Why implementation processes vary across the 5A's of the Smoking Cessation Guideline: administrators' perspectives

Unrelated to any research, 18 maternal and child health case management agencies adopted a smoking cessation program that included the ask, advise, assess, assist, and arrange components of the 2000 U.S. Public Health Service Smoking Cessation Guideline. To better understand what influences program implementation in practice, a study was conducted 18 months later at 16 (89%) of the agencies. Open-ended interviews with key administrative informants examined implementation processes (i.e., how each program component had been implemented at the organization level) and the administrators' rationales for such implementation. A separate structured telephone survey of the agency case managers (N = 63) assessed their implementation of each program component with smokers. Results showed that all agencies implemented the ask and advise components. Implementation of these components was well supported by the policies, contractual requirements, and operational tools that guided and coordinated all case management activities. No agency implemented the initially adopted program or any other structured approach to implementing the assess, assist, and arrange components. Administrative explanations indicated that these components (a) were not addressed by, and could not be easily incorporated into, the above existing policies and operational tools and (b) were perceived to be in the realm of case manager responsibilities and professional decisions, not requiring administrative attention. Several administrators also cited time constraints, other pressing case management issues, or lack of resources as additional barriers. Based on the findings, recommendations for systemic program support strategies are offered that could improve case management implementation of smoking cessation interventions beyond basic advice to quit.