Evaluation of an implementation support package to increase community mental health clinicians' routine delivery of preventive care for multiple health behaviours: a non-randomised controlled trial

BACKGROUND

People with a mental health condition are more likely to engage in risk behaviours compared to people without. Delivery of preventive care to improve such behaviours is recommended for community mental health services, but inadequately implemented. This study assessed the effectiveness of an implementation support package on clinicians' delivery of preventive care (assessment, advice, referral) for four risk behaviours (tobacco smoking, harmful alcohol consumption, physical inactivity, inadequate fruit and vegetable intake) compared to no implementation support. The participatory approach to developing the support package, and fidelity of the implementation strategies, are also described.

METHODS

A non-randomised controlled trial was undertaken in 2019-2020 with two community mental health services (control and target) in one health district in New South Wales, Australia. A 4-month support package consisting of multiple implementation strategies was delivered to one site following a two-phase participatory design process. Five implementation strategies were proposed to service managers by researchers. After consultation with managers and clinicians, the final implementation support package included four strategies: training and education materials, enabling resources and prompts, client activation material, and audit and feedback. Client-reported receipt of the three elements of preventive care for the four risk behaviours was collected from a cross-sectional sample of clients who had recently attended the service at baseline (6 months) and follow-up (5 months). Logistic regression models examined change in receipt of preventive care to assess effectiveness.

RESULTS

A total of 860 client surveys were completed (control baseline n = 168; target baseline n = 261; control follow-up n = 164; and target follow-up n = 267). Analyses revealed no significant differential changes in preventive care receipt between the target and control sites from baseline to follow-up, including across the four primary outcomes: assessed for all behaviours (OR = 1.19; 95% CI 0.55, 2.57; p = 0.65); advised for all relevant risk behaviours (OR = 1.18; 95% CI 0.39, 3.61; p = 0.77); referred for any relevant risk behaviour (OR = 0.80; 95% CI 0.40, 1.63; p = 0.55); and complete care (OR = 3.11; 95% CI 0.62, 15.63; p = 0.17). Fidelity of the implementation strategies was limited as one of the four strategies (audit and feedback) was not delivered, components of two strategies (enabling resources and prompts, and client activation material) were not delivered as intended, and one strategy (education and training) was delivered as intended although some components were offered late in the implementation period.

CONCLUSIONS

The implementation support package was ineffective at increasing preventive care delivery. Further investigation is required to determine optimal participatory design methods to develop effective implementation strategies, including those that support delivery of care in community mental health settings within the ongoing context of uncertain environmental challenges.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12619001379101.

Smoking Cessation Barriers among Individuals with Mental Illnesses: A Qualitative Study of Patients' and Healthcare Providers' Perspectives

In this paper we aimed to explore: (1) challenges that people with mental illnesses (MIs) describe in engaging in smoking cessation, (2) challenges that mental health providers (MHPs) perceive that people living with MIs face, and (3) how the perceived challenges are similar and/or different from both perspectives. Semi-structured interviews were used to obtain narrative data from 16 MHPs and 13 psychiatric inpatients with MIs. We identified themes purport societal, group, and individual factors may influence smoking cessation treatment engagement. The scope of the perceived challenges appeared varied in the narratives of MHPs as compared to those with MI.

Texas tobacco quitline knowledge, attitudes, and practices within healthcare agencies serving individuals with behavioral health needs: A multimethod study

Patients with behavioral health conditions have disproportionately high tobacco use rates and face significant barriers to accessing evidence-based tobacco cessation services. Tobacco quitlines are an effective and accessible resource, yet they are often underutilized. We identify knowledge, practices, and attitudes towards the Texas Tobacco Quitline (TTQL) within behavioral healthcare settings in Texas. Quantitative and qualitative data were collected in 2021 as part of a statewide needs assessment in behavioral healthcare settings. Survey respondents (n = 125) represented 23 Federally Qualified Health Centers, 29 local mental health authorities (LMHAs), 12 substance use treatment programs in LMHAs, and 61 standalone substance use treatment centers (26 people participated in qualitative interviews). Over half of respondents indicated familiarity with the TTQL and believed that the TTQL was helpful for quitting. Qualitative findings reveal potential concerns about inconsistency of services, long wait time, and the format of the quitline. About half of respondents indicated that their center promoted patient referral to TTQL, and few indicated that their center had an electronic referral system with direct TTQL referral capacity. Interview respondents reported overall lack of systematic follow up with patients regarding their use of the TTQL services. Findings suggest the need for (1) increased TTQL service awareness among healthcare providers; (2) further investigation into any changes needed to better serve patients with behavioral health conditions who use tobacco; and (3) electronic health record integration supporting direct referrals and enhanced protocols to support patient follow up after TTQL referral.

Effect of a Tobacco Cessation Intervention Incorporating Weight Management for Adults With Serious Mental Illness: A Randomized Clinical Trial

Importance

Tobacco smoking drives markedly elevated cardiovascular disease risk and preventable death in persons with serious mental illness, and these risks are compounded by the high prevalence of overweight/obesity that smoking cessation can exacerbate. Guideline-concordant combined pharmacotherapy and behavioral smoking cessation treatment improves abstinence but is not routinely offered in community settings, particularly to those not seeking to quit smoking immediately.

Objective

To determine the effectiveness of an 18-month pharmacotherapy and behavioral smoking cessation intervention incorporating weight management and support for physical activity in adults with serious mental illness interested in quitting smoking within 1 or 6 months.

Design, Setting, and Participants

This was a randomized clinical trial conducted from July 25, 2016, to March 20, 2020, at 4 community health programs. Adults with serious mental illness who smoked tobacco daily were included in the study. Participants were randomly assigned to intervention or control, stratified by willingness to try to quit immediately (within 1 month) or within 6 months. Assessors were masked to group assignment.

Interventions

Pharmacotherapy, primarily varenicline, dual-form nicotine replacement, or their combination; tailored individual and group counseling for motivational enhancement; smoking cessation and relapse prevention; weight management counseling; and support for physical activity. Controls received quitline referrals.

Main Outcome and Measures

The primary outcome was biochemically validated, 7-day point-prevalence tobacco abstinence at 18 months.

Results

Of the 298 individuals screened for study inclusion, 192 enrolled (mean [SD] age, 49.6 [11.7] years; 97 women [50.5%]) and were randomly assigned to intervention (97 [50.5%]) or control (95 [49.5%]) groups. Participants self-identified with the following race and ethnicity categories: 93 Black or African American (48.4%), 6 Hispanic or Latino (3.1%), 90 White (46.9%), and 9 other (4.7%). A total of 82 participants (42.7%) had a schizophrenia spectrum disorder, 62 (32.3%) had bipolar disorder, and 48 (25.0%) had major depressive disorder; 119 participants (62%) reported interest in quitting immediately (within 1 month). Primary outcome data were collected in 183 participants (95.3%). At 18 months, 26.4% of participants (observed count, 27 of 97 [27.8%]) in the intervention group and 5.7% of participants (observed count, 6 of 95 [6.3%]) in the control group achieved abstinence (adjusted odds ratio [OR], 5.9; 95% CI, 2.3-15.4; P < .001). Readiness to quit within 1 month did not statistically significantly modify the intervention's effect on abstinence. The intervention group did not have significantly greater weight gain than the control group (mean weight change difference, 1.6 kg; 95% CI, -1.5 to 4.7 kg).

Conclusions and Relevance

Findings of this randomized clinical trial showed that in persons with serious mental illness who are interested in quitting smoking within 6 months, an 18-month intervention with first-line pharmacotherapy and tailored behavioral support for smoking cessation and weight management increased tobacco abstinence without significant weight gain.

Trial Registration

ClinicalTrials.gov Identifier: NCT02424188.

Exploring the barriers and facilitators to the uptake of smoking cessation services for people in treatment or recovery from problematic drug or alcohol use: A qualitative systematic review

BACKGROUND

Smoking prevalence and the associated poor health and mortality is significantly higher among people with/recovering from problematic drug or alcohol (PDA) use in comparison with the general population. Evidence from existing systematic reviews shows smoking cessation enhances rather than compromises long-term abstinence from alcohol or drug use. However, these systematic reviews lack important contextual detail around the reasons why uptake of, and successful engagement with existing stop smoking services remains low for people in treatment or recovery from PDA use. This systematic review explores qualitative data on the barriers and facilitators to the uptake of smoking cessation services for people in treatment or recovery from PDA use. This key objective addresses the limited inclusion of qualitative studies in previous systematic reviews on this issue.

METHODS

A qualitative systematic review was conducted with searches across four electronic databases (PubMed, Embase, PsycINFO and Cumulative Index to Nursing and Allied Health Literature [CINAHL]). All studies that had a qualitative component about free smoking cessation/reduction programmes for people in treatment or recovery from PDA use were included. Studies that examined electronic smoking or services that required a fee were excluded. Study quality was assessed using National Institute for Health and Care Excellence checklist. Qualitative synthesis involved inductive thematic analysis. (PROSPERO Registration number: CRD42022298521).

RESULTS

8809 potentially eligible articles were identified, 72 full texts were screened and ten articles were included for full review. Barriers to uptake and engagement with existing stop smoking services centered on three key themes: perception of public health importance, programme structure, and intervention elements. Facilitators included supportive treatment environment and optimization of support/staff resources for smoking cessation service delivery.

CONCLUSION

Recommendations included influencing a change in the way people perceive the importance of smoking cessation activities during PDA use treatment or recovery. There was also some emphasis on the need to create the right environment for sustained adherence to treatment or recovery plans, and deliver the interventions within the health system as comprehensive care. The limited qualitative evidence on community-based and outpatient services highlights a research gap.

Prevalence of physical health conditions and health risk behaviours in people with severe mental illness in South Asia: multi-country cross-sectional survey

BACKGROUND

People with severe mental illness (SMI) die earlier than the general population, primarily because of physical disorders.

AIMS

We estimated the prevalence of physical health conditions, health risk behaviours, access to healthcare and health risk modification advice in people with SMI in Bangladesh, India and Pakistan, and compared results with the general population.

METHOD

We conducted a cross-sectional survey in adults with SMI attending mental hospitals in Bangladesh, India and Pakistan. Data were collected on non-communicable diseases, their risk factors, health risk behaviours, treatments, health risk modification advice, common mental disorders, health-related quality of life and infectious diseases. We performed a descriptive analysis and compared our findings with the general population in the World Health Organization (WHO) 'STEPwise Approach to Surveillance of NCDs' reports.

RESULTS

We recruited 3989 participants with SMI, of which 11% had diabetes, 23.3% had hypertension or high blood pressure and 46.3% had overweight or obesity. We found that 70.8% of participants with diabetes, high blood pressure and hypercholesterolemia were previously undiagnosed; of those diagnosed, only around half were receiving treatment. A total of 47% of men and 14% of women used tobacco; 45.6% and 89.1% of participants did not meet WHO recommendations for physical activity and fruit and vegetable intake, respectively. Compared with the general population, people with SMI were more likely to have diabetes, hypercholesterolemia and overweight or obesity, and less likely to receive tobacco cessation and weight management advice.

CONCLUSIONS

We found significant gaps in detection, prevention and treatment of non-communicable diseases and their risk factors in people with SMI.

Stages of the Smoke-Free Policy Implementation in a Psychiatric Hospital: Evolution, Effects, and Complications

Background: The Smoke-free Policy represents a challenge in mental health services. Aim: To compare the stages of a smoke-free policy in a psychiatric hospital, according to the prevalence of smokers, hospital admission acceptance by hospitalized people, psychiatric complications, and the prescription of psychotropic drugs. Methods: Cross-sectional study was conducted with a comparison before and after implementing the Smoke-free Policy in a psychiatric hospital. Secondary data were obtained in 2020 from the medical records of 573 discharged people from psychiatric hospitalizations between September 2017 and August 2018. Fisher's exact test and the Kruskal-Wallis test were applied. Results: In the transition stage, there were more hospitalizations by court order, discharge motivated by the patient's disruptiveness behavior, administration of psychotropic drugs before the schedule time, physical aggression, physical/chemical restraints, length of stay, and dosage of psychotropic drugs. After the ban, there was a reduction in discharges motivated by the patient's disruptiveness behavior and an increase in discharge due to improvement in psychiatric symptoms, less occurrence of anticipation or modification in the use of psychotropic drugs, and fewer attempts to escape, aggressiveness, and physical restraint. Conclusion: The implementation of the Smoke-free Policy has a positive impact on psychiatric hospitalizations, with an increase in discharge due to improvement in psychiatric symptoms and a reduction in discharges due to other reasons. However, the transition stage requires greater attention from the nursing team, as the moment of adaptation to new rules and routines is followed by a momentary worsened behavior of those hospitalized.

Organization-Level Factors Associated with Changes in the Delivery of the Five A's for Smoking Cessation following the Implementation of a Comprehensive Tobacco-Free Workplace Program within Substance Use Treatment Centers

Many adults with a substance use disorder smoke cigarettes. However, tobacco use is not commonly addressed in substance use treatment centers. This study examined how provider beliefs about addressing tobacco use during non-nicotine substance use treatment, provider self-efficacy in delivering tobacco use assessments, and perceived barriers to the routine provision of tobacco care were associated with changes in the delivery of the evidence-based five A's for smoking intervention (asking, advising, assessing, assisting, and arranging) at the organizational level. The data were from 15 substance use treatment centers that implemented a tobacco-free workplace program; data were collected before and after the program's implementation. Linear regression examined how center-level averages of provider factors (1) at pre-implementation and (2) post- minus pre-implementation were associated with changes in the use of the five A's for smoking in substance use treatment patients. The results indicated that centers with providers endorsing less agreement that tobacco use should be addressed in non-nicotine substance use treatment and reporting lower self-efficacy for providing tobacco use assessments at pre-implementation were associated with significant increases in asking patients about smoking, assessing interest in quitting and assisting with a quit attempt by post-implementation. Centers reporting more barriers at pre-implementation and centers that had greater reductions in reported barriers to treatment over time had greater increases in assessing patients' interest in quitting smoking and assisting with a quit attempt by post-implementation. Overall, the centers that had the most to learn regarding addressing patients' tobacco use had greater changes in their use of the five A's compared to centers whose personnel were already better informed and trained. Findings from this study advance implementation science and contribute information relevant to reducing the research-to-practice translational gap in tobacco control for a patient group that suffers tobacco-related health disparities.

Tobacco Screening Practices and Perceived Barriers to Offering Tobacco Cessation Services among Texas Health Care Centers Providing Behavioral Health Treatment

Tobacco use, and thus tobacco-related morbidity, is elevated amongst patients with behavioral health treatment needs. Consequently, it is important that centers providing health care to this group mandate providers' use of tobacco screenings to inform the need for tobacco use disorder intervention. This study examined the prevalence of mandated tobacco screenings in 80 centers providing health care to Texans with behavioral health needs, examined key factors that could enhance screening conduct, and delineated providers' perceived barriers to tobacco use intervention provision. The results indicated that 80% of surveyed centers mandated tobacco use screenings; those that did were significantly more likely than those that did not to have a hard stop for tobacco use status in health records and were marginally more likely to make training on tobacco screening available to providers. The most widespread barriers to tobacco use disorder care provision were relative perceived importance of competing diagnoses, lack of community resources to refer patients, perceived lack of time, lack of provider knowledge or confidence, and belief that patients do not comply with cessation treatment. Overall, the results suggest that there are opportunities for centers providing care to Texans with behavioral health needs to bolster their tobacco screening and intervention capacity to better address tobacco-related health disparities in this group. Health care centers can support their providers to intervene in tobacco use by mandating screenings, streamlining clinical workflows with hard stops in patient records, and educating providers about the importance of treating tobacco with brief evidence-based intervention strategies while providing accurate information about patients' interest in quitting and providers' potential impacts on a successful quit attempt.

Implementing Chronic Care Model Treatments for Cigarette Dependence in Community Mental Health Clinics

Objective: Tobacco use is rarely addressed in community mental healthcare settings, despite its high prevalence among people with serious mental illness. The aim of the current study was to gather stakeholder feedback regarding the feasibility of chronic care management strategies for tobacco dependence in community mental health centers (CMHCs). Chronic care strategies evaluated included the 5 As (Ask about tobacco use, Advise users of tobacco to quit, Assess interest in cessation, Assist with cessation, and Arrange for follow-up) and proactive telephone outreach (reaching out to all users of tobacco to offer connection to tobacco cessation treatment). Methods: Using a semi-structured interview guide informed by the Practical Robust Implementation and Sustainability Model, we conducted individual semi-structured interviews with providers, leaders, and clients across two CMHCs. Our objectives were to capture their attitudes toward smoking cessation treatment, two chronic care model interventions (i.e., proactive outreach, the 5 As), and to determine the infrastructure needed to implement such interventions in their CMHCs. Thematic analysis was conducted by two independent coders to uncover pertinent themes. Results: Participants (n = 20) included nine providers, six leaders, and five clients. Thematic analysis revealed three major themes: (1) characteristics of recipients, (2) characteristics of the intervention, and (3) infrastructure needed for implementation and sustainability. Providers, leaders, and clients all reported that tobacco cessation treatment was rarely provided in CMHCs and expressed an interest in such treatments becoming more available. The 5 As and proactive outreach were viewed as feasible and acceptable to deliver and receive. Providers, leaders, and clients wanted support to connect clients with smoking cessation treatment. Providers and leaders requested a range of implementation supports, including didactic trainings, decision aids, performance feedback, and coaching on evidence-based tobacco cessation treatments for people with serious mental illness. Clients requested tobacco cessation resources, such as a cessation counseling provided at the CMHC and prescriptions for cessation medication. Conclusions: CMHC providers, leaders, and clients are interested in making tobacco cessation services more widely accessible and available. The feedback gathered in this study can be used to inform the delivery and implementation of guideline-adherent tobacco dependence care in CMHCs.

An evaluation of the feasibility of implementing a novel tobacco dependence treatment program for high-risk individuals into clinical practice within a community mental health center

Background

Individuals with serious mental illnesses experience deaths related to smoking at a higher prevalence than individuals without a psychotic-spectrum disorders. Traditional smoking cessation programs are often not effective among individuals with chronic mental disorders. Little is known about how to implement a tobacco cessation treatment program for this at-risk population within a community health center. The current study used qualitative methods to examine the factors that may enhance or impede the delivery of a novel tobacco cessation treatment for smokers with a psychotic-spectrum disorder diagnosis in an integrated care community health center.

Methods

Using a case study design, we conducted 22 semi-structured interviews with primary care providers, mental health providers, addiction counselors, case managers, intake specialists, schedulers, pharmacists, and administrative staff employed at the organization. Interviews were transcribed and themes were identified through a rich coding process.

Results

We identified environmental factors, organizational factors, provider factors and patient factors which describe the potential factors that may enhance or impede the implementation of a smoking cessation program at the integrated care community health center. Most notably, we identified that community mental health centers looking to implement a smoking cessation program for individuals with chronic mental health disorders should ensure the incentives for providers to participate align with the program’s objectives. Additionally, organizations should invest in educating providers to address stigma related to smoking cessation and nicotine use.

Conclusions

The findings of our study provide valuable insight for administrators to consider when implementing a smoking cessation program in an integrated care community health center. Our findings provide public health practitioners with potential considerations that should be discussed when designing and implementing a smoking cessation program for individuals with chronic mental disorders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00517-y.

A systematic review of mental health professionals, patients and carers' perceived barriers and enablers to supporting smoking cessation in mental health settings

Introduction

Evidence-based smoking cessation and temporary abstinence interventions to address smoking in mental health settings are available, but the impact of these interventions is limited.

Aims and Methods

We aimed to identify and synthesize the perceived barriers and enablers to supporting smoking cessation in mental health settings. Six databases were searched for articles reporting the investigation of perceived barriers and enablers to supporting smoking cessation in mental health settings. Data were extracted and coded using a mixed inductive/deductive method to the theoretical domains framework, key barriers and enablers were identified through the combining of coding frequency, elaboration, and expressed importance.

Results

Of 31 included articles, 56 barriers/enablers were reported from the perspectives of mental healthcare professionals (MHPs), 48 from patient perspectives, 21 from mixed perspectives, and 0 from relatives/carers. Barriers to supporting smoking cessation or temporary abstinence in mental health settings mainly fell within the domains: environmental context and resources (eg, MHPs lack of time); knowledge (eg, interactions around smoking that did occur were ill informed); social influences (eg, smoking norms within social network); and intentions (eg, MHPs lack positive intentions to deliver support). Enablers mainly fell within the domains: environmental context and resources (eg, use of appropriate support materials) and social influences (eg, pro-quitting social norms).

Conclusions

The importance of overcoming competing demands on staff time and resources, the inclusion of tailored, personalized support, the exploitation of patients wider social support networks, and enhancing knowledge and awareness around the benefits smoking cessation is highlighted.

Implications

Identified barriers and enablers represent targets for future interventions to improve the support of smoking cessation in mental health settings. Future research needs to examine the perceptions of the carers and family/friends of patients in relation to the smoking behavior change support delivered to patients.

An evaluation of junior doctors' experience in smoking cessation training in a rural mental health setting

INTRODUCTION

Smoking prevalence remains high amongst people with mental illness, however, they are less likely to be screened for tobacco dependence and offered treatment to quit. Smoking cessation and education training are insufficient in medical schools, despite a positive relationship between training and practice once qualified. However, the question as to whether there is adequate skill and expertise to address smoking in people with mental illness within Australian mental health settings is unclear. Furthermore, people living in rural and remote areas smoke at higher rates, quit at lower rates than those in urban areas, and experience limitations in their ability to access smoking cessation supports. The Smokers' Clinic is an initiative established in a rural Australian mental health service offering a smoking cessation service to patients and staff employed by the service.

AIM

This study aims to assess the change in the knowledge and confidence of resident medical officers in their understanding of nicotine dependence, smoking cessation strategies and prescribing nicotine replacement therapy in a community mental health setting. It was hypothesized that providing education and supervised clinical experience would improve knowledge, increasing confidence and motivation in managing smoking cessation in mental health patients. The research was undertaken using data collected through a questionnaire obtained from surveying resident medical officers administering the Smokers' Clinic following a 10-week rural community mental health rotation.

MATERIALS AND METHODS

Twenty resident medical officers completed the 10-week rotation, with 14 completing the questionnaire. Knowledge of tobacco smoking, nicotine dependence and smoking cessation interventions improved with the experience of the Smokers' Clinic during the clinical rotation. Resident medical officers were motivated to spend additional time engaged in self-directed learning and all reported continued use of acquired experience and information in their clinical work after the rotation.

CONCLUSION

This study indicates the utility of a novel approach in delivering education, training, building clinical expertise, and facilitating sustained clinical capacity amongst junior medical staff for smoking cessation in a rural community mental health setting. It offers an efficient approach for mental health services to deliver smoking cessation services to reduce the morbidity and mortality burden associated with tobacco smoking.

Proactive tobacco treatment for veterans with posttraumatic stress disorder

OBJECTIVE

Individuals with posttraumatic stress disorder (PTSD) smoke at higher rates compared to the general population and experience significant barriers to initiating cessation treatment. Proactive outreach addresses these barriers by directly engaging with smokers and facilitating access to treatment. The objective of the present study was to evaluate a proactive outreach intervention for increasing rates of treatment utilization and abstinence among veteran smokers with and without PTSD.

METHOD

This is a secondary analysis of a randomized controlled trial conducted from 2013 to 2017 that demonstrated the effectiveness of proactive outreach among veterans using Veterans Affairs mental health care services. Electronic medical record data were used to identify participants with (n = 355) and without (n = 1,583) a diagnosis of PTSD. Logistic regressions modeled cessation treatment utilization (counseling, nicotine replacement therapy [NRT], and combination treatment) and abstinence (7-day point prevalence and 6-month prolonged at 6- and 12-month follow-ups) among participants randomized to proactive outreach versus usual care in the PTSD and non-PTSD subgroups, respectively.

RESULTS

Compared to usual care, proactive outreach increased combined counseling and NRT utilization among participants with PTSD (odds ratio [OR] = 26.25, 95% confidence interval [3.43, 201.17]) and without PTSD (OR = 10.20, [5.21, 19.98]). Proactive outreach also increased 7-day point prevalence abstinence at 12 months among participants with PTSD (OR = 2.62, [1.16, 5.91]) and without PTSD (OR = 1.61, [1.11, 2.34]).

CONCLUSIONS

Proactive outreach increased treatment utilization and abstinence among smokers with and without PTSD. Smokers with PTSD may need additional facilitation to initiate cessation treatment but are receptive when it is offered proactively. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Proactive outreach tobacco treatment for socioeconomically disadvantaged smokers with serious mental illness

Smokers with serious mental illness (SMI) face individual, interpersonal, and healthcare provider barriers to cessation treatment utilization and smoking abstinence. Proactive outreach strategies are designed to address these barriers by promoting heightened contact with smokers and facilitating access to evidence-based treatments. The present study examined the effect of proactive outreach among smokers with SMI (n = 939) who were enrolled in the publicly subsidized Minnesota Health Care Programs (MHCP) and compared this effect to that observed among MHCP smokers without SMI (n = 1382). Relative to usual care, the intervention increased treatment utilization among those with SMI (52.1% vs 40.0%, p = 0.002) and without SMI (39.3% vs 25.4%, p < 0.001). The intervention also increased prolonged smoking abstinence among those with SMI (14.9% vs 9.4%, p = 0.010) and without SMI (17.7% vs 13.6%, p = 0.09). Findings suggest that implementation of proactive outreach within publicly subsidized healthcare systems may alleviate the burden of smoking in this vulnerable population. Trial Registration ClinicalTrials.gov identifier: NCT01123967.

Tobacco Screening and Treatment of Patients With a Psychiatric Diagnosis, 2012-2015

INTRODUCTION

Smoking disproportionately affects individuals with psychiatric diagnoses. Providers can play a role in reducing tobacco-related morbidity among people with a psychiatric diagnosis by routinely screening and treating all patients for tobacco use. This study seeks to identify rates of tobacco screening, counseling, and medication orders during outpatient visits with adults who have a psychiatric diagnosis.

METHODS

Data from the 2012-2015 National Ambulatory Medical Care Survey were examined to calculate the proportion of visits with people who have a psychiatric diagnosis that included tobacco screening, counseling, or smoking-cessation medications. Logistic regression was used to identify patient and visit factors associated with tobacco screening and treatment. All analyses were conducted in 2018.

RESULTS

Seventy-two percent of visits included tobacco screening, 23% of visits with tobacco users included cessation counseling, and 4% of visits with tobacco users included a cessation medication order. Visits were more likely to include tobacco screening if they were for a nonpsychiatric condition, were >30 minutes, or were with a primary care physician (p<0.05). Visits were less likely to include tobacco screening if they were with a black, non-Hispanic patient or patient with Medicaid (p<0.05). Visits were more likely to include cessation counseling if they were for a nonpsychiatric condition (p<0.05), and were less likely to include counseling if they were with a Hispanic or self-pay patient (p<0.05).

CONCLUSIONS

There is still room for improvement in providing equitable treatment for people with psychiatric conditions for smoking, particularly in nonprimary settings.

A pilot study of Counsel to Quit®: Evaluating an Ask Advise Refer (AAR)-based tobacco cessation training for medical and mental healthcare providers

INTRODUCTION

Despite tobacco use as the largest preventable cause of premature death in the US, many healthcare providers continue to lack the knowledge and confidence in employing the Ask, Advise, Refer (AAR) model in tobacco cessation treatment delivery. This pilot study evaluated the feasibility and effectiveness of a novel AAR-styled training program, Counsel to Quit®, across a range of healthcare providers and disciplines (i.e., medical, mental health, other). The Counsel to Quit® training program primarily targeted publically-funded settings that serve communities with high smoking rates.

METHODS

Pre- and post-training surveys were administered to medical, mental health, and other professionals (N = 297) to evaluate the effectiveness of the 60-90 minute Counsel to Quit® counselor training program for improving confidence in the ability to discuss approved tobacco cessation interventions and address the current state of knowledge about the role of electronic cigarettes in tobacco cessation. The trainings were held across 14 different non-profit institutional settings in Chicago, IL.

RESULTS

The Counsel to Quit® program improved AAR beliefs, the confidence and ability to discuss smoking cessation, and knowledge on the role of electronic cigarettes in tobacco cessation among medical, mental health, and other providers (ps < .001). Interactions showed that Counsel to Quit® improved medical provider confidence in referring patients for smoking cessation the most (p < .001), and also improved mental health providers belief in the importance of tobacco cessation for preventative care the most (ps < .05).

CONCLUSIONS

Counsel to Quit® is a feasible and effective training for improving AAR beliefs across multiple healthcare provider domains and at different types of publicly-funded healthcare institutions. Further, this training increased provider preparedness to discuss the lack of evidence for e-cigarette use as a form of tobacco cessation.

'They're Going to Smoke Anyway': A Qualitative Study of Community Mental Health Staff and Consumer Perspectives on the Role of Social and Living Environments in Tobacco Use and Cessation

Background: Addressing the high prevalence of tobacco use experienced by people with severe mental illness (SMI) requires consideration of the influence of wider cultural, socioeconomic and environmental factors. This qualitative study aimed to examine the impact of social and living environments on tobacco use and cessation by people with SMI accessing community managed mental health services. The perspectives of both staff and consumers with SMI were explored. Methods: Semi-structured focus groups were undertaken with a purposive sample of community mental health staff and consumers from three sites in three major cities in NSW, Australia. Two sites provided outreach support, and one site provided residential support. Data were collected (2017-2018) until saturation was reached. Focus groups were audio-recorded and transcribed, and thematic analysis was conducted. Results: Thirty-one staff and 17 consumers participated separately in six focus groups. Themes identified by staff included a degree of fatalism, conceptualising tobacco use as choice rather than addiction and tensions between cessation support and broader models of care. Staff viewed smoke-free home and mental health service policies as effective at promoting quitting but contradictory to recovery-oriented models of care. Consumers identified smoking as an integral part of life and social networks, as a way of maintaining control and lack of social support to quit as key themes. While many consumers reported smoking inside the home, others described enforcing smoke-free rules. Conclusion: Social and living environments played an integral role in tobacco use and cessation for both staff and consumers. The role of community managed mental health organisations in addressing tobacco use within social and living environments was not strongly supported by staff and sometimes seen as antithetical to recovery-oriented models of care. Potential ways to address this include education and training for prospective and current community mental health organisation staff highlighting the synergy between the recovery-oriented model and provision of preventive health support.