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

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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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