Implementing Proactive Smoking Cessation Induction Interventions in a Certified Community Behavioral Health Clinic: A Pilot Type 2 Hybrid Effectiveness-Implementation Study

Abstract Background: People with mental health and substance use disorders have a high prevalence of tobacco use. Community mental health clinics, including certified behavioral health clinics, are a key entry point where people with mental health and substance use disorders receive care. Implementation strategies to deliver tobacco use disorder treatment in community health clinics are needed. Two promising strategies supported by clinical practice guidelines are proactive outreach (reaching out to people in a health system who smoke and providing treatment) and the 5As (mental health providers ask about tobacco use, advise to quit, assess interest in quitting, assist with cessation, and arrange for follow up). Methods: The current study is a pilot type two hybrid effectiveness-implementation trial conducted in a certified behavioral health clinic. The clinic received a multilevel implementation strategy comprising didactic training, performance feedback and organizational coaching to promote delivery of the 5As at intake and treatment planning visits. Clients of the organization who consented to the study also received three proactive outreach contacts over nine months offering connections to cessation counseling and medication. Clients completed study surveys at pre-implementation, implementation launch, and at 3-, 6- and 12-months post implementation launch. Providers completed surveys before and after training and at 3-, 6-, 9-, and 12-months post-training. Primary outcomes were feasibility and acceptability of the client intervention and organization implementation strategies. Secondary outcomes were preliminary indicators of patient effectiveness. Results: Client recruitment, intervention delivery, and study assessment were feasible, with 49 client participants recruited over 3 months. Outreach completion rates were higher for earlier calls and ranged from 67-94%. Retention was high with 84% of client participants completing the primary outcome assessment. The implementation strategy was also successful, with greater than 50% attendance at study trainings (77 of 125 providers attended), and feasible delivery of organizational coaching (coaching delivered to all 3 clinic sites) and performance feedback (all 3 clinic sites receiving monthly performance feedback). Acceptability ratings were high for both the intervention and the implementation strategy. Staff survey completion waned over time (completion rates 51-72%) and turnover was high. Client CO-confirmed abstinence rate at 12 months post enrollment was 8%. Conclusions: Implementing proactive tobacco use disorder treatment in a certified community behavioral health clinic was feasible and acceptable. A full scale trial to test the effectiveness of the study interventions and implementation strategy is warranted.