DESCRIPTION (provided by applicant): Smoking remains the leading cause of morbidity and mortality in the United States. The 2008 Public Health Service Guideline (PHS), Treating Tobacco Use and Dependence provides strong evidence that brief advice combined with assistance such as counseling and pharmacotherapy, can significantly increase quit rates. Unfortunately, provider adherence to Guideline recommendations is poor. Inadequate implementation of the Guideline in practice settings, particularly those serving ethnic minorities and other vulnerable populations, has contributed to growing disparities in smoking prevalence and tobacco-related illness. This proposal addresses this research-to-practice gap by examining the effectiveness of three practical and highly replicable strategies for implementing evidence-based guidelines for the treatment of tobacco dependence in dental public health clinics. Dental providers have a credible and central role in providing tobacco cessation services. The majority of smokers see a dentist annually and tobacco use is a known risk factor for oral disease. Moreover, controlled trials have demonstrated the efficacy and effectiveness of dental office-based cessation interventions. Yet dental care settings remain a relatively untapped venue for the treatment of tobacco dependence. In order to integrate evidence-based tobacco cessation treatment into routine dental practice, optimal implementation processes and strategies must be identified. We propose a 3-arm, cluster randomized controlled trial that will 1) Compare the effectiveness and cost of three promising strategies for implementation of the PHS tobacco use treatment guidelines: a) Staff training and current best practices (CBP); 2) CBP + provider performance feedback (PF) and 3) CBP + PF + provider reimbursement for delivery of tobacco cessation treatment (pay for performance) on provider adherence to recommended guidelines for tobacco use treatment; 2) Use a mixed-methods approach to examine potential theory-driven mechanisms at the organizational and provider level hypothesized to explain the comparative effectiveness of three strategies for implementation; and 3) Identify baseline organizational factors that influence the implementation of evidence-based tobacco use treatment practices in dental clinics. The trial will be conducted in 18 public dental care clinics
and information about implementation outcomes and processes will be derived from multiple data sources (patient exit interviews, provider surveys and semi- structured interviews). Guided by a conceptual framework that emphasizes provider beliefs and organizational characteristics, we will identify factors that influence the implementation process in dental clinics. The ultimate goal of the proposed research is to provide critical new knowledge to facilitate the widespread adoption, implementation, dissemination and sustained utilization of evidence-based tobacco use treatment strategies in dental practices across the U.S.
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