The Bucket Approach: Developing and Implementing an On-line Training Program in Tobacco Dependence Interventions Tailored for Behavioral Health Clinicians.

People coping with a mental illness and/or addictive disorders have a very high prevalence of smoking cigarettes. The Bucket Approach, a free online training, tailors evidence-based tobacco dependence interventions for behavioral health clinicians to increase the likelihood that they will also address the tobacco use of their patients. From October 2019 through August 2021, 999 people enrolled in and 447 people completed the training. Individuals who completed the training evaluated it highly with an overall mean score of 8.4 (scale = 1 for very poor to 10 for very good). 3- and 6-month follow-up surveys documented continued impact. The training resulted in substantial changes in beliefs about treating tobacco dependence. For example, before training, 18.3% of trainees strongly agreed with the statement, "The skills currently possessed by behavioral health clinicians can be easily applied to the treatment of tobacco dependence." This increased to 40.7% at the end of training.

Nine years of smoking data from incarcerated men: A call to action for tobacco dependence interventions.

People who are incarcerated use tobacco in high numbers before incarceration and the vast majority resume tobacco use soon after release despite institutional smoking bans. Nine years of surveys collected at a correctional facility in the Midwest, U.S., were analyzed to identify the needs of this high-risk population and suggest future directions for research and intervention development. For the most part, survey respondents considered themselves no longer addicted to tobacco and intended to remain tobacco free after release. They increasingly expected support to remain tobacco free from their home environment despite no change in home tobacco use. Over this nine-year period, significantly fewer respondents wanted materials and help to remain tobacco free, suggesting they have become more challenging to assist. Implications for intervention development and future research are discussed.

Measuring Therapeutic Alliance for Tobacco Cessation Counseling for Behavioral Health Clinicians.

INTRODUCTION: Those coping with significant mental illness smoke at a high prevalence rate. Increasingly, behavioral health clinicians (BHCs) are being asked to provide tobacco-dependence interventions. In this context, it is important to measure their success at doing so. While the Working Alliance Inventory (WAI) is a well-established measurement of the effectiveness of therapeutic alliance, it is not specific to tobacco-dependence interventions. The Working Alliance Inventory for Tobacco (WAIT-3) has been found valid for tobacco cessation counselors (health providers who address tobacco), but its validity has not been established when BHCs address tobacco cessation as part of addressing all other needs of their patients. The purpose of this study was to examine the validity of the WAIT-3 in the context of behavioral health clinicians. METHODS: Wisconsin Community Support Programs and Comprehensive Community Services programs distributed an anonymous, brief (14 items) survey to 1,930 of their clients. Measured variables included smoking status, behavioral intentions regarding quitting, and perception of help received from their clinic. Respondents could enter a chance to win a gift card as a thank you. RESULTS: WAIT-3 scores were correlated with quitting-related variables. Compared to those with lower WAIT-3 scores, those with higher scores reported more attempts to quit, were more motivated to quit, were more likely to have a smoking cessation/reduction goal in their general treatment plan, had more conversations about quitting with their BHC, and wanted more help from their BHC to quit. CONCLUSIONS: The WAIT-3 may be a valid way to measure the effectiveness of BHCs to address the tobacco use of their patients. Next steps include establishing its predictive validity.

Engaging Smokeless Tobacco Users in Population-Based Cessation Services: Findings From an Observational Study.

Although telephone quitlines are effective for helping smokeless tobacco (ST) users quit, ST users are underrepresented among quitline participants. After ClearWay MinnesotaSM implemented multiple changes to its quitline service (QUITPLAN® Services), utilization increased dramatically, including by ST users. We examined data from Minnesota and Wisconsin to determine whether these changes were unique to Minnesota. Four years of quitline registration data were analyzed for both states. A significant increase in enrollees reporting any ST use was seen in Minnesota after changes were made to services; no change was seen in Wisconsin. A 2-week starter kit of nicotine replacement therapy and the ability to register for services online were popular among Minnesotans reporting ST use. This study suggests that quitline services can be designed to increase participation by ST users.

The HUD smoke-free rule: Perceptions of residents post-implementation.

In July 2018, the U.S. Department of Housing and Urban Development (HUD) implemented a new Public health Agency rule prohibiting the use of tobacco in and within 25 feet of HUD housing. A convenience sample of 574 residents living in Milwaukee, Wisconsin multi-unit HUD complexes completed a survey from May through July 2019, designed to assess their perceptions of the new policy and its impact. Knowledge of the policy was strong, although continued educational efforts are needed. Attitudes about the policy were generally positive, although smokers held more negative attitudes than non-smokers. Some residents desired more and fairer policy enforcement. Most residents reported that smoke incursions were reduced post policy compared to pre policy, although such incursions still occurred. The policy has had a favorable health impact on smokers; over 80% made at least one positive change in their smoking, including 6.4% who said the policy motivated them to quit. There was no evidence that residents with mobility challenges were differentially affected by the policy. Overall, the HUD smoke-free policy was well received, reduced self-reported exposure to smoke and led most smokers to make positive changes in their smoking. Additional education on the policy, improved enforcement, and cessation services are needed.

Helping Low Income Pregnant Women Quit Smoking: Improving the First Breath Program.

BACKGROUND: Maternal smoking during pregnancy can have dire consequences for both baby and mother. In 2000, the Wisconsin Women's Health Foundation developed the First Breath program to address this challenge, particularly among low-income women. While this prenatal smoking cessation program was successful, 2 factors necessitated changes in the program: changes in the health care reimbursement environnment and a high postpartum relapse rate. METHODS: The First Breath program was revised using the concepts of implementation science and included focus groups of First Breath clients, a randomized control trial to test new postpartum services, and an implementation project to test the new method of delivering First Breath. RESULTS: A year after implementing the new First Breath program, results are encouraging. First Breath expanded its reach by 34% over 2017. Eighty-eight new First Breath sites (to a total of 235 sites) have been added, resulting in increased diversity. While there was significant relapse within the new program from prenatal abstinence to 1-month postpartum abstinence (from 13.6% to 7.3% abstinence, biochemically verified, intent-to-treat) there was not additional relapse through 6 months postpartum. CONCLUSION: Sustaining a valuable community-based tobacco dependence intervention program serving a vulnerable population requires continuous improvement built on measured outcomes and response to changes in the health care delivery system. First Breath may serve as a model program to aid underserved pregnant women who smoke.

Addressing Postpartum Smoking Relapse Among Low-Income Women: A Randomized Control Trial.

PURPOSE: Smoking during pregnancy can have dire consequences for both the baby and mother. Low-income pregnant women smoke at particularly high rates. Among women who quit during pregnancy, postpartum relapse is high. This randomized control trial tested the effect of adding postpartum assistance to an existing smoking cessation program (First Breath) designed for low-income women. METHODS: Of 185 study participants, 94 women were randomly assigned to the standard First Breath program (control) and 91 to an enhanced program. First Breath consisted of evidence-based smoking cessation counseling provided at every prenatal visit. The enhanced program included all First Breath services plus 4 in-home counseling visits (3 postpartum), 3 postpartum counseling calls, support to others in the home, and incentives (gift cards) totaling $100. The primary outcome was biochemically verified abstinence at 6 months postpartum. RESULTS: Among the 98 women who completed the study, the abstinence rate among the intervention participants (n=41) was significantly greater than among the control participants (n=57) (36.6% vs 12.3%, respectively; P<0.01). Analyzed on an intent-to-treat basis, with those lost to follow-up assumed to be smoking, the abstinence rate among intervention subjects (n=91) was 16.5% vs 7.4% among control participants (n=94); P=0.07. CONCLUSIONS: Extending smoking cessation interventions into the postpartum period may help address postpartum relapse.

The RICO Verdict and Corrective Statements: Catalysts for Policy Change?

OBJECTIVES: A federal court ruled tobacco companies violated racketeering laws and ordered them to publish corrective statements. This study assesses effects of exposure to the statements and related court findings on attitudes toward tobacco-related policies and tobacco company influences on policymaking. METHODS: We conducted a cross-sectional survey of US adults (N = 2010) prior to publication of the statements. Participants were randomly assigned to the "unexposed" group (N = 1004), which answered attitude questions before reading the statements and court findings, or the "exposed" group (N = 1006), which answered attitude questions after reading the statements and court findings. RESULTS: The exposed group was less likely to think lawmakers should trust tobacco companies as much as other companies (ß = -.24, p < .001) or that lawmakers should trust tobacco company lobbyists to provide accurate information (ß = -.17, p = .019), compared to the unexposed group. The exposed group also was more likely to support requiring graphic warning labels (ß = .15, p = .014) and point-of-sale quitline signs (ß = .13, p = .028). CONCLUSIONS: Exposure to the statements and court findings may aid tobacco industry denormalization and tobacco-related policy initiatives.

Feasibility of a Systems Approach to Treat Commercial Tobacco Dependence within American Indian Health Clinics.

American Indians and Alaska Natives (AI/ANs) have the highest smoking prevalence, smoking-related disease, and mortality rates of any racial or ethnic group. Three AI health clinics in Minnesota implemented an evidence-based tobacco dependence treatment intervention that included provider education and customized clinical system tools. A baseline assessment of each clinic facility guided the focus of the intervention and tailored the clinical system tools. Clinic staff were assessed with pre/post-training evaluations and annual assessments. Results indicated self-reported improvements in the rate of identifying smoking status (57% to 89%), documenting smoking status (from 60% to 80%), and providing evidence-based treatments such as pharmacotherapy (from 36% to 78%).

Helping Smokers with Severe Mental Illness Who Do Not Want to Quit.

BACKGROUND: People with a severe and persistent mental illness are far more likely to smoke than others. While a large portion would like to quit, they are less likely to make quit attempts and succeed. OBJECTIVE: This study used an Randomized Controlled Trial (RCT) to test an intervention designed to increase engagement in cessation treatment, quit attempts, and quitting in smokers who did not want to quit in the next 30 days. It also compared these smokers with those who were motivated to quit in the next 30 days. METHODS: Participants (N = 222), were smokers with significant mental illness receiving intensive outpatient care from Wisconsin Community Support Programs who were not interested in quitting in the next 30 days. They were randomly assigned to either an intervention group or an attention control group. The intervention, administered during four weekly sessions, included a motivational element, components designed to prepare the smoker for a quit attempt, and pre-quit nicotine patch. Additionally, 48 smokers motivated to quit in the next 30 days served as a comparison group. RESULTS: Compared to control participants, smokers receiving the intervention were more likely to be abstinent at the three month follow-up (biochemically verified, intent to treat, 8.5% vs. 1.0%, respectively, p = .01). They were also more likely to accept four more quitting preparation sessions (intent to treat, 50.8% vs 29.2%, respectively, p < .001) but were not more likely to call a telephone tobacco quit line. Conclusion/Importance: Brief motivational interventions increased engagement in cessation treatment and abstinence among smokers with signification mental illness.

Measuring the Integration of Tobacco Policy and Treatment into the Behavioral Health Care Delivery System: How Are We Doing?

People with a mental illness and/or drug use disorder have a higher rate of smoking than adults in general. To address this challenge, recommendations include integrating tobacco-free policies and tobacco dependency treatment into the behavioral health care delivery system. Currently, little is known regarding levels of such integration. A 65-item Internet survey measuring integration assessed three areas: a) policies addressing the use of tobacco products; b) provision of evidence-based tobacco dependence treatment; and, c) capacity to help employees/volunteers quit tobacco use. The survey was distributed to representatives of all behavioral health programs in Wisconsin. The survey response rate was 27.1%. Programs, on average, were 40% integrated. A significant proportion of programs (20%) were less than 20% integrated. A few programs (4.3%) exceeded 80% integration. Integration of tobacco policies and treatment into the behavioral health care delivery system remains limited and there is a need for technical assistance and training.

Motivating Low Socioeconomic Status Smokers to Accept Evidence-Based Smoking Cessation Treatment: A Brief Intervention for the Community Agency Setting.

INTRODUCTION: Individuals of low socioeconomic status (SES), smoke at very high rates but make fewer and less successful quit attempts than do other smokers. Low-SES smokers have specific beliefs about smoking and quitting that may serve as barriers to making quit attempts. The purpose of this study was to test the impact of a brief intervention addressing these beliefs on making calls to a telephone quit line. METHODS: Of 522 smokers entering the study at 5 Wisconsin Salvation Army (SA) sites, 102 expressed motivation to quit and served as a comparison group. The remaining 420 smokers were not motivated to quit and were randomly assigned to 1 of 3 conditions: an intervention group who received brief counseling focused on cessation goals and beliefs, an attention-control group, and a low contact control group. The primary outcome was the rate at which smokers made a call to the Wisconsin tobacco quit line (WTQL) during their SA visit. Secondary outcome measures included motivational variables, stage of change, changes in beliefs about smoking and quitting, and self-reported abstinence. RESULTS: Unmotivated participants in the intervention condition called the WTQL at a significantly higher rate (12.2%) than did those in the 2 control conditions (2.2% and 1.4%) (p < .01) and approached the rate of calling by participants who were initially motivated to quit (15.7%). Intervention condition participants also showed improved motivation to quit and stage of change. CONCLUSIONS: A brief, targeted motivational intervention focusing on cessation goals and beliefs increased the initiation of an evidence-based tobacco cessation treatment by low-SES smokers.

Changing low income smokers' beliefs about tobacco dependence treatment.

This field study tested an intervention that challenged beliefs about the effectiveness of various quit methods held by Salvation Army client smokers from two urban locations (N = 245). Data (surveys administered immediately after and one month post-intervention) were collected 2009-2010 and analyzed using primarily χ(2) and t-tests. The intervention changed client perceptions about the effectiveness of quitting methods. Compared to no-intervention controls, intervention participants reported significantly greater smoking reduction and greater likelihood of contacting the Wisconsin Tobacco Quit Line. Study implications/limitations are discussed and future research directions noted. This research was supported by grant UL1TR000427 from the Clinical and Translational Science Award (CTSA) program of the National Center for Advancing Translational Sciences, NIH.

Electronic health records as a tool for recruitment of participants' clinical effectiveness research: lessons learned from tobacco cessation.

Translating tobacco dependence treatments that are effective in research settings into real-world clinical settings remains challenging. Electronic health record (EHR) technology can facilitate this process. This paper describes the accomplishments and lessons learned from a translational team science (clinic/research) approach to the development of an EHR tool for participant recruitment and clinic engagement in tobacco cessation research. All team stakeholders-research, clinical, and IT-were engaged in the design and planning of the project. Results over the first 17 months of the study showed that over one half of all smokers, coming in for any type of clinic appointment, were offered participation in the study, a very high level of adherent use of the EHR. Study recruitment over this period was 1,071 individuals, over 12 % of smokers in the participating clinics.

Recruiting and engaging smokers in treatment in a primary care setting: developing a chronic care model implemented through a modified electronic health record.

Almost 35 million U.S. smokers visit primary care clinics annually, creating a need and opportunity to identify such smokers and engage them in evidence-based smoking treatment. The purpose of this study is to examine the feasibility and effectiveness of a chronic care model of treating tobacco dependence when it is integrated into primary care systems using electronic health records (EHRs). The EHR prompted primary care clinic staff to invite patients who smoked to participate in a tobacco treatment program. Patients who accepted and were eligible were offered smoking reduction or cessation treatment. More than 65 % of smokers were invited to participate, and 12.4 % of all smokers enrolled in treatment-30 % in smoking reduction and 70 % in cessation treatment. The chronic care model developed for treating tobacco dependence, integrated into the primary care system through the EHR, has the potential to engage up to 4.3 million smokers in treatment a year.

Barriers to effective tobacco-dependence treatment for the very poor.

OBJECTIVE: People who live in poverty have a high prevalence of smoking, are less likely to engage in evidence-based treatment, and find it harder to quit. Their beliefs about smoking and quitting can serve as barriers to quitting. Little is known about the smoking and quitting beliefs of the very poor (about U.S. $15,000 or less annual family income) because they tend not to be included in research. This study sought to assess beliefs about smoking and quitting by the very poor in relation to past quitting behavior and intention to quit in the future. METHOD: A survey was administered in person to residents in randomly selected addresses in two very impoverished Milwaukee, WI, ZIP codes during the day to ensure the inclusion of the very poor. RESULTS: Six hundred fifty-four people completed the survey, a response rate of 78.3%. Sixty-eight percent reported annual household incomes of less than $15,000 compared with 30.8% in the community as a whole and 13.0% of households nationally. Self-reported smoking prevalence was 42.1%. Specific beliefs about smoking and quitting were related to past quit attempts and intentions to quit in the future. Both race and income predicted beliefs and quitting-related variables independently and jointly. CONCLUSIONS: Continued tobacco-control progress requires addressing specific populations with known high tobacco use. One of these populations is those with low income. Efforts to engage them in treatment will have to address specific beliefs about smoking and quitting.

Advancing public health through continuing education of health care professionals.

This article describes how the CS2day (Cease Smoking Today) initiative positioned continuing education (CE) in the intersection between medicine and public health. The authors suggest that most CE activities address the medical challenges that clinicians confront, often to the neglect of the public health issues that are key risk factors for the onset and exacerbation of diseases. The authors further suggest that the educational activities of the CS2day initiative functioned as Type III translational science in that it facilitated the use of research-derived practice guidelines in clinical practice and in the community. The article concludes by stating that the successful results of the CS2day initiative illustrate what can happen when continuing education efforts develop from a public health problem rather than just a practice gap identified in a clinical practice setting.

Increasing consumer demand among Medicaid enrollees for tobacco dependence treatment: the Wisconsin "Medicaid covers it" campaign.

PURPOSE: Smoking prevalence among Medicaid enrollees is higher than among the general population, but use of evidence-based cessation treatment is low. We evaluated whether a communications campaign improved cessation treatment utilization. DESIGN: Quasi-experimental. SETTING: Wisconsin. SUBJECTS: Enrollees in the Wisconsin Family Medicaid program. The average monthly enrollment during the study period was approximately 170,000 individuals. INTERVENTION: Print materials for clinicians and consumers distributed to 13 health maintenance organizations (HMOs) serving Wisconsin Medicaid HMO enrollees. MEASURES: Wisconsin Medicaid pharmacy claims data for smoking cessation medications were analyzed before and after a targeted communications campaign. HMO enrollees were the intervention group. Fee-for-service enrollees were a quasi-experimental comparison group. Quit Line utilization data were also analyzed. ANALYSIS: Pharmacotherapy claims and number of registered Quit Line callers were compared precampaign and postcampaign. RESULTS: Precampaign, cessation pharmacotherapy claims declined for the intervention group and increased slightly for the comparison group (t  =  2.29, p  =  .03). Postcampaign, claims increased in both groups. However, the rate of increase in the intervention group was significantly greater than in the comparison group (t  =  -2.2, p  =  .04). A statistically significant increase was also seen in the average monthly number of Medicaid enrollees that registered for Quit Line services postcampaign compared to precampaign (F [1,22]  =  7.19, p  =  .01). CONCLUSION: This natural experiment demonstrated statistically significant improvements in both pharmacotherapy claims and Quit Line registrations among Medicaid enrollees. These findings may help inform other states' efforts to improve cessation treatment utilization.

The multiphase optimization strategy for engineering effective tobacco use interventions.

The multiphase optimization strategy (MOST) is a new methodological approach for building, optimizing, and evaluating multicomponent interventions. Conceptually rooted in engineering, MOST emphasizes efficiency and careful management of resources to move intervention science forward steadily and incrementally. MOST can be used to guide the evaluation of research evidence, develop an optimal intervention (the best set of intervention components), and enhance the translation of research findings, particularly type II translation. This article uses an ongoing study to illustrate the application of MOST in the evaluation of diverse intervention components derived from the phase-based framework reviewed in the companion article by Baker et al. (Ann Behav Med, in press, 2011). The article also discusses considerations, challenges, and potential benefits associated with using MOST and similar principled approaches to improving intervention efficacy, effectiveness, and cost-effectiveness. The applicability of this methodology may extend beyond smoking cessation to the development of behavioral interventions for other chronic health challenges.