Complementary Therapies in Clinical Practice 20 (2014) 181e187

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Smoking cessation dialogue and the complementary therapist: Reluctance to engage? Tomlinson Lynne a, b, Mackereth Peter b, c, * a

School of Social Work, Psychology & Public Health, Salford University, UK Complementary Health & Wellbeing Services, The Christie NHS Foundation Trust, Manchester, UK c Metropolitan University of Manchester, UK b

a r t i c l e i n f o

a b s t r a c t

Article history: Received 3 June 2014 Received in revised form 23 July 2014 Accepted 29 July 2014

Introduction: Our aim was to explore the experiences and views of complementary therapists (CT) regarding smoking cessation (SC) support within the oncology setting. Methods: Two oncology sites participated in the North West of England. Three focus groups were conducted (n ¼ 19) with resulting transcripts thematically analysed. Demographic data was collected via a short questionnaire. Results: Reasons were given for reluctance to engage in SC support, these included; fear of comprising the therapeutic relationship, patient's poor motivation and/or those living with life limiting disease. Nicotine Replacement Therapy (NRT) advice was regarded as a ‘medical’ activity. There was evidence of smoker-related stigmatisation. Conclusion: This study provided insights in how complementary therapists view a potential SC role. Research is needed to determine whether the findings are common to other areas of CT practice. Further training in SC support is suggested for those working in oncology settings. © 2014 Elsevier Ltd. All rights reserved.

Keywords: Focus groups Smoking cessation Complementary therapists Stigma

1. Introduction There are approximately 23% adults in England and 26% Adults in Scotland who are current smokers [1]. Smoking accounts for onethird of all cancer deaths and up to 90% of lung cancer cases [2]. Smokers are seven times more likely to die of the following cancers - bladder, cervix, kidney, larynx, pharynx, nasal cavities and sinuses, oral cavity, oesophagus, pancreas, stomach, liver and myeloid leukaemia [3]. There is also evidence that smoking is a causative factor in bowel and ovarian cancers [4]. Research has identified that smoking significantly reduces the longevity and quality of life of patients with a range of cancer [5,6], yet 50% of patients continue to smoke following diagnosis [7]. With specific regard to the oncology setting smoking during radiotherapy has been shown to adversely reduce the effectiveness of treatment, increase toxicity and increase side effects such as oral mucositis, loss of taste, xerostomia (dry mouth), weight loss, fatigue, pneumonitis, bone/soft tissue damage and poor voice quality

* Corresponding author. Complementary Health & Wellbeing Services, The Christie NHS Foundation Trust, Manchester M20 4BX, UK. E-mail address: [email protected] (M. Peter). http://dx.doi.org/10.1016/j.ctcp.2014.07.007 1744-3881/© 2014 Elsevier Ltd. All rights reserved.

[8,9]. It has been reported that smoking during chemotherapy can induce neutropenia exposing smokers to increased risk of infection [10]. Smokers during cancer treatment report increased side effects such as hair loss, memory problems, nausea, depression, insomnia, hot flushes, shortness of breath and pain [11,12]. Guidelines on smoking cessation recommend that all healthcare professionals (HCPs) ask their patients about the smoking status, and if found to be a smoker, provide brief advice on smoking cessation and refer for support, regardless of the reason for consultation [13]. The purpose of this strategy is to have consistent messages from every HCPs to move smokers toward a cessation attempt [14]. A Cochrane systematic review assessed the impact of Brief Interventions Training (BIT) and reported it increased HCPs confidence, levels of intervention and overall proficiency [15]. A systematic review of studies with general practitioners (GPs) identified consistent negative beliefs and attitudes toward the effectiveness of smoking cessation interventions, reporting unpleasant experiences talking to smokers and having lack of time and skills to engage with this work [16]. A later study by the same research team reported that GPs preferred to refer smoking cessation patients to skilled professionals within their own practices rather than to centralised cessation services [17]. A survey of HCPs (n ¼ 88) with follow on in-depth interviews (n ¼ 10),

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identified barriers to providing smoking cessation services; these included: e patients lacked motivation; stopping smoking makes no difference to prognosis; mentioning smoking alienated patients; more pressing issues; and not wanting to invade privacy [18]. Another barrier to smoking cessation intervention is the continued smoking amongst HCPs. An analysis of questionnaires from ward-based staff (n ¼ 1429) found that HCP smokers underestimated the consequences of smoking and were less likely to counsel patients about smoking risks [19]. They also found that those that never-smoked over-estimated risks and felt less qualified to counsel patients than smokers or ex-smokers. A survey of nurses (n ¼ 1074) found that smokers rated their role as health educator and role model below that of non-smoking and exsmoking nurses [20]. Smoking status was also found to affect how nurses rated cessation services [21]. No literature has been found that specifically examines the attitudes of complementary therapists (CTs) toward smoking cessation interventions. The aim of this study was: To explore the experiences and views of complementary therapists towards a role in smoking cessation support within oncology settings. 2. Methodology The researcher used ‘sensitising concepts’ generated from the literature review to act as reference or suggestion points for the research. In data analysis, sensitizing concepts suggestions seed the researcher's attention and focus, helping to deepen perception and organization of the field rather than rigidly define it. Importantly, they are reviewable and can be overwritten by emerging data patterns [22]. Qualitative data can provide rich descriptions of processes within specified contexts and move researchers beyond their initial conceptual frameworks [23]. A qualitative methodology was selected to best support the research aim. Focus groups were chosen for their capacity to explore how points of view can be debated, constructed and expressed [24]. Questions can be sequenced to allow participants to become familiar with the topic and recollect personal opinions and experiences [25]. They also offer the necessary flexibility to explore unanticipated issues, demonstrate high face validity and can generate sufficiently rich data within a reasonable timescale [26].

selected participants were chosen to comment on the accuracy and fairness of the analysis. No corrections were requested at any stage of the research process. 2.2. Participants A purposive sample of 19 participants were selected based on homogeneity of their experience i.e. 1) a minimum of 12 months experience in an oncology setting; and 2) occupational training in one or more complementary therapies (e.g. aromatherapy, massage, reflexology, reiki, acupuncture, hypnotherapy). Therapists were excluded if they had completed Smoking Cessation Training in the last five years. Three focus groups with a minimum of five participants were recruited using approved invitations posted on staff notice boards at two oncology centres. The rationale for smaller groups of less than eight implies that each participant needed to play a prominent role. Interested participants were provided with an information pack containing a participant invitation/information sheet for the focus group study, a consent form and a confidential demographic questionnaire. Each focus group lasted approximately 45 min. Two focus groups were held at site “A” and one at Site B; both were hosted by the same facilitator (first author LT). 2.3. Focus group interview questions The trigger questions for participants were formulated from the literature review and agreed by both facilitators. They were adapted as the interviews proceeded by adding questions arising from discussion. The opening question utilised a powerful scenario to evoke involvement in the debate [31]. Questions were designed to be open-ended to stimulate discussion without over-direction and facilitate participant responses [26]. Questions leading with the phrase “thinking about” or “from your personal experience” were used to establish a context for responses and ground the participants in their own experiences. Questions regarding roles and therapies overlapped each other intentionally. This offered our participants with opportunities to challenge each other, and to elaborate and even contradict themselves as they explored the complexity of their opinions [31]. The trigger questions are listed in Table 1. 2.4. Ethics

2.1. Analysis The interviews were digitally recorded and transcribed by the researcher to produce a verbatim record that included repetitions, hesitations, false starts and grammatical errors. Participant reviewing and verifying their own transcripts was regarded as essential to ensure the rigour of the data collected [27]. In an attempt to protect against ‘forcing’ data, the researcher used grounded theory inductive processes to ensure theoretical sufficiency for data coding and thematic analysis [28]. Our processes included; line-by-line coding to identify implicit/explicit meanings; focussed coding to organise and integrate frequently occurring data; and the identification of provisional conceptual categories, themes and subthemes. The constant comparative analysis of similar codes from different participants at different times and in different focus group interviews continued until data saturation was achieved [29]. To strengthen the reliability and internal validity of the research design a data sample was selected, thematically analysed and sent for analyst triangulation by our second author (PM). The results were not comparative and the coding process was repeated until agreement on themes/subthemes was achieved. To strengthen face validity, two randomly

Ethical approval for the study was obtained from the Ethics Committee, University of Salford. Managerial approval at the two sites was obtained. All participants were fully informed of the research aim and encouraged to seek clarification to ensure the

Table 1 Focus group trigger questions. What do you think about smoking and cancer treatment? Thinking about your role and what you do, has the issue of smoking emerged in your therapeutic practice? If so, what sort of things would help or hinder how you would talk to them about smoking? How do you think your role and advice compares to smoking cessation support from a doctor or nurse? From your personal experience, do you think that complementary therapies have a part to play in helping people stop smoking? What do you think about pharmaceutical aids to stopping smoking, e.g. NRT? Thinking of your complementary therapies in the workplace, do you think the smoking policies there affect you, other therapists or your patients in any way? Is there anything else that you consider important regarding smoking cessation support?

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validity of their consent. They were advised of the confidential, voluntary nature of their participation, their responsibility to coparticipants and their right to withdraw themselves and their data at any time without consequences.

Table 3 Key themes and sub themes. Themes

Sub themes

Debating the ethics of smoking cessation

Good or bad timing To ask or not to ask? Making an informed choice Substitution and motivation Stress, control and pleasure Walk of shame The two shouldn't go together It's the smell Maybe … by invitation only It's a medical thing Insider advantage In private and clinical practice

3. Findings

Filling the gaping hole

19 participants were recruited, all with had a minimum of 12 months experience of providing complementary therapies in an oncology setting. One participant withdrew their demographic questionnaire, but not their contribution, because of past smoking status; for this reason and informal discussion with other participants we have removed this data from the demographic report (see Table 2). The key themes and sub-themes are listed below in Table 3.

Judgment and hypocrisy

3.1. Theme 1: debating the ethics of smoking cessation

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Is it a role for us? Smoking experiences

I can understand them … not wanting to give up … if they are terminal … .then … perhaps that's the only crutch that they have [P4F3]

Good or bad timing The tension between health promotion and smoking behaviour raised issues of intrusion into people's lives:

I look at life as though the damage has already been done anyhow and … why should they take away something [P3F2].

… very fine line between … health promotion … and going one step

To ask or not to ask? Participants did ask about smoking status, but for some it was a paper exercise:

too far to pressurising them [P4F1] Some participants ‘imagined’ the viewpoint of the patient in a 'time of crisis' and equated cessation with deprivation or sense of futility:

How the question would be received was also considered from the patients’ perspective:

Table 2 Demographic characteristics of the participants. Indicator

Description

n ¼ 18a

%

Sex

Male Female Caucasian Mixed Other None Roman Catholic Church of England 31e40 years 41e50 years 51e60 years 61e70 years Less than 1 year 1e5 years 6e10 years Less than 1 year 1e5 years 6e10 years 11 years þ NHS Cancer Centre Private Practice Other charity service Hospice College/University NVQ Certificate Diploma Degree Hypnotherapy Massage Aromatherapy Reflexology Relaxation techniques

2 16 14 2 0 16 1 1 4 6 6 2 2 4 11 1 4 8 5 13 12 9 8 1 1 3 5 14 8 15 14 10 10 16 6

11% 89% 78% 11% 0% 89% 6% 6% 22% 33% 33% 11% 11% 22% 61% 6% 22% 44% 28% 72% 67% 50% 44% 6% 6% 17% 28% 78% 44% 83% 78% 56% 56% 89% 33%

Ethnic group

Religion

Age group

Years as a therapist

Years working in cancer care

Place of work

Level of training

Complementary therapy training

Registered health professional a

One data set missing (withdrawn).

… with my own private clients, I gave them the consultation form … question is there “do you smoke?” … but I never felt qualified to … carry that through [P2F1]

If I put myself in their shoes and if I still smoked … I'd be thinking, it's my fault I'm ill … I wouldn't want to be judged [P5F2] Participants debated the relevance of smoking status to patients’ immediate needs, some never asked about smoking:

… it's a challenging question … and I don't do smoking cessation … [P6F2] Several participants used strategies for asking about smoking in an ‘appropriate’ manner:

… so you can say … ’did you know we had a smoking cessation service?, if that's any help to you?’

… that's how I phrase it … they must be sick of being asked if they smoke [P4F2] Making an informed choice Some participants discussed the impact of a diagnosis of cancer, the benefits of stopping to treatment outcomes and how this might motivate a stopping attempt: I think for some people it is an absolute motivator … It's crunch time [P4F2] Written information was suggested as a means of preserving patient autonomy and minimise therapist discomfort:

… if it's trying to persuade them to stop smoking … you’re being judgemental … .whereas if you’re giving them some piece of paper … it's neutral [P2F3]

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3.2. Theme 2: filling a gaping hole Substitution and motivation Participants were concerned what could replace smoking:

… would you like somebody to take something away from you that you really enjoyed? … that would leave a gaping hole? [P3F2]. The groups discussed the use of NRT, E-cigarettes or other substitutes and the need to support patient's choice: I wouldn't feel it was up to me to tell them … to either use patches or whatever [P2F3] Reservations were expressed about the limitations of medication and importance of motivation: Unless you really, really want to, no matter how many times … you try … you won't give up … .sorry [P3F1]

All groups identified that therapists potentially engaged in behaviours that were problematic:

… for instance I probably have … you know, I eat a lot of chocolate [P5F3] The two shouldn't go together. Participants expressed their initial ‘gut’ responses to seeing patients smoking and receiving treatment: Smoking and cancer treatment shouldn't go together [P1F2] It always amazes me … the number of patients outside … .drips up … having on-going treatment … who have got to have a fix [P2F3]. Staff observed smoking outside the oncology settings were seen as undermining the service:

… you see workers here … smoking … cancer patients see that and we’re … trying to get them to stop[P3F2]

Participant considered that interventions could also be considered as temporary management and sensitive support for smokers during hospital stays:

Many participants felt that to be a smoker and HCP was incompatible:

It's not stopping smoking … its needing any support while they are in … it's a really unfriendly environment for a smoker [P1F2]

… if they were telling the people to stop I think that would be rather hypocritical [P1F3]

… they are going through an awful lot of trauma … so they need that … ongoing extra support [P1F1]

A self declared smoker gave their perspective:

Stress, control and pleasure Statements by therapists often defended a ‘stress calculation’ and/or ‘not now’ tactic:

… to expect a cancer patient to give up smoking when they’re suffering with a stressful period in their life must be really difficult [P2F2]

… I couldn't follow through … just because of my choice of not [stopping smoking] [P4F1] It's the smell Cigarette ‘smell’ was also something that patients needed to be protected from:

… putting myself in the position of the client, I would find that really, really uncomfortable [P1F2]

Some participants emphasised the importance of smoking to the person's pleasure: ....it's a pleasurable … .thing for them … you know sit down and have a cup of tea and a cigarette [P1F3] Other comments included how patients perceived smoking as a means of control:

… she didn't want to stop smoking … it was the only thing she got any control over … when she was having the chemo and everything else [P6F3]

3.3. Theme 3: judgment and hypocrisy The walk of shame Participants with smoking histories sharing their experiences of being judged:

… I was forced to defend myself against 15 people in the room … who were … very anti-smoking [P4F1] A participant talked about a patient who was shamed into stopping smoking as she could not:

… deal with that walk of shame … taking my drip down [to the roadside] [R1F1]

Participants needed to protect themselves as well:

… that's how I am … I do find it offensive [P2F1] … I would struggle … with a complementary therapist who smokes, being honest, because … they smell [P1F2] A participant with a smoking history talked about feelings of stigmatisation:

… there's an element of almost like sin, like you’re doing something wrong … you can be a really good … nurse … therapist … if you smoke … as long as you come to work and don't smell [P5F2]

3.4. Theme 4: is it a role for us? May be … by invitation only Several participants emphasised that they would approach smoking by invitation only:

… if they approached it with me … I could … pass on some information [P5F3] Going beyond information giving and relaxation was mostly seen as a specialist role:

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I use … those sort of techniques … if people need or want nicotine patches … they need to … talk to their GP [P3F3]

… that's the beauty of private practice that you can say ‘no’ [to smokers] [P1F2]

Confidence in making interventions was generally linked to adequate training:

Participants described how they had negotiated with smokers about their behaviours:

… as a complementary therapist and a nurse I do know and understand about [smoking cessation] treatments available [P5F1]

… working in the community … I wouldn't go into a house if they were smoking [P1F2]

It's a medical thing or is it? Participants believed that smoking cessation was a separate from their therapeutic role:

Other participants felt that in private work they could reject smoking cessation work:

I just don't think it's my place … I think it's medical … it's either a nurse … or a doctor … .as far as I'm concerned I'm there to help make their life easier [P2F3] I would be out of my depth … that would be for the GP to give advice on [P5F2]

I have people seeking smoking cessation [private practice] I’ve turned them a way because as a smoker I don't feel like it's my place to [P4F1] The advantages of working in a clinical environment included being able to refer patients easily:

… working here [hospital] is great because you can then direct The groups identified elements that they believed were unique to CT. These included the positive perceptions of others towards their therapeutic role:

… they don't … see therapists as being authority … as you’re giving a treatment … people … open up a lot more [P4F3] … perceive[d] to have … .the time … to listen … probably the most important part of someone wanting to give up [P2F1] The intention and modality of therapy treatments was also considered important: It's about making them feel better about themselves, so they don't need that crutch [P2F2]

… strategies that they can use that are more healthy … will give them the same effect … so … I would feel that is, the part for complementary therapies to play [P1F2]

them to whoever is responsible [P4F3] For one participant defining personal limits was equated with modelling self-care to patients:

… and we don't allow ourselves to be put into a situation that we are not comfortable with … [that way] we enable our clients to do the same [P1F2] Participants were happy to work with patients who were using NRT products but uncomfortable being exposed to ‘vapourizing’ from an e-cigarette:

… not the ‘e’ cigarette though! [P4F3]. A situation was described that required urgent intervention:

… we had a very dramatic moment … a lady on oxygen, with a cylinder … she … hide behind the corner to have a cigarette [P3F3]

3.5. Theme 5: smoking experiences Insider advantage Participants discussed whether ex-smokers had an ‘insiders’ advantage to smoking cessation work: I think you'd have the empathy because you'd really know what it's like … and how hard it is to give up [P5F2] Ex-smoking participants referred to their own motivation to stop:

… mine was - I want to see my kids have grandchildren. What am I playing at? [P3F1] I'd stop smoking for a few months … I'd think oh that's quite easy … but then I'd start again [P3F3] An example was also given of effortless cessation:

… but then I gave up over a weekend … it was easy [P1F2] In private and clinical practice. Participants discussed the advantages of private in controlling who they see:

4. Discussion 4.1. Reluctance to engage Our participants were largely hesitant about engaging in the question of smoking status and support to stop. There was concern amongst that asking the smoking question would reinforce a sense of guilt from patients living with a cancer diagnosis, which would be untimely and intrusive. Research has found that significant medical events such as a cancer diagnosis may serve as ‘teachable moments’ (TMs) for smoking cessation [7]. TMs can be conceptualised as a window of opportunity for HCPs to motivate individuals to modify harmful health behaviours [9]. The oncology setting provides a particularly potent context for TMs as diagnosis and treatment represent times when patients look to HCPs for extra support [32]. Research suggests that on diagnosis of cancer, motivation and interest in cessation significantly increases and this extends into survivorship as well [8]. It has been reported that HCPS play a critical role in assisting patients stop smoking and preventing relapse [33]. Clearly our participants, all therapists, were mostly reluctant to engage in smoking cessation, and looked to HCPs to do this work or avoided it completely.

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One group regarded written information on smoking and cancer treatment as particularly appropriate, and neutralised their discomfort in addressing this issue e it would be the patient's choice to read it. Leaflets on smoking cessation services are thought to be key in persuading a wide range of smokers to attempt to stop [13]. It's argued that self-help materials have no additional benefit over a personalised smoking cessation session; however tailored self-help materials are viewed as more effective than non-tailored [15]. A 2007 survey suggested that 53% of smokers have sought help for stopping smoking and 41% of smokers said they had read leaflets on how to stop. In 76% of cases, advice was in the form of a discussion about smoking and 24% of smokers were given only printed literature representing an increase from 15% in 1996 to 22% in 2007 [34]. Participants reported that the smoking ban had drawn attention to the unacceptability of smoking in public. Recent commentators have expressed concern about ‘smoker-related stigmatisation’ [35]. Goffman [36] defined the term stigma as ‘ … an attribute that is deeply discrediting’ (p.13). Participants, who currently smoked, reported a degree of hostility from colleagues. Anecdotal evidence was also given about a patient who stopped smoking from a sense of shame. Theorists have proposed that stigmatisation can have positive consequences facilitating healthy behaviours [37]. It has been asserted that stigmatisation is ethically acceptable if it reduces the burdens of smoking-related morbidity and mortality [38]. Beliefs concerning responsibility for one's own cancer are correlated with higher levels of guilt, internalised shame, anxiety and depression [39]. Stigma linked to smoking is a particular issue identified for lung cancer patients [40]. Our participants were aware of colleagues who smoked and deemed this incongruent with their professional role, objecting to the smell of tobacco, both for themselves and for patients. Most participants felt that their role should be a supportive one, geared to stress reduction, with smoking cessation work patient driven and dealt with sensitively. Advice or administering pharmacotherapies was deemed best left to medical professionals. Those therapists with nurse/medical backgrounds appeared more confident to provide information regarding the treatments available. Participants reported that they would feel more comfortable about referring or working with cessation interventions if they had adequate knowledge, training and support. There was a reported willingness to work ‘integratively’. Such an approach could be a useful way of ensuring that CTs have a role in supporting smoking cessation in clinical environments, however their training needs would need to be sufficiently addressed with the smoking cessation messages remaining consistent. Our participants did recognise that they had the skills to listen, support and assist with mood and wellbeing utilising complementary therapies. Effective management of mood has been suggested as a key factor in preventing smoking relapse and maintaining use of NRT and other smoking cessation interventions [41]. Research is needed to assess smoking cessation programs for cancer patients (and the growing population of cancer survivors) possible barriers to cessation and how predictors, such as self-efficacy correlate with successful cessation. Self-efficacy has been found to be a consistent predictor of smoking behaviour and relates to motivation to stop, successful cessation and managing relapse [42,43]. Self-motivation in cancer patients has also been correlated to receiving current treatment [44]. This may be due to debilitating side-effects or recovery from surgery that can deter smoking in the short-term and periods of hospitalisation that can provide a protected environment and reinforce initial abstinence [9]. 4.2. Smoking experiences A minority of participants referred to their own smoking histories and attempts to stop smoking. Ex-smokers placed emphasis

on the need for intrinsic motivation to be successful. Balmford and Borland [45] have challenged such beliefs and stress the importance upon promoting effective pharmacological or behavioural aids in supporting cessation attempts. They also emphasise the importance of informing smokers that doubts/ambivalence do not require elimination before making a decision to stop smoking, and in some cases, can be helpful in promoting realistic contingency planning. Research indicates that smokers perceive ex-smoker cessation advisors as more empathic and their personal experiences of smoking were valued more highly than medical expertise [46]. It could be argued that appropriate use of self-disclosure as an ex-smoker may also strengthen rapport. The sub-themes showed empathic identification with the patients' dilemma regarding cessation and balancing the impact on treatment. It has been identified that patients with cancer may have higher levels of co-morbidity, more difficulties stopping due to high nicotine dependence, more stress and emotional distress, poorer health and physical functioning [47]. Longer duration of support and interventions that build in smoking relapse prevention may need to be considered to promote cessation in the long term [48]. Tailored intensive interventions combining behavioural strategies with pharmacotherapy have been found to be more effective with highly dependent smokers, such as lung, head and neck cancer patients [49]. It has been emphasised that cessation programmes also need to consider supporting relatives and family members [50]. The purpose being to reduce the risk of relapse through access to cigarettes and to reduce tensions and conflicts that may result with partners continuing to smoke, especially in the context of a lung cancer diagnosis [51]. 4.3. In private and clinical practice Some participants differentiated between private and clinical practice in terms of choosing or not to work with clients who smoked and their need to maintain a smoke-free environment. In both private and clinical setting, smoking colleagues were perceived as potentially problematic, undermining the ethos of smoke free environments and the message to go smoke free during cancer treatment. Patients using medically approved forms of NRT such as patches, lozenges, gum or inhalators were considered safe but vapourizing/e-cigarettes were not. These findings represent insights into concerns that CTs have regarding exposure to tobacco and managing their own therapeutic environment. Focus group two discussed potential strategies to manage their disgust at the smell of tobacco. This included informally directing patients to other therapists, reminding themselves of the patients' situation/ short treatment time or within private practice by being able to refuse smokers as clients. 5. Limitations The participants were only audio-taped and the written transcripts do not identify the subtleties of non-verbal transactions, tonality and pacing. Equally important is the inability to categorise silences or withdrawal from discussion which has an eloquence of its own. We elected to withdraw our participants' smoking histories from the demographic report, following withdrawal of this data by one participant and follow-up discussion with others. Clearly, this was for some a sensitive issue, and a potential source of bias in our findings. Future researchers may want to investigate this area further to understand more fully the effects of stigma upon participants in smoking related studies. The study included only two sites so our findings cannot be generalised to all oncology settings.

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6. Conclusion The interviews provided some insights into the importance of autonomy and comfort for therapists in engaging (or considering) smoking cessation dialogue with patients. Further training in SC brief interventions is warranted as an important step in helping CTs to be part of an integrative oncology service that promotes smoke free cancer care. This research finding appears to be new and no comparative literature in smoking cessation or complementary therapies could be found. It is suggested that further research would be needed to ascertain views and opinions beyond the two oncology sites in this project. It will also be important to investigate therapeutic outcomes of integrating CTs, within a package of support, for patients engaging in smoking cessation during cancer treatment. Conflict of interest statement None declared. Acknowledgements The authors would like to thanks Julie Jones, Senior Lecturer Salford University for her supervision with this study. We would also like to thank the participants at both sites for taking part in the focus groups. References [1] NHS. Statistics on smoking. London: NHS Information Centre; 2008. [2] DoH. Cancer reform strategy. London: Department of Health; 2007. [3] Gandini S, Botteri E, Iodice S, Boniol M, Lowenfels AB, Maisonneuve P, et al. Tobacco smoking and cancer: a meta-analysis. Int J Cancer 2008;122(1): 155e64. [4] Secretan B. A review of human carcinogensepart E: tobacco, areca nut, alcohol, coal smoke, and salted fish. Lancet Oncol 2009;10(11):1033e4. [5] Baile WF. Alcohol and nicotine dependency in patients with head and neck cancer. J Supportive Oncol 2008;6:165e6. [6] Tsao AS, Liu D, Lee JJ, Spitz M, Hong WK. Smoking affects treatment outcome in patients with advanced non-small cell lung cancer. Cancer 2006;106(11): 2428e36. [7] Sanderson Cox L, African NL, Tercyak KP, Taylor KL. Nicotine dependence treatment for patients with cancer: review and recommendations. Cancer 2003;98:632e44. [8] Gritz ER, Fingeret MC, Vidrine DJ, Lazev AB, Mehta NV, Reece GP. Successes and failures of the teachable moment. Cancer 2006;106:17e27. [9] McBride CM, Emmons KM, Lipkus IM. Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res 2003;18: 156e70. [10] Laufman LR, Spiridonidis H, Laufman H, Baker L, Kuebler P, Young D. Smoking status affects chemotherapy-induced neutropenia [Abstract] J Clin Oncol 2004;22(14). supplement 8097. [11] Duffy SA, Terrell JE, Valenstein M, Ronis DL, Copeland LA, Connors M. Effect of smoking, alcohol, and depression on the quality of life of head and neck cancer patients. Gen Hosp Psychiatry 2002;24:140e7. [12] Peppone L, Mustian K, Palesh O, Plazza K, Janelsins M, Roscoe J, et al. The effect of smoking on side effects among cancer patients throughout treatment: a URCC CCOP Study of 947 patients [Abstract]. In: Presentation at the 34th Annual Meeting of the American Society of Preventative oncology March 20e23, 2010; 2010. [13] NICE. Public Health Intervention Guidance. Brief interventions and referral for smoking cessation in primary care and other settings. London: National Institute for Clinical Excellence; 2006. [14] BASSP. Statement on the minimum standards for training to stop smoking practitioners. British Association for Stop Smoking Practitioners; 2007. [15] Lancaster T, Silagy C, Fowler G. Training health professionals in smoking cessation (review). Cochrane Database Syst Rev 2000;3:CD000214. [16] Vogt F, Hall S, Marteau TM. General practitioners' and family physicians' negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review. Addiction 2005;100:1423e31. [17] Vogt F, Hall S, Marteau TM. General practitioners' beliefs about effectiveness and intentions to recommend smoking cessation services: qualitative and quantitative studies. BMC Fam Pract 2007;8(39):1e11.

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