Practice-informed implementation: a multi-method approach to map strategies for sustainable tobacco treatment...

Tobacco use remains the leading cause of preventable disease and death in the U.S., yet integration of evidence-based tobacco treatment in healthcare is often inconsistent and not sustained. To address this gap, there is a growing need for implementation strategies that are informed by real-world practice and tailored to local context. This study evaluates the implementation and sustainability of a tobacco treatment program within a large Midwestern health system, developed through a health systems change partnership with the Indiana Department of Health. Using a practice-informed approach, we applied multiple implementation science frameworks to retrospectively identify contextual factors influencing implementation and to map strategies across distinct implementation phases.

We used a multi-methods design, integrating data from semi-structured interviews (n = 15), and the Clinical Sustainability Assessment Tool (CSAT). Interviews were guided by the Consolidated Framework for Implementation Research (CFIR) and analyzed thematically to identify determinants of implementation and sustainment. The CSAT was administered to core program staff to assess organizational capacity for long-term sustainability. Strategy mapping was conducted using the Replicating Effective Programs (REP) and Expert Recommendations for Implementing Change (ERIC) frameworks to sequence implementation strategies across four phases: pre-conditions, pre-implementation, implementation, and maintenance.

Interviews revealed iterative adaptations to the Nicotine Dependence Program, including EHR integration, virtual care expansion, and strategic workforce development. Key facilitators included leadership engagement, presence of a dedicated implementation leader, alignment with organizational culture, and integration into existing workflows. Barriers included limited reimbursement mechanisms and workforce constraints. CSAT results indicated high sustainability potential (mean score: 6.1/7), with strong ratings in outcomes and effectiveness, staff engagement, and monitoring and evaluation. Strategy mapping identified over 20 discrete strategies across REP phases, offering a replicable blueprint for other systems.

Practice-informed, context-responsive implementation can lead to sustainable systems change for tobacco treatment. Findings highlight the importance of inner setting factors, including leadership support, workflow compatibility, and culture of continuous improvement, in sustaining evidence-based interventions. This study provides a model for drawing evidence from real-world implementation to identify strategies which can serve as a guide for health systems seeking to integrate and sustain evidence-based tobacco treatment services.