Understanding counselors' implementation of tobacco cessation services with patients

A cluster-randomized trial of a brief multi-component intervention to improve tobacco outcomes in substance use treatment

BACKGROUND

Smoking prevalence is high among people in substance use disorder (SUD) treatment, and program interventions to address smoking are often complex and lengthy. This cluster-randomized trial tested whether a brief multi-component intervention impacted tobacco outcomes among staff and clients.

METHODS

Seven SUD treatment programs were randomly assigned to the multi-component intervention or to waitlist control. The 6-month intervention included a leadership motivation assessment, program incentives, 4 staff training sessions and a leadership learning community session. Survey data were collected from staff and clients at pre- and post-intervention. Outcomes were first compared across condition (intervention vs waitlist control), and then examined pre- to post-intervention with condition collapsed.

RESULTS

Staff in the intervention (n = 48) and control conditions (n = 26) did not differ at post-intervention on smoking prevalence, self-efficacy to help clients quit, or practices used to help clients quit smoking. Intervention clients (n = 113) did not differ from controls (n = 61) in smoking prevalence or receipt of tobacco services. Pre-post comparisons collapsed across condition showed a decrease in client and staff smoking prevalence, which could not be attributed to the intervention, and a decrease in client receipt of cessation medication.

CONCLUSION

The brief multi-component intervention did not support changes in smoking prevalence or in tobacco-related services received by clients. Other intervention features are needed to reduce smoking among SUD clients.

TRIAL REGISTRATION

Randomization occurred at the program level and outcomes measured are program-level measures. Accordingly, the trial is not registered.

Implementing tobacco-free policy in residential substance use disorders treatment: Practice changes among staff

Introduction

Implementing tobacco-free policies in substance use disorders (SUD) treatment may reduce tobacco-related, health disparities. This study examined adoption of tobacco-related policy and practices in six residential programs participating in a California-sponsored, 18-month, tobacco-free policy intervention.

Methods

Directors (N=6) completed surveys of tobacco-related policies before and after the intervention. Staff completed cross-sectional surveys assessing tobacco-related training, beliefs, practices, workplace smoking policy, tobacco cessation program services, and smoking status pre- (n=135) and post-intervention (n=144).

Results

Director surveys indicated no programs had tobacco-free grounds, one provided tobacco-related staff training, and two provided nicotine replacement therapy (NRT) pre-intervention. At post-intervention, 5 programs had implemented tobacco-free grounds, 6 provided tobacco cessation training, and 3 provided NRT. Across all programs, staff were more likely to report smoke-free workplaces (AOR = 5.76, 95% CI1.14,29.18) post- versus pre-intervention. Staff positive beliefs towards addressing tobacco use were higher post-intervention (p<0.001). Odds of clinical staff reporting tobacco-related training participation (AOR = 19.63, 95% CI14.21,27.13) and program-level provision of NRT (AOR = 4.01, 95% CI 1.54, 10.43) increased post- versus pre-intervention. Clinical staff reporting they provided tobacco cessation services were also higher post-intervention (p= 0.045). There were no changes in smoking prevalence or quit intention among smoking staff.

Conclusion

A tobacco-free policy intervention in SUD treatment was associated with implementation of tobacco-free grounds, tobacco-related training among staff, more positive staff beliefs towards and delivery of tobacco cessation services to clients. The model may be improved with greater emphasis on staff policy awareness, facilitating availability of NRT, and reducing staff smoking.

Organizational Factors Moderating Changes in Tobacco Use Dependence Care Delivery Following a Comprehensive Tobacco-Free Workplace Intervention in Non-Profit Substance Use Treatment Centers

Although tobacco use is the leading preventable cause of death and is elevated among patients with substance use disorders, many substance use treatment centers (SUTCs) do not offer tobacco use interventions (i.e., screening and treatment). This study examined a key outcome of the implementation of a tobacco-free workplace program that provided education and specialized training to employees; namely, changes in clinician provision of the five As (Asking about tobacco use; Advising to quit; Assessing willingness to quit; Assisting with quitting; Arranging follow-up) from before to after the larger program implementation. The five As are a brief tobacco screening and treatment protocol that was taught as part of the program and that formed the basis for further intervention (e.g., provision of nicotine replacement therapies, Motivational Interviewing to enhance desire and willingness to make a quit attempt). Moreover, we also examined organizational moderators that may have impacted changes in the delivery of the five As over time among clinicians from 15 participating SUTCs. The number of the centers' total and unique annual patient visits; full-time employees; and organizational readiness for implementing change were assessed as potential moderators of change in clinicians' behaviors over time. Clinicians completed pre- and post-program implementation surveys assessing their provision of the five As. Results demonstrated significant increases in Asking (p = 0.0036), Advising (p = 0.0176), Assisting (p < 0.0001), and Arranging (p < 0.0001). SUTCs with higher Change Efficacy (p = 0.025) and lower Resource Availability (p = 0.019) had greater increases in Asking. SUTCs with lower Resource Availability had greater increases in Assessing (p = 0.010). These results help guide tobacco control program implementation to increase the provision of tobacco use interventions (i.e., the five As) to SUTC patients and elucidate Change Efficacy and Resource Availability as organizational factors promoting this clinician behavior change.

Occupational health professionals' attitudes, knowledge, and motivation concerning smoking cessation-Cross-sectional survey

OBJECTIVES

Occupational health (OH) professionals could play a prominent role in smoking cessation treatment and support (SCTS) and help individuals and workplaces become smoke free. However, their role has not been evaluated. The aim of this study was to assess differences between OH professionals' perceptions of their role in SCTS by measuring three groups of OH professionals' attitudes, knowledge, and motivation concerning SCTS.

METHODS

We collected data through an online survey completed by a cross-sectional sample of OH professionals: OH physicians (n = 182), OH nurses (n = 296), and OH physiotherapists (n = 96), collected from national trade union registers. The differences between the OH professional groups were analyzed using ANOVA, the Kruskal-Wallis, and chi-square tests.

RESULTS

The OH professionals had a positive attitude toward offering SCTS and were highly motivated to enhance their knowledge of this topic and acquire further training. The OH physicians and OH nurses assessed their current knowledge as sufficient. Conversely, the OH physiotherapists' level of knowledge was seen as insufficient. Traditionally, OH physicians and OH nurses have been responsible for carrying out SCTS, but the majority of the OH physiotherapists thought that SCTS should also be included in their job description.

CONCLUSIONS

All the OH professionals were highly motivated to deepen their knowledge of SCTS. The barriers between different professionals need to be recognized in occupational health services (OHS). OHS should organize its SCTS more effectively, strengthen their contributions to smoking cessation programs, and recognize the potential of OH physiotherapists for providing SCTS and enable them to expand their training.

Associations Between Organizational Culture, Workplace Health Climate, and Employee Smoking at Smaller Workplaces

Background:

Smaller workplaces frequently employ low-wage earners, who have higher smoking rates. Organizational culture and workplace health climate are two characteristics that could influence employee smoking. The purpose of this study was to examine the associations between organizational culture, workplace health climate, and smoking among employees at small (20-99 employees) and very small (<20 employees) workplaces. We proposed the following hypotheses: a stronger clan culture will be associated with a better workplace health climate (HP1); a better workplace health climate will be associated with lower odds of current smoking (HP2); and there will be an association between workplace health climate and smoking intensity (HP3) and between workplace health climate and quit intention (HP4).

Methods:

Executives and employees completed separate online questionnaires. Data collection occurred between June and October 2017. We used regression and Fisher’s exact tests to answer study hypotheses.

Results:

Workplaces with stronger clan cultures had a better workplace health climate (b = 0.27, P < .05), providing support for HP1. A better workplace health climate was associated with lower odds of being a current smoker (odds ratio [OR] = 0.08; 95% confidence interval [CI]: 0.01, 0.53), providing support for HP2. No significant relationship existed between workplace health climate and smoking intensity (P = .50) or between workplace health climate and intention to quit smoking (P = .32); therefore, HP3 and HP4 were not supported.

Conclusion:

Certain culture types may inform an organization’s health climate. Despite a lower likelihood of current smoking in workplaces with better health climates, a better health climate may not be sufficient to produce changes in smoking behavior and intentions.

Impact of an Online Training Program in Smoking Cessation Interventions in Hospitals

PURPOSE

To assess changes in the self-reported performance of smoking cessation interventions according to the 5A's model (Ask; Advise; Assess; Assist; and Arrange follow-up) among clinicians; and to identify the main barriers and facilitators in smoking cessation implementation before and after an online smoking cessation training program.

DESIGN

Pre-post evaluation.

METHODS

We assessed self-reported smoking cessation interventions in the implementation of the 5A's model among clinicians working in Catalan hospitals (Spain). In addition, we assessed individual-, behavioral-, and organizational-level factors that act as barriers and facilitators in the implementation of the 5A's model. We used a questionnaire of 63 items reflecting each of the 5A's performance (scored from 0 = none to 10 = most possible). The questionnaire was completed both immediately before and 6 months after the training. We analyzed the data of those participants who had a clinical role and answered pre- and post-questionnaires. We used the nonparametric test for paired data (Wilcoxon) to examine changes in scores.

FINDINGS

A total of 127 clinicians completed the pre-post questionnaire; 63.0% were registered nurses, 17.3% were nursing assistants, 7.9% were physicians, and 11.8% were other professionals (p < .001). Overall, there were significant increases in the implementation of the assist component (from a score of 4.5 to 5.2; p < .003) and arrange a follow-up component (from 3.6 to 4.5; p < .001) of the intervention. Scores in the perception of the level of overall preparation, preparedness in using smoking cessation drugs, level of competence, and organizational recognition improved (p < .001) at the follow-up; however, the score in the perception that implementing smoking cessation is part of their job decreased (from 6.3 to 4.4; p < .001).

CONCLUSIONS

The online training had a positive impact on the implementation of assist and arrange follow-up components. Although self-preparedness in the management of smokers increased, the motivation and involvement of key professionals decreased. Organizational factors related to the incorporation of resources (such as protocols, records, etc.) should be improved for the correct progression of smoking cessation interventions within the institutions.

CLINICAL RELEVANCE

Smoking cessation training programs should incorporate some motivational content to increase the engagement of health professionals in smoking cessation interventions in their clinical practice.

Exploring individual and contextual factors contributing to tobacco cessation intervention implementation

BACKGROUND

Previous research suggests that smoking cessation interventions are poorly implemented. This study reports the development and testing of a questionnaire including knowledge, attitude, behavioral, and organizational (KABO) factors affecting the implementation of smoking cessation practices in hospitals by health care providers and organizations.

METHODS

An initial pool of 44 items was developed to assess the individual knowledge, attitudes, and beliefs of health professionals towards smoking cessation practices according to the 5 A's intervention model, as well as organizational barriers and opportunities for its implementation. Items were measured in a scale from 0="Not at all/Never" to 10 = "Completely/Always". Data were collected from health workers (n = 702) in Catalonia. The validity of the instrument was measured by: (a) analyzing the items, (b) assessing the internal structure, (c) estimating the internal consistency, and (d) analyzing the relationship between this tool and the 5 A's intervention model.

RESULTS

Seven domains were extracted: individual skills, positive organizational support, attitudes and beliefs, individual commitment, organizational resources, beliefs about patient desire/readiness to quit, and organizational endorsement. These domains explained 69.7% of the variance, and allowed for the development of a refined 26-item version of the questionnaire. Both the seven domains and the total scale showed adequate internal consistency.

CONCLUSIONS

Psychometric testing indicates that the KABO questionnaire is a reliable and valid instrument for assessing the main barriers and facilitators to smoking cessation intervention implementation. Individual factors better explained the implementation of smoking cessation interventions in hospitals, and the seven identified domains can be used for further investigations into how the implementation of evidence-based practices impacts smoking cessation performance.

Organizational culture and the adoption of anti-smoking initiatives at small to very small workplaces: An organizational level analysis

INTRODUCTION

Many workplaces have adopted anti-smoking initiatives to reduce smoking behavior, but small workplaces are less likely to adopt these initiatives. One factor that could influence adoption is organizational culture, defined as the values and assumptions shared by members of an organization. The aim of this study was to examine the types of organizational culture associated with smoking policy strength and adoption of smoking cessation activities at small (20–99 employees) and very small (<20 employees) workplaces. Two study hypotheses were made: An increase in clan culture (characterized by participation in decision-making and human resources development) will be associated with an increase in smoking policy strength (H1) and higher odds of having cessation activities in the workplace (H2).

METHODS

Between June and October 2017, executives and employees coming from small and very small workplaces participated in separate surveys. Executives answered questions about their workplace’s anti-smoking initiatives, while employees completed a 12-item questionnaire about organizational culture. We aggregated employee data to perform linear and logistic regression at the organizational level.

RESULTS

Organizational culture was not significantly associated with smoking policy strength, therefore H1 was not supported. Counter to H2, an increase in clan culture was associated with lower odds of offering smoking cessation activities (OR=0.06; 95% CI: 0.01–0.58).

CONCLUSIONS

We did not find support for the hypothesized relationships. External factors and additional cultural characteristics may explain study findings. Continued research on culture and ways to improve tobacco control within smaller workplaces is needed.

A qualitative assessment of the smoking policies and cessation activities at smaller workplaces

Background

To reduce the negative consequences of smoking, workplaces have adopted and implemented anti-smoking initiatives. Compared to large workplaces, less research exists about these initiatives at smaller workplaces, which are more likely to hire low-wage workers with higher rates of smoking. The purpose of this study was to describe and compare the smoking policies and smoking cessation activities at small (20–99 employees) and very small (< 20 employees) workplaces.

Methods

Thirty-two key informants coming from small and very small workplaces in Iowa completed qualitative telephone interviews. Data collection occurred between October 2016 and February 2017. Participants gave descriptions of the anti-smoking initiatives at their workplace. Additional interview topics included questions on enforcement, reasons for adoption, and barriers and facilitators to adoption and implementation. The data were analyzed using counts and content and thematic analysis.

Results

Workplace smoking policies were nearly universal (n = 31, 97%), and most workplaces (n = 21, 66%) offered activities to help employees quit smoking. Reasons for adoption included the Iowa Smokefree Air Act, to improve employee health, and organizational benefits (e.g., reduced insurance costs). Few challenges existed to adoption and implementation. Commonly cited facilitators included the Iowa Smokefree Air Act, no issues with compliance, and support from others. Compared to small workplaces, very small workplaces offered cessation activities less often and had fewer tobacco policy restrictions.

Conclusions

This study showed well-established tobacco control efforts in small workplaces, but very small workplaces lagged behind. To reduce potential health disparities in smoking, future research and intervention efforts in tobacco control should focus on very small workplaces.

Factors associated with implementation of the 5A's smoking cessation model

Background

Several health organizations have adopted the 5A’s brief intervention model (Ask, Advise, Assess, Assist, Arrange), based on evidence-based guidelines for smoking cessation. We examine individual, cognitive, behavioral, and organizational factors associated with the 5A’s performance among clinical healthcare workers in Catalonia. We also investigate how these factors interact and potentially predict the implementation of each component of the 5A’s.

Methods

A cross-sectional survey was conducted among clinical health workers enrolled in an online smoking cessation training course (n = 580). The survey included questions about individual characteristics as well as cognitive, behavioral, and organizational factors previously identified in research. We assessed self-reported performance of the 5A’s, assessed on a scale from 0 to 10, and used Multivariate regression to examine factors associated with its performance.

Results

The performance means (standard deviation) were moderate for the first 3A’s [Ask: 6.4 (3.1); Advise: 7.1 (2.7); Assess: 6.3 (2.8)] and low for the last 2A’s [Assist: 4.4 (2.9); Arrange: 3.2 (3.3)]. We observed a high correlation between Assist and Arrange (r = 0.704, p < 0.001). Having positive experiences and feeling competent were positively associated with performing the 5A’s model and having organizational support with Assist and Arrange. Personal tobacco use among healthcare workers was negatively associated with Advice and Arrange.

Conclusions

Our study found that clinical healthcare workers do not perform the 5A’s completely. The main barriers identified suggest the need of training and making available practical guidelines in healthcare services. Organizational support is essential for moving towards the implementation of Assist and Arrange.

Electronic supplementary material

The online version of this article (10.1186/s12971-017-0146-7) contains supplementary material, which is available to authorized users.

Implementation of smoking cessation treatment in substance use disorder treatment settings: a review

BACKGROUND

The high prevalence of smoking among individuals receiving treatment for substance use disorder (SUD) has led to repeated calls for integrating smoking cessation treatment into these settings.

OBJECTIVES

This review summarizes key findings from the research on the implementation of smoking cessation in SUD treatment.

METHODS

PubMed searches of articles published from 2000 to 2015 yielded 48 empirical studies that focused on the delivery of smoking cessation in the US specialty SUD treatment settings in which organizations and counselors were the unit of analysis. Most studies used observational designs to gather data from organizations and counselors. Organizational studies show that few SUD treatment programs offer cessation counseling or pharmacotherapy. Organizational barriers include limited training, inadequate resources, and cultural norms that do not recognize smoking cessation as part of the organization's mission. Smoking cessation services are more likely to be available in medically oriented treatment settings, larger treatment programs, those offering a broader array of comprehensive services, and those that are more reliant on fee-for-service reimbursement (e.g., insurance, Medicaid). Surveys of counselors also show very low implementation. Counselors' personal skills and attitudes, their perceptions of managerial and coworker support for smoking cessation, and the availability of resources and reimbursement to support these services are correlated with implementation. State policies requiring treatment programs to offer tobacco treatment increase both adoption and implementation, yet these services continue to reach only modest percentages of the patients.

CONCLUSIONS

Few studies have tested specific implementation strategies. Such research is needed to determine how to accelerate the diffusion of these evidence-based practices to the SUD treatment field.

Factors Linked to Substance Use Disorder Counselors' (Non)Implementation Likelihood of Tobacco Cessation 5 A's, Counseling, and Pharmacotherapy

STUDY BACKGROUND

Despite efforts to promote the use of tobacco cessation services (TCS), implementation extensiveness remains limited. This study investigated three factors (cognitive, behavioral, environmental) identified by social cognitive theory as predictors of substance use disorder counselors' likelihood of use versus non-use of tobacco cessation (TC) 5 A's (ask patients about tobacco use, advise to quit, assess willingness to quit, assist in quitting, arrange for follow-up contact), counseling, and pharmacotherapy with their patients who smoke cigarettes.

METHODS

Data were collected in 2010 from 942 counselors working in 257 treatment programs that offered TCS. Cognitive factors included perceived job competence and TC attitudes. Behavioral factors encompassed TC-related skills and general training. External factors consisted of TC financial resource availability and coworker TC attitudes. Data were analyzed using logistic regression models with nested data.

RESULTS

Approximately 86% of counselors used the 5 A's, 76% used counseling, and 53% used pharmacotherapy. When counselors had greater TC-related skills and greater general training they were more likely to implement the 5 A's. Implementation of counseling was more likely when counselors had more positive attitudes toward TC treatment, greater general training, greater financial resource availability, and when coworkers had more positive attitudes toward TC treatment. Implementation of pharmacotherapy was more likely when counselors had more positive attitudes toward TC treatment, greater general training, and greater financial resource availability.

CONCLUSION

Findings indicate that interventions to promote TCS implementation should consider all three factors simultaneously as suggested by social cognitive theory.