Addressing Tobacco Use Among Consumers and Staff at Behavioral Health Treatment Facilities Through Comprehensive Workplace Programming

Initial leadership concerns and availability of tobacco cessation services moderate changes in employee-reported concerns about tobacco-free workplace policy implementation over time

Tobacco-free workplace policies (TFWPs) are underused evidence-based interventions that reduce the elevated use of tobacco among substance use treatment center (SUTC) employees and patients. SUTC employees' anticipated concerns about stakeholder pushback are barriers to TFWP adoption. Examination of discrepancies between anticipated and actualized employee-reported TFWP concerns arising from coworkers, patients, and community members in the context of leadership concerns and tobacco cessation care availability for employees may inform strategies to increase TFWP uptake. This study analyzed changes in employee-reported TFWP concerns from before to after a comprehensive tobacco-free workplace intervention that included TFWP implementation, using Chi-square/Fisher's exact tests. Preimplementation leadership policy concerns and tobacco cessation care availability were examined as moderators in generalized linear mixed models. Overall, 452 employees and 13 leaders provided data from 13 SUTCs collectively serving >82 000 patients annually. Results revealed significant decreases over time in employee-reported concerns about TFWP resistance from coworkers. Moderation analyses indicated that employee-anticipated concerns from coworkers and patients, respectively, were less likely to be actualized in SUTCs where leadership endorsed preimplementation TFWP concerns, whereas employee-reported patient concerns rose over time in SUTCs where leadership had no initial implementation concerns. Additionally, employee-anticipated concerns from coworkers were overestimated in SUTCs that did not offer tobacco cessation care to employees. Results supporting the nonactualization of anticipated employee concerns following TFWP implementation can be used to engage other SUTCs for TFWP adoption. Furthermore, moderation effects may suggest that center characteristics translate to greater attention to rollout, ultimately enhancing TFWP stakeholder acceptance.

A randomized clinical trial testing two implementation strategies to promote the treatment of tobacco dependence in community mental healthcare

INTRODUCTION

People with serious mental illness (SMI) are more likely to smoke and less likely to receive tobacco treatment. Implementation strategies may address clinician and organizational barriers to treating tobacco in mental healthcare.

METHODS

A cluster-randomized trial (Clinic N=13, Client N=610, Staff N=222) tested two models to promote tobacco treatment in community mental healthcare: standard didactic training vs. Addressing Tobacco Through Organizational Change (ATTOC), an organizational model that provides clinician and leadership training and addresses system barriers to tobacco treatment. Primary outcomes were changes in tobacco treatment from clients, staff, and medical records. Secondary outcomes were changes in smoking, mental health, and quality of life (QOL), and staff skills and barriers to treat tobacco.

RESULTS

Clients at ATTOC sites reported a significant increase in receiving tobacco treatment from clinician at weeks 12 and 24 (ps<0.05) and tobacco treatments and policies from clinics at weeks 12, 24, 36, and 52 (ps<0.05), vs. standard sites. ATTOC staff reported a significant increase in skills to treat tobacco at week 36 (p=0.05), vs. standard sites. For both models, tobacco use medications, from clients (week 52) and medical records (week 36), increased (ps<0.05), while perceived barriers decreased at weeks 24 and 52 (ps<0.05); 4.3% of clients quit smoking which was not associated with model. QOL and mental health improved over 24 weeks for both models (ps<0.05).

CONCLUSIONS

Standard training and ATTOC improve use of evidence-based tobacco treatments in community mental healthcare without worsening mental health, but ATTOC may more effectively address this practice gap.

Behavioral health care provider's beliefs, confidence, and knowledge in treating cigarette smoking in relation to their use of the 5A's intervention

Introduction

Evidence-based smoking cessation interventions are underused settings where behavioral health treatment is provided, contributing to smoking-related health disparities in this patient group. This study assessed the relationship of provider's beliefs about patients' smoking, perceptions of treatment capability, and knowledge of referral options and their use of the 5A's (Ask, Advise, Assess, Assist, and Arrange) intervention for smoking cessation.

Methods

Surveys were collected from providers in healthcare settings in Texas where patients receive behavioral health care (N = 86; 9 federally qualified health centers, 16 Local Mental Health Authorities (LMHAs), 6 substance use treatment programs in LMHAs, and 55 stand-alone substance use treatment centers). Logistic regression analyses were used to assess the association between provider's beliefs about patients' concern and desire to quit smoking; perceptions of their confidence, skills, and effectiveness in treating smoking; their knowledge of referral options; and their use of the 5A's with patients who smoked.

Results

Providers who believed that patients were concerned about smoking and wanted to quit; who perceived themselves as confident in providing cessation care, having the required skills, and being effective in providing advice; and/or who had greater referral knowledge were more likely to use the 5A's with patients who smoked than their (respective) provider counterparts (ps < 0.05).

Conclusion

Provider-level constructs affect their 5A's provision for patients with behavioral health needs. Future work should train providers to correct misconceptions about patients' interest in quitting, bolster their confidence, and provide referral options to support tobacco provision efforts.

Educating Substance Use Treatment Center Providers on Tobacco Use Treatments Is Associated with Increased Provision of Counseling and Medication to Patients Who Use Tobacco

Tobacco use is the leading preventable cause of death in America and is elevated among patients with non-tobacco substance use disorders. Substance use treatment centers (SUTCs) do not commonly address their patients' tobacco use. Lack of knowledge on treating tobacco use with counseling and medication may be a barrier that underlies this inaction. A multi-component tobacco-free workplace program implemented in Texas SUTCs educated providers on treating tobacco use with evidence-based medication (or referral) and counseling. This study examined how center-level changes in knowledge from pre- to post-implementation (i.e., over time) affected center-level behavioral changes in providers' provision of tobacco use treatment over time. Providers from 15 SUTCs completed pre- and post-implementation surveys (pre N = 259; post N = 194) assessing (1) perceived barriers to treating tobacco use, specifically, a lack of knowledge on treating tobacco use with counseling or medication; (2) receipt of past-year education on treating tobacco use with counseling or medication; and (3) their intervention practices, specifically, the self-reported regular use of (a) counseling or (b) medication intervention or referral with patients who use tobacco. Generalized linear mixed models explored associations between provider-reported knowledge barriers, education receipt, and intervention practices over time. Overall, recent counseling education receipt was endorsed by 32.00% versus 70.21% of providers from pre- to post-implementation; the regular use of counseling to treat tobacco use was endorsed by 19.31% versus 28.87% from pre- to post-implementation. Recent medication education receipt was endorsed by 20.46% versus 71.88% of providers from pre- to post-implementation; the regular use of medication to treat tobacco use was endorsed by 31.66% versus 55.15% from pre- to post-implementation. All changes were statistically significant (ps < 0.05). High versus low reductions in the provider-reported barrier of "lack of knowledge on pharmacotherapy treatment" over time were a significant moderator of effects, such that SUTCs with high reductions in this barrier were more likely to report greater increases in both medication education receipt and medication treatment/referral for patients who use tobacco over time. In conclusion, a tobacco-free workplace program implementation strategy that included SUTC provider education improved knowledge and resulted in increased delivery of evidence-based treatment of tobacco use at SUTCs; however, treatment provision rates-in particular, offering tobacco cessation counseling-remained less than desirable, suggesting that barriers beyond lack of knowledge may be important to address to improve tobacco use care in SUTCs. Moderation results suggest (1) differences in the mechanisms underlying uptake of counseling education versus medication education and (2) that the relative difficulty of providing counseling versus providing medication persists regardless of knowledge gains.

Changes in Substance Use Treatment Providers' Delivery of the 5A's for Non-Cigarette Tobacco Use in the Context of a Comprehensive Tobacco-Free Workplace Program Implementation

Tobacco use treatment is not prioritized in substance use treatment centers (SUTCs), leading to tobacco-related health inequities for patients with substance use disorders (SUDs) and necessitating efforts to enhance providers' care provision. Training providers on how to treat tobacco use increases their intervention on patients' smoking, but limited work addresses its effects on their non-cigarette tobacco use intervention provision. This study redressed this gap using data from 15 unaffiliated SUTCs in Texas (serving 82,927 patients/year) participating in a tobacco-free workplace program (TFWP) that included provider education on treating tobacco use, including non-cigarette tobacco use. SUTC providers completed surveys before (n = 259) and after (n = 194) TFWP implementation. Past-month screening/intervention provision for non-cigarette tobacco use (the 5A's; ask, advise, assess, assist, arrange) and provider factors theoretically and practically presumed to underlie change [i.e., beliefs about concurrently treating tobacco use disorder (TUD) and other SUDs, self-efficacy for tobacco use assessment (TUA) delivery, barriers to treating tobacco dependence, receipt of tobacco intervention training] were assessed. Generalized linear or linear mixed models assessed changes over time from before to after TFWP implementation; low vs. high SUTC-level changes in provider factors were examined as moderators of changes in 5A's delivery. Results indicated significant improvement in each provider factor and increases in providers' asking, assisting, and arranging for non-cigarette tobacco use over time (ps < 0.04). Relative to their counterparts, SUTCs with high changes in providers' beliefs in favor of treating patients' tobacco use had greater odds of advising, assessing, assisting, and arranging patients, and SUTCs with greater barrier reductions had greater odds of advising and assisting patients. Results suggest that TFWPs can address training deficits and alter providers' beliefs about treating non-tobacco TUD during SUD care, improve their TUA delivery self-efficacy, and reduce intervention barriers, ultimately increasing intervention provision for patients' non-cigarette tobacco use. SUTCs with the greatest room for improvement in provider beliefs and barriers to care provision seem excellent candidates for TFWP implementation aimed at increasing non-cigarette tobacco use care delivery.

Enhancing Provider Delivery of Tobacco Treatment Within the Inpatient Psychiatric Setting

People with mental illnesses (MI) smoke at higher rates than the general population. However, few mental health providers (MHPs) deliver tobacco treatment to patients with MI especially within inpatient psychiatric settings. According to evidence, fewer than half of MHPs in the US mental and behavioral health settings provide the recommended evidence-based tobacco treatment interventions to their clients with MI. This paper uses the theory of planned behavior to examine factors associated with provider intentions to deliver and their experiences in providing evidence-based tobacco treatment to clients with MI. Data were obtained from a cross-sectional survey of 219 providers in a state psychiatric hospital in Kentucky. Attitudes, subjective norms, and perceived behavioral control were associated with providers' intentions to deliver tobacco treatment when controlling for demographic and work-related variables. However, only profession, subjective norms, and attitudes were associated with reported provision of evidence-based tobacco treatment. Given the underuse of routine tobacco treatment for this vulnerable population, understanding factors influencing provider delivery of tobacco treatment is needed to guide strategies for reducing the disproportionate rates of tobacco use and related burden among people with MI.

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.

Collaborative Learning: A Qualitative Study Exploring Factors Contributing to a Successful Tobacco Cessation Train-the-Trainer Program as a Community of Practice

Individuals with behavioral health conditions account for 50% of annual smoking-related deaths, yet rarely receive tobacco dependence treatment within local mental health authorities (LMHAs). As lack of training and knowledge are key barriers to providing tobacco dependence treatment, Taking Texas Tobacco-Free (TTTF) developed an iterative, 4-6-months train-the-trainer program to embed expertise and delivery of sustained education on tobacco-free workplace policies and practices in participating centers. We explore the employee "champions'" train-the-trainer program experiences using a community of practice (CoP) model to identify key contributors to successful program implementation. Across 3 different LMHAs, we conducted semi-structured individual and group interviews online at 2 time points. We interviewed each champion twice (except for 1 champion who dropped out between measurements); pre-implementation (3 group interviews; N = 4 + 4 + 3 = 11 champions); post-implementation (7 individual interviews and 1 group interview; 7 + 3 = 10 champions). Therefore, 11 champions participated in pre- and post-implementation interviews from July 2020-May 2021. Guided by an iterative, thematic analysis and constant comparison process, we inductively coded and summarized data into themes. Five factors contributed to successful program implementation: value of peer support/feedback; building knowledge, champion confidence, and program ownership; informative curriculum, adaptable to targeted populations; staying abreast of current tobacco/nicotine research and products; and TTTF team responsiveness and practical coaching/assistance. Champions reported the TTTF train-the-trainer program was successful and identified attitudes and CoP processes that effectively built organizational capacity and expertise to sustainably address tobacco dependence. Study findings can guide other agencies in implementing sustainable tobacco-free training programs.

Implementation and Outcomes of a Comprehensive Tobacco Free Workplace Program in Opioid Treatment Centers

Tobacco use is exceedingly high among individuals receiving care for opioid addiction, but not commonly addressed by clinicians in treatment settings. Taking Texas Tobacco Free (TTTF) is a comprehensive tobacco-free workplace (TFW) program that builds treatment centers' capacity to address tobacco use with evidence-based tobacco cessation policies and practices. Here, we examine the process and outcomes of TTTF's implementation within 7 opioid addiction centers. Program goals were structured according to the RE-AIM framework. Pre- and post-implementation data were collected from client facing and non-client facing employees to assess changes in education, training receipt, knowledge, and intervention behaviors, relative to program goals. Centers reported tobacco screenings conducted and nicotine replacement therapy (NRT) delivered through 6 months post-implementation. Overall, 64.56% of employees participated in TTTF-delivered tobacco education, with a 54.9% gain in tobacco control and treatment knowledge (p < 0.0001), and significant increases in exposure to education about tobacco use and harms among individuals with opioid use disorder (p = 0.0401). There were significant gains in clinicians' receipt of training in 9/9 tobacco education areas (ps ≤ 0.0118). From pre- to post-implementation, there were mean increases in the use of the 5A's (ask, advise, assess, assist, and arrange) and other evidence-based interventions for tobacco cessation, with statistically significant gains seen in NRT provision/referral (p < 0.0001). Several program goals were achieved or exceeded; however, 100% center participation in specialized clinical trainings was among notable exceptions. One program withdrew due to competing pandemic concerns; all others implemented comprehensive TFW policies. Overall, TTTF may have improved participating opioid treatment centers' capacity to address tobacco use, although study limitations, including lower post-implementation evaluation response rates, suggest that results require replication in other opioid addiction treatment settings.

Implementation and Outcomes of a Train-the-Trainer Program at Behavioral Health Treatment Centers as a Mechanism to Maintain Organizational Capacity to Address Tobacco Use Disorder

Despite prior successful implementation of Taking Texas Tobacco Free (TTTF), an evidence-based tobacco-free workplace program, in local mental health authorities (LMHAs), post-implementation employee attrition necessitated continuing education on tobacco-free policies and tobacco treatment practices. Here, we report on the outcomes of a train-the-trainer program which trained "champions" to deliver tobacco cessation education at their LMHAs. Three LMHAs participated in program implementation via 10 champions, iteratively trained and coached by TTTF. Measures administered evaluated four goals: (1) increase champions' self-efficacy in delivering trainings, (2) achieve program fidelity via TTTF staff evaluation of trainer effectiveness and knowledge increases among attending employees, (3) achieve stakeholder program acceptability, and (4) achieve program adoption via an increase in follow-up trainings. Champions' self-efficacy increased throughout TTTF training. TTTF staff ratings of champion-led trainings met the targeted range for trainer effectiveness; employees had a 28.71% knowledge increase over baseline post-training (p < 0.001). Employees rated champions' training delivery "very good" to "excellent", on average; both champions and employees were, on average, "satisfied" to "extremely satisfied" with the curriculum and training received. There was an increase over baseline in trainings delivered during follow-up, and trainings increased in length and topic coverage. Ultimately, the train-the-trainer program achieved the intended goals, although not all changes were statistically significant, likely at least partially attributable to small sample sizes. Overall, these results suggest that TTTF's train-the-trainer program was successful in its delivery and intention to build capacity for the provision of in-house tobacco education trainings to behavioral health employees/providers. However, further evaluation in additional settings, with more champions, et cetera, is necessary to validate these findings, ensure their replicability, link program implementation with reduced patient tobacco use rates, and assess long-term sustainability.

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.

Organizational-Level Moderators Impacting Tobacco-Related Knowledge Change after Tobacco Education Training in Substance Use Treatment Centers

Tobacco use is disproportionately elevated among patients with substance use disorders relative to the general U.S. population. Tobacco interventions are lacking within substance use treatment centers (SUTCs) due to lack of knowledge and training. This study examined knowledge gain and the organizational factors that might moderate knowledge gains following tobacco education training provided to employees (N = 580) within 15 SUTCs that were participating in a tobacco-free workplace program. The number of total annual patient visits, unique annual patient visits, number of full-time employees, and organizational readiness for implementing change (ORIC) as assessed prior to implementation were examined as potential moderators. Results demonstrated significant knowledge gain (p < 0.001) after training overall; individually, 13 SUTCs had significant knowledge gain (p's < 0.014). SUTCs with fewer total annual patient visits and fewer full-time employees showed greater knowledge gains. The ORIC total score and all but one of its subscales (Resource Availability) moderated knowledge gain. SUTCs with greater initial Change Efficacy (p = 0.029), Valence (p = 0.027), and Commitment (p < 0.001) had greater knowledge gain than SUTCs with lower scores on these constructs; SUTCs with greater Task Knowledge (p < 0.001) regarding requirements for change exhibited less knowledge gain. Understanding the organizational-level factors impacting training effectiveness can inform efforts in organizational change and tobacco control program implementation.

Addressing Smoking Cessation among Women in Substance Use Treatment: A Qualitative Approach to Guiding Tailored Interventions

Intersecting socially marginalized identities and unique biopsychosocial factors place women with substance use disorders (SUDs) experiencing myriad disadvantages at higher risk for smoking and stigmatization. Here, based on our work with women receiving care for SUDs in four participating treatment/women-serving centers (N = 6 individual clinics), we: (1) describe the functions of smoking for women with SUDs; and (2) explore participants’ experiences of a comprehensive tobacco-free workplace (TFW) program, Taking Texas Tobacco-Free (TTTF), that was implemented during their SUD treatment. Ultimately, information gleaned was intended to inform the development of women-tailored tobacco interventions. Data collection occurred pre- and post-TTTF implementation and entailed conducting client (7) and clinician (5) focus groups. Using thematic analysis, we identified four main themes: “the social context of smoking,” “challenges to finding support and better coping methods,” “addressing underlying conditions: building inner and outer supportive environments,” and “sustaining support: TFW program experiences.” Women reported that: smoking served as a “coping mechanism” for stress and facilitated socialization; stigmatization hindered quitting; non-stigmatizing counseling cessation support provided alternative coping strategies; and, with clinicians, the cessation opportunities TTTF presented are valuable. Clinicians reported organizational support, or lack thereof, and tobacco-related misconceptions as the main facilitator/barriers to treating tobacco addiction. Effective tobacco cessation interventions for women with SUDs should be informed by, and tailored to, their gendered experiences, needs, and recommendations. Participants recommended replacing smoking with healthy stress alleviating strategies; the importance of adopting non-judgmental, supportive, cessation interventions; and the support of TFW programs and nicotine replacement therapy to aid in quitting.

Organizational Characteristics and Readiness for Tobacco-Free Workplace Program Implementation Moderates Changes in Clinician's Delivery of Smoking Interventions within Behavioral Health Treatment Clinics

BACKGROUND

Smoking is elevated amongst individuals with behavioral health disorders, but not commonly addressed. Taking Texas Tobacco Free is an evidence-based, tobacco-free workplace program that addresses this, in-part, by providing clinician training to treat tobacco use in local mental health authorities (LMHAs). This study examined organizational moderators of change in intervention delivery from pre- to post-program implementation.

METHODS

LMHA leaders completed the Organizational Readiness for Implementing Change (ORIC) and provided organization demographics pre-implementation. Clinicians (N = 1237) were anonymously surveyed about their consistent use of the 5As (Asking about smoking; Advising clientele to quit; Assessing willingness to quit; Assisting them to quit; Arranging follow-up) pre- and post-program implementation. Adjusted generalized linear mixed models were used for analyses (responses nested within LMHAs), with interaction terms used to assess moderation effects.

RESULTS

Clinician delivery of 5As increased pre- to post-implementation (p < .001). LMHAs with fewer employees (ref = ≤300) demonstrated greater increases in Asking, Assessing, and Assisting over time. LMHAs with fewer patients (ref = ≤10 000) evinced greater changes in Asking over time. Less initial ORIC Change Efficacy, Change Commitment, and Task Knowledge were each associated with greater pre- to post-implementation changes in Asking. Less initial Task Knowledge was associated with greater increases in Advising, Assessing, and Assisting. Finally, less initial Resource Availability was associated with greater increases in Assisting (all moderation term ps < .025).

CONCLUSION

The smallest and least ready LMHAs showed the largest gains in tobacco cessation intervention delivery; thus, low initial readiness was not a barrier for program implementation, particularly when efficacy-building training and resources are provided.

IMPLICATIONS

This study examined organizational moderators of increases in tobacco cessation treatment delivery over time following the implementation of a comprehensive tobacco-free workplace program within 20 of 39 LMHAs across Texas (hundreds of clinics; servicing >50% of the state) from 2013 to 2018. Overall, LMHAs with fewer employees and patients, and that demonstrated the least initial readiness for change, evinced greater gains in intervention delivery. Findings add to dissemination and implementation science by supporting that low initial readiness was not a barrier for this aspect of tobacco-free workplace program implementation when resources and clinician training sessions were provided.

Clinician Training in the Adaptation of a Comprehensive Tobacco-Free Workplace Program in Agencies Serving the Homeless and Vulnerably Housed

Tobacco use is exceedingly high among those who are homeless or at risk of homelessness but not commonly addressed by clinicians. Taking Texas Tobacco Free (TTTF) is a tobacco control program that addresses known clinician barriers to intervention (e.g., low training receipt, limited resources). Here, we examine the process and outcomes of TTTF's adaptation within four agencies that provide housing or other services to individuals who are homeless or vulnerably housed. Pre- and post-implementation data were collected from clinicians (N = 68) to assess changes in training receipt, knowledge, and intervention behaviors, relative to program goals. Results indicated significant gains in clinicians' receipt of training in 9 (of 9) target areas (p's ≤ 0.0042) and a 53% knowledge gain (p < 0.0001). From pre- to post-implementation, there were mean increases in the use of the 5As (ask, advise, assess, assist, and arrange) and other evidence-based interventions for tobacco cessation, with significant gains seen in assisting residents/clients to quit, arranging follow-ups, and providing or referring for non-nicotine medications (p's ≤ 0.0491). All program goals, except gains related to advising smokers to quit and the use of specific interventions (behavioral counseling), were met. Overall, TTTF improved clinicians' capacity to address tobacco use among homeless and vulnerably housed individuals and can serve as a model for tobacco control efforts in similar agencies.

Tobacco-related knowledge following a comprehensive tobacco-free workplace program within behavioral health facilities: Identifying organizational moderators

OBJECTIVE

Although smoking prevalence rates among behavioral health consumers is nearly five times that of the general population, evidence-based policies and practices to address tobacco use are uncommon within behavioral health settings. This study assessed changes in non-clinical, general staff and clinician tobacco-related knowledge following brief education provided as part of a comprehensive tobacco-free workplace program implementation and explored organizational moderators of pre- to post-education knowledge change.

METHODS

Fifteen behavioral health facilities, comprising hundreds of individual clinics in Texas, participated in a one (for general staff) or two (for clinicians) hour educational session.

RESULTS

There were large effect sizes in general staff knowledge gain within each consortium, and large effect sizes in clinician knowledge gain in all but one consortium. Knowledge of the requirements for change, perceived availability of resources, and total number of client contacts moderated general staff knowledge gain. Value in the change and total number of client contacts moderated training effectiveness among clinicians.

CONCLUSIONS

We conclude that a brief tobacco-related education for behavioral health employees was effective in increase attendee knowledge.

PRACTICE IMPLICATIONS

Attention to organization-level factors moderating knowledge gain has the potential to guide and improve program implementation.

Evaluation of the Taking Texas Tobacco Free Workplace Program within behavioral health centers

Despite the health benefits of tobacco control and cessation initiatives, tobacco users with behavioral health disorders (BHDs) have less access to evidence-based tobacco dependence treatment. Academic-community partnerships can help guide the translation of tobacco-related research findings and evidence-based guidelines into real-world applications. Through a comprehensive, evidence-based, multilevel, and multicomponent program, Taking Texas Tobacco Free (TTTF) facilitated the implementation of tobacco-free workplaces at 18 local mental health authorities in Texas, comprising over 250 individual community behavioral health centers. Compared with preprogram implementation, key accomplishments postimplementation include: (1) educated over 5,000 employees (nonclinical staff and providers) on the hazards of tobacco use and benefits of quitting, particularly among people with BHD; providers were additionally trained on the use of evidence based practices (EBPs; i.e. 5A's model, use of pharmacotherapy) to identify and treat tobacco use among people with BHD; (2) providers' significant increase in conducting tobacco-use assessments and using EBPs; (3) significant decrease in nonclinical staff tobacco use; (4) increase in quit attempts among consumers as evidenced by the demand for nicotine replacement therapy; and (5) reach to over 115,000 community members through outreach and education about the benefits of quitting tobacco use and maintaining a healthy lifestyle. TTTF demonstrated that the implementation of a comprehensive tobacco-free workplace program in behavioral health settings is feasible and beneficial, facilitating the capacity building of healthcare professionals and enhancing their resulting engagement in EBPs, and promoting healthier lifestyles among employees, consumers, and community members as a whole.

A tele-mentoring tobacco cessation case consultation and education model for healthcare providers in community mental health centers

Smoking prevalence among individuals with mental and behavioral health needs is considerably higher compared to the general population, but evidence-based smoking cessation therapies are underutilized in mental and behavioral healthcare settings, despite the fact that these treatments are both safe and effective. The goal of this paper is to present the background, design and pilot of Project TEACH (Tobacco Education and Cessation in the Health System) developed to improve clinical practice by offering specialized training in the provision of smoking cessation interventions to care providers in community mental health centers in Texas. This is achieved through engaging the expertise of clinicians at the MD Anderson Cancer Center’s Tobacco Treatment Program and disseminating this expertise to care providers by means of a novel tele-mentoring approach called Project ECHO (Extension for Community Healthcare Outcomes). Evaluation of our pilot ECHO training project demonstrated that the training was very well received and resulted in self-reported enhancement of the providers’ professional practice. This is the first project to extend the collaborative ECHO model to train healthcare providers in smoking cessation. This approach has potential to reduce smoking rates among smokers with mental and behavioral health needs, and consequently contribute to the prevention of cancer and other chronic diseases in this vulnerable population.

Implementation of a tobacco-free workplace program at a local mental health authority

Tobacco-free workplace policies that incorporate evidence-based practices can increase the reach and effectiveness of tobacco dependence treatment among underserved populations but may be underutilized due to limited knowledge about implementation processes. This paper describes the implementation of a comprehensive tobacco-free workplace program at a behavioral healthcare community center in Texas. The center participated in a tobacco-free workplace program implementation project that provided guidance and resources and allowed center autonomy in implementation. Six employee-based subcommittees guided implementation of program components including consumer and staff surveys, policy development, signage, tobacco use assessments, communication, and nicotine replacement distribution. Timeline development, successes, challenges, lessons learned, and sustainability initiatives are delineated. Concerns about the tobacco-free workplace policy from the center's staff and consumers were gradually replaced by strong support for the initiative. Program success was enabled by consistent support from the center's leadership, publicity of program efforts, and educational campaigns. The center surpassed the program expectations when it adopted a tobacco-free hiring policy, which was not an initial program goal. This center's path to a tobacco-free workplace provides an implementation and sustainability model for other behavioral health community centers and other organizations to become tobacco free.