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

Abstract

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=1,237) 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<0.001). 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<0.025). 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 trainings 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 local mental health authorities (LMHAs) across Texas (hundreds of clinics; servicing >50% of the state) from 2013-2018. 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.

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

“…Taking Texas Tobacco Free has been implemented throughout Texas in behavioral health treatment settings and substance use treatment centers [ 33 , 34 , 35 , 36 , 37 , 38 , 39 ]. Implementation outcome data have supported significant increases in tobacco-related knowledge among employees, increases in clinicians’ self-reported use of the five As, and increases in organizational capacity for tobacco intervention provision to patients [ 33 , 34 , 35 , 36 , 37 , 39 , 40 , 41 ]. The five As are an evidence-based, brief tobacco cessation intervention that has been recommended in clinical treatment guidelines [ 29 , 42 ].…”

“…Although tobacco control programs have been shown to be effective, it is currently unclear how and which organizational moderators impact the degree of adoption and program effectiveness among substance use treatment centers. In a prior study done with behavioral health treatment facilities, the number of unique patients served annually and the number of full-time employees moderated changes in clinicians’ delivery of the 5As to patients [ 37 ]. Apart from center demographics, center readiness also moderated changes in clinician behavior in that study.…”

“…Apart from center demographics, center readiness also moderated changes in clinician behavior in that study. Specifically, belief that employees could take the steps for change (i.e., Change Efficacy), that employees had motivation to implement the change (i.e., Change Commitment), that employees had knowledge about the requirements for change (i.e., Task Knowledge), and that employees perceived that resources needed to implement a change were available (i.e., Resource Availability) moderated these changes [ 37 ].…”

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

“…The training included education on the dangers of tobacco use, the addictiveness of nicotine, the prevalence of tobacco use among individuals with non-nicotine substance use disorders, the tobacco industries’ targeting of individuals with behavioral health needs, and empirically-based methods to address tobacco use disorder (including the importance of tobacco-free workplace policies and how to uphold them). Several other components of the TTTF program were enacted thereafter as detailed elsewhere [ 14 , 28 , 29 , 34 , 35 , 36 , 37 , 38 ], including sending program champions to Certified Tobacco Treatment Specialist trainings, Motivational Interviewing trainings, etc., but are not the subject of this report. Program champions are individuals who are identified by the center to lead and be the primary contact for implementation of the tobacco-free workplace program within their center.…”

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

“…Our comprehensive program focuses on treating tobacco dependence among groups experiencing disadvantage with the highest smoking rates and need for assistance in quitting. To date, TTTF has been successfully implemented in 300 mental health centers [ 30 , 31 , 32 , 33 , 34 , 35 ] and has recently expanded into 30 standalone SUTCs/community centers [ 36 , 37 , 38 ], four of which serve women only and are the subject of this report.…”