Barriers to and Facilitators of Delivering Brief Tobacco and Alcohol Interventions in Integrated Primary Care Settings

ABSTRACT

Objective: Tobacco and excessive alcohol use are 2 of the top 3 preventable causes of death in the United States, yet most patients using these substances do not pursue treatment. Most patients do visit their primary care provider (PCP) annually, but PCPs report that they are not very effective in addressing behavior change with patients. Brief interventions for alcohol and tobacco use are effective and can be delivered by behavioral health providers (BHPs) embedded in the primary care setting. However, BHPs do not report frequent use of these interventions. The aim of the current study was to conduct the first examination of barriers to and facilitators of implementing brief interventions for at-risk drinking and tobacco use among integrated BHPs.

Methods: BHPs (N = 285) working in a primary care setting for at least 6 months with at least 10% effort allocated to clinical activities were recruited through professional listservs (August–September 2016) and completed an online survey that assessed barriers to and facilitators of delivering brief tobacco and alcohol interventions in routine clinical practice.

Results: BHPs were primarily psychologists (48%) and social workers (33%) with cognitive-behavioral orientation (51%). The primary barriers to addressing tobacco use and at-risk drinking reported by BHPs was the perception that patients did not want to discuss or did not want to change these behaviors. The primary facilitators of addressing tobacco use and at-risk drinking were patients identifying cessation or reduction as a treatment goal, positive provider-patient relationship, and receiving referrals specifically for tobacco or alcohol use.

Conclusions: Clinicians, researchers, and administrators should focus on strategies to increase the regularity with which BHPs assess and provide intervention for smoking and alcohol use in the context of other primary presenting concerns.

Prim Care Companion CNS Disord 2019;21(6):19m02497

To cite: Wray JM, Funderburk JS, Gass JC, et al. Barriers to and facilitators of delivering brief tobacco and alcohol interventions in integrated primary care settings. Prim Care Companion CNS Disord. 2019;21(6):19m02497.

To share: https://doi.org/10.4088/PCC.19m02497

© Copyright 2019 Physicians Postgraduate Press, Inc.

aMental Health Service, Ralph H. Johnson VA Medical Center, Charleston, South Carolina

bVA Center for Integrated Healthcare, VA Western New York Healthcare System, Buffalo, New York

cDepartment of Psychiatry, Medical University of South Carolina, Charleston, South Carolina

dDepartment of Psychology, Syracuse University, Syracuse, New York

eDepartment of Psychiatry, University of Rochester, Rochester, New York

fDepartment of Psychology, University at Buffalo, Buffalo, New York

*Corresponding author: Jennifer M. Wray, PhD, Mental Health Service 116, Ralph H. Johnson VA Medical Center, 109 Bee St, Charleston, SC 29401 ([email protected]).

Tobacco use and at-risk drinking are among the top preventable causes of death in the United States,1 and quitting tobacco and reducing alcohol use to recommended limits can have substantial health benefits.2,3 Brief interventions for tobacco use and at-risk drinking (alcohol use above National Institute on Alcohol Abuse and Alcoholism [NIAAA] guidelines: > 4 drinks/day or > 14 drinks/week for men and > 3 drinks/day or > 7 drinks/week for women and men over age 65 years) are efficacious.4,5 As such, primary care has long been identified as a promising setting for the delivery of interventions for these behaviors.

Unfortunately, rates of implementing brief interventions for at-risk drinking and tobacco use are low.6–8 Primary care providers (PCPs) cite barriers to addressing tobacco and alcohol use such as multiple competing demands, lack of training in interventions for these behaviors, not having sufficient time to address these concerns, and feeling ineffective at addressing behavior change with patients.9,10 PCPs have the option of referring patients who are at-risk drinkers or who use tobacco to behavioral health providers (BHPs; such as psychologists, clinical social workers, or other mental health providers) in clinics in which a BHP is part of the patient’s treatment team (eg, in integrated primary care settings) for interventions that target these behaviors.

BHPs embedded in the primary care setting could fill a gap between PCPs and specialty services by administering brief alcohol and tobacco interventions.11 BHPs have the potential to deliver effective brief interventions for tobacco use and at-risk drinking due to their background and expertise in behavior change strategies.12 In addition, while interventions administered by BHPs in primary care are intended to be brief, BHPs have more time (relative to a PCP) to work with patients. However, BHPs in primary care typically do not report delivering these types of interventions in their clinical practice.13 Preliminary work with BHPs working in specialty mental health programs has demonstrated that training in tobacco cessation treatments increases both implementation of these services and quit attempts among patients,14 which suggests that training BHPs working in the primary care setting may increase utilization of interventions for tobacco use and at-risk drinking.

In integrated primary care clinics, professionals from different disciplines collaborate on a shared treatment plan individualized for each primary care patient,15 and each provider on the team plays a unique and complementary role in patient care. Based on the literature,2–13 one role of PCPs may be to identify patients who are appropriate for brief interventions for tobacco use and at-risk drinking and connect them with BHPs. Subsequently, BHPs could use their expertise in behavior change strategies to implement an appropriate intervention with the patient. Strategies to help BHPs more effectively target tobacco use and alcohol misuse could increase rates of brief treatments for tobacco use and at-risk drinking in the primary care setting.

An abundance of research has identified barriers to implementing brief alcohol intervention and tobacco cessation services among medical and behavioral health professionals.9,16–18 However, barriers have not yet been assessed among integrated BHPs, who may experience unique challenges with delivering these interventions in primary care. As such, the purpose of this study was to identify barriers to and facilitators of implementing brief alcohol and tobacco interventions among integrated BHPs.

METHODS

BHPs working in integrated primary care clinics were recruited via e-mail (by sending out a description of the study) to participate in an online survey administered through PsychData. This e-mail was sent through several listservs relevant to BHPs in integrated primary care clinics (ie, Society for Behavioral Medicine’s Integrated Primary Care [IPC] Special Interest Group [SIG], Collaborative Family Healthcare Association listserv, UMass Center for IPC, APA Division 38 IPC, ABCT Behavioral Medicine and IPC SIG, and VA Mental and Behavioral Health Patient Aligned Care Team). At the time of recruitment, 3,429 individuals were signed up for these listservs (note, we were unable to calculate the number of unique providers the survey reached, as BHPs may have been participating in multiple listservs). BHPs were eligible if they worked in a primary care setting for at least 6 months and allocated at least 10% effort to clinical activities.

Eligible BHPs who agreed to participate in the study answered questions about barriers to and facilitators of implementing brief tobacco and alcohol interventions in their clinical practice. The survey items were created for the purposes of this study by combining variables previously identified in the literature with factors identified by unstructured interviews with practicing BHPs working in primary care settings (n = 5), as we were interested in identifying barriers and facilitators that may be unique to practice in the primary care setting. In the survey instructions provided to the BHPs, we defined at-risk drinking as follows: “At-risk drinking can be defined as drinking above NIAAA-recommended guidelines (more than 14 drinks per week or 4 drinks per day for males; more than 7 drinks per week or 3 drinks per day for females) or through a positive screen for at-risk drinking (eg, a score of 4 or more for males and a score of 3 or more for females on the AUDIT-C).”19

Potential barriers were 22 items (eg, lack of training/guidance, poor knowledge of an intervention, lack of time) rated on a scale from 1 to 4 (1 = not a barrier, 2 = minor barrier, 3 = moderate barrier, 4 = significant barrier). Participants also rated facilitators of implementing brief interventions (10 items such as having a good relationship with the patient, having an appropriate setting for the discussion, education on alcohol/tobacco treatment) on a scale from 1 to 4 (1 = does/would not help at all, 2 = a little helpful, 3 = moderately helpful, 4 = extremely helpful). Barriers and facilitators were rated separately for brief tobacco and brief alcohol interventions.

BHPs also answered questions about their backgrounds, including number of years practicing in primary care, number of patients treated per week, and professional degree. BHPs were offered educational materials about ways to implement brief tobacco and alcohol interventions in their clinical practice in exchange for their participation.

Data analysis was largely descriptive. The frequency and percentage of each sample characteristic were calculated in addition to median and standard deviations for characteristics related to the type of clinic. Central tendency (mean, mode, and standard deviation) statistics were calculated from the numeric values for each barrier and facilitator. Barriers and facilitators were split into quartiles based on the average ratings given for each item.

RESULTS

Sample characteristics are presented in Table 1. BHPs (n = 285) who participated in this study were working in primary care clinics (median number of PCPs working in these clinics = 12) and reported seeing a mean of 23 patients per week (median = 21, SD = 11.5, range, 0–60). BHPs reported that patients were typically seen through scheduled appointments (48.7%) and warm handoffs from another provider in the clinic (ie, unscheduled visits on the same day as the primary care appointment, 28.6%) and less frequently through “walk-in” visits (ie, unscheduled and without a same-day primary care appointment, 6.7%), as a conjoint appointment with the PCP (8.3%), or in the context of a group intervention (5.0%).

Only 13 BHPs (4.6%) reported no previous training in brief alcohol interventions or interventions targeting heavy or at-risk drinking, and only 38 BHPs (13.3%) reported no previous training in interventions targeting tobacco use. However, the most frequently reported training in these interventions was “independent reading” (62% for brief alcohol interventions and 58% for tobacco interventions). BHPs reported delivering a brief tobacco intervention to fewer than one-third of their patients who use tobacco (mean = 31.7%, SD = 32.7%, range, 0%–100%) and a brief alcohol intervention to only 40% of their patients who are positive for at-risk drinking (mean = 39.7%, SD = 35.8%, range, 0%–100%).

The items ranked as the most significant (top quartile) barriers to implementing brief interventions were similar for alcohol and tobacco and were as follows: (1) “patients have more immediate needs/problems to address than tobacco use” (top barrier for tobacco only), (2) “the patient is not interested in quitting/cutting down,” (3) “the patient does not identify tobacco/alcohol use as a treatment goal,” (4) “patients are not motivated to cut down/quit,” (5) “I am not getting referrals specifically for tobacco/alcohol use,” and (6) “Patients don’t want to talk about their tobacco/alcohol use” (>Table 2 provides descriptive statistics).

The items ranked as the most important facilitators (top quartile) of implementing brief alcohol and tobacco interventions were the same for alcohol and tobacco and were as follows: (1) “the patient identifying tobacco/alcohol cessation/reduction as a treatment goal,” (2) “having a good relationship with the patient,” and (3) “getting referrals from the PCP or other primary care staff specifically for tobacco/alcohol use” (Table 2).

DISCUSSION

The primary barrier to addressing tobacco and alcohol use identified by BHPs was the perception that patients did not want to discuss or change these behaviors. The BHPs reported that the patient identifying cessation or reduction as a primary goal of treatment, having a good relationship with the patient, and receiving direct referrals for these concerns would facilitate the implementation of brief alcohol and tobacco interventions.

BHPs’ perceptions that primary care patients presenting with other concerns are uninterested in cutting down or quitting or not motivated to do so are generally not supported in the literature. For instance, 1 study20 found that two-thirds of smokers reported that quitting smoking was either very or extremely important to their health. Similarly, alcohol users in primary care settings have been found to have moderate motivation to cut down or quit drinking.12 Among individuals with other behavioral health concerns (eg, depression, anxiety, posttraumatic stress disorder [PTSD], substance use), motivation to quit smoking and drinking has been repeatedly demonstrated to be at least moderate.21–23

Related to the barrier of patients not identifying tobacco or alcohol use as a treatment goal, there is evidence that if a provider does not bring up a topic, patients will often not initiate a conversation in that area. This finding suggests that it may be the BHP who is responsible for initiating conversations around these behaviors in patients presenting with other primary concerns.24 Further, regular assessment can lead to increased motivation to make a change.25,26 Thus, we recommend that BHPs in primary care regularly engage in discussions about tobacco and alcohol use with patients, including assessing readiness and motivation to make a change to these behaviors.27

Most patients who use tobacco and alcohol do not present to BHPs in integrated primary care settings with tobacco or alcohol reduction or cessation as their primary concern.13,28 However, these behaviors are often comorbid with other psychiatric concerns. There is evidence that tobacco and excessive alcohol use are primary contributors to early death in patients with psychiatric comorbidities29 and that quitting smoking and reducing drinking leads to positive mental health outcomes (eg, reduced depression and anxiety symptom severity30–32).

In general, the highest-rated barriers and facilitators were the same for tobacco and alcohol with one notable discrepancy. BHPs reported that the primary barrier to addressing tobacco use was the perception that the patient has more immediate needs than smoking; this item was not a highly rated barrier for addressing alcohol use. This finding suggests that providers believe tobacco use is not as pressing a concern as other problems discussed within the appointment. However, tobacco use accounts for half a million annual deaths in the United States and worsens the prognosis for nearly any medical diagnosis.33 Furthermore, tobacco use has been shown to exacerbate the symptoms of common presenting concerns in primary care13 such as chronic pain34 and insomnia35 and is associated with higher levels of psychiatric symptomatology and dysfunction.30

Finally, in the present study, we found that BHPs in primary care settings are delivering brief interventions for at-risk drinking less than half of the time and brief interventions for tobacco use less than a third of the time when patients are positive for at-risk drinking and tobacco use, respectively. This is unfortunate, as even brief interventions increase the likelihood that an individual will attempt behavior change.4,36 Therefore, at least brief discussions are recommended even for patients who do not present with tobacco or alcohol use as their primary concern.37

Limitations of the Current Research

The majority (69%) of the BHPs who participated worked in a Veterans Affairs setting or federally qualified health care center, which have important differences from other settings (eg, billing). However, the Veterans Health Administration has the largest integrated health care system in the United States,38 and thus the high proportion of these providers in our survey was expected. Similarly, social workers and psychologists made up most of the sample, and thus responses may not be generalizable to other BHPs (such as prescribers, licensed marriage and family therapists). Future work might examine the impact of site or provider type on barriers to and facilitators of implementing brief tobacco and alcohol interventions. An additional limitation is that this research specifically examined BHPs working in primary care settings, and the conclusions cannot necessarily be generalized to BHPs in specialty mental health care settings. However, there is a breadth of evidence demonstrating that in specialty mental health and substance use clinics, tobacco use is often not addressed21,39 for similar reasons described by the BHPs in our sample, suggesting convergence. Finally, BHPs who have some interest in tobacco or alcohol use may have been more likely to respond to this survey, potentially biasing results.

Future Directions

On the basis of the findings of the current study in conjunction with results of previous research, we encourage BHPs in integrated settings to discuss tobacco and alcohol use even when these issues are not the patient’s primary concern, are not the referral question, or are perceived by the BHP to be of low importance to the patient. As evidenced by the mean number of patients seen per week and reported past training in interventions for alcohol and tobacco use, BHPs have more time and training (relative to PCPs) to address these concerns.

It is likely that BHPs in integrated primary care settings would benefit from higher-quality training (and institutional support for such training or opportunities for continuing medical education), as the most commonly cited type of training was independent readings. Increased education and training can include psychoeducation about research demonstrating improved mental health outcomes among those who quit or reduce use, as well as intervention strategies that BHPs can use with patients not presenting for concerns related to alcohol or tobacco use. For example, motivational interviewing strategies40 are recommended for patients not ready to make a change. Further, simply assessing tobacco and alcohol use can have a demonstrable effect on readiness to change and future cessation outcomes.25,26

BHPs in this study noted that having an increased number of referrals for tobacco and alcohol use is a facilitator for addressing these behaviors. Educational efforts may thus be most efficacious when they include PCPs and other primary care team members. Efforts to increase the number of referrals for tobacco use and at-risk drinking are integral to increasing the likelihood of these individuals receiving behavioral health services.41 As part of team-based care, PCPs and their team members meet regularly to discuss patient care. In this context, referral to and from PCPs (who can provide medication support) and BHPs (who can provide behavioral support) can seamlessly occur. Further, clarification of roles within the team as to how best to approach patient care when alcohol or tobacco use should be a treatment target as well as routine delivery of brief interventions for all patients who screen positive for tobacco use or at-risk drinking are recommended. Finally, use of conjoint appointments (ie, PCP and BHP meeting together with a patient) should be considered to help facilitate collaboration between the PCP and BHP while working with patients on health behavior change.

Submitted: June 11, 2019; accepted August 12, 2019.

Published online: November 14, 2019.

Potential conflicts of interest: None.

Funding/support: This research was supported by the VA Center for Integrated Healthcare Pilot Grant Program and the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment.

Role of the sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of data; or preparation, review, or approval of the manuscript.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs or the United States government.

Previous presentation: Components of this work were presented at the 2016 Annual Meeting of the Collaborative Family Healthcare Association; October 13–15, 2016; Charlotte, North Carolina.

Acknowledgments: The authors wish to thank the research staff within the Center for Integrated Healthcare for help in preparation of this manuscript.

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