Experiences With Tobacco Dependence Treatment Training Among Respiratory Care Clinicians

To the Editor:

At any time, more than two-thirds of individuals who use tobacco want to quit.¹ The health care system plays a key role in providing medications and effectively connecting patients to tobaccodependence treatment (TDT). However, delivery of TDT is highly variable in the clinical setting, even for patients with established lung diseases like COPD. Lack of adequate TDT training for clinicians may be a cause of low treatment use. Our goal was to understand how clinicians treating patients with COPD and tobacco use perceive the training they received and what recommendations they have for improvement.

Methods

Weconducted a single-center qualitative evaluation of clinicians caring for patients with COPD to evaluate educational experiences with TDT. Evaluation was nested within a larger qualitative program development. The study was approved by the Minneapolis VA Health Care System Institutional Review Board. Clinicians were sampled to ensure representation from leadership and prespecified key clinical roles caring for patients with COPD. Initial participants were asked to refer potential additional participants to sample across departments and roles. Clinicians were contacted directly by the principal investigator (A.M.)and were interviewed by a research coordinator (M.C.) using a semistructured interview guide. Interviews were recorded, transcribed, and coded using NVIVO software (QSR International) using directed content analysis in which four interview questions were grouped into three themes. The first five transcripts were coded simultaneously by the principal investigator and research coordinator, with discrepancies resolved through consensus. The remaining transcripts were coded by the research coordinator, with every fifth subsequent transcript reviewed with the principal investigator to ensure agreement. Data then were summarized in a matrix organized by participant, role, and topic, with associated exemplar quotations.

Results

The sample (n = 21) included primary care physicians (n = 4), pulmonary physicians (n = 4), a health psychologist (n = 1), primary and specialty care nurses (n = 5), population health pharmacists (n = 4), and respiratory therapists (n = 3). See the Table 1 for characteristics and Table 2 for exemplar quotations.

TABLE 1 ].

Demographics and Roles of Participating Clinicians

Characteristic	Data
Role	…
Pharmacist	4
Primary care physician	4
Primary care nurse	2
Specialty care nurse	3
Pulmonologist	4
Psychologist	1
Respiratory therapist	3
Sex	…
Male	6
Female	15
Y in practice	17.2 (1–39)
Y in current VA role	6.9 (1–15)

Data are presented as No. or mean (range). VA = Veterans Affairs.

TABLE 2 ].

Exemplar Quotations Regarding Previous Training Experiences in Tobacco Dependence Treatment

Theme	Participant	Quotation
Format and timing	Pharmacist 2	“So we’ve had, through the VA, several—we call them boot camps—which are more kind of targeted training for various disease states, including tobacco cessation.”
	Primary care nurse 1	Interviewer: “Tell me about any training you received.” Participant: “Without trying to be a smart aleck, I would say none. I mean, we get handouts once in awhile … .”
	Primary care physician 4	“Medical school, residency … has teaching on [tobacco cessation]. And then I’ve done motivational interviewing training. And just informal team-based work with our clinic pharmacist, you know, grand rounds, things like that…. I don’t think I had any formal classes per se. Maybe like 1-hour-long lecture type of things.”
	Pulmonologist 1	“I think during our fellowship we had a lecture or two on smoking cessation and that’s probably the extent of specific things on tobacco cessation.”
	Respiratory therapist 1	“They go [through] it briefly in respiratory school, but no side class, or official certification.”
	Specialty care nurse 2	“It’s just the independent learning (about tobacco cessation) right?”
Content and adequacy	Pharmacist 2	“It was an overview of … both pharmacotherapy and … a behavioral approach, with regards to motivational interviewing.”
	Primary care nurse 2	“Nursing school was a long time ago and it was pretty minimal from what I can recall. We got the lesson about the effects of what smoking does to the body, but not cessation techniques. Then here at the VA, I would say also minimal.”
	Primary care physician 4	“I think I’m not as well trained on the evidence supporting other (behavioral) type of therapies … . Those are probably more learned on the job.”
	Psychologist 2	“I’ve had training in motivational interviewing, which can address a broad range of conditions, including tobacco [use] … and I’ve had various trainings in … [cognitive behavioral therapy].”
	Pulmonologist 2	“[We covered] motivational interviewing … and in terms of pharmacotherapies, so use of both nicotine products, as well as varenicline or bupropion.”
	Respiratory therapist 1	“[We learned] different things available as far as pharmaceutical options, lozenges … it’s more or less we’re taught to encourage our patients to stick with whatever their doctor has prescribed.”
Recommended improvements	Pharmacist 1	“I think probably as a learner, as a resident, you know, some more formal education from the get-go … would have been for the better, especially just in, you know, the behavioral aspects.”
	Primary care nurse 1	“If I say, ‘Are you interested in quitting?’ … and they say, ‘Nope,’ I move on. [I could use more about] what I could say or do differently to really engage somebody in a conversation about it.”
	Primary care nurse 2	“Most of the resources that I know about are something that maybe the younger generation would not want to pursue like a phone number versus now I know there’s a lot of apps … so just (education on) updated resources, I guess.”
	Pulmonologist1	“It could be improved by giving different scenarios maybe or people who … haven’t tried anything or a person who has tried something like Chantix, but had a bad experience. Like, how to handle that.”
	Specialty care nurse 1	“I truly need more refresher[s] because I know that research changes and so do the therapies and the therapeutics.”
	Specialty care nurse 2	“[I need updates on] … things available or things we are doing now, because of course treatment options change over 40 years, right?”

Among Diverse Clinicians Caring for Patients With COPD

Previous Training Experiences: Format and Timing

The type, timing, and depth of the training varied across specialties. All interviewees received at least some informal training. Most physicians reported lecture-based training at different stages of their education (eg, medical school, residency, fellowship) and sometimes as continuing medical education. Physicians did not report interactive trainings, such as observed encounters or standardized patient interactions. One physician noted they kept up to date through podcasts. Pharmacists reported predominantly postgraduate training completed as part of job duties. Most of the pharmacists (3/4) participated in in-service training in the form of boot camps or online modules covering TDT as part of a formal competency. Roughly one-half of nurses (2/5) reported little to no training on TDT, and none were trained in motivational interviewing. The experience of respiratory therapists was similar to that of nurses, with most reporting little to no training.

Previous Training Experiences: Content and Adequacy

Roughly one-half of participants believed that TDT training was insufficient throughout their education (10/21). Most pharmacists (3/4), all primary care physicians (4/4), and the psychologist (1/1) believed that their training was sufficient. Across most roles, the largest gap was in motivational interventions, treatment tailoring, and behavioral therapies. For physicians, the primary focus of their lecture-based curriculum revolved around guidelines on pharmacologic management of tobacco dependence. Of the physicians interviewed, about one-half (4/9) had received at least some training in motivational interviewing. However, 100% of pharmacists (4/4) reported training in the behavioral components of TDT, motivational interviewing, or both. Two pharmacists received additional behavioral or motivational training by shadowing a health psychologist. Although one respiratory therapist reported receiving training on the pharmaceutical options available for tobacco dependence, two of three reported that their training consisted of encouraging patients to “stick with whatever their doctor prescribed” or “use the [quit] line.” No respiratory therapists received training in motivational interviewing or behavioral TDT. Nurses indicated that their training centered on health effects of smoking.

Recommended Improvements

Several participants, including most nurses (3/5), believed that more frequent training sessions on the current methods available for tobacco cessation treatment and the supporting evidence would be beneficial. A common theme across roles was a desire for more behavioral training, especially for patients who do not initially express interest in quitting or who are refractory to prior treatment attempts. Motivational interventions, treatment tailoring, and practical ways to link patients to the right resources all were areas for improvement. Physicians recommended more in-depth TDT training early on in medical school and more interactive training (eg, cases, standardized patients) instead of didactic sessions. Pharmacists believed that more education in the behavioral aspects of tobacco dependence and motivational interviewing “from the get-go” should be emphasized in their undergraduate training, rather than only in the postgraduate period.

Discussion

TDT training seems to be inconsistent in depth, format, content, and timing among clinicians caring for patients who use tobacco and have COPD, with many clinicians perceiving their training as inadequate. Only those who reported providing TDT and counseling as part of their job (eg, population health pharmacists, health psychologist) reported participating in robust active learning techniques such as shadowing, workshops, and assessment of competency.

Prior research demonstrates that the most effective training programs incorporate some form of active, case-based learning.^2–4 This includes standardized patient interactions, observed patient encounters, and role-playing. The active component seems to be a key element for refining skills and improving confidence for addressing tobacco use. A number of primary care physicians believed that their training was adequate, despite generally not participating in those learning strategies. It is unclear whether they overestimate their competence or whether their experiences on the job and through continuing education were sufficient to fill any gaps. Future work could assess this.

Our study has limitations, including the small qualitative sample and the single-center design. Results may be subject to recall and desirability bias. Clinicians may have forgotten trainings, particularly if they were low in intensity.

In conclusion, although health care providers are positioned uniquely to provide TDT, many of participants reported inadequate training with significant gaps in content. Augmented training in pragmatic, effective care models such as ask-adviseconnect and motivational interviewing may increase clinicians’ effectiveness and confidence.^5,6 To ensure that clinicians are well prepared to provide TDT to patients with respiratory disease, standardized, longitudinal training that encompasses active learning and individual competency assessments should be implemented broadly.