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

ObjectiveAdults 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. MethodsThis was a secondary, mixed-methods analysis of 196 participants in the trials 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. ResultsYear-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. ConclusionsFeasible 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. HighlightsO_LIGreater participant engagement with community health workers (CHWs) (e.g., visit number, duration) was associated with higher tobacco abstinence rates in a two-year intervention for adults with serious mental illness and tobacco use disorder. C_LIO_LIInterviews with participants, CHWs, and primary care providers (PCPs) indicated that CHWs built trust, facilitated health behavior change, helped participants overcome adverse social determinants of health and other barriers to obtaining effective tobacco use disorder treatment. C_LIO_LITraining and supervision were perceived to be essential to CHW effectiveness; CHWs and PCPs suggested insufficient integration of CHWs into psychiatric rehabilitation and healthcare teams as an addressable implementation barrier. C_LI