Implementation strategies to increase tobacco treatment in mental health settings: a systematic review

Tobacco smoking rates have declined for the general population, but remain high for individuals with mental illness. Increasing access to tobacco treatment interventions in mental health settings is essential to address this health inequity. This systematic review aimed to determine how implementation strategies change mental health provider delivery of tobacco interventions.

We searched PubMed, PsycInfo, CINAHL, Ovid MedLine, Embase, and grey literature from inception through December 31, 2024. Implementation strategies, behavior change mechanisms, and outcomes were categorized using the Expert Recommendations for Implementing Change (ERIC) taxonomy, capability-opportunity-motivation behavioral model, and Reach, Effectiveness, Adoption, Implementation, Maintenance framework, respectively. Changes in provider adoption of implementation activities or the 5As (Ask, Advise, Assess, Assist, Arrange), and changes in reach of 5As to patients, were primary outcomes and reported as a percentage change after, compared to before, the implementation strategy.

Twenty of 786 studies met inclusion criteria. Half (55%) were at serious risk of bias due to confounding. For behavior change mechanisms, all outpatient studies addressed clinician capability, and all inpatient studies addressed clinician opportunity to provide tobacco interventions. Reach was the most common outcome evaluated, with the largest absolute increases in proportion of patients being Assisted with referrals across both outpatient (42%) and inpatient (11%) settings after implementation. ERIC domains that maximized nicotine replacement therapy (NRT) delivery differed by setting: Strategies used in the engaging consumers domain were associated with 16% NRT increases in outpatient settings and supporting clinicians and changing infrastructure increased NRT by 20% in inpatient settings.

Interactions between setting, implementation domain, and outcomes improved reach of tobacco interventions to varying degrees in mental health settings, but formal analyses are needed to confirm hypothesized moderators (inpatient vs. outpatient) and mediators (capability, opportunity, motivation) of change. Strategies that engage consumers in outpatient settings and change infrastructure in inpatient settings may be particularly useful for improving reach of tobacco medications. Future implementation trials must monitor changes in the gold-standard tobacco interventions (medication + counseling) to maximize the clinical impact of provider practice improvements. Clinical-research partnerships are also needed to explore feasible ways to evaluate smoking changes in real-world clinical settings.