A Cluster Randomized Trial Testing Two Knowledge Strategies to Facilitate the Integration of Mood Management into Smoking Cessation Programming in Primary Healthcare Systems

Authors: Minian N, Ahad S, Ivanova A, Zawertailo L, Baliunas D, Ravindran A, Oliveira CD, Mulder C, Noormohamed A, and Selby P

Presenter: Dr. Nadia Minian

Institution: Centre for Addition and Mental Health


Knowledge Brokers (KBs) are often utilized in implementing complex interventions, even though there is conflicting evidence regarding their effectiveness. The objective of this study was to compare a remote knowledge broker (rKB) vs generalized, exclusively email-based prompts, in implementing a mood management intervention for depressed smokers enrolled in a smoking cessation program (the Smoking Treatment for Ontario Patients, STOP, program) in Family Health Teams (FHTs).  This intervention was chosen given:
1) The need to address mood among STOP participants; 38% of smokers have current or past depression; their 6-month quit rates are significantly lower than participants without depression.
2) The strong evidence showing its effectiveness; a Cochrane review demonstrated that integrating a mood management component within standard smoking cessation programming significantly increases long-term abstinence rates among smokers with current or past depression.



The Interactive Systems Framework for Dissemination and Implementation underpins this two arm cluster pragmatic mixed method randomized hybrid type III trial.  Across Ontario, 123 FHTs participating in a smoking cessation program were randomly allocated 1:1 to receive either: a generalized monthly email focused on implementing a depression component to a smoking cessation program, or a remotely situated knowledge broker offering tailored support via phone and email, to encourage the implementation of an evidence-based mood intervention to smokers presenting depressive symptoms.  The primary outcome was the adoption and sustainability of the mood intervention over 12 months, which was measured at the site level, and operationally defined as the proportion of eligible baseline visits which result in practitioners delivering the mood management intervention to patients as measured by the STOP patient management portal. The secondary outcome, measured at the patient level, is smoking abstinence at 6-month follow-up, measured by self-report of having abstained from smoking for at least 7 previous days.
All FHTs were invited to participate in two interactive webinars aimed at increasing healthcare provider specific capacity in delivering mood interventions. Participating FHTs also received access to an integrated care pathway within the STOP portal to facilitate the delivery of a brief intervention and a self-help mood management resource.



Over 50 healthcare providers attended at least one interactive webinar. Between February 2018 and January 2019, 7,175 smokers were screened for depression, among whom 2,765 (39%) reported current/past depression. Among those who reported current/past depression, 983 smokers (36%) were offered a self-help mood management resource. 782 (80%) of the patients who were offered a resource, accepted it. Adjusted regression analyses of 2,763 participants with complete covariate data showed there was no significant between-group difference in the odds of participants accepting the mood management resource (OR=0.93, 95% CI: 0.60-1.43).



Results from our current investigation indicate that both KT interventions are equally effective at engaging providers from multidisciplinary healthcare settings to implement evidence-based mood interventions into practice. Future research will seek to investigate the cost-effectiveness of each intervention to better understand their feasibility for implementation within complex health systems. 


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