A Pragmatic Cluster-Randomized Trial of Provider Education and Community Health Worker Support for Tobacco Cessation

Community Health Workers Research: Where Are We Now? A Narrative Review of an Expanding Workforce for Mental Health

ABSTRACT

In an evolving health care landscape, community health workers (CHWs) have emerged as invaluable assets, bridging gaps to mental health service access and fostering community resilience. In this article, we explore the multifaceted responsibilities shouldered by CHWs, encompassing outreach, education, and support, and underscore their unique abilities to establish trust within diverse communities. We also highlight evolving recognition of CHWs as integral health care team members and examine the growing body of evidence on CHW effectiveness in enhancing mental health outcomes, reducing disparities, and promoting preventative measures. Additionally, we review how, in the wake of the COVID-19 pandemic, the CHW role has shifted with increased demand for their services within the mental health care landscape. The pandemic laid bare the vulnerabilities in existing health care structures, disproportionately affecting communities with limited resource access, including mental health support. Furthermore, we review six primary research domains that could potentially help expand the CHW workforce: standardization and training, sustainability and retention, integration into health systems, impact measurement, cost-effectiveness and financing, and scaling up and adaptation. Last, we examine the pandemic's transformative effects on CHWs; we shed light on their resilience and adaptability in the face of unprecedented challenges and underscore their heightened relevance within the evolving health care response paradigm post-COVID.

Disparities in cigarette smoking and the health of marginalized populations in the U.S.: a simulation analysis

INTRODUCTION

People with low socioeconomic status (SES) or serious psychological distress (SPD) in the U.S. face ongoing and future disparities in tobacco smoking. We sought to estimate how smoking disparities contribute to disparities in life expectancy and aggregate life-years in these marginalized subpopulations.

METHODS

We used the Simulation of Tobacco and Nicotine Outcomes and Policy (STOP) microsimulation model to project life expectancy as a function of subpopulation (low SES, higher SES, SPD, or non-SPD) and cigarette smoking status. Low SES was defined as having at least one of the following: income below poverty, less than high school education, or Medicaid insurance. Higher SES individuals belonged to none of these categories. SPD was defined as Kessler-6 score ≥ 13; non-SPD was a Kessler-6 score < 13. To project individual life expectancy losses from smoking, we simulated 40-year-olds stratified by gender, subpopulation (by SES or by SPD, with no change), and smoking status (current/never, with no change). To project time to reach 5% cigarette smoking prevalence (U.S.) - reflecting one tobacco "endgame" threshold - in each subpopulation, we simulated the entire subpopulations of people with low SES, higher SES, SPD, and non-SPD, incorporating corresponding distributions of gender, age, and smoking status and accounting for changes in smoking behaviors and secular smoking trends. We then estimated total life-years accumulated under status quo and alternate scenarios in which smoking dynamics in the marginalized subpopulations matched those of their less marginalized counterparts.

RESULTS

The model showed that, for individuals with low SES or SPD, smoking is associated with substantial loss of life expectancy (9.8-11.5y). Marginalized subpopulations would reach 5% smoking prevalence 20y (low SES) and 17y (SPD) sooner if smoking trends mirrored their less marginalized counterparts; these differences result in 5.3 million (low SES) and 966,000 (SPD) excess life-years lost over 40y.

CONCLUSIONS

Differences in cigarette smoking portend substantial ongoing and future disparities in life expectancy and time to reach 5% smoking prevalence. Reducing tobacco-related disparities in the U.S. will require an explicitly equity-focused vision, and the tobacco endgame will only be truly achieved when it includes all groups.

Integrated Nicotine Replacement and Behavioral Support to Reduce Smoking in Opioid Agonist Therapy: A Randomized Clinical Trial

Importance

Approximately 85% of individuals receiving opioid agonist therapy for opioid dependence smoke tobacco. Despite the significant health risks associated with smoking-related diseases, there has been limited evaluation of smoking interventions tailored to this population.

Objective

To determine the effectiveness of an intervention combining nicotine replacement with brief behavioral support in reducing cigarette use.

Design, Setting, and Participants

This multicenter randomized clinical trial was conducted from April 2022 to October 2023 in 7 specialized opioid agonist therapy clinics in Bergen and Stavanger, Norway. The analyst was blinded to patient groupings. Assessors (study nurses) were not fully blinded to participant allocation. Individuals diagnosed with opioid dependency receiving opioid agonist therapy at participating clinics and smoking at least 1 cigarette per day were eligible for participation. Data analysis was performed from December 2023 through October 2024.

Intervention

In addition to standard opioid agonist therapy, participants in the intervention group received a 16-week integrated treatment combining nicotine replacement with brief behavioral support. Participants in the control group received only standard opioid agonist therapy.

Main Outcomes and Measures

The primary outcome was at least a 50% reduction in the number of cigarettes smoked, self-reported as cigarette use in the past 7 days at week 16. The analysis followed intention-to-treat principles. Cigarette use was self-reported as per the timeline-follow-back method.

Results

Among the 259 participants (mean [SD] age, 48.5 [10.4] years; 80 [30.9%] female), 135 were allocated to the intervention group and 124 to the control group. The odds ratio of at least halving the number of cigarettes smoked was 2.07 (95% CI, 1.14-3.75) in the intervention group compared with the control group.

Conclusions and Relevance

Providing integrated nicotine replacement and behavioral support at opioid agonist treatment clinics effectively helped opioid-dependent participants reduce the number of cigarettes smoked.

Trial Registration

ClinicalTrials.gov Identifier: NCT05290025.

Association of Tobacco Dependence Treatment Coverage Expansion With Smoking Behaviors Among Medicaid Beneficiaries Living With Substance Use Disorder

INTRODUCTION

Many U.S. states expanded the generosity of Medicaid insurance coverage of tobacco dependence treatment over the last fifteen years, but little is known about how coverage impacts cigarette smoking, especially for individuals with substance use disorder.

METHODS

Data are from the 2009 to 2018 National Survey on Drug Use and Health and include Medicaid beneficiaries 18-64 years old with past year substance use disorder who smoked at least 100 cigarettes in their lifetime. Outcomes were smoking cessation, nicotine dependence, and number of cigarettes smoked per month. Difference-in-differences models were estimated for smoking behavior by state and year of comprehensive tobacco dependence treatment coverage, estimating multivariable linear probability models, adjusted for sociodemographic characteristics, co-occurring mental illness, and area-level provider supply. All data were analyzed in 2023 and 2024.

RESULTS

Rates of nicotine dependence among individuals with past-year SUD increased slightly between 2009 and 2018 among individuals living in states with comprehensive tobacco dependence treatment coverage (55.6% to 58.6%) and changed little among individuals living in states with no or partial TDT coverage (60.0% to 59.5%). Quit rates increased for individuals with substance use disorder during this time, with no differences by comprehensive tobacco dependence treatment coverage. In adjusted models, no significant association between comprehensive Medicaid tobacco dependence treatment coverage and smoking behaviors was identified (e.g., cessation: β= -0.02, CI=-0.08, 0.04). One-year lagged outcomes and sensitivity analyses accounting for the differential time of initiation of state policies demonstrated similar results.

CONCLUSIONS

Comprehensive tobacco dependence treatment coverage had no differential effect on smoking cessation among ever smokers with or without substance use disorder, and its expansion was not associated with changes in smoking behaviors for Medicaid beneficiaries with substance use disorder. Other multilevel interventions may be needed to impact smoking cessation rates, such as awareness and education campaigns of expanded tobacco dependence treatment coverage benefits, and interventions that reduce social and structural barriers to treatment.

Pulmonary and Cardiac Smoking-Related History Improves Abstinence Rates in an Urban, Socioeconomically Disadvantaged Patient Population

BACKGROUND

Tobacco use continues to take the lives of many, and targeted interventions can counter this health burden. One possible target population is patients who have had a smoking-related diagnosis, as they may have a greater drive to quit.

OBJECTIVE

To assess whether patients with previous cardiac or pulmonary conditions directly attributable to smoking have greater rates of abstinence post-discharge from hospitalization in the CHART-NY trial.

DESIGN

CHART-NY was a randomized comparative effectiveness trial comparing a more intensive versus a less intensive smoking cessation intervention after hospital discharge. We divided the 1618 CHART-NY participants into a smoking-related history group of 597 and a nonsmoking-related history group of 1021 based on cardiac or pulmonary conditions in a retrospective chart review. We conducted chi-squared analyses on baseline characteristics. Using follow-up survey data, we conducted chi-squared analyses on abstinence outcomes and made logistic regression models for the predictive value of smoking-related conditions on abstinence.

PARTICIPANTS

A total of 1059 and 1084 participants in CHART-NY who completed both 2- and 6-month follow-up surveys respectively.

MAIN MEASURES

Self-reported 30-day abstinence at 2- and 6-month follow-up and survey data for baseline characteristics.

KEY RESULTS

Those abstinent at 6-month follow-up were more likely to have a smoking-attributable history (OR = 1.40, 95% CI 1.09-1.81). When stratified based on intervention, only the intensive counseling group was significant (OR = 1.53, 95% CI 1.08-2.17). The regression model using a smoking-related comorbidity score was significant at 6 months (OR = 1.29, p = 0.03), and the multivariate logistic regression model analyzing each smoking-related condition separately demonstrated significance for myocardial infarction at 6 months (OR = 1.66, p = 0.03).

CONCLUSIONS

People who smoke who have experienced smoking-related conditions may be more likely to benefit from smoking cessation interventions, especially intensive telephone-based counseling. Multiple conditions had an additive effect in predicting long-term abstinence after intervention, and myocardial infarction had the greatest predictive value.

Implementation of Community Health Worker Support for Tobacco Cessation: A Mixed-Methods Study

OBJECTIVE

Adults with serious mental illness have high rates of tobacco use disorder and underuse pharmacotherapy for tobacco cessation. In a previous randomized controlled trial, participants receiving community health worker (CHW) support and education for their primary care providers (PCPs) had higher tobacco abstinence rates at 2 years, partly because of increased initiation of tobacco-cessation pharmacotherapy. The authors aimed to determine the association between CHW-participant engagement and tobacco abstinence outcomes.

METHODS

The authors conducted a secondary, mixed-methods analysis of 196 participants in the trial's intervention arm. Effects of the number and duration of CHW visits, number of smoking-cessation group sessions attended, and number of CHW-attended PCP visits on initiation of tobacco-cessation pharmacotherapy and tobacco abstinence were modeled via logistic regression. Interviews with 12 CHWs, 17 patient participants, and 17 PCPs were analyzed thematically.

RESULTS

Year 2 tobacco abstinence was significantly associated with CHW visit number (OR=1.85, 95% CI=1.29-2.66), visit duration (OR=1.51, 95% CI=1.00-2.28), and number of group sessions attended (OR=1.85, 95% CI=1.33-2.58); effects on pharmacotherapy initiation were similar. One to three CHW visits per month across 2 years were optimal for achieving abstinence. Interviews identified CHW-patient engagement facilitators (i.e., trust, goal accountability, skills reinforcement, assistance in overcoming barriers to treatment access, and adherence). Training and supervision facilitated CHW effectiveness; barriers included PCPs' and care teams' limited understanding of the CHW role.

CONCLUSIONS

Greater CHW-participant engagement, within feasible dose ranges, was associated with tobacco abstinence among adults with serious mental illness. Implementation of CHW interventions may benefit from further CHW training and integration within clinical teams.

Strategies to improve the implementation of preventive care in primary care: a systematic review and meta-analysis

BACKGROUND

Action on smoking, obesity, excess alcohol, and physical inactivity in primary care is effective and cost-effective, but implementation is low. The aim was to examine the effectiveness of strategies to increase the implementation of preventive healthcare in primary care.

METHODS

CINAHL, CENTRAL, The Cochrane Database of Systematic Reviews, Dissertations & Theses - Global, Embase, Europe PMC, MEDLINE and PsycINFO were searched from inception through 5 October 2023 with no date of publication or language limits. Randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies comparing implementation strategies (team changes; changes to the electronic patient registry; facilitated relay of information; continuous quality improvement; clinician education; clinical reminders; financial incentives or multicomponent interventions) to usual care were included. Two reviewers screened studies, extracted data, and assessed bias with an adapted Cochrane risk of bias tool for Effective Practice and Organisation of Care reviews. Meta-analysis was conducted with random-effects models. Narrative synthesis was conducted where meta-analysis was not possible. Outcome measures included process and behavioural outcomes at the closest point to 12 months for each implementation strategy.

RESULTS

Eighty-five studies were included comprising of 4,210,946 participants from 3713 clusters in 71 cluster trials, 6748 participants in 5 randomised trials, 5,966,552 participants in 8 interrupted time series, and 176,061 participants in 1 controlled before after study. There was evidence that clinical reminders (OR 3.46; 95% CI 1.72-6.96; I2 = 89.4%), clinician education (OR 1.89; 95% CI 1.46-2.46; I2 = 80.6%), facilitated relay of information (OR 1.95, 95% CI 1.10-3.46, I2 = 88.2%), and multicomponent interventions (OR 3.10; 95% CI 1.60-5.99, I2 = 96.1%) increased processes of care. Multicomponent intervention results were robust to sensitivity analysis. There was no evidence that other implementation strategies affected processes of care or that any of the implementation strategies improved behavioural outcomes. No studies reported on interventions specifically designed for remote consultations. Limitations included high statistical heterogeneity and many studies did not account for clustering.

CONCLUSIONS

Multicomponent interventions may be the most effective implementation strategy. There was no evidence that implementation interventions improved behavioural outcomes.

TRIAL REGISTRATION

PROSPERO CRD42022350912.

Implementation of Community Health Worker Support for Tobacco Cessation: A Mixed-Methods Study

Objective

Adults with serious mental illness have high tobacco use disorder rates and underutilization of first-line tobacco cessation pharmacotherapy. In a randomized trial, participants offered community health worker (CHW) support and primary care provider (PCP) education had higher tobacco abstinence rates at two years, partly through increased tobacco cessation pharmacotherapy initiation. This study determined the association between participant-CHW engagement and tobacco abstinence outcomes.

Methods

This was a secondary, mixed-methods analysis of 196 participants in the trial's intervention arm. Effects of CHW visit number and duration, CHW co-led smoking cessation group sessions attended, and CHW-attended PCP visit number on tobacco use disorder pharmacotherapy initiation and tobacco abstinence were modeled using logistic regression. Interviews with 12 CHWs, 16 participants, and 17 PCPs were analyzed thematically.

Results

Year-two tobacco abstinence was associated with CHW visit number (OR=1.85, 95% CI=[1.29, 2.66]) and duration (OR=1.85, 95% CI=[1.33, 2.58]) and number of groups attended (OR=1.51, 95% CI=[1.00, 2.28]); effects on pharmacotherapy initiation were similar. 1-3 CHW visits per month over two years was optimal for achieving abstinence. Interviews identified engagement facilitators, including CHWs establishing trust, providing goal accountability, skills reinforcement, and assistance overcoming barriers to treatment access and adherence related to social determinants of health and illness factors. Robust training and supervision facilitated CHW effectiveness. Barriers included PCPs' and care teams' limited understanding of the CHW role.

Conclusions

Feasible CHW engagement was associated with tobacco abstinence in adults with serious mental illness. CHW implementation may benefit from promoting CHW training and integration within clinical teams.

Alternative combusted tobacco product and multiple tobacco product use among individuals with serious mental illness enrolled in a large pragmatic randomized controlled trial

OBJECTIVE

Use of combustible alternative tobacco products (ATPs; e.g., little cigars, loose tobacco, multiple tobacco product types [TPTs]) is increasingly common. Inexpensive, combusted ATPs (e.g little cigars) are predominantly marketed to lower-income communities. Prevalence of combusted ATP use among those with serious mental illness (SMI) is unknown.

METHODS

We examined rates and correlates of combusted ATP use and association with tobacco abstinence in a secondary analysis of a single-cohort (N = 1007) trial of tobacco-smoking adults with SMI and severe SMI-related functional impairment. The parent study aimed to test a community-health worker-delivered intervention for promoting smoking cessation among adults with SMI. Participants were surveyed at baseline on demographic and smoking characteristics including combusted TPT (cigarettes, cigars/little cigars, loose tobacco), and breath carbon-monoxide (CO). CO-verified 7-day point-prevalence tobacco abstinence was assessed at Year 2.

RESULTS

At baseline, 59% of participants reported using cigarettes only, 25% multiple (>1) combusted TPTs, 12% cigars/little cigars only, and 4% loose tobacco (e.g., "rollies", pipes) only. Those reporting any ATP use at baseline had higher expired CO concentration and reported using more tobacco products per day than exclusive cigarette users (p's < 0.05). ATP use was not associated with abstinence in adjusted logistic regression models (p's > 0.05).

CONCLUSIONS

Use of ATPs was associated with use of more tobacco products per day and greater tobacco toxicant exposure than exclusive cigarette use in this population. Future policy efforts work to change preferential taxation policies (e.g., lower taxation for cigar products) and disproportionate marketing of ATPs to lower-income communities.

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.

Effectiveness of personalized tobacco cessation intervention package among patients with schizophrenia and related psychotic disorders - A two-group experimental study

INTRODUCTION

Persons with schizophrenia and related psychotic disorders (PwS) smoke more, and have twice the rate of mortality, with 10-25 years lower life expectancy than the general population. Evidence-based tobacco cessation interventions would help in quitting.

AIM

To evaluate the effectiveness of a personalized tobacco cessation intervention package for patients attending the outpatient psychiatry department.

METHODS

The study adopted a two-group experimental design in PwS, using a simple randomization method. Eligible participants were randomly allocated to either the intervention group (n = 85) receiving the intervention package or the control group (n = 85) receiving brief advice to stop tobacco. The study outcomes were measured at baseline, 1, 3, and 6 months. SPSS 23 was used for data analysis. Intention-to-treat analysis was used to manage missing data. The p-value of < 0.05 is considered statistically significant.

RESULTS

At 6 months, there was a significant difference (p < 0.001) in 7 days point-prevalence abstinence (28 % vs 10.8 %), reduction of tobacco by at least 50 % (62.4 % vs 40.9 %) with an attrition rate of 15.3 % vs 30.5 % in intervention and control group respectively. Reduction in nicotine dependence and tobacco craving, an increase in motivation level, quit attempts and clinical improvement favored the intervention group. 16.5 % of participants expressed interest in pharmacotherapy for tobacco cessation, 3.5 % were referred to a specialized tobacco cessation center, two control group participants were hospitalized for drug default, and withdrawal symptoms reported were mild.

CONCLUSION

Implementing a tobacco cessation intervention based on the stage of motivation aids in abstinence and reduction of tobacco use in PwS.