External facilitation to expand reach of tobacco treatment to SMI Veterans

Significance: Tobacco smoking and its health consequences disproportionally impact Veterans. Veterans with serious mental illness (SMI Veterans; schizophrenia spectrum, bipolar spectrum, and other psychotic disorders) have among the highest rates of smoking in VA and die 10-15 years earlier than those without SMI, largely due to smoking-related conditions. Seven FDA-approved tobacco medications are available in VA that are low-cost, safe, and effective for SMI Veterans when combined with brief behavioral counseling: nicotine replacement therapies (lozenge, gum, patch, nasal spray), bupropion, and varenicline. Nearly 70% of SMI Veterans who smoke want to quit, but they are 26% less likely to be prescribed tobacco medication (10.9% vs. 14.3% prescription rate). SMI providers face numerous barriers to treating smoking. External facilitation can address these barriers by coordinating evidence-supported implementation activities, such as educational outreach and auditing with feedback, and shows promise for improving tobacco medication prescriptions in VA mental health clinics. Despite the availability of tobacco treatment in VA, smoking-related conditions remain the leading cause of death for SMI Veterans and account for nearly 8% of VA health care expenditures: $2.7 billion annually. Integrating tobacco medication into routine mental health care can maximize the use of existing resources and expand the reach of tobacco medication to Veterans with the highest smoking, but lowest treatment rates. Innovation & Impact: Innovations of this project include evaluating evidence-supported implementation strategies in mental health clinics, addressing barriers to tobacco treatment across patient, provider, and system levels, evaluating changes in prescribing practices for all FDA-approved tobacco medications, including non- prescribers in implementation activities, using data to refine the implementation strategy, and capitalizing on existing VA resources that support quality improvement and tobacco treatment. This project will serve as preliminary data for a fully powered effectiveness-implementation trial with the potential to improve timely access to care, address a leading cause of death for SMI Veterans, and reduce smoking-related health care costs. Specific Aims: This pilot study will refine and evaluate the feasibility and acceptability of an externalfacilitation strategy that aims to increase prescriber adoption of tobacco medication. Specific aims are to: Aim 1: Trial an external facilitation strategy designed to improve tobacco medication prescribing in Perry Point SMI clinics. Aim 2: Evaluate the feasibility and acceptability of the external facilitation strategy, monitor provider adoption of tobacco medication, and refine the strategy accordingly. Aim 3: Implement the refined external facilitation strategy in Baltimore SMI clinics, re-evaluate feasibility, acceptability, and adoption, and explore reach and effectiveness of tobacco medication. Methodology: This pilot study will use mixed methods to evaluate changes in the feasibility and acceptability of an external facilitation strategy and provider adoption of tobacco medication through activity tracking, surveys, and semi-structured interviews with providers (Perry Point n ~ 11, Baltimore n ~ 24) at two VA Maryland Health Care System facilities. Secondary outcomes will be changes in monthly reach of tobacco medication to SMI Veterans (Perry Point n ~ 75, Baltimore n ~ 165) and changes in smoking rates using EHR data. Path to Implementation: With support from local leadership, VA’s Quality Enhancement Research Initiative, and operational partners, results from this proposal will a yield an implementation blueprint for how to tailor implementation activities designed to improve tobacco medication to local needs. Additionally, findings from this proposal will serve as preliminary data for a fully powered, multisite hybrid effectiveness-implementation trial as part of a Merit app Project Number: 1IK2RD000661-01A2 | Fiscal Year: 2026 | NIH Institute/Center: Veterans Affairs (VA) | Principal Investigator: Corinne Kacmarek | Institution: BALTIMORE VA MEDICAL CENTER, BALTIMORE, MD | Activity Code: IK2 | Study Section: HSR-4 Mental and Behavioral Health[HSR4] View on NIH RePORTER: https://reporter.nih.gov/project-details/11350017