title: A Mixed-Methods Assessment of a Brief Smoking Cessation Intervention Implemented in Ohio Public Health Clinics, 2013.
abstract: OBJECTIVE
  In 2006, the state of Ohio initiated the implementation of a brief smoking cessation intervention (5As: Ask, Advise, Assess, Assist, and Arrange) in select public health clinics that serve low-income pregnant and post-partum women. Funds later became available to expand the program statewide by 2015. However, close to half of the clinics initially trained stopped implementation of the 5As. To help guide the proposed statewide expansion plan for implementation of the 5As, this study assessed barriers and facilitators related to 5As implementation among clinics that had ever received training.
  
  
  METHODS
  A mixed-methods approach was used, comprising semi-structured interviews with clinic program directors (n = 21) and a survey of clinic staff members (n = 120), to assess implementation-related barriers, facilitators, training needs, and staff confidence in delivering the 5As.
  
  
  RESULTS
  Semi-structured interviews of program directors elucidated implementation barriers including time constraints, low self-efficacy in engaging resistant clients, and paperwork-related documentation challenges. Facilitators included availability of community referral resources, and integration of cessation interventions into the clinic workflow. Program directors believed they would benefit from more hands-on training in delivering the 5As. The survey results showed that a majority of staff felt confident advising (61%) or referring clients for tobacco dependence treatment (74%), but fewer felt confident about discussing treatment options with clients (29%) or providing support to clients who had relapsed (30%).
  
  
  CONCLUSIONS
  Time constraints and documentation issues were major barriers to implementing the 5As. Simplified documentation processes and training enhancements, coupled with systems change, may enhance delivery of evidence-based smoking cessation interventions.
authors.affiliation: Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA. iagaku@cdc.gov.|Epidemic Intelligence Service, Division of Applied Sciences, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, GA, USA. iagaku@cdc.gov.
authors.forename: Israel T
authors.initials: IT
authors.lastname: Agaku
authors.affiliation: Epidemic Intelligence Service, Division of Applied Sciences, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, GA, USA. xdg1@cdc.gov.|Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA. xdg1@cdc.gov.
authors.forename: Oluwatosin
authors.initials: O
authors.lastname: Olaiya
authors.affiliation: Epidemic Intelligence Service, Division of Applied Sciences, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, GA, USA. fyq6@cdc.gov.|Ohio Department of Health, Columbus, OH, USA. fyq6@cdc.gov.|U.S. Public Health Service Commissioned Corps, Atlanta, GA, USA. fyq6@cdc.gov.
authors.forename: Celia
authors.initials: C
authors.lastname: Quinn
authors.affiliation: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA. vct2@cdc.gov.
authors.forename: Van T
authors.initials: VT
authors.lastname: Tong
authors.affiliation: Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA. nKuiper@cdc.gov.
authors.forename: Nicole M
authors.initials: NM
authors.lastname: Kuiper
authors.affiliation: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA. ElizabethJ.Conrey@odh.ohio.gov.|Ohio Department of Health, Columbus, OH, USA. ElizabethJ.Conrey@odh.ohio.gov.
authors.forename: Elizabeth J
authors.initials: EJ
authors.lastname: Conrey
authors.affiliation: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA. aec4@cdc.gov.|U.S. Public Health Service Commissioned Corps, Atlanta, GA, USA. aec4@cdc.gov.
authors.forename: Andrea J
authors.initials: AJ
authors.lastname: Sharma
authors.affiliation: Ohio Department of Health, Columbus, OH, USA. Sierra.Mullen@odh.ohio.gov.|CDC/CSTE Applied Epidemiology Fellowship Program, Atlanta, GA, USA. Sierra.Mullen@odh.ohio.gov.
authors.forename: Sierra
authors.initials: S
authors.lastname: Mullen
authors.affiliation: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA. DDee@cdc.gov.|U.S. Public Health Service Commissioned Corps, Atlanta, GA, USA. DDee@cdc.gov.
authors.forename: Deborah
authors.initials: D
authors.lastname: Dee
mesh_terms: D005260:Female; D006293:Health Promotion / Q000379:methods; D006801:Humans; D009820:Ohio; D011203:Poverty; D011247:Pregnancy; D016540:Smoking Cessation / Q000379:methods*; D011795:Surveys and Questionnaires; D014481:United States; D014492:United States Public Health Service
keywords: Cessation counselling; Pregnancy; Smoking; WIC