Background
Methods
-
First, that regularly raising the issue of tobacco cessation might compromise their relationship with patients, particularly those whose key complaints may not be seen by the patient as tobacco-related.
-
Second, given that most patients pay for CAM services out-of-pocket, practitioners were concerned that promoting cessation might cause patients to leave their practice.
-
Third, practitioners were concerned that introducing cessation materials, such as pamphlets or posters, to new patients might be perceived as a “sales pitch” aimed at promoting additional, fee-based products or services [26].
Overall objective | ▪ Train chiropractors, acupuncturists and massage therapists to perform tobacco BIs with their patients |
Aims | ▪ Evaluate the effectiveness of the CAMR training by studying practitioner BI behavior and patient tobacco cessation activity. ▪ Conduct a qualitative study with a sub-sample of enrolled practitioners and patients to examine factors associated with implementing tobacco cessation BIs |
Design and methods | ▪ Single group, Pre/post post design; assessments measured knowledge, attitudes, beliefs and confidence about tobacco BIs (assessed at baseline, and 3-, 6-, 9- and 12-months post-training). ▪ Training was a one-day, in-person workshop and included a one-hour in-situ “practice patient” learning activity 1–2 weeks later. ▪ Practitioners were provided tobacco cessation materials (pamphlets and posters) to display in their practices and distribute to their patients. ▪ After the CAMR training, research staff visited practices every 2–4 weeks for 3 months, to encourage practitioners to incorporate study patient materials and implement tobacco cessation activities into routine practice. ▪ N = 99 practitioners (30 chiropractors, 27 acupuncturists and 42 massage therapists) enrolled in the study. ▪ N = 595 clients of enrolled practitioners participated in the study. ▪ Of these participants, 54 practitioners and 38 patients were selected for qualitative interviews spread across all three cohorts. |
Qualitative methods
Practitioner interviews
Patient interviews
Qualitative participants
Months 3–4 | Months 7–9 | Month 12 | Total | ||
---|---|---|---|---|---|
Practitioners | # eligible |
n = 45 |
n = 45 |
n = 43 |
n = 133 |
# completed |
n = 38 |
n = 32 |
n = 31 |
n = 101 | |
Response rate | 84.4% | 71.1% | 72.1% | 75.9% | |
Clients | # eligible |
n = 13 |
n = 37 |
n = 21 |
n = 71 |
# completed |
n = 10 |
n = 26 |
n = 14 |
n = 50 | |
Response rate | 76.9% | 70.3% | 66.7% | 70.4% |
Qualitative analysis
Results
Concern 1: Potential harm to the patient-practitioner relationship
Practitioners’ perspective
I was more comfortable with learning how to put together the detriments of smoking, linking it with something that would be occurring. For instance, a massage client who has a stiff shoulder and upper back issues. He’s a smoker and through the training I learned that because smoking inhibits some of the circulation and it doesn’t allow muscles and tissue to heal as readily as a nonsmoker, I was able to bring that up. (Massage Therapist, 4 months post-training)
I didn’t realize that tobacco was tied to pain levels. I didn't realize that people would not heal as quickly if they smoked. It’s good to be able to point that out to patients, that we’ve been working on this problem and some of the reason you still have pain could be because you’re still smoking. (Acupuncturist, 4 months post-training)
Patients’ perspective
She made me feel empowered. She made me feel whole, that it was okay where I was right there, and that I could move forward to what I really truly wanted. It was just important that I really wanted it. It had to be a conscious choice of mine that I wanted it, not somebody else wanted it. … I just felt empowered—empowered and accepted, and not judged at all. (Acupuncture patient, 12 months post-training)
Concern 2: Intrusiveness of BI in CAM practice
Practitioners’ perspective
It surprised me that it wasn’t as difficult as you think. The resistance isn’t there as much as you think it is. Because with the training, with the material, it’s not as much as like a parent to a child lecture. It’s more like, “Here, I want to help you,” and we’ve got tools. (Chiropractor, 7 months post-training)
I’m definitely more willing to bring up tobacco outside of the initial intake form. I’m more willing to—more able to talk to people about it. Before, I had a hard time because I’m not a smoker, and I don’t like smoking. I don’t enjoy it in any sense, anywhere for anybody, and so I always felt like I maybe would come off as a little too biased and a little too headstrong, and so I was hesitant because I didn’t want to offend anybody, but now I feel a lot better about it. (Chiropractor, 12 months post-training)
Patients’ perspective
Yes, it’s appropriate… It definitely adds value to going to the appointment; I’m having the therapy because it’s more than just the massage. It’s also how that affects your entire life and what things you can do to achieve more benefits from the massage. (Massage client, 4 months post-training)
Concern 3: The possibility of cessation support being perceived as a “sales-pitch”
Practitioners’ perspective
It gives it a professional look rather than just me by myself saying, “Oh, you should think about quitting.” It gives me the nice documentation and presentation look of it: that I did go through training, I did learn about this, I did take continuing education on it, and it is through a well-known university, University of Arizona… A lot of them say, “Oh, the University of Arizona does this. Oh, that's so neat.” I guess it validates the information, and it gives it substance. (Licensed Massage Therapist (LMT), 7 months post-training)
I’ve noticed that having the pamphlets available to the patient makes it a lot easier because it’s a way of conversing about the different aspects of quitting and having medications available, having ASH Line available. Then being able to just—if they’re not real open to it, just say, “Okay, well, here, take these. If you’d like to continue the conversation, we can. I’ll follow up later.” (Acupuncturist, 12 months post-training)
Patients’ perspective
[The practitioner] has a little area where people sit when they first come in. I thought, “Oh, God, is she gonna start advertising with us, and hitting us with stuff?” … At first it kind of put me off. Then I realized that it was yet another avenue of talking about a healthy body and keeping one’s body healthy. Actually, I really sort of admired her for doing that. (Massage Client, 4 months post-training)
Strategies for implementing brief tobacco intervention in routine CAM practice
I’ve always asked if they smoked before [CAM] Reach, but now I have the education and the resources to follow up and do something about it rather than it just being another question on the intake form. I believe that it will remain the same, and I believe I’ll still be following up with clients and asking them because it seems to give my clients and I a closer relationship as far as their health is concerned. They share more when they realize I care about everything, not just coming in and giving a massage and leaving. (LMT, 12 months post-training)
I have to admit that I really did not pursue [tobacco] until I became a part of this [study]... I really did not pursue it. Now it’s just a regular part of my history taking… I love being a source of information for people that are interested in how we can live healthier lives, so that’s perfect for me. (Chiropractor, 3 months post-training)
Acupuncture is much better at treating other things than tobacco cessation. The way I would look at it is that at least if somebody were willing to come in for tobacco cessation, it means that they’re thinking of quitting. That, whether it’s acupuncture or anything else, is a good thing. (Acupuncturist, 4 months post-training)