Introduction:
The CTTS program has been shown to decrease smoking among lay populations but has not been applied to healthcare providers (HCP) who smoke. The program was adapted into a 1 ½ day training for Macedonian physicians, 1/3 of whom are active smokers. An important objective was to understand how aCTTS impacts the smoking behavior and counseling activities of healthcare providers.

Methods:
A mixed-methods design was used. A longitudinal survey was conducted at baseline and 6- and 12-months post-intervention. Bivariate and multivariate analyses were used to determine significant changes across time and refine associations between HCP demographic characteristics, smoking history, and changes in knowledge and self-efficacy for counseling. Qualitative interviews were conducted with key informants at baseline and with HCP who use tobacco at 6 months post-intervention. Interviews were transcribed, coded, and analyzed thematically to surface key findings from interview transcripts, which were then compared with salient quantitative findings.

Results:
While 1/3 of HCPs currently smoke, almost half indicated they had smoked at least 100 cigarettes in their lifetime. While half of current HCP who smoke indicated, at baseline, an interest in quitting within the next 6 months, that number did not decrease significantly. Interviews with HCP who smoke revealed a lack of specialized training, lack of medications and resources, and feelings of stigma and hypocrisy drove behavior. Despite this, HCP who smoke counseled patients at the same average rate as their nonsmoking peers. HCP who smoke framed patient counseling as a matter of managing exacerbation instead of preventing disease.

Conclusions:
Overcoming fatalism among HCP who smoke is a vital first step to achieving universal cessation among the healthcare establishment. Further research is needed to reverse attitudes that prioritize secondary over primary prevention, in addition to providing skills to manage stigma and training and resources to support quitting.

Funding:
Authors gratefully acknowledge funding through Pfizer Grants for Learning and Change (European Division) and the Global Bridges Healthcare Alliance for Tobacco Dependence Treatment, Mayo Clinic.