Introduction:
Macedonia has one of the highest rates of tobacco use in the world. An estimated 37% of the adult population are tobacco consumers (46.5% for men and 26.7% for women). Tobacco is inexpensive and is a part of the socio-economic life for a significant number of Macedonian residents. The country lacks the public health and clinical infrastructure needed to deliver effective tobacco cessation counseling. To address this critical medical, training, and education gap, we implemented a comprehensive, culturally appropriate modified Certified Tobacco Treatment Specialist (CTTS) training program for Macedonian physicians.

Methods:
Utilizing formative qualitative data, the CTTS program was adapted to meet the context of tobacco use and access to preventive measures (e.g., counseling, pharmaceuticals) in Macedonia. An evaluation survey was developed based on a ‘systems model for clinical care’. Evaluation data were collected at baseline, two days post, and six months post. Process evaluation includes physician log-books for recording weekly encounters with patients who are former or current smokers.

Results:
Macedonian physician champions and US partners trained 97 physicians in the counseling methodology. Statistically significant improvements (p<0.001) in knowledge over six months were demonstrated on multiple topics, including health risks, nicotine knowledge, addiction behavior, and vulnerable populations. Provider self-efficacy scores for conducting counseling activities increased by over 50%. Patient-level perception and outcome data are currently being collected and will be reported. To date, over 20,000 counseling sessions have been reported, lasting on average 8.3 minutes, which represents 45% of an entire visit’s length.

Conclusions:
The aCTTS training filled a critical gap by equipping physicians with tools to address the profound tobacco use prevalence in Macedonia. Results indicate both a desire and readiness on the part of physicians to learn and implement clinical changes to reduce tobacco use and improve the health of their patients and themselves.

Funding:
This project receiving funding from Pfizer International Grants for Learning & Change.