Background: Nicotine dependence is three to four times more common among individuals with a substance use disorder (SUD) than among individuals without an SUD. Up to half of long-term smokers will die from smoking-related illness, making tobacco dependence (TD) the most lethal form of addiction. VHA policy and VA/DoD clinical practice guidelines specify provision of tobacco dependence treatment for all tobacco-dependent Veterans in SUD treatment programs. Despite extensive evidence and clear guideline recommendations, however, SUD providers have historically failed to include tobacco dependence as a focus of treatment. Seventy-nine percent of patients in substance abuse residential rehabilitation treatment programs (SARRTPs) are identified tobacco users. Yet tobacco treatment implementation within SARRTPs has been low and variable, i.e., only 10% of tobacco-using patients receive both documented tobacco treatment and an ICD-9 tobacco dependence diagnosis, and facility level pharmacotherapy receipt among these patients ranges from 0% to 100%. This project represents the next step in an ongoing program of research aimed at increasing tobacco treatment implementation in SARRTP programs, driven by our close collaboration with the Office of Clinical Public Health Tobacco & Health: Policy and Programs, the Office of Mental Health Operations, and the Mental Health Services MHRRTP and Addictive Disorders Programs. Objectives: This project aims to increase tobacco dependence pharmacotherapy implementation for tobacco-dependent patients in SARRTP using a multifaceted facilitation model with documented success in other VHA mental health implementation efforts. Secondary aims include: 1) evaluating the impact of the implementation intervention on tobacco use status, 2) evaluating the impact of the implementation intervention on continuity of care for tobacco-dependent patients, and 3) tracking implementation program costs to conduct economic analyses. Methods: Guided by the Promoting Action on Research Implementation in Health Services model and the Theory of Planned Behavior, we will adapt and test the facilitation intervention in three SARRTPs using an interrupted time series design (ITS) design. First, we will incorporate staff interviews and surveys in a developmental formative evaluation to adapt and tailor the facilitation intervention. Second, we will conduct a summative evaluation of the facilitation intervention and evaluate implementation outcomes. Evaluation: Following the Cochrane quality criteria for appropriate ITS design methods, we will evaluate the average within-program effects of the implementation intervention using a segmented regression strategy with appropriate power for detecting differences in TD pharmacotherapy receipt among tobacco-using patients in SARRTP. We will also evaluate whether changes in the intervention sites exceed secular trends in six non-intervention sites. We will use administrative data to capture the primary pharmacotherapy outcomes as well as smoking status and continuity of tobacco care outcomes. We will also conduct an exploratory analysis of TD counseling during SARRTP using chart review. Throughout the second phase we will continue to conduct formative evaluation activities aimed at understanding the process, progress, and impact of the implementation program. Impact: The Veterans Health Administration (VHA) has 63 SARRTPs with over 1,600 total beds for Veterans with SUD and other vulnerabilities who require intensive treatment and support. Demand for SARRTP beds is high. A large proportion of Veterans served in SARRTPs use tobacco. This project aims to improve their access to the health, social, and economic benefits of tobacco treatment.
Up to 50% of long-term smokers will die from smoking related illness,10 making tobacco dependence the most lethal form of addiction. VHA substance use disorder residential rehabilitation treatment programs (SARRTPS) serve some of our most vulnerable Veteran populations. Over 75% of SARRTP patients smoke. This study aims to improve Veteran health by improving tobacco treatment in SARRTP programs. Tobacco treatment is highly cost effective, and gaps in tobacco treatment implementation are of particular concern given the extensive evidence base underlying the VA/DoD Clinical Practice Guidelines for Tobacco Use. VHA policy mandates implementation of the VA/DoD guidelines for all Veterans who use tobacco, including Veterans in specialty SUD settings. Improving tobacco treatment for patients with SUDs can significantly improve health outcomes and reduce overall healthcare costs.
