For nearly 3 decades, cessation training in the US has focused on conventional biomedical health practitioners, primarily physicians. Only more recently has cessation training included non-physicians, e.g. nurses, respiratory therapists, dentists, and dental hygienists [
27,
32]. But with rare exceptions [
33], the focus remains on training biomedical health professionals.
CAM practitioners have characteristics and practice patterns that may make them better suited to health and wellness promotion than conventional practitioners. Compared to conventional biomedical practitioners, visits with CAM practitioners are often longer and more frequent [
13,
34,
35], providing more time to address complex lifestyle issues. They often see patients for regular health maintenance/wellness care, allowing for repeated follow-ups and reassessment of behavioral changes [
13].
Analysis of 2002 and 2007 data from the National Health Interview Survey in the U.S. found that CAM practitioners provide care for significant numbers of smokers [
36]. A population-based survey of CAM use in an eastern region of Germany also found that a significant proportion of CAM users were current smokers (28.6%) [
37] Published English-language reports of population-based surveys of CAM use in non-U.S. population are sparse. Most published reports focus on specific clinical populations, e.g. outpatients to a health center, cancer survivors. Some clinical population studies have reported significant rates of tobacco use among CAM users. A Swedish health centre-based survey of 1442 patients found that among users of manual manipulative CAM therapies, 14.7% were current smokers, and 18.8% were current snuff takers. Of those using manipulative CAM therapies and herbs, 25.6% were current smokers, and 37.5% were current snuff takers [
38]. In the U.S., as in some other countries, some populations with higher rates of CAM use are also at higher risk for tobacco use. These populations include: the uninsured/underinsured [
4,
7,
39]; some low-income and rural populations [
40-
42]; some ethnic/racial minority and new immigrant groups and persons living with specific conditions such as HIV/AIDS [
43,
44], mental illness [
45,
46] and cancer [
47-
49].
Despite their increasingly important role in healthcare, and potential to promote tobacco cessation, CAM practitioners have largely been overlooked in the public health tobacco control agenda. Further, because of the different professional background and training, clinical practice models, scope of practice and practice patterns that clearly distinguish CAM practitioners from conventional biomedical practitioners, existing tobacco cessation training programs designed for conventional practitioners may not be well-suited for CAM practitioners.
To ensure that the CAMR intervention had context validity for the three CAM disciplines engaged in this study, we used an iterative and community based participatory research (CBPR) approach to develop an intervention protocol integrating conventional tobacco cessation interventions recommended by the PHS Guideline into real world CAM practice. The CAMR intervention builds on an existing program of research [
25,
50-
53] that developed the Helpers Program (“Helpers”), the foundational curriculum for the CAMR intervention. Helpers is a community-based brief intervention (BI) training program that teaches lay community members how to offer a structured, four-step “helping conversation” to tobacco users. The helping conversation uses active listening skills and motivational communication strategies to encourage quitting tobacco (i.e. permanently stopping/giving up tobacco) without confrontation, or “nagging” [
53]. One of the inspirations for CAMR came from local CAM practitioners (chiropractor, acupuncturist, and massage therapist) who had participated in a prior NCI-sponsored study of community-based tobacco cessation BI training for the lay public (Project Reach) [
25]. These CAM practitioners recognized the value of such training for their own practices, and at the end of the study approached the research team with the recommendation and request that cessation training, tailored to the needs of CAM practitioners, be offered to their disciplines. The purpose of this paper is to describe the iterative CBPR process we used to develop the CAMR intervention protocol and the resulting intervention that included both a patient/client centered tobacco cessation BI training and a practice system intervention tailored for CAM practitioners. We note that the CAM disciplines participating in the CAMR study customarily use different terms to refer to persons seeking their care. Chiropractors and acupuncturists usually refer to “patients”, whereas massage therapists usually say “clients”. For simplicity, we will use “patients” throughout this paper.
Results
Step 1 results– Exploratory interviews with key informants
Step 1 aimed to better understand CAM practitioners’ potential barriers and facilitators to conducting helping conversations. Major themes from the interviews are summarized in Table
1.
Table 1
Major themes from key informant interviews
Interest in CAMR Study
| Thought tobacco cessation was relevant and important to practice; CAMR and participation in tobacco cessation viewed as a public health service |
Experience w/ Tobacco use (TU) Conversations
| TU conversations not typically initiated by practitioners unless requested by client/patient; TU not uniformly assessed among new clients/patients; practitioners felt most comfortable with initiating conversations about TU with established clients/patients |
Barriers to TU Conversations
| Patient might perceive TU conversations as intrusive - potential client alienation or confrontation; being perceived as giving a “sales pitch”; time constraints; cost effectiveness of TU conversations; scope of practice concerns (massage therapists); potential for patient to be dissatisfied and leave the practice |
Training Content Desired
| Tobacco use effects on health and the healing process, link between tobacco use and common presenting problems; TU conversation starters; biomedical and psychological perspectives of tobacco addiction; TU cessation referral resources |
Tone Desired
| Encouraging, supportive, focused on listening and referral |
Environmental/System Change
| Intake appointments typically long, allow for lifestyle conversations; return client flow allows for follow up conversations; intake forms could be modified to include TU questions; posters and handouts welcomed in practice |
Research/Training logistics
| No-cost training and CEUs extremely desirable; practice patient protocol acceptable and positively regarded |
Practitioners uniformly felt that tobacco use was detrimental to patient’s health and that cessation training was relevant to their practices. Three practitioners also viewed engaging in tobacco cessation as a public service or public health role for their CAM discipline.
“And I think there’s a lot of chiropractors there, and they see a lot of patients, and this [tobacco cessation] would be one way—chiropractic is supposed to be about creating a healthier body, and therefore, I think chiropractors are perfect for this [promoting tobacco cessation]. And I think the profession as a whole, if some chiropractors got involved, the American Chiropractic Association, would throw their full support to chiropractors doing something like this, because I would think it would only help chiropractors to be seen as doing more of a public service. [RS, chiropractor]
Two frequently cited barriers to addressing tobacco use with patients/clients were similar to those encountered among conventional practitioners, i.e. time constraints [
55] and lack of training.
“Some [chiropractors] are high volume and won’t take much time, but others will.” [KS, chiropractor, talking about barriers to talking to patients about tobacco cessation]
“I hadn’t really thought about why is it I’m not seeing smoking cessation and like I said, I never felt that successful at it, initially, and then, so people have called me and I’ve started to deflect; ‘Why don’t you see someone else who specializes in this?’” [LM, acupuncturist, talking about why she does not routinely address tobacco use in her practice]
“I bet there’s a lot of new information that I’m not aware of, the whole neuro-transmitter thing, I bet there’s a lot of great stuff that I should know. And it would probably prompt me to think about how I use acupuncture and how I might go, OK, if I can understand it in this neurological way, this modern way, how would I bring my acupuncture ideas to bear on that, that would interest me a lot. ‘Cause I think that that piece about any addictive substance is so interesting.” [LM, acupuncturist, talking about her interest in receiving cessation training]
“ I probably do not bring it up, um, and I let the client bring it up first, then maybe would go into, the physical effects of that and how its affecting the condition that maybe they’re complaining about, but I think I would also need more information about that too, I don’t think—My study at massage school, I actually did research on using massage with alcoholism, but not with tobacco.” [CR, Massage therapist, talking about barriers to talking about tobacco use with clients]
Barriers that differed from those commonly cited by conventional practitioners were: perceived intrusiveness or potential patient/client social discomfort or alienation– i.e. social risk [
34] and concerns over whether addressing tobacco use fit within their scope of practice.
“… when [they are] on the massage table, because they’re naked, and there's a sheet over and they're laying down and I’m standing up and I'm clothed, I've tried to avoid anything that would increase that power differential or increase, maybe, a shame level.” [GA, Massage Therapist]
“… so we really have to be extremely careful when we’re making suggestions. There is a away that you can make suggestions based on your own personal experience, or somebody else’s experience that sounds similar to theirs…just passing on that information, you are not prescribing or diagnosing and so we do that sometimes, but we really have to be careful with that.” [CR, massage therapist, talking about discussing tobacco use with client and scope of practice]
Practitioners expressed more hesitancy to bring up tobacco use with new patients, preferring to defer addressing tobacco use until later in the relationship. Two practitioners were concerned that raising the issue of tobacco could potentially to be perceived by patient as a “sales pitch” for additional CAM services.
“I think it’s easier done [bringing up smoking] when you have a patient relationship, which is built over the years, it’s much easier to deal with it. You know, if you bring it up to a new patient on a second visit, then it’s sort of you don’t have the trust bond that you do with your older patients.” [RS, chiropractor]
“I could see myself doing it in the clinic maybe after a session, if the conversation had come up, if we were talking about—if they were asking me questions about it, then definitely. Or if I had to approach it with them, I would do it very carefully, in a roundabout way most likely, and then try to have them bring themselves into it. …. I’d want to make sure that they obviously are interested in quitting because it really needs to be them. That’s why I usually let them come to me.” [DD, Massage therapist, talking about speaking to clients about quitting tobacco]
Practitioners conveyed frustration with the difficulty of motivating patient behavior change related to lifestyle issues, the associated paucity of sustained behavior change, and patients’ frequent expectations of a “quick and easy” fix – echoing sentiments often expressed by conventional medical practitioners.
“… one woman I’ve seen off and on for many years, I tried to help her quit smoking with acupuncture and it didn’t work. Now she’s finally quitting. She’s tried and tried and tried. Finally, she’s quitting with that drug Chantix.” [LM, Acupuncturist, talking about difficulty of sustained behavior change]
“But what I felt like was, some of the people I worked with who were smoking cigarettes, they were really hoping it [acupuncture] would be magic, and that they wouldn’t have to do any of the emotional work of really looking at the addiction.” [LM, Acupuncturist]
“But I do have cases where people are not ready. I think people believe that this [acupuncture] can make them quit. I said, nothing under the sun can make you quit, when you are ready to quit, then you can come to me, and I’ll help you quit. But don’t think that these cigarettes can erased your memory; that you’ve never been smoking before, that you never knew what smoking is all about.” [SL, Acupuncturist]
Informants were also asked whether they thought that a learning/assessment activity that featured an in-office “practice patient” (standardized patient) as a way to evaluate and clinical skills and receive feedback would be useful and acceptable. Participants thought this an interesting idea, likely to be clinically useful and well accepted. Practitioners reported two factors that would encourage their participation in tobacco cessation training: being free of charge and practitioners would receipt continuing education credits for training participation.
Data from Step 1 led us to develop a sensitive and context-driven approach to how and when to approach different patients about tobacco use. It also led us to document that participating practitioners found their patients to be receptive to tobacco conversations.
Step 2 results - Survey of local CAM practitioner community
Step 2 aimed to gather information from the local CAM practitioner community on domains potentially effecting acceptability of the CAM Reach intervention (based on results of Step 1). Overall survey response rate was 23% (n = 356), with differences in response rate by discipline: chiropractors, 30% (n = 56); acupuncturists 50% (n = 63); massage therapists, 19% (n = 237). Overall, nearly two thirds (64.6%) of those responding reported no previous cessation training. Prior cessation training was most common among acupuncturists and least common among massage therapists. Practitioners reported infrequently advising patients/clients to quit tobacco. Approximately two-thirds of practitioners responding were interested in receiving cessation training. See Table
2.
Table 2
Prior tobacco cessation training, interest in training by practitioner type
Prior Cessation Training |
None | 64.6 | 8.5 | 66.1 | 78.9 |
In professional school | 19.9 | 72.9 | 17.9 | 6.6 |
Cont. Education | 11.1 | 35.6 | 16.1 | 3.5 |
Learned on own | 17.3 | 37.3 | 12.5 | 13.2 |
Interest in Cessation Training |
Yes | 66.4 | 62.3 | 66.7 | 67.3 |
No | 10.3 | 13.2 | 4.4 | 10.8 |
Unsure | 23.5 | 24.5 | 28.9 | 22.0 |
Step 3 results - Demonstration of existing tobacco cessation curriculum
This step aimed was to evaluate an existing training (Helpers) as a foundational curriculum for CAM Reach and to identify key areas for tailoring. Practitioners reacted positively to the Helpers overall training content and instructional approach, including the patient-centered, motivational focus of the structured helping conversation. They demonstrated keen interest in the pathophysiology of tobacco’s health effects as well as the conventional/PHS guideline-based therapies, particularly cessation medications, wanting to know more so that they would feel comfortable responding to patients’ questions. In the training debriefing, practitioners asked numerous questions and recommended expansion of these two content areas of the training. Despite prompting by investigators, practitioners showed much less interest in hearing more about CAM therapies for cessation. Practitioners wanted inclusion of new and different training tools and patient handouts (e.g. handouts addressing the link between tobacco use and common presenting problems of patients; a detailed handout about medications that could be provided to interested patients; and a quick reference of benefits of quitting) and recommended additional skill-building activities in the instructional design. They also made suggestions for types of video role-plays (e.g. depicting practitioner interactions with patients who were more resistant to talking about their tobacco use, as well as receptive patients) and practitioner interview clips for the multi-media aspects of the training. Despite the differences in professional backgrounds and scope of practice among the three CAM disciplines, there were no recommendations for discipline-specific tailoring other than inclusion of interview clips from the same CAM discipline as the practitioner audience. Practitioners also saw value in keeping the interview clips from different CAM disciplines and did not recommend limiting clips to practitioners from the same discipline as the audience. Practitioners uniformly viewed the in-office “practice patient” (standardized patient) learning activity as a positive, informative experience and supported its inclusion in the final study intervention protocol.
Step 4 results – Adaptation and revision of existing curriculum
This step aimed to adapt the existing Helpers curriculum for context validity for each of the three CAM disciplines included in this study. A key conceptual adaptation of the curriculum was to emphasize the role of the relationship between practitioners and patients/clients. The CAM Reach training was framed as based on three fundamental principles: 1) tobacco cessation is a process, not an event; 2) practitioners can offer helping conversations to a tobacco user at any stage in the process of quitting; 3) helping conversations are part of a supportive, healing relationship.
Specific content was added to address second-hand smoke, and third-hand smoke exposure, and to provide minor expansion of CAM therapies content to address current research about CAM therapies for cessation. Content was added on screening for second-hand smoke exposure in non-tobacco users. A referral resource for patients who were interested in helping the sources of their second-hand smoke exposure – usually a friend or family member - to give up tobacco was also added. This resource is the Helpers Program on-line training, described above [
53]. Finally, learning activities were expanded and arranged so that participants would have progressive practice with helping conversation skills over the course of the training, with a summative skills practice role-play at the end of the training. A standardized “practice patient” experience was added as a summative learning activity/skills evaluation to be administered in the practitioner’s office approximately two weeks after the training workshop. The workshop content was reconfigured into an introduction and four modules (Table
3). The total training length was expanded to eight contact hours (7 hour workshop plus 1 hour in-office standardized patient). The final workshop was accepted for eight hours of continuing education units by the Arizona licensing boards for chiropractic, acupuncture and massage therapy.
Table 3
CAM reach training curriculum modules
Introduction | Overall knowledge and skills goals for the training, three guiding principles of Reach training, four steps of a Helping conversation, video example of helping conversation between practitioner and patient. |
Module 1 - Awareness | Scope of the tobacco problem, tobacco’s effects on health and healing, importance of linking effects of tobacco use to patient’s health concerns, practice systems to identify tobacco use, harm from second hand and third hand smoke exposure, the CAM practitioner’s role in helping, context of helping, getting the helping conversation started, skills practice role play |
Module 2 - Understanding | Tobacco products and their harmful constituents, aspects of tobacco addiction (biological, psychological, social), active listening and communication skills (open-ended questions, reframing, body language), motivators and barriers to quitting (i.e. giving up tobacco), assessing readiness to quit, skills practice role play |
Module 3 - Helping | PHS guideline, types of cessation behavioral support services, cessation medications, referral skills, CAM approaches for tobacco cessation, motivational strategies (i.e. motivating and clarifying questions, eliciting ‘change talk’, ‘rolling with resistance’, emphasizing benefits of quitting, negotiating action), importance of continuing to offer helping conversations – even with patients not ready to quit, components of a simple quit plan, skills practice role play |
Module 4 - Relating | Finishing the helping conversation on a positive note, setting the stage/leaving door open to have future helping conversations, tips and strategies for following up, two final skills practice role play |
Closure | Distribution of printed practice support materials, discussion of how to use/implement printed materials to engage patients and promote practitioner’s willingness to help tobacco users quit, explanation of practice patient (standardized patient) office visit |
Step 5 results - External subject matter expert review
The purpose was to gather feedback and advice for further necessary revisions from nationally/internationally recognized experts in the three CAM disciplines, tobacco cessation, and integrative medicine. Congruent with results from Step 3, national advisors also supported the interprofessional education approach, recommending only a minor amount of tailoring for each practitioner type. There was also strong support for the conceptual shift toward a relationship-centered intervention approach with an instructional design and activities emphasizing progressive skills building. National advisors also provided substantive contextual input on specific issues including: typical content/training received in typical CAM school curricula, professional scopes of practice, integration of conventional therapies, and potential practitioner role in discussing/providing information on cessation medications. National advisor feedback and contextual information informed additional tailoring of curriculum content, patient handouts, and instructional design for the unique needs of chiropractors, acupuncturists and massage therapists. Advisors also commented on the dissemination potential of the proposed CAMR intervention and recommended exploration of online training possibilities as well as integration of CAMR tobacco cessation training into CAM primary professional education settings.
Step 6 results – Pilot test of revised curriculum
Step 6 aimed to confirm integration of results from prior development steps and identify last revisions needed to produce the final CAMR training intervention. Participant feedback confirmed that national and local advisor recommendations had been effectively incorporated and also recommended the elimination of one learning activity that was felt to be overly technical and not helpful to explain or reinforce content. In particular, CAM practitioners in attendance were very positive about the new content on pathophysiology of tobacco health effects and cessation medications. Practitioners commented that although they felt any recommendation to use medications was outside of their scope of practice, they noted that patients frequently ask them about medications (both over-the-counter and prescription). Practitioners found the medication information interesting and useful in that they were now more comfortable with offering the CAMR patient handouts about medications and/or directing their patients to physicians, pharmacists or “quit lines” (free telephone-based stop smoking counseling services that are widely available in all U.S. states) for more information and assistance with cessation medications. Practitioners liked that the CAMR training resulted in new knowledge and skills that were immediately applicable in their practices. Other feedback included recommendations for minor re-ordering of slides, video role-plays, and practitioner testimonials for better instructional flow. As in Step 3, the in-office standardized patient exercise was uniformly viewed as a positive and very helpful learning experience.
Final CAMR intervention protocol
The final CAMR intervention protocol and content is outlined in Table
4. Broadly, the protocol called for both practitioner education and system change components that create a welcoming and information rich environment for patients. For example, there were seven different display posters, stickers with tobacco screening questions for intake forms, chart stickers (to signify tobacco users). The display posters depicted a variety of people with text encouraging patients/clients to ask their practitioner about quitting tobacco or second hand smoke, e.g. “Ask your [practitioner type] about quitting tobacco”. One poster’s text addressed pain: “Did you know that smoking can increase your pain? Ask us for help to quit”.
Table 4
Final CAM reach intervention protocol
CAMR training workshop | 7 hour, in-person continuing education workshop (7 CEUs) |
Practice patient/system change visit | 1 hour in-office visit to conduct practice patient assessment and help implement office system changes (1 CEU) |
Patient education materials | 10 brochures: |
Tobacco and Your Body: Surprising things that you may not know; Secondhand and Thirdhand Smoke: Surprising things that you need to know; Thinking of Quitting Tobacco? We Can Help; Medications that Help with Quitting Tobacco; The Personal Quit Plan; Simple Quit Plan; Quit Line brochure; Helpers Brochure (for those wishing to help others quit tobacco); Roadmap for Quitting Tobacco; Benefits of Quitting Timeline |
Practice support materials | Display posters, intake form stickers, chart stickers, brochure holders |
7 different display posters, stickers with tobacco screening questions for intake forms, chart stickers (to signify tobacco users). Display posters depicted a variety of people with text encouraging patients/clients to ask their practitioner about quitting tobacco or second hand smoke, e.g. “Ask your [practitioner type] about quitting tobacco”, and “Got pain? Did you know that quitting tobacco can help? Ask us how”. |
Discussion
Researchers conducting CAM research have consistently faced methodological critiques of interventions that lack context validity within real world CAM clinical practice. The CAMR intervention protocol development process addressed context validity from both the perspective of CAM practitioners as well as conventional biomedicine. Incorporation of the latest thinking in tobacco cessation from conventional research as well as formative research with CAM practitioners was essential to the formulation of the three guiding principles of the CAMR intervention: 1) tobacco cessation is a process, 2) practitioners can offer helping conversations to a tobacco user at any stage in the process; 3) helping conversations are part of a supportive, healing relationship.
By attending to context validity, the CAMR intervention was able to bridge a gap between the proscriptive 5 A’s approach the PHS Guideline recommends for conventional biomedical practitioners (i.e. ask about tobacco use at every visit and advise the user to quit) and the relatively greater hesitancy of CAM practitioners to bring up tobacco use with new patients. The final CAMR intervention emphasizes a motivational, relationship-centered approach to the helping conversation, in which the four steps of a helping conversation (Awareness, Understanding, Helping, Relating) are sequenced to help the practitioner address tobacco use, while attending to the relationship. For example, the Awareness step prompts the practitioner to identify links between the patient’s tobacco use and their reasons for seeking treatment and to offer the patient information, thus laying groundwork for addressing tobacco use now, or at a future visit. The Understanding step helps the practitioner to attend to the relationship by asking about the patient’s reasons for wanting to quit tobacco and their readiness to quit tobacco before offering Helping (e.g. advice, information, motivational strategies) that is in alignment with the patient’s acceptance and readiness to take action. Finally, Relating emphasizes the practitioner’s role in attending to the relationship by seeking permission to follow-up and providing ongoing support for behavior change.
The iterative development process also yielded some interesting outcomes. First, the participating practitioners expressed much more interest in having more information about biomedical models of the mechanisms of tobacco’s health effects and also cessation medications, than additional information about CAM therapies specifically for tobacco cessation. Discussion with national advisors, indicated that practitioners were likely to be already familiar with therapies from their own system of treatment.
Second, the development process did not identify a need to extensively tailor the CAMR intervention for each CAM discipline. Rather, participating practitioners’ and advisors’ comments confirmed earlier formative research results about the course content (information and skills training) as having relevance and clinical application across different CAM disciplines (e.g. body-system specific health consequences of tobacco use, communication skills). Notably, practitioners spontaneously identified other health behaviors that might be addressed using the same communication skill set. Practitioners also pointed to the potential for interprofessional education – the opportunity for practitioners from different CAM disciplines to learn from one another
vis a vis such conduits as videos modeling how practitioners from another CAM discipline approached patients about tobacco their use. An interprofessional approach to training is particularly relevant for those who practice with CAM practitioners from other disciplines – a common scenario [
56]. A third interesting outcome were the similarities between the frustrations expressed by CAM practitioners and conventional practitioners over the challenges of motivating patients/clients to make and sustain healthy behavior changes.
A limitation of the study is that the participating CAM practitioners self-selected to be in a research study on tobacco cessation, and thus may not be fully representative of the general population of CAM practitioners. There were a limited number of CAM practitioners participating in the development steps (other than the mail survey). These practitioners also self-selected to participate in an intervention development process, so their results may not be generalizable. Another limitation is the low response rate of chiropractors and massage therapists in Step 2. It is possible that the high proportion of respondents with no previous cessation training, and an interest in receiving cessation training is over estimated. Such practitioners may have been more likely to answer a survey about tobacco cessation training and may not reflect the actual need or demand for cessation training among the general population of CAM practitioners.
Acupuncturists’ higher response rate to the community CAM practitioner survey may be a reflection of more acupuncturists reporting having had prior training in tobacco cessation, either in their primary professional training or as continuing education. This may indicate greater interest and/or familiarity with the topic of tobacco cessation and a higher likelihood of responding to a survey about tobacco cessation training. Of the three CAM disciplines participating in our study, only acupuncturists have specific treatments within their core practices that are for treatment of drug withdrawal. Our national advisors indicated that there is a well-known acupuncture protocol for treating drug withdrawal that can be applied to nicotine withdrawal, and that this protocol is typically taught in acupuncture school. The present study was conducted in the U.S. Primary professional training, scope of practice, and government or industry regulation of CAM practitioners in other countries may be different. Accordingly, care must be taken in any transferability and generalizability of study findings and the resulting CAMR intervention protocol to CAM practitioners in other countries.
In conclusion, the CAMR intervention protocol, with its focus on patient-centered care and the role of the patient-practitioner relationship, has potential to serve as a common touchstone that has context validity yet could generalize across three vastly different CAM disciplines and their varied practice contexts – and connect practitioners in a way conducive to interprofessional education and practice. More importantly, can the CAMR intervention change CAM Practitioner clinical behavior in real-world practice settings? This question is the focus of the practice-based CAMR study and must be answered be answered before wider adoption of the CAMR intervention protocol. A related research question follows: Could the same common focus on patient-centered care and the patient –practitioner relationship also help bring together both conventional and CAM Practitioners in collaborative efforts to help patients give up tobacco use? With the growing interest by conventional health practitioners and the public in integrative medicine, and CAM practitioners’ growing interest in ways to enhance their contributions to public health education and promotion, this question also deserves further research.
Shared frustrations over motivating patients to make and sustain healthy behavior change are common among practitioners of all types, providing a departure point for productive dialogue and exchange of experiences. A common desire for more effective ways to promote healthy behavior change provides an opportunity for collaboration in what we have elsewhere described as a community of cessation practice [
57]. This desire can serve as the basis for cessation training in a shared repertoire of behavior change strategies and tools, e.g. helping conversations, active listening skills, and motivational communication strategies that could help bring CAM and conventional practitioners together toward a common goal of reducing tobacco use [
57].
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
All authors contributed to the study conceptualization, participated in its design and intervention development and helped to draft the manuscript. MLM, CKR and MAN carried out the qualitative interviewing of CAM practitioners. All authors read and approved the final manuscript.