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

The research team, led by Shayna Farris and colleagues at the University of North Carolina at Chapel Hill and the University of Maryland, surveyed adults recruited to reflect the US population of e-cigarette users. The investigators applied survey weights so that the results better represented the broader population, rather than allowing the composition of the online sample to determine the estimates. Participants answered questions about whether their vaping exceeded their intentions, what consequences followed, how they perceived the health risks of e-cigarettes, whether people around them encouraged them to cut down, and whether they intended to quit. The researchers then used linear regression, a statistical method that estimates how strongly several characteristics are associated with an outcome while accounting for other measured variables. Because the study captured responses at one point in time, it can reveal patterns and correlations but cannot establish that any particular factor causes uncontrolled vaping.

The distinction between uncontrolled behavior and its consequences is scientifically important. Addiction is not defined only by dramatic harm; it can also involve impaired control, persistent urges and repeated use despite a desire to reduce it. In this study, participants’ perception that vaping was frequently uncontrolled was much more common than frequent negative consequences. That gap may reflect the relatively portable and discreet nature of e-cigarettes. Unlike combustible cigarettes, many vaping devices can be used rapidly and repeatedly in settings where smoking is prohibited, sometimes without a clear beginning or end to a session. Nicotine delivery can therefore become woven into ordinary activities—commuting, working, socializing or scrolling on a phone. A user may recognize that they are reaching for the device more often than planned even if the pattern has not yet led to an unmistakable crisis. In behavioral terms, perceived loss of control may function as an early-warning signal that appears before dependence becomes visibly disruptive.

Age emerged as one of the clearest correlates. Younger adults reported both more frequent perceptions that their vaping was uncontrolled and more frequent consequences from uncontrolled use. The finding does not prove that youth itself causes loss of control, but it is consistent with the way nicotine dependence can develop during periods when habits, reward systems and social routines are still changing. Younger adults may also be more exposed to products designed for rapid, convenient use, as well as to social settings in which vaping is normalized. Nicotine acts primarily by binding to nicotinic acetylcholine receptors in the brain, triggering the release of neurotransmitters including dopamine in reward-related circuits. Repeated exposure can strengthen associations between nicotine and environmental cues, making ordinary moments—waking, taking a break or being with friends—capable of provoking an urge. The resulting cycle is not simply a matter of weak willpower: it involves learned cues, withdrawal relief and reinforcement of repeated dosing.

Another strong marker was how soon participants vaped after waking. People who used an e-cigarette shortly after getting up reported higher levels of both uncontrolled vaping and its consequences, with the associations reaching high statistical significance. Time to first cigarette has long been used as a behavioral indicator of nicotine dependence because it captures the urgency of obtaining nicotine after overnight abstinence. Applying a similar logic to e-cigarettes, early-morning vaping may indicate that nicotine is being used to relieve withdrawal symptoms or restore a desired internal state after several hours without it. During abstinence, dependent users can experience irritability, restlessness, difficulty concentrating and strong cravings; vaping soon after waking may represent an attempt to reverse those effects. The new findings suggest that this simple behavioral measure may help researchers and clinicians identify adults whose vaping is more tightly governed by dependence than by occasional preference. It is not, however, a diagnostic test on its own.

Perceptions of risk were also linked to uncontrolled use, producing a seemingly paradoxical result: participants who believed vaping carried greater health risks were more likely to report that their use was uncontrolled and more likely to report consequences. The association may reflect what behavioral scientists call cognitive dissonance—the tension between recognizing a behavior as risky and continuing to perform it. Alternatively, people who have already experienced unpleasant effects or difficulty cutting down may have revised their risk perceptions upward. Because the survey was cross-sectional, the researchers cannot determine which direction the relationship runs. It is also possible that heavier users have encountered more health information, symptoms or conversations that make risks more salient. The finding nonetheless challenges the assumption that awareness alone reliably produces behavior change. Knowing that nicotine vaping may be harmful can coexist with dependence, and in some cases may sharpen a person’s recognition that their behavior is no longer under full voluntary control.

Social signals were associated with the same pattern. Adults were more likely to report uncontrolled vaping when friends or family members had discussed limiting their own use, when other people had told them to cut down, or when they expressed an intention to quit. These factors may be interpreted in two ways. They could indicate that social pressure and quit intentions help motivate restraint, or they could identify people whose vaping has already become noticeable enough to prompt concern. Either way, the results show that uncontrolled vaping is embedded in a social environment. Nicotine use is influenced not only by pharmacology but also by observation, conversation and expectations about what constitutes acceptable behavior. A request from a partner to stop vaping may expose a conflict between immediate nicotine reinforcement and longer-term goals. The researchers’ emphasis on ongoing surveillance reflects this complexity: future studies will need to follow people over time to discover whether social cues precede attempts to limit vaping, arise because of escalating use, or do both.

When participants were asked why they tried to limit their vaping, three motives stood out: cost, concern about health effects and a desire not to become dependent. Financial pressure may be especially potent because frequent vaping can turn a product often marketed as inexpensive or convenient into a recurring household expense. Health concerns provide a more direct long-term motive, while fear of dependence reflects a desire to preserve autonomy before the habit becomes harder to change. These motives may help shape public-health interventions, but they also reveal a challenge for messaging. A warning that simply repeats that vaping is dangerous may have limited impact if a person already accepts that premise yet cannot reduce use. Effective cessation support may need to address cravings, withdrawal, routines and high-risk cues, while helping people translate a general intention to quit into concrete behavioral steps. Existing research has begun testing text-message programs and medications for vaping cessation, but the current study does not evaluate any treatment.

The findings arrive as e-cigarette use remains a moving target for public-health researchers. Devices, nicotine concentrations, flavors and regulations change rapidly, complicating comparisons across surveys and years. Some adults use e-cigarettes while trying to move away from combustible cigarettes, whereas others vape without a history of smoking or use both products. The present study focused on adults who vape and was designed to characterize their experiences, not to settle the broader debate over the relative risks of cigarettes and e-cigarettes. Its results also rely on self-reported perceptions and consequences, which may be affected by memory, interpretation or reluctance to disclose behavior. The sample’s online format, despite weighting, may not perfectly represent every person who vapes. Even with those limitations, the 23 percent estimate makes the central message difficult to ignore: loss of control is common enough to warrant routine measurement. Tracking it could give researchers a more sensitive indicator of emerging dependence than consumption frequency alone.

For individuals who vape, the study suggests that repeatedly using more than intended, reaching for a device soon after waking, or feeling unable to follow through on plans to cut down should not be dismissed as harmless habits. For clinicians and policymakers, it points toward a need to ask not only whether someone vapes, but how much control they feel they have over the behavior and what happens when they try to limit it. The researchers’ call for continued surveillance is ultimately a call to treat vaping as a dynamic behavior rather than a static category. A person can move from experimentation to routine use, from routine use to dependence, and from dependence to attempted cessation—sometimes without a dramatic event marking the transition. By identifying that transition while it is still experienced mainly as an internal struggle, public-health programs may have a better chance of offering support before financial costs, health concerns or social conflict become the price of stopping.

Subject of Research: Uncontrolled vaping, nicotine dependence, and vaping restraint among US adults who use e-cigarettes

Article Title: Prevalence and correlates of uncontrolled vaping among US adults

Article References: Farris, S., Licciardello Queen, T., Sakhuja, M. et al. “Prevalence and correlates of uncontrolled vaping among US adults.” Journal of Behavioral Medicine 49, 529–539 (2026). Original research article

Image Credits: AI Generated

DOI: 10.1007/s10865-026-00659-1

Keywords: e-cigarettes, vaping behavior, uncontrolled vaping, nicotine dependence, addiction, vaping cessation, US adults, public health