Multi-level barriers and facilitators to implementing tobacco screening and cessation counseling in a Federally Qualified Health Center

Salgin et al. BMC Health Services Research (2025) 25:1457 https://doi.org/10.1186/s12913-025-13617-5 BMC Health Services Research Open Access RESEARCH Multi-level barriers and facilitators to implementing tobacco screening and cessation counseling in a Federally Qualified Health Center Linda Salgin1,2,3* , Jennifer K. Felner3, Amanda Velasquez3, Borsika A. Rabin1,4, David Strong1, Marva Seifert5 and Jerel P. Calzo3 Abstract Background Despite persistent tobacco control efforts, the prevalence of smoking, especially among low-income populations, remains high. The prevalence of tobacco use among the primarily low-income populations served by Federally Qualified Health Centers (FQHCs), is approximately 5 percentage points higher than the national average. Evidence based interventions such as clinician delivered tobacco cessation counseling are brief and effective, however, providers are often faced with various barriers that impede their ability to offer tobacco related counseling consistently. The purpose of this study was to understand multilevel and multi-perspective barriers and facilitators to implementing tobacco screening and cessation counseling at a large, multi-site FQHC. Methods This study used a descriptive qualitative design. Semi-structured interviews were conducted among a diverse group of FQHC staff including providers, clinical staff (e.g., nurse, medical assistant), clinic site managers, and administrators. Interviews were guided by the Practical, Robust Implementation and Sustainability Model (PRISM), lasting an average of 35 min. Data analysis included descriptive statistics to summarize participant characteristics and applied thematic analysis to identify themes related to barriers and facilitators in implementing tobacco screening and cessation counseling. Results Sixteen FQHC staff participated in the study. Participants were between the ages of 31–69 years old (M = 47.6, SD = 11.2) and had 4–45 years of medical experience (Median = 17.25). Participants represented various roles within the FQHC with 8 Providers, 5 Administrators, and 1 Registered Nurse, Care Coordinator, and Medical Assistant each. Key themes were identified across PRISM contextual domains, including provider knowledge gaps and time constraints, patients’ motivation to quit and hesitation to disclose tobacco use, as well as external referral challenges. Prioritizing tobacco cessation alongside other important health conditions, coupled with rapport building and involving dedicated support staff in tobacco cessation efforts, were perceived to be key strategies to increase consistent delivery of tobacco cessation services. *Correspondence: Linda Salgin Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Salgin et al. BMC Health Services Research (2025) 25:1457 Page 2 of 14 Conclusion This study sheds light on the multifaceted barriers and facilitators to implementing tobacco cessation services within a large multi-site FQHC. By addressing these key determinants, FQHCs can further enhance ongoing efforts to reduce tobacco use among low-income communities and improve patients’ overall health. Title registration Not applicable. Keywords Tobacco use cessation, Smoking cessations, Low-Income population, Implementation science, Community health center, Qualitative research Introduction In the United States (US), 15–20% of all-cause deaths can be attributed to tobacco product use [1]. Despite persistent tobacco control efforts, the prevalence of smoking, especially among low-income populations, remains high [2, 3]. Research has highlighted that populations with an income of $30,000 or less annually have 19.7–24.7% prevalence of any tobacco use, nearly double the rate of the general adult population [2, 3]. Individuals experiencing poverty are also more likely to have chronic diseases such as cardiovascular disease, obesity, hypertension, and lung cancer [4, 5] which are exacerbated by tobacco product use. Thus, these communities experience a disproportionate burden of tobacco related morbidity and mortality relative to those with higher incomes [6]. Federally Qualified Health Centers (FQHCs) are nonprofit community health centers funded by the Health Resources and Services Administration that are typically located in medically underserved communities that offer primary care and preventative health services to all patients, regardless of their ability to pay [7, 8]. There are nearly 1,500 FQHCs across the US operating over 15,000 service delivery sites and, in 2023, FQHCs served more than 32.5 million US Americans, 90% of whom were lowincome [9]. Notably, a study by Flocke et al. found that the prevalence of tobacco use among FQHC patients was 29.3%, approximately 5 percentage points higher than the national average [10]. Other studies among FQHC patients have found similar results with smoking prevalence rates between 26–30% [11, 12], underscoring the potential high impact FQHCs can have on underrepresented populations when promoting tobacco cessation [13]. A range of evidence-based smoking cessation strategies are available, that have been proven to be effective among diverse populations, especially those disproportionately impacted by tobacco product use, such as individuals with low incomes [14]. One of the most cost-effective methods to increase the likelihood of quitting tobacco product use includes clinician delivered tobacco cessation counseling (TCC) such as the 5 A’s (Ask, Advise, Assess, Assist, Arrange) or 3 A’s (Ask, Advise, Act/Refer) [15, 16]. TCC is a multi-step process that often first starts with screening for tobacco use. If a patient is a tobacco user, clinicians can make a strong and personalized recommendation to quitting tobacco use and refer patients to behavioral counseling and/or pharmacotherapy [14, 17]. Studies have consistently shown that patients who receive TCC are more likely to quit smoking [18–20]. With at least 70% of tobacco users seeing a provider annually [14], the literature has highlighted the importance of screening for and discussing tobacco use at every clinical (...truncated)