The Emerging Global Tobacco Treatment Workforce: Characteristics of Tobacco Treatment Specialists Trained in Council-Accredited Training Programs from 2017 to 2019

Tobacco use is projected to kill 1 billion people in the 21st century. Tobacco Use Disorder (TUD) is one of the most common substance use disorders in the world. Evidence-based treatment of TUD is effective, but treatment accessibility remains very low. A dearth of specially trained clinicians is a significant barrier to treatment accessibility, even within systems of care that implement brief intervention models. The treatment of TUD is becoming more complex and tailoring treatment to address new and traditional tobacco products is needed. The Council for Tobacco Treatment Training Programs (Council) is the accrediting body for Tobacco Treatment Specialist (TTS) training programs. Between 2016 and 2019, n = 7761 trainees completed Council-accredited TTS training programs. Trainees were primarily from North America (92.6%) and the Eastern Mediterranean (6.1%) and were trained via in-person group workshops in medical and academic settings. From 2016 to 2019, the number of Council-accredited training programs increased from 14 to 22 and annual number of trainees increased by 28.5%. Trainees have diverse professional backgrounds and work in diverse settings but were primarily White (69.1%) and female (78.7%) located in North America. Nearly two-thirds intended to implement tobacco treatment services in their setting; two-thirds had been providing tobacco treatment for 1 year or less; and 20% were sent to training by their employers. These findings suggest that the training programs are contributing to the development of a new workforce of TTSs as well as the development of new programmatic tobacco treatment services in diverse settings. Developing strategies to support attendance from demographically and geographically diverse professionals might increase the proportion of trainees from marginalized groups and regions of the world with significant tobacco-related inequities.


Introduction
While tobacco control efforts have made progress in reducing the prevalence of cigarette smoking, Tobacco Use Disorder (TUD) is one of the most common substance use disorders in the world [1,2] and tobacco use remains a leading cause of preventable death and disease, responsible for more than 8 million deaths worldwide every year [3]. Over 600,000 of these deaths annually are from secondhand smoke, including 30% children [4,5]. Moreover, tobacco use has a disproportionate impact on lower socioeconomic groups [3]. Over 80% of the 1.3 billion tobacco users worldwide live in low or middle-income countries with some of the highest rates of tobacco-related death, disease, and health care costs [6]. If current consumption rates continue, smoking cigarettes alone is projected to kill 1 billion people in the 21st century [7,8]. Tobacco use also imposes substantial global economic burdens. The average cost of smoking cigarettes globally is 1.8% of the gross domestic product (GDP) [9], but this burden is not equally shared. Nearly 40% of this burden is shouldered by developing countries, causing significant financial liability on already-limited budgets [10]. For example, Jordan loses 6% of its GDP to tobacco use annually [11]. Accordingly, tobacco use is one of the leading causes of health inequities in the world [12,13].
The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), developed to address the worldwide proliferation of tobacco products, is focused on international efforts to reduce demand for and supply of tobacco products [14]. At present, 182 parties covering 90% of the world have joined the treaty. Article 14 of the FCTC states that each party should take evidence-based measures to promote tobacco cessation and provide treatment for tobacco dependence, but little progress has been made in many parts of the world [15]. For instance, the Eastern Mediterranean has some of the highest tobacco smoking prevalence rates in the world [16,17]. Over 42% of men in the United Arab Emirates [18], and 70% of men in Jordan smoke cigarettes [11]. In Lebanon, 50% of men and women smoke cigarettes [16]. Nearly 20% of young people in the Eastern Mediterranean smoke tobacco in waterpipes [17]. The Gulf Cooperation Council (GCC: United Arab Emirates, Saudi Arabia, Qatar, Kuwait, Oman, Bahrain) has prioritized the reduction of tobacco smoking [19,20]. The WHO Regional Committee for the Eastern Mediterranean lists tobacco control as a crucial part of a regional framework for action to control premature death from non-communicable diseases [3,21].
TUD is a complex behavior influenced by powerful biological, psychological, social, and cultural factors [22][23][24]. Most tobacco users want to quit and many make attempts to quit every year, but few attempts result in long-term abstinence [25,26]. For example, in Jordan, 57% of cigarette smokers intend to quit in the next year and 42% in the next 30 days [27]. In the US, 70% of cigarette smokers want to quit and more than half make a quit attempt each year, but less than 10% of these attempts result in 6 months of abstinence [26]. Nearly 80% of tobacco users have difficulty quitting, experience withdrawal symptoms, and continue to use tobacco despite the knowledge of the harm [23]. Moreover, the complexity of treating TUD is increasing as new tobacco products are introduced and combined with traditional tobacco products worldwide. In addition to traditional cigarettes, cigars, cigarillos, and a wide variety of smokeless tobacco products, there are hundreds of different electronic nicotine delivery systems (ENDS, e.g., e-cigarettes, vaping devices) with thousands of flavors [28], dissolvable tobacco products, and heat-not-burn delivery systems [29]. (See Supplementary Materials for examples of tobacco product use common in certain regions of the world.) Detailed knowledge of this changing landscape is required to engage in meaningful and effective discussions with tobacco users.
Evidence-based treatment of TUD dramatically increases the chances of achieving longterm abstinence [30][31][32], but utilization of evidence-based approaches worldwide remains very low [25]. The highest standard of care for TUD is evidence-based behavioral treatment provided by highly skilled practitioners, guided by treatment manuals, and combined with pharmacotherapy [33][34][35][36][37][38]. In the US, one of the wealthiest countries in the world, less than one third of quit attempts are aided by evidence-based treatment and less than 5% receive the highest standard of care [25,26]. Greater use of evidence-based treatments would result in more individuals achieving long-term abstinence more quickly and reduced tobacco-related death, disease, and economic loss worldwide.
Lack of treatment access is a primary contributor to low utilization of evidence-based treatments for TUD [24,39]. In addition to lack of clinician time [40][41][42], internationally one of the most common barriers to providing treatment is a lack of training in the treatment of TUD [15,[40][41][42][43][44][45][46][47][48][49]. Advanced provider training is linked with improved tobacco treatment skills and clearly improves patient outcomes [36,37,50,51]. Moreover, lack of provider training disproportionately affects individuals with complex TUD presentations such as individuals using multiple tobacco products, with mental health conditions, with cancer and other chronic health conditions, and pregnant women, all of whom show clear benefits from specialized TUD treatment [52][53][54].
Systematic, brief intervention models are recommended by many clinical practice guidelines [31,[55][56][57] and have significantly increased the number of cigarette smokers identified and advised to quit; nevertheless, after decades of implementation, few tobacco users are provided with evidenced-based assistance [26,58]. Complementary models, however, that incorporate specialist treatment into brief intervention models (e.g., Ask, Advise, Connect) and are tested in real-world settings can dramatically increase the proportion of patients who receive treatment [34,36,[59][60][61][62]. Recent advances in lung cancer screening have also provided opportunities for highly trained specialists to reach high-risk populations [63].
Although there are dozens of different tobacco treatment training programs worldwide, little is known about the characteristics of individuals who seek advanced training in the treatment of TUD [15,44,64]. Established in 2008, the Council for Tobacco Treatment Training Programs (www.ctttp.org (accessed on 24 February 2021)) has developed an interdisciplinary approach to implementing training standards [65] for Tobacco Treatment Specialists (TTSs) with the goal of ensuring that TTSs are prepared to meet the needs of dynamic, diverse, and complex populations of tobacco users in diverse settings. As the number of accredited training programs and trainees has grown, little is known about the nature of the accredited programs and the trainees and whether the Council and these training efforts are well-positioned to meet the needs of tobacco users in diverse settings. This study of the data collected by the Council from 2016-2019 aimed to examine the nature of the training programs, the characteristics of the trainees, and to make recommendations for developing a tobacco treatment workforce that meets tobacco treatment needs worldwide.

Materials and Methods
Council accreditation requires a TTS training program to complete a formal application and review process, often with guidance provided by Council reviewers. Each application describes the nature of the training program, the target treatment population, and other unique characteristics in detail, including its goals and objectives, faculty, and process for inviting professionals, who serve culturally and linguistically diverse populations. The application requires the program to demonstrate how they teach each of the required skills, how they engage in self-evaluation, and how they evaluate trainee learning. The application is reviewed by the Board of Councilors, experts in the field, and accreditation is awarded when the Board of Councilors determines that the training program meets all the training standards. Continued accreditation is subject to annual review.
All Council-accredited training programs meet the same minimum training standards, but differ in their missions, settings, training models, training modalities, and the tailored focus they provide trainees. Successful completion of a Council-accredited TTS training program is necessary to be eligible for the National Certificate of Tobacco Treatment Practice (NCTTP) (https://www.naadac.org/NCTTP (accessed on 24 February 2021)).For instance, some programs, such as Optum's Quit for Life, National Jewish Health ® , MercyCare, and Healthways, train professionals only within their organizations. While most programs train professionals on their campuses, many programs also travel to other sites, nationally and internationally, to provide training. From 2016-2019 most programs provided the bulk of the training via in-person workshops.
In 2016 and 2017, the Council, in collaboration with the training programs, implemented mandatory reporting. In 2016, all programs were required to report the number of trainees trained annually. In 2017, the collection of a minimal common set of data from trainees was implemented. This data is collected by the programs, generally prior to training, and reported in a de-identified manner to the Council by January 31 following the reporting year. The minimal data set includes basic demographic information as well as professional background, work setting, experience in the treatment of tobacco dependence, and reasons for seeking training including: "I want to treat tobacco users," "My organization is requiring me to," "I want to get certified," "I want to learn more about the field of tobacco treatment," and "I want to do research." Trainees can identify more than one reason.
Data was compiled by the Council management (Jessica Retzlaff) and analyzed by Drs. Carl and Sheffer. Descriptive analyses were conducted for all variables (range, means, standard deviations, frequencies, percentages). Pearson correlation coefficient was calculated between the number of hours per week devoted to tobacco treatment and the number of years working in tobacco treatment. Professional background and work setting were categorized within common professional themes. For example, registered, licensed, surgical, hospice, and palliative care nurses were categorized under nursing. (n = 15), Africa (n = 11), and Australia (n = 1); were predominantly White (69.1%), women (78.7%), and had completed at least some college education (93%). See Table 1. From 2016 to 2019, the annual number of trainees increased by 28.5%. See Table 2. A complete list of training programs accredited through 2020 is included in Table 3.      The ACT Center has trained TTSs in Mississippi across the US and internationally since 1999. This program attracts a broad range of professionals who work in a variety of health care, academic, community, and other settings. A unique aspect of this program is that clinical skills are taught within the context of hands-on mastery of the ACT Center Tobacco Treatment clinical treatment protocol. Substantial time is dedicated to hands-on practice delivering this treatment protocol. This manualized, evidence-based approach is the product of many years of testing and experience and represents an effective balance of state-of-the-art clinical procedures. The WVU training program teaches evidence-based tobacco treatment to a wide variety of healthcare professionals. This mission is accomplished with a multidisciplinary team of expert faculty from dentistry, medicine, nursing, pharmacy, social work, and public health. Training is provided in a three-day in-person workshop but also will be provided as part of the required curricula of the WVU Schools of Dentistry, Medicine, Nursing, Pharmacy, and Public Health. Trainee professional background and work setting were diverse. (See Tables 4 and 5) About 80% of respondents were from 13 professional backgrounds and nearly 20% were from 16 less frequently reported professional backgrounds. The response rate for this item was relatively low, 74%, which might reflect difficulty in answering the question among trainees without mainstream professional backgrounds. Over half (50.4%) of trainees worked in larger institutions such as hospitals, medical centers, or academic medical centers; however, 42.7% worked in one of seven other settings, and 6.9% worked in one of 17 less frequently reported settings.  * Reported by less than 1% of respondents, but includes such diverse work settings as dental practices, government agencies, homeless shelters, research, health insurance companies, and the military.

Between
The reasons for attending training, experience of trainees in the field of tobacco treatment, and the amount of time devoted to tobacco treatment indicate that most trainees were new to the tobacco treatment workforce. The most frequently reported reasons for training were to implement tobacco treatment services (61%), to learn (56.6%), and to become certified (52.1%). A meaningful proportion of trainees (15%) attended to improve their tobacco-related research and evaluation skills. Two-thirds (n = 2583; 66.2%) were new to the field having worked in tobacco treatment for 1 year or less. Nearly half of those working 1 year or less (44.5%; n = 1735) reported 0 years of working in tobacco treatment. Another 19.9% (n = 777) of trainees had worked in tobacco treatment for 5 years or less. In terms of time spent delivering tobacco treatment services, 44.7% (n = 1874) spent two days or less working in tobacco treatment. The number of hours per week working in tobacco treatment was positively correlated with the number of years working in tobacco treatment (Pearson correlation 0.24, p < 0.0001). The more years working in tobacco treatment, the more hours per week trainees reported working in tobacco treatment. See Table 1.

Discussion
The Council-accredited TTS training programs, diverse in terms of mission, setting, and training modalities, appear to be contributing to the development of an emerging, highly trained tobacco treatment workforce. The number of Council-accredited TTS train-ing programs and trainees has steadily increased in the last decade. Findings show a 28.5% increase in the number of trainees from 2016-2019. This increase coincides with the addition of eight new training programs from 2016-2019, two of which are located in the Eastern Mediterranean, a region with remarkably high tobacco smoking prevalence rates and a tremendous need for accessible, high quality, tobacco treatment. Training is an important step in developing the resources needed to provide access to tobacco treatment [15] and understanding the nature of the training programs and the characteristics of the trainees is key to developing a tobacco treatment workforce that meets tobacco treatment needs worldwide.
Trainees were from diverse professional and educational backgrounds and worked in a wide variety of medical, behavioral health, public health, and community settings which suggests that the interdisciplinary approach to developing the training standards was effective in meeting the needs of diverse professionals. Nonetheless, one of the most striking characteristics of trainees was their inexperience with tobacco treatment. Over 40% were not currently providing any tobacco treatment, and two-thirds had been providing tobacco treatment for 1 year or less. Yet nearly two-thirds of trainees intended to implement tobacco treatment services in their setting, and more than half were seeking TTS certification. This suggests that the Council-accredited training programs are indeed developing an emerging workforce with professionally diverse backgrounds seeking to identify as TTSs as well as contributing to the development of programmatic tobacco treatment services.
The demographic background of this emerging workforce, however, has not been particularly diverse. Trainees were primarily White (70%) and female (80%), about 14% Black or African American, and centered in North America, with little change during the observation period. While the two new programs in the Eastern Mediterranean have the potential to increase diversity, efforts to enhance diversity and inclusion within all programs is needed. A more diverse tobacco treatment workforce is key to meeting the needs of the many marginalized groups that experience tobacco-related disparities [66]. Coordinated efforts to increase trainee demographic and regional diversity are needed and well within the mission of the Council.
The primary catchment areas for many programs has been regional; however, the onset of the COVID-19 pandemic from SARS-CoV-2 virus in early 2020 caused nearly all programs to cancel in-person workshops and develop virtual training opportunities that have the potential to reach more diverse trainees. Virtual training opportunities also might enable distant groups to benefit from the expertise of particular training programs. For instance, health care settings across the world that treat individuals from the Eastern Mediterranean for TUD can now potentially access virtual training tailored to treating this population. Analyses of trainee data in the coming years will provide insight into the impact of the proliferation of virtual TTS training opportunities on the number and characteristics of trainees.
Nonetheless, many programs have a special niche within their institutions or within their state or regional tobacco control programs and thus their missions are not necessarily focused on volume or reach. With a few exceptions, the programs that have been training TTSs for the longest period of time tended to train a higher proportion of trainees. For instance, the University of Massachusetts program trained 27% of the trainees and the Mayo Clinic program trained 11.8% of the trainees between 2016-2019. These programs have dedicated staff, were established about 20 years ago, and travel nationally and internationally, which is likely to contribute to a higher volume of trainees.
Training a workforce in the evidence-based treatment of tobacco dependence is needed to improve access to effective treatment for TUD [14], particularly in low and middleincome countries. To this end, support and resources to develop training programs and fund trainee attendance is needed. Funding from Global Bridges was used to support attendance of some trainees at the King Hussein Comprehensive Cancer Center, but that is likely to be the exception. While the Council does not collect data on how trainees fund attendance, the high proportion of trainees who attend because they are sent by their employers as well as the high proportion of trainees who work in larger institutions such as hospitals, medical centers, and academic medical centers suggests that a large proportion of trainees' attendance is paid by employers. New virtual training opportunities have the potential to accelerate accessibility, but barriers remain including the cost of tuition, engaging in 30-40 h of training time, and access to high-speed internet. Within the mission of the Council is developing strategies to support attendance from demographically and geographically diverse professionals; doing so might increase the number of trainees from less well-supported organizations, from marginalized groups, and from low and middleincome countries. Asynchronous virtual training opportunities and blended (synchronous and asynchronous) training can help professionals train around busy work schedules. Ensuring professionals are released from duties or compensated for the time they devote to training would also help improve access. In the future, collecting the source of support for attendance might be an important new addition to the Council's minimum data set.
The strengths of this study include the characterization of multiple years of trainees who completed TTS training within a large group of training partners, accredited by one organization with one set of training standards. The large number of trainees allows for some generalization. Being a descriptive study, however, there are no methods for making causal conclusions about the nature of the programs and the characteristics of the trainees.

Conclusions
A highly skilled tobacco treatment workforce is a critical component in building the infrastructure and systems of care to increase the accessibility of treatment for TUD. The treatment of TUD is becoming more complex and tailoring treatment to address new and traditional tobacco products is needed. The Council is committed to the development and proliferation of training that meets the needs of a dynamic, diverse, and complex population of tobacco users. Council-accredited TTS training programs are contributing to the development of an emerging workforce prepared for the tobacco treatment challenges of the 21st century. Developing strategies to support attendance from demographically and geographically diverse professionals might increase the number of trainees from less well-supported organizations, from marginalized groups, and from regions of the world that experience tobacco-related inequities.

Institutional Review Board Statement:
The study was conducted according to the guidelines of the Declaration of Helsinki. This project reports on data collected in established educational settings, using normal and accredited education practices. The data included no identifying information and no ability to trace the data back to any individual. There was no potential adverse impact on trainees or instructors. The project that contributed support to this study was approved by Roswell Park Comprehensive Cancer Center Institutional Review Board (I-455719).

Informed Consent Statement:
This is an analysis of curated de-identified database collected by the training programs in established educational settings using normal educational practices and organized by the Council. Informed consent for human subjects was not applicable.

Data Availability Statement:
The data presented in this study are available on request and agreement with the Council for Tobacco Treatment Training Programs, Inc. The data are not publicly available but accessible with the appropriate data use agreement with the Council. Data requests should be made to info@ctttp.org.

Conflicts of Interest:
The authors declare no conflict of interest.