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Primary healthcare provider knowledge, beliefs and clinic-based practices regarding alternative tobacco
products and marijuana: a qualitative study
Ta Misha S. Bascombe1, Kimberly N. Scott2, Denise Ballard2, Samantha A. Smith1, Winifred Thompson1 and Carla J. Berg1*
1Department of Behavioral Sciences & Health Education, Emory University Rollins School of Public Health, 1518 Clifton
Road NE, Atlanta, GA 30322, USA and 2Cancer Coalition of South Georgia, Albany, GA 31707, USA
*Correspondence to: C. J. Berg. E-mail: cjberg@emory.edu
Received on July 7, 2015; accepted on December 20, 2015
Abstract
Use prevalence of alternative tobacco products
and marijuana has increased dramatically.
Unfortunately, clinical guidelines have focused
on traditional cigarettes with limited attention
regarding these emerging public health issues.
Thus, it is critical to understand how healthcare
professionals view this issue and are responding to it. This qualitative study explored knowledge,
beliefs and clinic-based practices regarding
traditional and alternative tobacco products
(cigar-like products, smokeless tobacco, hookah,
e-cigarettes) and marijuana among rural and
urban Georgia primary healthcare providers.
The sample comprised 20 healthcare providers
in primary care settings located in the Atlanta Metropolitan area and rural southern Georgia
who participated in semi-structured interviews.
Results indicated a lack of knowledge about these
products, with some believing that some products
were less harmful than traditional cigarettes or
that they may be effective in promoting cessation
or harm reduction. Few reported explicitly as-
sessing use of these various products in clinic. In addition, healthcare providers reported
a need for empirical evidence to inform their clin-
ical practice. Healthcare providers must system-
atically assess use of the range of tobacco
products and marijuana. Evidence-based recom-
mendations or information sources are needed to
inform clinical practice and help providers
navigate conversations with patients using or
inquiring about these products.
Introduction
Tobacco is a risk factor for heart disease, diabetes,
cancer, stroke and other chronic diseases [1]. While
cigarette use in the United States has generally
declined in the past 30 years [2], alternative tobacco
products such as small cigars (e.g. little cigars, cig-
arillos), smokeless tobacco, hookah and electronic
cigarettes (e-cigarettes) have been gaining popular-
ity in more recent years [3, 4]. From 1998 to 2006,
large cigar consumption increased by 45%, while
consumption of small cigars increased by 154%
[5]. The use of smokeless tobacco (e.g. chew,
snus) has steadily increased from 2000, especially
among young adult males [6]. Research also has
shown an increase in hookah use, particularly
among college-aged young adults [7]. Finally, the
popularity of e-cigarettes has more than doubled in
recent years, posing a potential new health risk in
tobacco users [8]. According to the 2012–13
National Adult Tobacco Survey [9], an estimated
25.2% of US adults report using some type of to-
bacco product every day, some days or rarely, with
62.7% of users using at least one tobacco product
daily. Among those tobacco products that respond-
ents reported using were: cigar products 5.8%;
smokeless tobacco 3.8%; water pipes/hookah 3.9%
and e-cigarettes 4.2% [9]. As such, healthcare
HEALTH EDUCATION RESEARCH Vol.31 no.3 2016
Pages 375–383
Advance Access published 22 January 2016
� The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com
doi:10.1093/her/cyv103
practices that focus only on cigarettes [10] are no
longer an option, particularly since no amount of
exposure to tobacco is safe [1].
In addition to the emergence of alternative to-
bacco products in the United States, there has also
been an increase in marijuana use, particularly
among users of many different tobacco products
[11]. Although marijuana is not a tobacco product,
it can have some of the same health effects as to-
bacco. For example, it can cause breathing prob-
lems, increased heart rate and complications with
child development during and after pregnancy
[12]. In addition, it also can increase cancer risk,
cause loss of coordination and increase issues with
memory, learning and problem solving [13]. As
such, the increasing prevalence of marijuana use
must also be taken into account in the clinical set-
ting, particularly since tobacco and marijuana use
are highly correlated [14].
Healthcare providers play a crucial role in behav-
ior change, especially in tobacco cessation [10].
Smokers often say that advice from their healthcare
provider is an important part of their motivation to
quit [15]. However, the Clinical Practice Guidelines
for Tobacco Dependence focus almost exclusively
on traditional tobacco products (e.g. cigarettes,
chew) [10]. Thus, healthcare providers are providing
care in a context where the market and the terrain of
tobacco use is changing and marijuana use is
increasing, particularly among tobacco users.
Unfortunately, clinical practice guidelines have not
yet been established to address these emerging and
complex public health issues. As such, examining
knowledge, beliefs and clinical practices in relation
to alternative tobacco use and marijuana among
healthcare providers is the first step in understanding
and ultimately intervening on these issues.
Thus, the purpose of this study was to qualita-
tively explore knowledge, beliefs and practices
associated with traditional and alternative tobacco
products and marijuana among healthcare providers.
Our specific aims were to (i) assess knowledge and
beliefs regarding traditional versus alternative to-
bacco products and marijuana among healthcare
providers in diverse primary care settings in
Georgia; (ii) assess clinic-based practices related
to traditional versus alternative tobacco products
and marijuana among these healthcare providers
and (iii) assess providers’ perceived needs for re-
search and information regarding the diverse range
of tobacco products and marijuana to inform clinical
practice.
Methods
Research design
This was a qualitative research study assessing
knowledge, beliefs and clinic-based practices re-
garding traditional and alternative tobacco products
and marijuana among rural and urban Georgia
healthcare providers. Data from the study were col-
lected from 20 healthcare providers in the Atlanta
Metropolitan area and rural southern Georgia via
individual, semi-structured interviews. Emory
University’s Institutional Review Board approved
this study.
Participants and sampling
Using convenience sampling, we recruited health-
care providers from the Atlanta Metropolitan area
and rural southern Georgia. To be eligible to partici-
pate, individuals had to (i) be a physician, physician
assistant or nurse in the primary care setting and (ii)
practice in the Atlanta Metropolitan area or in the 32
county service area of the Cancer Coalition of South
Georgia. The rural southern Georgia providers were
identified through various clinics and practices in
the Cancer Coalition of South Georgia’s service
area. Research staff contacted the clinics via tele-
phone and requested to speak to primary care pro-
viders that met criteria for the study and who might
be willing and able to participate. A total of six
healthcare providers consented and participated in
the interview. To recruit providers in the Atlanta
Metropolitan area, a list of metro-Atlanta providers
were compiled using the Emory Healthcare
Network and were chosen based on specialty (i.e.
internal medicine, OB/GYN, family medicine). The
list was revised to only include those in the Emory
Directory who had published emails. An initial
email was sent out to the providers, and those who
T. M. S. Bascombe et al.
376
responded positively were screened for eligibility
and, if eligible, scheduled for an interview. The
final list of providers in the Atlanta Metropolitan
area included 60 providers, of whom 14 consented
and completed the interview (response rate-
¼ 23.3%). At the point at which these 20 individuals had completed the interviews, the research team
conferred to determine if additional recruitment
was needed; however, the interviewer indicated
that saturation had been reached. Thus, a total of
20 healthcare providers serve as the sample for the
current study.
Data collection and measures
The interviews were conducted via face-to-face in
a private and quiet location for those providers in
the rural southern Georgia area and via telephone for
the metro-Atlanta healthcare providers. Consent
was obtained in-person or via oral consent, respect-
ively. The semi-structured interview lasted
25–45 min. Participants were debriefed, thanked
and excused following the completion of the
interview.
The semi-structured interview guide was de-
veloped by the study team and pilot tested through
mock interviews; the guide was revised after the first
three interviews. The interview began with struc-
tured questions regarding sociodemographics,
education and work as a healthcare provider. The
semi-structured interview qualitatively assessed
knowledge, beliefs and clinic-based practices
related to traditional and alternative tobacco use
and marijuana use. Specifically, we asked about cig-
arettes, cigar-like products, smokeless tobacco,
hookah, e-cigarettes and marijuana. Example ques-
tions on knowledge and beliefs regarding these
products included ‘When you hear the words “to-
bacco products”, what things come to mind? What
do you know about [each tobacco product, mari-
juana]? What do you think about the health risks
of [each tobacco product, marijuana] compared to
cigarettes? What about the potential for addiction of
[each tobacco product, marijuana]?’ Questions
referring to clinic-based practices regarding the
range of tobacco products included, ‘During a
regular clinic visit, what questions do you ask
about tobacco use? What things, if any, make you
think to ask about tobacco use? What is the specific
question you ask about tobacco? What tobacco
products do you ask about? How frequently do
you ask about [each tobacco product] use during
clinic visits? How often do patients ask you about
[each tobacco product]? What do they ask? What do
you tell them? How do you address marijuana
within a clinical encounter? How often is marijuana
assessed?’ Questions referring to needed informa-
tion and research included ‘What do you wish you
knew about some of these products? What questions
do you wish the research communities would ad-
dress about these products? What are your concerns
about these products?’ All questions had a set of
probes to draw additional information on the spe-
cific topics.
Data analysis
All interviews were recorded, the audio record-
ings were uploaded to a secure, password-
protected computer and the recordings were
transcribed verbatim by a contracted professional
transcription service. Quantitative data were
entered into SPSS. Descriptive analyses were con-
ducted. Qualitative data were analyzed using
MaxQDA (VERBI GmbH). Two members of the
authorship team (MPH-level research staff) ran-
domly selected three interview transcripts, which
they then used to generate preliminary codes using
deductive and inductive coding methods. All
codes were compiled and developed into a code-
book for analysis. The transcriptions from each
interview were independently reviewed and
coded using the preliminary codebook that was
developed. All new codes that arose during
coding were added to the codebook and applied
to all transcripts. Interview transcripts identified
themes that arose during the interviews, and rep-
resentative quotes were extracted to present
below. Responses and themes were compared
and contrasted across healthcare providers (e.g.
rural vs. metro-Atlanta); only themes that differed
across groups were highlighted in the results.
Healthcare providers and tobacco practices
377
Results
Study participants
Twenty participants were of an average of 45.25
(SD¼ 9.79) years and had an average of 15.93 (SD¼ 8.96) years of experience. The sample comprised 13 (65.0%) females, with 12 (60.0%)
being White/Caucasian, 5 (25.0%) Black/African
American, 2 (10.0%) Asian American and 1
(5.0%) Hispanic/Latino. The sample included 15
(75.0%) physicians, 3 (15.0%) nurses and 2
(10.0%) physician assistants. Participants had vari-
ous specialties including public health (n¼ 3, 15.0%), family medicine (n¼ 7, 35.0%), internal medicine (n¼ 6, 30.0%) and obstetrics and gyne- cology (n¼ 4, 20.0%).
Knowledge and beliefs
Participants were asked what they think of when
someone mentioned tobacco products. Almost
every participant mentioned three products: cigar-
ettes, chewing tobacco and cigars. Very few partici-
pants mentioned hookah, e-cigarettes or any other
form of tobacco. Moreover, thematic differences in
relation to knowledge and beliefs about these prod-
ucts across provider settings (rural vs. urban) were
not identified.
Cigars and cigarillos. Participants were asked
about their general opinions on cigars and cigar-like
products (cigarillos, little cigars) in addition to
health risks, addiction and interactions with their
patients about the products. Some participants
noted that they treat cigars like they treat all type
of tobacco products and discourage their patients
from using them. Furthermore, some participants
believed that the popularity of cigars is on the rise,
especially among women. When asked about health
risks, most participants indicated that they believed
that they are not as risky as cigarettes. One partici-
pant said,
I mean, my impression is that numbers are
lower, and some people don’t inhale them,
so perhaps the risk is somewhat lower or at
least for lung cancer.
Most participants thought that cigars may be
addictive. However, many suggested that it may
take longer for people to get addicted since they
may not be inhaling or they may not be using
these products as frequently as cigarettes. One par-
ticipant said,
You know, I think anything that has nicotine
probably has the potential for addiction. I
would say with cigars, it’s probably slightly
lower, not because of the cigar itself, but just
because of the kind of social setting in which
you can smoke a cigar. When they smoke a
cigar, they don’t inhale. I think they probably
consume less with the cigar. It may take a
longer time to get addicted, but eventually it
happens.
Smokeless tobacco. All participants knew about
smokeless tobacco and had various ideas on the
health risks of those types of products. Some sug-
gested that chew and snus were more prevalent in
more rural areas of the country. One participant said,
Well, I know they’re more commonly used in
the less educated and the more rural areas. I
know that they’re at risk for more systemic
conditions even though it’s not as much as
inhaled.
Health risks that were mentioned throughout the
interviews centered on different types of cancers
rather than pulmonary afflictions. One participant
said,
I think it’s not likely as much of a risk for lung
cancer, esophageal cancer, stomach cancer,
but it can be for mouth cancer, although that
is hard to quantify. I think there’s been some
mixed messages lately.
In addition, many participants mentioned that
their patients tend to not think they are at risk for
health complications because they are not inhaling
the tobacco. Most participants not only agreed that
there were elevated oral cancer risks, but the addic-
tion potential was still high even though it is not a
product that was meant to be inhaled.
T. M. S. Bascombe et al.
378
Hookah. While some participants mentioned
hookah being a part of Middle Eastern culture,
others saw it as a popular, social activity among
young people. One participant even thought that
hookah is just a fad saying,
I think hookah is something that is going to be
trendy. I don’t think it’s going to be around
long. I think it’s going to be with the younger
generation, and I think after this trend or this
fad dies down, that’s going to be it.
Still, many of the participants did not know much
about the product at all besides the fact that it exists
and people use it for recreational smoking.
Most of the participants were unfamiliar with the
health risks and potential addictiveness of hookah.
However, despite the lack of knowledge, some pro-
viders said the type of product smoked is irrelevant
because all were bad for the users’ health. One par-
ticipant had tried hookah but indicated that they
were unaware of the health effects:
I’ve tried it and I was like, wow, this is kind of
cool, but is this good for me? I don’t know.
I’ve done it once or twice. I have no idea about
the health effects of that—no idea—and I
think those are growing in popularity. Every
now and then you see new signs for a hookah
lounge somewhere. I wondered if it was legal.
I was assured it was legal, but I really have no
idea of the health effects.
Despite little knowledge about hookah, a few pro-
viders thought that there was still the potential for
addiction. Although hookah is not brought up in
clinic visits often, a couple of participants noted
that patients would bring it up when asked about
different types of tobacco they smoke.
E-cigarettes. Many participants said that they
were unsure of the health effects of e-cigarettes,
and some did not even know what they were.
Many participants indicated believing that
e-cigarettes may be effective in helping smokers
quit using traditional cigarettes, and some reported
patients indicating that e-cigarettes helped them
avoid smoking tobacco. One participant said,
I actually think that in three to five years
they’ll be the recommended way of stopping
cigarette use. I think the clinical data is going
to show that they are much more effective
than using a nicotine patch, because they ad-
dress the habit.
There were many instances where participants
expressed their interest in finding out if e-cigarettes
can be used for smoking cessation. Some partici-
pants had already recommended using them instead
of traditional cigarettes for some of their patients.
One participant said,
The new alternative to cigarettes is the elec-
tronic cigarettes. We bring that up as an option,
talk about a different medication, and with me, I
only offer it to the ones who specifically ask.
Most participants noted that the health risks of
e-cigarettes are largely unknown. However, most
suggested that they could not be worse than cigar-
ettes. Many participants mentioned that, in general,
e-cigarette use does not come up in clinic visits very
often; however, usually when it was mentioned, the
conversation was about using them to quit smoking
traditional cigarettes.
Marijuana. Participants were asked about their
general opinions on marijuana. Many participants
indicated that they believed that it was mostly
young people who are using this drug and that mari-
juana is a gateway drug to other illicit drugs.
Participants spent most of the time discussing the
various health risks that are associated with marijuana
use. Many were concerned with the adolescent health
risks of its use, and many considered marijuana to
have the same health risks as cigarettes and other
combustible tobacco products. One participant said,
I honestly think that the health risks are the
same as smoking cigarettes because it’s the
smoking—it’s the burning of the lungs—
that’s actually the problem. It’s not the nico-
tine in the cigarettes that’s causing harm. It’s
the actual smoke and the inhalation of the
smoke . . . and I don’t think that those side ef-
fects of marijuana have been studied or have
Healthcare providers and tobacco practices
379
been researched enough because everybody
seems to think that marijuana is safe.
In addition, many participants noted that the
effects of marijuana use may be worse and more
prevalent in habitual smokers when compared to
those who smoke only occasionally. Moreover, par-
ticipants had mixed reviews on the addictive proper-
ties of marijuana. Some believed that marijuana was
very addictive and that patients are in denial about
its addictiveness, while others believed that it was
not as addictive or as dangerous as traditional
cigarettes.
Clinic-based practices
Participants were asked various questions about their
clinic-based practices in regards to tobacco use.
Little, if any, differences in clinic-based practices
were reported across provider settings. Most partici-
pants noted that they inquire about tobacco products
during the intake process, but they typically do not
ask about specific tobacco products. If they see a pa-
tient more frequently than once a year, they may not
ask about tobacco at every visit.
When asked about the tools that they offer their
patients to help quit smoking, the strategies most
frequently mentioned were brochures, brief counsel-
ing, the Quit Line and pharmacotherapy (including
nicotine replacement therapy and prescription medi-
cation). However, most reported that these strategies
were largely applied only to cigarette users rather
than alternative tobacco users and that, even among
cigarette smokers, these strategies were not regu-
larly offered. One participant said,
We have various options, which start from
directing them to the Georgia Quit Line, to-
bacco quit line, which has a lot of resources
and information, and then we also offer them
over the counter products, which are numer-
ous. Then, of course, there’s prescription
medications. . . .
Participants described varying follow-up prac-
tices. Most said that they would follow-up with a
patient at their next visit. However, a few partici-
pants offer some more insight into this process.
In regards to marijuana, most participants
indicated that they assess marijuana during their
routine questionnaire about drug use. They believed
that many patients do not report marijuana use, even
when explicitly asked. Some participants noted that
those patients that do report use indicate using it
recreationally or for relaxation, pain management
and other medicinal purposes. Thus, offering
assistance is a challenge. Several also mentioned
that compounding the issue is a lack of clarity
about what assistance could be provided and in
what circumstances this type of assistance is
appropriate.
Perceived areas for needed research and information
Participants’ responses to the additional research on
alternative tobacco products and marijuana that is
needed included health risks/effects, addictiveness
and effects on adolescents. One participant said,
What would be really helpful I think for pro-
viders, for me as a provider, and I think for a
lot of my colleagues, would be like a little grid
that would give you cancer risks, cardiovas-
cular risks, addiction risks, and other health
risks, and the list of products going across.
Many participants noted a need for research
regarding the potential of e-cigarettes to serve as a
cessation or harm reduction aid for cigarette
smokers. One participant noted,
I’m actually waiting for the data to come out
about e-cigarettes. It’s going to take a while to
get long-term data, but I think we’re going to
be surprised at what we find. It seems like a
safe alternative. I don’t tell my patients that,
but just from a physiologic standpoint it seems
that, like I said, it can’t be worse than
cigarettes.
Discussion
This research study served to qualitatively examine
healthcare providers’ knowledge, beliefs and
T. M. S. Bascombe et al.
380
clinic-based practices regarding traditional and al-
ternative tobacco products as well as marijuana. In
addition, this study assessed healthcare providers’
perspectives on the research necessary to support
clinicians. Findings indicated a lack of knowledge
about these products in general, their health impli-
cations and their potential addictiveness. Most par-
ticipants reported difficulty knowing how to address
these products in the clinical setting due to a lack of
empirical evidence to inform their discussions or
clinical practice guidelines that advise them on
how to address the array of products.
In the context of decreased use of cigarettes and
increasing quit rates [2], the increasing popularity of
the alternative tobacco products (smokeless tobacco,
cigars, hookah, e-cigarettes, etc.) and marijuana, es-
pecially among young people, indicates the need to
study how and why these products are being used,
their health effects and their addictive properties.
There has been burgeoning research in this area
over the past 5 years [3, 9]; however, the research
has not definitively determined the range of health
effects of these products or their potential for addic-
tion, how they interact with one another and how
these products might impact cessation or abstinence.
Thus, the research community has not definitely in-
formed guidelines on how healthcare providers
should assess or address the use of alternative to-
bacco products and marijuana. Despite the lack of
conclusive research, there is a major need to provide
practitioners with information or resources highlight-
ing the state of the science regarding the health im-
plications of these alternative tobacco products and
marijuana that can facilitate their communication
with patients to promote informed decision making.
Many participants believed that, because many of
these products are mainly used socially or on occa-
sion, there is a lower risk for people who use them.
However, the current knowledge is not available to
say whether or not this is true [16, 17]. Many respond-
ents still perceive these products as less harmful than
cigarettes, which aligns with the published literature
documenting this in the general population [18, 19].
Of note, some admitted telling their patients that they
would rather they smoke e-cigarettes than traditional
cigarettes [16, 20]. This aligns with prior research
indicating that a proportion of people who have
talked with their healthcare provider about using or
switching to e-cigarettes reported that their doctor
recommended using them in place of cigarettes [19].
A major concern is that standard assessments of
tobacco use in the clinical setting typically do not
specify the range of tobacco products that are in-
creasingly being used. As such, it is possible that
patients and clinicians assume that only traditional
tobacco products, particularly cigarettes, are rele-
vant. Thus, this likely represents a missed opportun-
ity to assess use of alternative tobacco products.
However, healthcare providers in this study felt ill
equipped to address the range of tobacco products,
partially because of a lack of formal clinical practice
guidelines to assist them in this context. Moreover,
despite the increase in marijuana use in the general
population, similar guidelines to address this issue
have not yet been established [11].
This study has implications for research and prac-
tice. First, the research community must establish a
firm empirical basis regarding the health effects of
these products and their potential for addiction to
inform practice. In particular, the use of e-cigarettes
to promote cessation needs to be addressed to aid prac-
titioners in discussions around this topic. In addition,
interviews of healthcare providers should be con-
ducted in other settings to gauge the varying know-
ledge and attitudes of providers outside of Georgia and
the southeast region of the United States. It would be
interesting to see the opinions of providers in the states
and regions where marijuana has differing levels of
legalization and decriminalization. It would also be
an asset if more nurses, physician’s assistants and
other allied health providers are included in future
studies as they may spend more time with patients
counseling them on preventive health practices.
Limitations
Study limitations include a lack of generalizability,
but the study itself can be applied to similar popu-
lations. Qualitative studies are not meant to be gen-
eralizable to similar populations; however, they do
have transferability. The second limitation is that
Healthcare providers and tobacco practices
381
this study only had a sample size of 20 people, which
is small due to the nature of the population being
hard to reach mainly due to lack of time. However,
our research did reach the point of saturation.
Conclusions
This study provides a good foundation for further
investigating how the use of alternative tobacco prod-
ucts and marijuana is being addressed in the health-
care setting. The findings suggest that there is a lack
of knowledge about these products and sparse cred-
ible resources highlighting the health risks or poten-
tial for addiction of these products. Moreover, the
potential of these products, particularly e-cigarettes,
to aid in harm reduction or cessation of traditional
cigarettes should be examined within the context of
robust randomized controlled trials. More research is
needed to give the healthcare providers the tools to
make informed decisions about assessing and inter-
vening on patients’ use of various tobacco products
and marijuana. In the meantime, providers need re-
sources to aid them in articulating the existing re-
search within the context of the clinical encounter.
Acknowledgements
The authors acknowledge and thank the Cancer
Coalition of South Georgia for their collaboration
on this research and Matchless Transcription for
transcribing the interviews.
Funding
Supported by the National Center for Advancing
Translational Sciences of the National Institutes of
Health under Award Number UL1TR000454. The
content is solely the responsibility of the authors and
does not necessarily represent the official views of
the National Institutes of Health.
Conflict of interest statement
None declared.
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