Proactive Outreach Brings Smoking Cessation to Mental Health Clinics

People living with mental health and substance use disorders smoke at rates two to three times higher than the general population, and the consequences are devastating. Individuals with serious mental illness die fifteen to twenty-five years earlier than others, driven primarily by smoking-related diseases. Yet the clinics that serve this population have long struggled to deliver the very treatments proven to help people quit. A new pilot study published in Community Mental Health Journal suggests a practical way forward: combine proactive telephone outreach with provider-delivered brief treatment inside a Certified Community Behavioral Health Clinic, supported by a multilevel implementation strategy that trains, coaches, and holds clinics accountable. The results show that such a program can be delivered feasibly and is welcomed by both clients and staff, even though quit rates in this difficult-to-treat population remain soberingly low.

The study, led by Sandra Japuntich of Hennepin Healthcare Research Institute and the University of Minnesota Medical School, was designed as a pilot type 2 hybrid effectiveness-implementation trial, a research design that gives equal weight to testing whether an intervention can help patients and whether the organizational machinery needed to deliver it can actually function in a real-world clinic. The setting was a Certified Community Behavioral Health Clinic, or CCBHC, in rural Minnesota, an organization with five campuses serving roughly 10,000 clients each year across case management, crisis services, chemical dependence treatment, outpatient mental health, and family therapy. CCBHCs are a value-based model of community mental health care developed by the Substance Abuse and Mental Health Services Administration and the Centers for Medicare and Medicaid Services, and they now serve more than three million Americans with mental health and substance use disorders annually.

The intervention rested on two complementary strategies grounded in clinical practice guidelines. The first was the 5As framework, long recommended by the US Public Health Service for every healthcare setting: ask about tobacco use, advise quitting, assess interest in quitting, assist with cessation, and arrange follow-up. Mental health providers were instructed to deliver the 5As at intake and at treatment planning visits every six months. The second strategy was proactive outreach, a chronic disease management approach in which a registry of clients who smoke is generated from health records and dedicated staff telephone clients regardless of their stated readiness to quit, offering connections to cessation counseling and medication. Three clinic staff members, two peer support specialists and a case manager, were trained as tobacco treatment specialists and made three outreach contacts per participant over nine months, following a person-centered manual designed to build motivation, strengthen self-efficacy, and encourage treatment use.

Crucially, the researchers recognized that simply telling clinicians what to do rarely changes practice. Barriers such as competing clinical priorities, fear that addressing smoking could destabilize clients, and lack of training consistently undermine tobacco treatment in mental health settings. To overcome these, the team adapted the Science to Service Laboratory, a multicomponent implementation strategy previously used by the Addiction Technology Transfer Center Network. The approach bundled a two-hour virtual didactic training for all clinical staff, monthly performance feedback reports drawn from patient surveys and chart documentation, and external coaching in which a tobacco treatment expert attended monthly staff meetings at each of the three clinic sites for case consultation and brief topical discussions, while also meeting monthly with the clinic’s Chief Clinical Officer. Experimental evidence has shown that didactic training combined with ongoing feedback and coaching outperforms self-study or single-component training approaches.

On the feasibility front, the study largely succeeded. Forty-nine client participants were recruited over three months, nearly matching the recruitment target of fifty. The first two outreach calls achieved connection rates of 90 and 94 percent respectively, with the third call still reaching 67 percent of participants, figures consistent with or exceeding previous proactive outreach studies that reported response rates between 62 and 71 percent. Study assessment completion ranged from 85 to 98 percent, and 84 percent of client participants completed the primary outcome assessment at twelve months. On the implementation side, 77 of 125 employed providers attended the training sessions, coaching was delivered at 27 of 29 scheduled staff meetings, and all three clinic sites received monthly performance feedback. Client satisfaction, measured with the eight-item Client Satisfaction Questionnaire, averaged 26.32 out of 32 at twelve months, indicating high acceptability of the intervention.

The participant population underscored why this work matters. Clients were 64.6 percent female and predominantly White, and 80 percent met criteria for serious mental illness based on the Kessler-6 measure of psychological distress. They smoked an average of 15.35 cigarettes per day, showed moderate nicotine dependence on the Fagerström Test for Cigarette Dependence, and reported moderate motivation and confidence to quit. Most had previously tried cessation medications, most commonly nicotine replacement therapy, but few had ever tried cessation counseling. Qualitative interviews, analyzed using the Practical Robust Implementation and Sustainability Model, revealed that clients expected to be asked about smoking in healthcare settings and appreciated the accountability of multiple touchpoints, while providers viewed tobacco treatment as a good fit with the CCBHC mission of integrating behavioral and physical health care, a notable shift from the reluctance documented in earlier research.

Implementation data showed genuine movement in provider behavior. Provider surveys revealed statistically significant improvements in asking about tobacco use, advising cessation, and assisting with treatment between baseline and the nine-month follow-up. Once a revised tobacco clinical reminder embedded all relevant documentation fields on a single form, rates of documented asking, assessing, and assisting all reached 100 percent. On any given outreach call, between 27 and 43 percent of clients requested counseling, and nearly all who requested it, 95 to 100 percent, received it. Across the study, 38.8 percent of participants reported using cessation counseling at some point, 49.0 percent reported using cessation medication, and 28.6 percent used both, suggesting the intervention succeeded in connecting clients to evidence-based care.

The harder truth lies in the cessation outcomes. Self-reported seven-day point-prevalence abstinence was 10.4 percent at three months, 8.3 percent at six months, and 12.5 percent at twelve months. Of the six participants reporting abstinence at twelve months, five completed a carbon monoxide breath test and four showed values confirming abstinence, yielding a biochemically verified twelve-month abstinence rate of 8.3 percent. Participants did reduce their smoking by an average of 3.42 cigarettes per day from baseline to twelve months. These numbers align with a broader pattern: clinic-level implementation strategies alone have not yet produced statistically significant increases in client-level cessation in community mental health settings. A trial across 13 community mental health clinics improved provider skills and medication use but achieved only 4.2 percent self-reported abstinence at one year, and a cluster-randomized trial in drug and alcohol treatment centers changed medication use without changing abstinence. In contrast, proactive interventions delivered regardless of readiness to quit have produced significant population-level gains, including a 50 percent relative increase in abstinence from a single outreach call to veterans using mental health clinics and a 2.4-fold increase in quit rates from a community health worker intervention for people with serious mental illness.

The intervention also proved safe. Two serious adverse events, one hospitalization and one death, were reported, neither judged related to the study, and global distress scores showed no significant change from baseline across any follow-up timepoint. The study’s limitations are clear: it was small, non-randomized, and conducted at a single rural clinic with a population that was nearly 90 percent White, so it cannot isolate the contribution of each treatment component or generalize to all populations. High staff turnover, with 28 percent of surveyed providers leaving within a year, threatens sustainability, and provider survey completion declined from 72 to 54 percent over time. Providers themselves offered practical fixes, including refresher trainings, embedded electronic health record reminders, champions, and turnover-resistant plans, and noted that the 5As may be more sustainable than standalone counseling because it can be billed within regular visits. The research team’s next step is a fully powered, multi-site randomized clinical trial. If proactive outreach and clinic-wide implementation supports can demonstrate effectiveness at scale, CCBHCs, which already track tobacco screening and treatment as organizational performance metrics, may become the frontline battleground where the deadliest health disparity facing people with serious mental illness finally begins to shrink.

Subject of Research: A pilot type 2 hybrid effectiveness-implementation study of proactive smoking cessation interventions delivered in a Certified Community Behavioral Health Clinic

Article Title: Implementing Proactive Smoking Cessation Induction Interventions in a Certified Community Behavioral Health Clinic: A Pilot Type 2 Hybrid Effectiveness-Implementation Study

Article References: Japuntich, S., Adkins-Hempel, M., Sacasa, N. G., Lundtvedt, C., Becker, S., Helseth, S., Pratt, R., Tidey, J., Dunsiger, S., Evins, A. E., & Fu, S. (2026). Implementing Proactive Smoking Cessation Induction Interventions in a Certified Community Behavioral Health Clinic: A Pilot Type 2 Hybrid Effectiveness-Implementation Study. Community Mental Health Journal. https://doi.org/10.1007/s10597-026-01727-1

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01727-1

Keywords: smoking cessation, tobacco use disorder, mental health, Certified Community Behavioral Health Clinic, proactive outreach, implementation science, serious mental illness, 5As, nicotine dependence, behavioral health, hybrid effectiveness-implementation trial, community mental health