Use of complementary and alternative medicines by patients with chronic obstructive pulmonary disease

Johnson George, David C M Kong, Kay Stewart, Lisa L Ioannides-Demos and Nick M Santamaria
Med J Aust 2004; 181 (5): 248-251. || doi: 10.5694/j.1326-5377.2004.tb06262.x
Published online: 6 September 2004


Objectives: To investigate complementary and alternative medicine (CAM) use by patients with chronic obstructive pulmonary disease (COPD) and to explore their beliefs about CAM.

Design and participants: Cross-sectional study of 173 patients with moderate to severe COPD, and indepth interviews with a purposive sample of 28 patients.

Setting: Ambulatory care.

Main outcome measures: Use of CAM; beliefs about the value of CAM.

Results: 71 patients (41%) claimed to be using some form of CAM. Most commonly used were multivitamins and minerals, and garlic was the most commonly used herbal preparation. Patients reported that advertisements and people with prior experience of using CAM were their major sources of information. Extent of knowledge about CAM, degree of faith in CAM and personal attitudes influenced decisions to try CAM. Patients used CAM to promote general wellbeing, to counteract drug side effects, to compensate for dietary deficiencies and to ameliorate their disease. Efficacy appeared less important to users than safety. CAM practitioners were regarded as more convincing, informative, considerate and available compared with mainstream health professionals.

Conclusions: Communication between patients and mainstream health professionals about CAM use could be improved by health professionals being more accepting of CAM use and having some basic knowledge about commonly used CAM preparations.

Complementary medicines, also known as “traditional” or “alternative” medicines, include vitamin, mineral, plant or herbal, naturopathic and homoeopathic preparations and some aromatherapy products.1

Patients’ decisions to use or not to use any type of medication are influenced by their personal beliefs about the necessity to take the medication and their concerns about taking it.2 Studies have shown that a person’s interest in complementary and alternative medicines (CAM) is determined by various psychosocial factors.3-5 Little research has been done on factors associated with CAM use among Australian patients, and there have been calls for research, mainly using qualitative approaches, to better understand CAM use.6

Users of CAM in Australia7 and other countries3,8,9 report chronic respiratory conditions as being among their leading health problems, but there is little confirmatory evidence to support the role of CAM in these ailments.10 Chronic obstructive pulmonary disease (COPD) is the fifth leading cause of global mortality11 and accounts for more than 4% of all deaths in Australia.12 In the Australian population, the prevalence of COPD is higher in males than in females (19.4 per 1000 v 13.0 per 1000), and older people (> 65 years) account for two-thirds of those reporting COPD as their main disabling condition.12

Among the various CAM preparations, only ginseng, used in combination with ongoing respiratory medications, has proven clinical efficacy in COPD.13 However, ginseng’s potential for interactions with common drugs — warfarin, digoxin, nifedipine, loop diuretics and monoamine oxidase inhibitors — overshadows its benefits.14

We aimed to investigate current CAM use by patients with COPD and to explore their beliefs about CAM.


Our study was nested within a randomised controlled trial (RCT) investigating the impact of a multidisciplinary community management program for patients with moderate to severe COPD (forced expiratory volume in 1 second [FEV1] < 60% predicted). Subjects were enrolled in the RCT (n = 173), based on their lung function, from among patients admitted to a major tertiary-care hospital for an acute exacerbation of COPD in the preceding 2 years, and from hospital and community-based voluntary databases of respiratory patients.

Cross-sectional study

During home visits, the pharmacists (L L I-D and J G) recorded baseline data on use of current prescription and non-prescription medications and CAM.

Although broader definitions of CAM exist,15 for the purposes of our study products listed in Schedule 14 of the Therapeutic Goods Regulations1 were classified as CAM. Laxatives such as bisacodyl with senna, calcium supplements and vitamin D were not classified as CAM, because of their common clinical use in this patient group for preventing constipation and osteoporosis.

Cross-sectional study

The mean age (SD) of the 173 patients was 70.0 (9.6) years and 62.4% were men. CAM use was self-reported by 71 patients (41%), of whom 39 (55%) were men. They used from one to four different CAM preparations, with a mean (SD) of 1.7 (0.9) CAM preparations per user. The Box shows the types of CAM used.

The proportion of patients using vitamins/minerals and herbal/natural preparations was 23/65 (35% [95% CI, 23%–47%]) and 15/65 (23% [95% CI, 13%–33%]) among women, and 31/108 (29% [95% CI, 20%–38%]) and 15/108 (14% [95% CI, 7%–21%]) among men, respectively. The mean age (SD) of patients who used CAM (71.6 [8.5] years) was not significantly different from that of non-users.


This is the first Australian study to explore beliefs about CAM in a sample of chronically ill patients. We found that use of CAM preparations by patients with COPD was higher than in the general Australian population,7 but falls in the range of CAM usage reported among Australians with other chronic disease conditions.17-19 Our participants’ age and sex distribution was representative of that of community-based COPD patients.12

That patients generally obtain information on CAM and CAM practitioners from advertisements and recommendations from friends or family with previous experience of CAM has been reported elsewhere.8,17,18,20 This reflects the lack of a reliable and unbiased source of information on CAM for the public. The report submitted to the Australian government by the Expert Committee on Complementary Medicines in the Health System21 might improve this situation.

Use of CAM in conjunction with, rather than as a replacement for, existing treatments is consistent with previous studies.3,4,18,20,22 Avoiding side effects was a major motivation behind CAM use, according to a community-based survey.8 Use of CAM for general wellbeing and to compensate for dietary deficiencies contrasts with usage reported in the 1999 National Health Survey,7 but matches the findings of a recent Australian study.18 Unlike other reports,4,5,8,20 dissatisfaction with or lack of effectiveness of conventional treatment and desire for greater autonomy were not mentioned as reasons for using CAM in our study.

Eagerness to experiment with different treatment options, including CAM, has been reported previously in patients suffering from incurable conditions.17 A belief in the safety of CAM because of its “naturalness” is known to appeal to patients.5,17,20 Patients with COPD often have multiple co-morbidities23 requiring complex medication regimens.24 The ready availability of CAM from health food shops and supermarkets could jeopardise these patients’ safety. For example, several CAM preparations used by patients in this study — vitamin E, avocado, coenzyme Q10, garlic, ginkgo, saw palmetto, omega-3/fish oil and ginger — are known to alter platelet aggregation.14,25,26 Changes in international normalised ratios (INR) in patients taking warfarin after initiation or cessation of a self-prescribed multivitamin supplement have been reported.27 The potential for such adverse events is greater when patients do not disclose information relating to their intake of CAM preparations to their mainstream health professionals.

Mainstream healthcare providers are known to be less informed about the use of CAM preparations by their patients,5,17,22,28 and physicians’ comfort level when discussing CAM with patients is known to be poor.29 Other studies have found similar reasons for patients not disclosing CAM use to their mainstream health professionals.5,28 Interestingly, difficulty communicating with medical practitioners and insufficient time were the least important reasons given.28 The Expert Committee on Complementary Medicines in the Health System recommends that medical practitioners include questions (in a non-judgemental way) about use of CAM when taking a patient history, and include complementary medicines in adverse drug reaction reports.21

Our findings suggest that CAM practitioners are more receptive to conventional medicine than mainstream health professionals are towards CAM. Improved communication between CAM practitioners and mainstream health professionals could improve health professionals’ knowledge of their patients’ use of CAM.

Our study has several limitations. We relied on self-reporting by patients and indepth interviews for information on CAM use, and our findings were not verified against any objective measures. The study design does not allow our results to be generalised to COPD patients as a whole. The congruence of our findings with those in published reports on other patient populations substantiates our study’s reliability; however, patients participating in clinical trials tend to be more health conscious and their views on health may not be representative of the general patient population.

Two out of five patients with moderate to severe COPD were found to use CAM preparations in conjunction with their existing treatments, mainly for general wellbeing. Unbiased information on the safety and efficacy of CAM for both health professionals and the public is warranted. Mainstream health professionals need to be more accepting of CAM use and possess basic knowledge about the commonly used CAM preparations. This might improve communication between patients and mainstream health professionals on CAM issues, in turn facilitating optimal treatment outcomes.

Received 5 March 2004, accepted 16 July 2004

  • Johnson George1
  • David C M Kong2
  • Kay Stewart3
  • Lisa L Ioannides-Demos4
  • Nick M Santamaria5

  • 1 Department of Pharmacy Practice, Faculty of Pharmacy, Monash University, Melbourne, VIC.
  • 2 Ambulatory and Community Services, The Alfred, Melbourne, VIC.



We thank Anna Priamo and Nelly Procopiou for their help in data collection, and are grateful to the patients who participated in this study. This study is part of a larger research program funded by the Department of Veterans’ Affairs. The qualitative phase of the study was funded by the Novartis Hospital Pharmacy Research Grant of the Society of Hospital Pharmacists of Australia. Johnson George is the recipient of a Monash Graduate Scholarship and a Monash International Postgraduate Research Scholarship. The Department of Veterans’ Affairs, Novartis and the Society of Hospital Pharmacists of Australia were not involved in the study design, data collection, analysis or interpretation, and had no influence on the writing or submission of this article.

Competing interests:

None identified.

  • 1. Complementary medicines information sheets: Therapeutic Goods Administration, 2003. Available at: (accessed Jul 2004).
  • 2. Horne R, Weinman J. Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res 1999; 47: 555-567.
  • 3. Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998; 279: 1548-1553.
  • 4. Sirois FM, Gick ML. An investigation of the health beliefs and motivations of complementary medicine clients. Soc Sci Med 2002; 55: 1025-1037.
  • 5. Wagner PJ, Jester D, LeClair B, et al. Taking the edge off: why patients choose St John’s Wort. J Fam Pract 1999; 48: 615-619.
  • 6. Sibbritt D, Adams J, Easthope G, Young A. Complementary and alternative medicine (CAM) use among elderly Australian women who have cancer. Support Care Cancer 2003; 11: 548-550.
  • 7. Australian Bureau of Statistics. National Health Survey: use of medications, Australia. Canberra: ABS, 1999. (Catalogue No. 4377.0.) Available at: (accessed Jul 2004).
  • 8. Palinkas LA, Kabongo ML. The use of complementary and alternative medicine by primary care patients. A SURF*NET study. J Fam Pract 2000; 49: 1121-1130.
  • 9. Ong CK, Petersen S, Bodeker GC, Stewart-Brown S. Health status of people using complementary and alternative medical practitioner services in 4 English counties. Am J Public Health 2002; 92: 1653-1656.
  • 10. Pauwels RA, Buist AS, Calverley PM, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop summary. Am J Respir Crit Care Med 2001; 163: 1256-1276.
  • 11. World Health Organization. World Health Report 2001. Geneva: WHO, 2001. Available at: (accessed Jul 2004).
  • 12. Australia’s Health 2002. Canberra: Australian Institute of Health and Welfare, 2002; 493. Available at: (accessed Jul 2004).
  • 13. Gross D, Shenkman Z, Bleiberg B, et al. Ginseng improves pulmonary functions and exercise capacity in patients with COPD. Monaldi Arch Chest Dis 2002; 57: 242-246.
  • 14. Tatro DS, editor. Drug interaction facts: herbal supplements and food. St Louis, Mo: Facts and Comparisons, 2003.
  • 15. Zollman C, Vickers A. What is complementary medicine? BMJ 1999; 319: 693-696.
  • 16. NVivo [computer program], version 1.2. Melbourne: Qualitative Solutions and Research, 2000.
  • 17. Begbie SD, Kerestes ZL, Bell DR. Patterns of alternative medicine use by cancer patients. Med J Aust 1996; 165: 545-548. <MJA full text>
  • 18. Alderman CP, Kiepfer B. Complementary medicine use by psychiatry patients of an Australian hospital. Ann Pharmacother 2003; 37: 1779-1784.
  • 19. Clifford RM, Batty KT, Davis W, Davis TME. Prevalence and predictors of complementary medicine usage in diabetes: Fremantle Diabetes Study. Pharm Prac Res 2003; 33: 260-264.
  • 20. Quattropani C, Ausfeld B, Straumann A, et al. Complementary alternative medicine in patients with inflammatory bowel disease: use and attitudes. Scand J Gastroenterol 2003; 38: 277-282.
  • 21. Expert Committee on Complementary Medicines in the Health System. Complementary medicines in the Australian health system, 2003; 165. Available at: (accessed Jul 2004).
  • 22. Featherstone C, Godden D, Selvaraj S, et al. Characteristics associated with reported CAM use in patients attending six GP practices in the Tayside and Grampian regions of Scotland: a survey. Complement Ther Med 2003; 11: 168-176.
  • 23. Mapel DW, Picchi MA, Hurley JS, et al. Utilization in COPD: patient characteristics and diagnostic evaluation. Chest 2000; 117: 346S-353S.
  • 24. Dolce JJ, Crisp C, Manzella B, et al. Medication adherence patterns in chronic obstructive pulmonary disease. Chest 1991; 99: 837-841.
  • 25. Tatro DS, editor. Drug interaction facts. St Louis, Mo: Facts and Comparisons, 2003.
  • 26. Cheema P, El-Mefty O, Jazieh AR. Intraoperative haemorrhage associated with the use of extract of saw palmetto herb: a case report and review of literature. J Intern Med 2001; 250: 167-169.
  • 27. Kurnik D, Lubetsky A, Loebstein R, et al. Multivitamin supplements may affect warfarin anticoagulation in susceptible patients. Ann Pharmacother 2003; 37: 1603-1606.
  • 28. Adler SR, Fosket JR. Disclosing complementary and alternative medicine use in the medical encounter: a qualitative study in women with breast cancer. J Fam Pract 1999; 48: 453-458.
  • 29. Corbin Winslow L, Shapiro H. Physicians want education about complementary and alternative medicine to enhance communication with their patients. Arch Intern Med 2002; 162: 1176-1181.


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