The potential feasibility of tobacco-focused medication therapy management in pharmacies affiliated with Federally Qualified Health Centers: Perspectives of pharmacists

Abstract

Background:

Tobacco-focused medication therapy management (MTM) interventions executed in pharmacies located in Federally Qualified Health Centers (FQHC) may provide an innovative means to reach smokers with low incomes and reduce health disparities. However, greater understanding of the intervention’s potential feasibility in this setting is needed.

Objective:

To inform the feasibility of implementing an MTM program to address tobacco and nicotine dependence in the FQHC setting by assessing the experience and perceptions of pharmacists working in pharmacies associated with FQHCs.

Methods:

A convergent mixed methods approach was used to assess indicators associated with the domains of the Consolidated Framework for Implementation Research (CFIR). Pharmacists from FQHC-based pharmacies in the Southeast United States completed surveys (n=24) and interviews (n=15). Quantitative data were summarized descriptively. Qualitative data were content coded.

Results:

Quantitative and qualitative data were mapped across all five CFIR domains. Pharmacists report high rates of tobacco and nicotine use among their patients and that addressing their use is important. 62.5% of pharmacists had some or a great deal of experience with tobacco and nicotine dependence. Quantitative and qualitative data demonstrate that the pharmacists and their FQHCs would support MTM efforts focused on tobacco and nicotine dependence. Qualitative findings highlight that pharmacists view an MTM intervention as aligning with their current workflow. Quantitative and qualitative data highlight how factors related to pharmacists’ engagement in introducing tobacco and nicotine dependence treatment programs to patients, the electronic medical record, time, staffing, and patient-level barriers could impact the feasibility of an MTM intervention focused on tobacco and nicotine dependence.

Conclusion:

Findings suggest an MTM intervention focused on tobacco and nicotine dependence has the potential to be feasible within FQHC-based pharmacies. Considerations related to training, staffing, time, identifying participants, and supporting participant engagement must be taken into account to support its implementation.

INTRODUCTION

Cigarette smoking is estimated to account for 30% of all cancer deaths,¹ and smoking increases the risk of 19 types of cancer.² While only 12.5% of U.S. adults smoke cigarettes, rates are disproportionately higher among certain populations, including those with lower socioeconomic status.³ Notably, individuals with an annual income of <$35,000 are three times more likely to report smoking in the past 30 days (20.2%) compared to individuals with an annual income ≥$100,000.³ As a result, this population subgroup is more likely to have higher odds of oral cancer, lung cancer, and lung cancer mortality compared to those with higher incomes.⁴

Furthermore, though effective tobacco and nicotine dependence treatments programs and medications exist, not all population groups are able to equally access these resources.⁵ Notably, those with medium to high levels of socioeconomic distress were less likely to report having received assistance to quit smoking from a health care provider.⁶ Thus, there is a need for innovative strategies to increase access to tobacco and nicotine dependence treatment services for smokers with lower incomes to decrease disparities and improve population health.⁷

Nicotine replacement therapy (NRT), a cessation-related pharmacotherapy, can effectively reduce tobacco and nicotine dependence.⁸ When NRT is coupled with behavioral support, there is significantly increased success in quit attempts.^9,10 Medication therapy management (MTM) provides a pathway to couple NRT and behavioral support. MTM is a service designed to increase medication adherence and proper usage that utilizes pharmacists to provide education and counseling directly to patients. Pharmacists are uniquely situated to interact directly with patients and provide specific expertise on medication. Importantly, patients interact with pharmacists at almost a two to one ratio when compared to physicians and other primary care providers.^11–13 While the use of MTM for tobacco and nicotine dependence treatment is underutilized,¹⁴ MTM is widely used in the treatment of other health conditions, including diabetes and hypertension,^15,16 and, thus, offers scalable means to increase access to tobacco and nicotine dependence treatment.^17,18 Yet, more needs to be understood about its feasibility in settings reaching smokers with low incomes.

Federally Qualified Health Centers (FQHCs) provide primary and preventative care services to rural, low income, and uninsured populations.^19,20 Since 2011, FQHCs have been required to report tobacco use screening rates and delivery of tobacco and nicotine dependence treatment interventions to the Health Resources and Services Administration (HRSA).²¹ Almost 30% of patients at FQHCs report current smoking, with 79% of these smokers expressing a desire to quit. Yet, they also reported low utilization of tobacco and nicotine dependence treatment opportunities.²² Importantly, pharmacist-led MTM in FQHCs have been successfully executed for the management of other health conditions.²³ Taken together, this evidence suggests an opportunity exists to use tobacco-focused MTM services at FQHCs to reduce health disparities among smokers served in these health settings.

However, as the implementation of tobacco-focused MTM is not common, it is important to explore what would influence the potential feasibility of its implementation in FQHC-based pharmacies before further developing and testing a related intervention. Importantly, Bowen and colleagues define feasibility studies as one that helps researchers prepare for full scale trials.²⁴ Feasibility studies help answer three questions: “Can it work?,” “Does it work?,” and “Will it work?” and use a variety of methods, including surveys, interviews, and randomized control trial designs.²⁴

OBJECTIVES

The purpose of the current study was to assess the experience and perceptions of pharmacists working in pharmacies associated with FQHCs related to tobacco and nicotine dependence to inform the feasibility (“Can it work?”) of implementing an MTM intervention focused on tobacco and nicotine dependence in the FQHC setting.

METHODS

This convergent mixed methods study used data from surveys (quantitative) and interviews (qualitative) completed by pharmacists working in pharmacies affiliated with FQHCs. Study procedures were approved by the University of Virginia Institutional Review Board.

Inclusion Criteria

Study inclusion criteria were for participants to be a pharmacist and an employee of a pharmacy embedded in an FQHC located in Virginia, West Virginia, Kentucky, North Carolina, or Tennessee.

Procedure

Using the HRSA health center locator tool, the study team identified 60 FQHCs with pharmacies located in the five targeted states. Researchers contacted these pharmacies between August 2022 and May 2023. They asked to speak with the pharmacy manager or pharmacist. During the call, the researcher introduced the study and answered any questions. If the pharmacy was interested in participating, research staff worked with the site contact to identify who would participate.

The identified pharmacist was then contacted and consented by phone. After completing consent, enrolled participants were emailed a secure Qualtrics link to complete the study survey. Pharmacists who did not initially complete the survey received a follow-up email and/or phone call at least twice over an approximately three-week period.

At the end of the survey, participants indicated whether they wanted to be contacted to participate in a phone-based interview focused on understanding more about the potential feasibility of providing tobacco and nicotine dependence treatment resources in their pharmacy. Nineteen pharmacists expressed interest.

Interviews were conducted by trained researchers between October 2022 and April 2023. A second researcher took notes during the interview. The audio-recorded interviews were approximately 45-minutes long and took place using the Zoom platform.²⁵

Measures

The selection of quantitative and qualitative measures was informed by the domains of the Consolidated Framework for Implementation Research (CFIR).^26,27 CFIR is a determinant framework of contextual factors that influence the implementation of evidence-based interventions. It is among the most commonly used implementation science frameworks.²⁸ These factors make it a strong framework to explore factors that could impact the external validity of an intervention and provide indication of an intervention’s potential feasibility. CFIR consists of five domains: Innovation (i.e., the “thing” being implemented), Outer Setting (i.e., the setting in which the Inner Setting exists), Inner Setting (i.e., the setting in which the innovation is implemented), Individuals (i.e., the roles and characteristics of the individuals implementing the innovation), and Implementation Process (i.e., the activities and strategies used to implement the innovation).²⁷ Please note, survey and focus group questions used the terms “tobacco cessation” or “smoking cessation” as opposed to “tobacco and nicotine dependence treatment.” Survey items were adapted from previous studies with professionals who had previously implemented educational interventions related to for tobacco and nicotine treatment.^{14,17,18,29,30}

Survey.

The survey assessed demographic characteristics (i.e., sex, age, race) and their experience as a pharmacist (i.e., educational attainment, years working as a pharmacist: overall, in an FQHC setting, and in their current region). Questions also assessed their experience with and perceptions of tobacco and nicotine dependence treatment efforts, including MTM.

Pharmacists’ personal experience with tobacco and nicotine dependence treatment (five items; Individual).

One item captured self-rated experience on a four-point scale from no experience to a great deal of experience. Another captured which of five tobacco and nicotine dependence treatment activities (e.g., NRT products, counseling, self-help materials, referral to a quit line, and referral to other tobacco and nicotine dependence treatment resources) pharmacists currently engaged in [Yes/No]. Three items assessed their comfort on a five-point scale [1=uncomfortable to 5=very comfortable] related to executing each of the three components of the Ask-Advise-Connect activities. The Ask-Advise-Connect model is a nationally recommended approach for tobacco and nicotine dependence treatment through the Clinical Practice Guidelines.³¹

Pharmacy level tobacco and nicotine dependence treatment activities (seven items, Inner Setting).

Pharmacists identified whether “tobacco cessation” counseling was offered by the pharmacy [Yes/No]. They also rated their perceptions of their FQHC pharmacy’s prioritization of “tobacco cessation,” offering sufficient services, support of “cessation” services, administrative support, patient interest, and medical provider support. Ratings were on a 5-point scale [1=strongly disagree to 5=strongly agree].

Pharmacists’ perceptions of their customers’ need and receptivity to tobacco and nicotine dependence treatment (five items, Outer Setting).

Three items assessed what percent of their patients they believed used cigarettes, smokeless tobacco, and electronic cigarettes [0-25%, 26-50%, 51-75%, 76-100%]. Two items assessed how frequently patients requested “smoking cessation” support from the pharmacy [1=several times per week to 4=every few months] and how receptive they thought their customers were to having a conversation about their tobacco use [1=Not at all to 5= Extremely].

Perceptions related to implementing MTM treatment (ten items, Innovation, Outer Setting, Inner Setting, Implementation Process).

All items were measured on a 5-point agreement scale [1=strongly disagree to 5=strongly agree]. Pharmacists rated perceptions related to time, staffing, space, balance with other activities, training/experience, documentation, billing, management support, technology barriers, and number of eligible patients.

Interview guide (all domains).

A semi-structured interview guide expanded on the experience with and perceptions of “tobacco cessation” efforts. Specifically, nine open-ended questions collected data related to how “tobacco cessation” efforts were conducted in their pharmacy, how the pharmacist envisioned the process of implementing an MTM “tobacco cessation” intervention in their pharmacy, barriers to delivering an MTM “tobacco cessation” intervention in their pharmacy, and resources needed to make conducting the MTM intervention possible. Questions included probes to ensure responses were both clear and detailed.

Data Analysis

Quantitative.

Quantitative data were analyzed using SPSS.³² Descriptive statistics, including frequencies and means, were used to summarize all quantitative items.

Qualitative.

Audio files of interviews were transcribed using Trint.³³ Trained research staff reviewed and cleaned the transcripts. First, using the transcripts, two researchers (CD, AW) independently created structured summaries of the interviews. The summaries included: (i) perceptions of “tobacco cessation” at the pharmacy, FQHC, and patient levels; (ii) experience with “tobacco cessation” focused MTM at the pharmacist and FQHC levels; (iii) pharmacist skills related to “tobacco cessation;” (iv) patient-level factors relevant to engaging in “tobacco cessation;” and (v) design of the FQHC pharmacy in relation to delivering “tobacco cessation.” Summaries captured findings related to both “tobacco cessation” in general and specific to MTM. Second, the summaries for each interview were compared and merged, with discrepancies discussed. Third, an overall structured summary of all the interviews was created by a single researcher (CD) and reviewed for accuracy by another researcher (KP). Fourth, two researchers (KP, CD) looked across each of the categories in the structured summary and identified emerging concepts. Fifth, these concepts were then categorized into whether they reflected experience with “tobacco cessation” in general or specifically to tobacco-focused MTM and by CFIR domain.

Data triangulation.

Quantitative and qualitative data were triangulated during data interpretation. Specifically, findings related to the same CFIR domain were compiled and compared.

RESULTS

Participants

Figure 1 illustrates the recruitment and enrollment of pharmacists into the study. Of the 60 contacted FQHCs with embedded pharmacies, 22 had one or more pharmacists enroll (i.e., complete consent); 20 had one or more a pharmacist complete a survey; and 14 had one or more pharmacists complete an interview. Some FQHCs had multiple pharmacists participate as they had pharmacies at different clinics within their system. Overall, 24 pharmacists completed the survey and 15 completed the interview.

Figure 1.

Flow chart of pharmacist enrollment and engagement

Table 1 presents the characteristics of the FQHCs, pharmacies, and pharmacists that completed the survey. These FQHCs were evenly distributed across the six states, with pharmacists from 4 to 5 FHQCs participating from each state. Participants were, on average, 45.9 years old, female (60.9%), White (82.6%), and had a Pharm.D. (70.8%). The pharmacists had been in practice an average of 21.3 years, with 7.2 years working in an FQHC setting and 18.1 years in the study region. While of a similar age, race, and education, the subset of pharmacists (n=15) who completed interviews were more likely to be female (71.4%) and have less experience overall (20.3 years, SD= 13.27), in FQHC setting (5.7 years, SD=5.23), and in the region (17.3 years, SD=14.87).

Table 1.

Characteristics of pharmacists (n=24)

	n(%) or m(SD)
Age	45.9 (12.6)a
Gender
Male	9 (37.5%)
Female	14 (58.3%)
Did not reply	1 (4.2%)
Highest Degree
BS Pharm	7 (29.2%)
PharmD	17 (70.8%)
Race
Black/African American	2 (8.3%)
Other	2 (8.3%)
White	19 (79.2%)
Did not reply	1 (4.2%)
Pharmacist experience (years)
Overall	21.3 (12.7)a
Working in an FQHC	7.2 (8.2)b
Working in the region	18.1 (14.1)
State in which pharmacy was located
Virginia	5 (20.8%)
West Virginia	5 (20.8%)
Kentucky	5 (20.8%)
North Carolina	4 (16.7%)
Tennessee	5 (20.8%)

Note.

^aout of 23 responses, 1 participant did not reply;

Note.

^bout of 22 responses; 2 participants did not reply

Quantitative Findings

Pharmacist tobacco cession related experiences and perceptions.

Over half (62.5%) of pharmacists had some or a great deal of experience providing “tobacco cessation” resources to customers (Table 2). Pharmacists reported providing multiple “tobacco cessation” resources to customers, with more than half currently providing NRT (87.5%) and counseling (79.2%). Pharmacists indicated that they were “comfortable” engaging in activities associated with the Ask-Advise-Connect Model, with average scores of 3.63 (SD=1.14), 3.71 (SD=0.91), and 4.00 (SD=0.89) for connecting, asking, and advising, respectively.

Table 2.

Pharmacist experiences and perceptions of tobacco and nicotine dependence treatment

	n(%) or m(SD)
Pharmacists’ experience providing “tobacco cessation” resources to customers
A little experience	9 (37.5%)
Some experience	12 (50.0%)
A great deal of experience	3 (12.5%)
“Tobacco cessation” services currently offered by pharmacists
NRT products	21 (87.5%)
Counseling	19 (79.2%)
Self-help materials	10 (41.7%)
Referral to a quit line	8 (33.3%)
Referral to other “smoking cessation” resource	3 (12.5%)
Pharmacists’ comfort to engage in activities associated with the Ask-Advise-Connect modela
Asking a customer about their tobacco use	3.71 (0.91)
Providing advice on the use of prescription “tobacco cessation” medications (e.g., varenicline, bupropion)	4.00 (0.89)
Connecting a customer to a “tobacco cessation“ program or resource	3.63 (1.14)
Pharmacy provides “tobacco cessation“ counseling
Yes	11 (45.8%)
No	13 (54.2%)
Pharmacist perceptions of their FQHC in relation to “tobacco cessation“b,c
My health system prioritizes “smoking cessation” services to patients	3.04 (0.71)
My health system provides sufficient “smoking cessation” services to patients	2.87 (0.82)
My health system would support offering patients “smoking cessation” services through the pharmacy	3.39 (0.66)
Administrators would support a “smoking cessation” MTM	3.35 (0.71)
Patients would be interested in receiving “smoking cessation” through the pharmacy	3.09 (0.733)
Medical providers would support the pharmacy providing “smoking cessation”	3.39 (0.66)

Note.

^aResponse options range from 1 = not at all comfortable to 5= extremely comfortable

Note.

^bResponse options range from 1 = strongly disagree to 4= strongly agree

Note.

^cAverages are out of 23 responses; 1 participant did not reply

NRT: Nicotine Replacement Therapy

Slightly less than half of pharmacists (45.8%) indicated that their pharmacy currently offered “tobacco cessation” counseling. Pharmacists generally “agreed” that their FQHCs supported and had interest in “tobacco cessation;” scores ranged from 2.87 for the sufficiency of “cessation” services provided to 3.39 for both perceptions of their health system support for offering “smoking cessation” services through the pharmacy and of medical provider support for pharmacy offered “tobacco cessation” services.

Perceptions of customers’ tobacco use and receptivity for tobacco and nicotine dependence treatment.

As presented in Table 3, 70% of pharmacists reported more than a quarter of their customers smoke cigarettes, and 34% reported that more than a quarter use electronic cigarettes. Additionally, approximately 37% of pharmacists reported that customers requested “smoking cessation” support once a week or more. Pharmacists rated their perception of the customers’ receptivity to conversations with a pharmacist about their tobacco use as moderate (2.79, SD=0.78).

Table 3.

Perceptions of customer’s tobacco use and receptivity to tobacco cessation (n=24)

	n(%)
Perceived customers tobacco use
Cigarette use
0-25%	5 (20.8%)
26-50%	11 (45.8%)
51-75%	6 (25.0%)
76-100%	0 (0.0%)
Does not know	2 (8.3%)
Smokeless tobacco use
0-25%	14 (58.3%)
26-50%	6 (25.0%)
51-75%	1 (4.2%)
76-100%	0 (0.0%)
Does not know	3 (12.5%)
Electronic cigarette use
0-25%	12 (50.0%)
26-50%	6 (25.0%)
51-75%	1 (4.2%)
76-100%	1 (4.2%)
Does not know	3 (12.5%)
Did not reply	1 (4.2%)
Customers request smoking cessation support
Several times per week	2 (8.3%)
Once a week	7 (29.2%)
Once a month	3 (12.5%)
Every few months	12 (50.0%)
Customers perceived receptivity to conversation with pharmacist about tobacco usea	2.79 (0.78)

Note.

^aResponse options range from 1 = Not at all to 5= Extremely

Perceptions related to implementing MTM treatment to customers.

Figure 2 presents pharmacists’ agreement with statements associated with the capacity of their pharmacy to implement MTM treatment in general. Statements with the highest level of pharmacists replying “agree” or “strongly agree” were related to having enough MTM patients (54.3%), having few technology barriers (54.2%), and having management support (54.2%). Statements with the highest level of pharmacists replying “disagree” or “strongly disagree” were the load of dispensing activities being light (58.3%), having sufficient staffing (54.8%), and having adequate time (70.9%). The other four indicators – adequacy of space, difficulty of documentation, adequacy of pharmacists’ training, and difficulty of MTM billing – had responses that were relatively even in the proportion of pharmacists either disagreeing/strongly disagreeing or agreeing/strongly agreeing with the statements.

Figure 2.

Pharmacists’ (n=24) perceptions of factors associated with their FQHC-based pharmacies’ capacity to implement tobacco-focused Medication Therapy Management (MTM)

Qualitative

Table 4 presents the ten key concepts associated with pharmacists’ experience with and perceptions of tobacco and nicotine dependence treatment in general and specific to MTM identified in the content analysis. The table also presents exemplar quotes for each concept. Five of the concepts were related to general tobacco and nicotine dependence treatment and five were specific to MTM. Concepts mapped across all CFIR domains.

Table 4:

Key concepts related to pharmacists’ experience with and perceptions of tobacco cessation in general and specific to MTM mapped to CFIR domains.

Concept	General or MTM Specific	Quote
Innovation
Tobacco related MTM efforts fit within MTM efforts pharmacies successfully utilize.	MTM-specific	It should be easy to run reports that show they’re smokers and you could send out fliers to those particular people… [T]hat’s how they started out with the diabetes program… they had a good turnout for it. 104 [A tobacco MTM] would probably be similar to the program we had like six years ago where you… had a program that would be… free to the patients, but it would be more that type of a deal where… instead of just an initial visit, there’s more follow up, some documentation too. Even if you had something where they had to sign like a contract or something where there’s some accountability where they are going, it might make it more successful. 111
Implementation Processes
Most pharmacies use or have the ability to identify and track patients needing tobacco cessation using their electronic medical record.	MTM-specific	Our electronic medical record system that the providers use, are identifying patients that have said they’ve smoked, and haven’t been asked about smoking cessation in a certain period of time. It’s one of our quality improvement initiatives. 103 We can see their chart because they’re in the facility network. I’m sure there’s a way that the IT people could somehow link us to patients that have been flagged that they want smoking cessation. So it wouldn’t actually be that challenging in the [FQHC] facility due to the fact that everything’s so streamlined. 114
Insurance and reimbursement processes for tobacco cessation products are cumbersome.	General	…Reimbursement… trying to get insurances to pay for some of these products is [difficult]… I had a Medicare D patient and the provider [wrote] for nicotine patches. Well, Medicare doesn’t cover over the counter products. And so the patient didn’t get it. And they were not interested in the nasal spray, or the nicotrol inhaler. 102 Now that the [Chantix] generics available, it’s really pricey. Our State Medicaid does pay for that. But if you’re uninsured it’s kind of a barrier to try and get that medication to them. 111
Pharmacists do not usually initiate tobacco cessation efforts.	General	I don’t come out and say, “Hey, are you smoking? Do you want to quit?” Sometimes that can [come across as] … offensive, especially [since] I’m not their doctor … So, I generally stay in my lane. 109 The only other [tobacco cessation service] we would do is in the outpatient setting, if they had questions on how to use a nicotine patch, where to apply it, how to apply it, the ins and outs. I feel like that’s probably the only role that we play as far as just encouraging them to pick it up. Not as much… as the providers do. I don’t think we have any patients come to us and be like, “I want to quit smoking, Help me do it.” It’s just not something you really see around here. 114
Individuals
Pharmacists engage in tobacco cessation and believe it is a priority for their patients and supported by their health system.	General	My administration would even help some of the cost [of product] if we were to able to get at least half of the cost paid on the patches, or lozenges, or whatever. …We do want to help our patients [quit using tobacco]…that’s our goal. 102 …our director is really open to new programs and new ways of engaging patients that involves pharmacy more than just dispensing the product and that being all that we do. So I think [a smoking cessation MTM] would be something that everyone in the health system would be on board with as far as our accuracy goes. 106
Pharmacists have the “right” professional skills to execute a tobacco-focused MTM intervention.	MTM-specific	Utilizing pharmacists means that you have someone with a doctorate level education and … coupled with the fact that most nicotine replacement products are over the counter medications. These are things that we can really make recommendations for without having to defer to a provider. 103 I think [tobacco cessation/MTM] is great. We did a lot of it, like a lot of training on it in pharmacy school where you have to go in and see your patient per se and figure out what was best for them… 110 We’re the most easily accessible health care providers too…. You rarely get to speak to your doctor if you call outside of an appointment. The pharmacist, you could just walk in and be like, “hey,” because we’re right there. … And frankly, we probably have a lot more knowledge about some of the treatments. 112
Inner Setting
Dedicated staffing is needed for the MTM to work	MTM-specific	Our clinic is one of the busiest clinics and I’m the only pharmacist that’s here. That would impede me from going to the window at all times. We other we have other things that I have to protect as far as verifying prescriptions and things of that nature. So there’s a lot to take in hand. But if I had it my way, I would probably have another pharmacist in here so that I can be more available for those counseling opportunities. 109 … some of our other sites actually have specialized clinical pharmacists who focus primarily on MTM. I think that is their hope once we move that we will grow and be able to expand that way, have additional pharmacists. 115
The design of pharmacies in FQHCs can influence the execution of tobacco-focused MTM.	MTM-specific	The phone is probably going to be the best solution because the retail setting is very tough to do [counseling] … [t]here are just too many people around there’s no confidentiality and it’s just so busy… [There’s not a room] in most pharmacies… 105 “There really isn’t a designated space [in the pharmacy] for consultations… [but] we do have quite a few exam rooms.” 106
Outer Setting
Patient-level barriers (e.g., low motivation to quit, limited technology access, low SES, limited transportation) impact the effectiveness of tobacco cessation efforts.	General	So, usually their motivation to pick up the prescription [for tobacco cessation products] is at the time of service, [But]… more likely than not, they’re needing to use the Quitline [to get the products for free] … [but even if they act right away] it could take 24 hours [for them to get the products]103 Just giving people a pill, a lozenge, a patch, is not going to work until they have realized that they need to quit smoking. 107
Patients’ acute health needs are prioritized over tobacco cessation.	General	…our patients are very complex and usually when we get prescriptions dumped over, it’s like 15 per patient. So that’s [their smoking] probably not at the top of the list. You’re worried about their diabetes and hypertension … in like a 30 minute visit, you really can’t address all of the things you need to. 110 I don’t think [smoking cessation] is a focus right now. I think it could be. I think it would… be well received if it was to become a focus. But right now it’s not necessarily a focus. It’s really kind of getting out of the out of COVID… then we’re still trying to do immunizations and everything. But as a as a culture, as far as a culture for the health center, I think it would be well received to be, you know, be a focus. I don’t think I mean, it’s not a priority for current funding right now. 113

Overall, pharmacists found that tobacco-related MTM efforts fit within MTM efforts pharmacies successfully utilize, suggesting that this evidence-based intervention can fit within the structure of an FQHC-based pharmacy. However, pharmacists discussed they do not usually initiate “tobacco cessation” efforts but reported having the ability to or already use their electronic medical record (EMR) system to identify and track participants who use tobacco products and would benefit from tobacco and nicotine dependence treatment. Given that this usual process starts with a provider, pharmacists reported hesitation initiating treatment efforts unless initiated by a patient. Furthermore, the cumbersome insurance and reimbursement processes associated with tobacco and nicotine dependence treatment medications increases barriers for an intervention incorporating them.

Nonetheless, pharmacists reported currently engaging in and prioritizing “tobacco cessation” in general and have the professional skills to execute tobacco-focused MTM. However, pharmacists also acknowledged that features and resources of the pharmacy and/or FQHC can impact the potential for MTM-based tobacco and nicotine dependence treatment efforts, with a specific focus on staffing of the pharmacy and the physical design of the pharmacy. The pharmacists mentioned how the specifics of these features could either negatively or positively impact the feasibility of tobacco-focused MTM. Finally, pharmacists mentioned additional barriers outside of the immediate pharmacy, including patient-level barriers and prioritization of patients’ acute health needs over “tobacco cessation”.

DISCUSSION

Overall, study findings suggest the inclusion of MTM as a strategy to facilitate tobacco and nicotine dependence treatment in pharmacies embedded in FQHCs is potentially feasible due to the perceived importance and relative compatibility of the Innovation. Findings identify addressable factors, particularly related to the Implementation Process, Inner Setting, Individuals, and Outer Setting domains, which could facilitate or hinder the implementation of tobacco-focused MTM in the pharmacy settings. These findings inform recommendations that would increase the potential feasibility of tobacco-focused MTM intervention into pharmacies, particularly those in FQHCs.

Regarding the intervention itself, findings across data sources are mixed about whether a tobacco-focused MTM intervention and its associated implementation processes are compatible with the functioning of FQHC-based pharmacies. Importantly, MTM is an innovation the pharmacists and FQHCs are familiar with due to its use in the treatment of other health conditions. Also, pharmacists report that using their EMR to identify and track tobacco users for an MTM program should be possible as it has been used this way previously for other MTM programs. Yet, evidence suggests this may be more of a desired aspect than a functional one.^34,35 Notably, pharmacists reported a limited role in initiating tobacco and nicotine dependence treatment and MTM for other conditions suggesting that there is limited use of the EMR for this process. Our findings reflect those found in the literature that suggest that pharmacists contributed to less than 12.5% of referrals into MTM programs.³⁶ Lastly, cumbersome insurance billing processes were noted, suggesting that the difficulty to bill insurance for the services could limit a pharmacy’s ability to engage in MTM for tobacco and nicotine dependence treatment. Thus, findings related to Innovation and Implementation suggest that a tobacco-focused MTM intervention can be compatible as it mirrors existing activities and processes, but considerations would need to be made to support patient identification and billing processes.

Findings related to the Inner Setting and Individual domains of CFIR are generally positive regarding the potential feasibility of a tobacco-focused MTM intervention in FQHC-based pharmacies. Due to the benefits for patients, pharmacists believe “tobacco cessation” is important and are generally open to engaging in tobacco and nicotine dependence treatment efforts. Furthermore, they believe their FQHC and its providers would support a tobacco-focused MTM intervention in the pharmacy. This pharmacist-level support mirrors past evidence that suggests that pharmacists are motivated to engage with programs that improve patient outcomes and access to services,³⁷ and have a willingness to expand their services and scope of work.^37,38 However, while qualitative findings identify that pharmacists have the skills to support tobacco and nicotine dependence treatment efforts in general and an MTM intervention specifically, quantitative findings identify that they only have moderate confidence to implement an MTM intervention. This lower level of confidence may be driven by their limited experience providing tobacco and nicotine dependence counseling, as, while the majority offer NRT, less than half work in pharmacies that offer related counseling. This is not surprising as FQHC services for tobacco and nicotine dependence treatment in general are limited.^35,39 Lastly, findings stress the importance of ensuring adequate staffing and protected time to feasibly implement a tobacco-focused MTM intervention in this setting. Staffing and time are well-established barriers to implementing evidence-based interventions in FQHCs and pharmacies.^{34,35,37,40,41} This may be driven by the fact that, while the role of a pharmacist can extend beyond dispensing medication, ³⁷ pharmacists continue to maximize medication dispensation in order to ensure consistent revenue for the pharmacy.^23,38,42 These findings highlight underlying motivation for a tobacco-focused MTM intervention and the existing and often untapped skills of pharmacists related to this intervention. However, to capitalize on these potential facilitators, a tobacco-focused MTM intervention would need to incorporate pharmacist training and financial support that would allow for additional staff to ensure time for MTM sessions.

Factors outside of the pharmacy may also positively or negatively influence the potential for tobacco-focused MTM in FQHC-based pharmacies. Chief among these Outer Setting influences is the evidence that patients who receive care at FQHCs have tobacco use rates substantially higher than the average US population.⁴³ This, coupled with evidence about the pharmacists’ recognition of the importance of tobacco and nicotine dependence treatment and willingness to offer, provides strong motivation to support the implementation of a tobacco-focused MTM intervention in this setting. However, external barriers include mixed perceptions of the influence of patient-level barriers to participation, such as patients’ interests and related to social determinants of health. Previous research has identified low motivation as a key barrier to quitting among tobacco users with low incomes,^35,41,44 as well as the cost of NRT, balancing NRT within the context of patients taking medications for other health conditions, transportation, time, and personal beliefs about tobacco and nicotine dependence treatment.^40,44–49 Thus, any MTM intervention would need to ensure patient engagement and continued motivation of the pharmacists by addressing patient barriers.

Together, the study findings identify five key considerations that could increase the feasibility of a tobacco-focused MTM intervention in FQHC-based pharmacies. First, the intervention should help pharmacists initiate the conversation about tobacco and nicotine dependence treatment between themselves and patients. For example, scripts could be provided for the pharmacist; robust promotional materials for the intervention could be used to encourage patients to talk to the pharmacists about tobacco and nicotine dependence treatment; and providers should also be engaged so patients hear about MTM from multiple professionals. Second, supports and guidance should be provided for FQHCs so they can tap into the capacity of their EMR to identify and follow patients. Third, MTM programs should consider the financial realities of pharmacies by facilitating reimbursement processes and considering the costs of staffing in the design of the program. Fourth, MTM programs should be flexible in the design of their implementation strategies to support faithful delivery, allow for appropriate staffing of pharmacies, and meet the needs of patients. This flexible design could include creating action plans that offer personalized intervention implementation, adjustable timelines for participant counseling sessions, and include phone and in-person options. Fifth, tobacco-focused MTM programs should consider incorporating components to support the motivation of pharmacists to implement the program and for patients to enroll. For pharmacists, a motivational component could include ongoing support to address barriers and celebration of successes. For patients, incorporation of social marketing campaigns related to tobacco and nicotine dependence treatment could be used prior to the roll out of the MTM intervention.

Study findings should be interpreted in the context of five limitations. First, all participants come from a specific region in the southeastern United States, which could limit generalizability. However, participants had a variety and length of experiences within the FQHC setting and with tobacco and nicotine dependence treatment. Second, the study only includes the perspectives of pharmacists working in FQHCs with attached pharmacies; this approach means that the perspectives of pharmacists embedded in FQHCs that do not have a pharmacy are missing. Third, feasibility domains were only assessed using self-report related to experience and perceptions. Fourth, the low response rate may suggest a sample positively biased towards the inclusion of tobacco and nicotine dependence treatment initiatives. Nonetheless, participants discussed both positive and negative facets that could impact tobacco and nicotine dependence treatment. Fifth, the sample size is relatively small. However, code saturation across interviews with a relatively homogenous sample (e.g., same profession) has been demonstrated to be reached with as few as nine interviews.^50,51

Conclusion

A tobacco-focused MTM intervention has the potential to be a feasible strategy to facilitate tobacco and nicotine dependence treatment among patients served by pharmacies embedded in FQHCs. Though generally compatible with the needs of FQHC-based pharmacies, findings highlight considerations to feasibility indicators of acceptability at the clinic and pharmacist levels, demand, implementation, practicality, and integration. These considerations are related to staffing, time, identifying patients, and supporting patient engagement in the intervention. Before testing the efficacy of a tobacco-focused MTM intervention, additional feasibility research should be conducted. Foci of this research include (1) conducting environmental scans of FQHC pharmacy settings and (2) assessing the potential efficacy of the intervention.

KEY POINTS.

What was already known:

• Medication therapy management (MTM) is widely used by pharmacists to support the treatment of chronic health conditions, including diabetes and hypertension.

• MTM provides a pathway to pair nicotine replacement therapy (NRT) with behavioral support, which has been shown to significantly increased success in quit attempts. Yet, the use of MTM as a means of tobacco and nicotine dependence treatment is underutilized.

• Federally Qualified Health Centers serve a population that uses tobacco products at a higher rate than other populations and that is less likely to be able to access evidence-based tobacco and nicotine dependence treatment interventions.

What this study adds

• Study findings suggest using MTM as a means of tobacco and nicotine dependence treatment in pharmacies embedded in FQHCs has the potential to be feasible, in large part due to the perceived importance of addressing the tobacco use of patients in this setting and relative compatibility of the intervention.

• Findings highlight factors related to the Consolidated Framework for Implementation Research’s domains of Implementation Process, Inner Setting, Individuals, and Outer Setting domains that may hinder the implementation of MTM to address tobacco and nicotine dependence treatment in this setting, as well as strategies to address them.