Do cigarette graphic warnings encourage smokers to attend a smoking cessation programme: a quasi-experimental study.

OBJECTIVE: This study assessed whether exposure to cigarette graphic warning labels (GWLs) increased attendance to a smoking cessation programme. METHOD: From 2014 to 2016, alternating cohorts of smokers in 3 residential drug treatment programmes received either GWLs (experimental) or transparent (control) labels placed on their cigarette packs for 30 days. The primary outcome was the proportion of participants who chose to attend a smoking cessation group after the labelling period. RESULTS: The sample (N=601) was 72.6% male, with a mean age of 41.9 (SD=11.16) and included African-American (37%), White (29.4%) and Hispanic (19.6%) participants. While similar on most measures, controls were more likely to be married, had been in the treatment programme longer and registered higher on expired carbon monoxide (CO). After labelling, the proportion attending at least one cessation group was 26% in the experimental condition and 18.8% among controls. In an intent-to-treat analysis adjusting for group differences at baseline, and for 2 levels of nesting, those who received GWLs were more likely than controls to attend the smoking cessation group (OR=1.58, 95% CI 1.02 to 2.44). CONCLUSIONS: Smokers who received GWLs on their cigarette packs were more likely to attend a cessation programme. Thus, this study is one of the first to document a change in a directly observed behavioural outcome as a function of month-long exposure to cigarette pack GWLs.

A Comparison of Daily Versus Weekly Electronic Cigarette Users in Treatment for Substance Abuse.

Objective: This research examined electronic cigarette (e-cigarette) use by individuals in treatment for substance abuse, a population with a high prevalence of tobacco use and poor smoking cessation outcomes. Methods: We surveyed 1127 individuals from 24 substance abuse treatment centers across the United States. Bivariate analyses and logistic regression were used to examine factors associated with daily (N = 87) versus weekly (N = 81) e-cigarette use. Results: Among the full sample, 59.8% reported any lifetime use of e-cigarettes, with 23.6% reporting past 30-day use. Daily e-cigarette users were more likely to have used second-generation, tank-type e-cigarettes, χ2(1,N = 165) = 11.54, p = .001, used more flavors overall, t(168) = 2.15, p = .03, and were more likely to report using their e-cigarette continuously throughout the day, χ2(4,N = 168) = 16.7, p = .002, compared to weekly e-cigarette users. Over half (57.7%) of the daily and weekly e-cigarette users reported having an e-cigarette device that broke. The logistic regression model adjusting for clinic type and days with poor mental health found that daily e-cigarette users were significantly more likely than weekly e-cigarette users to be from methadone clinics (adjusted odds ratio [AOR] = 2.40, p = .04), and former smokers (AOR = 6.37, p < .002). Conclusions: Daily e-cigarette users in substance abuse treatment were more likely to be from methadone clinics and former cigarette smokers. However, the majority (73.6%) of daily e-cigarette users were current cigarette smokers. E-cigarette device type reliability (eg, breakage) may be an important factor to consider among drug treatment and other populations with lower socioeconomic status. Implications: This study found several differences in the device type, flavors, and use characteristics of daily versus weekly e-cigarette users. While majority of e-cigarette users in substance abuse treatment were current cigarette smokers, daily e-cigarette users were more likely to be former cigarette smokers. Administrators of substance abuse treatment programs should evaluate potential benefits and harms of e-cigarettes when developing program policies.

Addiction Treatment Clients' Reactions to Graphic Warning Labels on Cigarette Packs.

Graphic warning labels (GWLs) on cigarette packs have been tested among diverse groups at high risk for tobacco use. However, little is known about the effectiveness of GWL interventions for persons with substance use disorders, whose smoking prevalence is 3 to 4 times that of the general population. After an experimental study which exposed clients in residential addiction treatment to GWLs for 30 days, we conducted five focus groups with trial participants (N = 33) to explore how exposure to the labels may have impacted their readiness to quit smoking. Focus group interviews were analyzed thematically. Interviewees reported that GWLs were more effective than text-based warnings for increasing quit intentions due to greater cognitive and emotional impact. Male and female interviewees expressed gender-specific reactions to the labels. Addiction treatment programs are a strategic site for GWL and other tobacco interventions due to the tobacco-vulnerable populations they serve.

Quitting smoking during substance use disorders treatment: Patient and treatment-related variables.

Although individuals in substance use disorders (SUD) treatment continue to smoke at high rates, regulatory, policy and programming changes promoting tobacco cessation are being implemented and some patients quit successfully. We examined associations of smoking patterns, tobacco advertising receptivity, anti-tobacco message awareness, health risk perception, attitudes towards addressing smoking and availability of smoking cessation services with quitting smoking during SUD treatment. Surveys were completed by 1127 patients in 24 programs chosen randomly, stratified by program type (residential, methadone maintenance, outpatient), from among publicly funded, adult treatment programs within the National Drug Abuse Treatment Clinical Trials Network. Among respondents who had been in SUD treatment for at least one month, there were 631 current smokers and 52 former smokers who reported quitting smoking during treatment for at least one month prior to survey completion; these respondents comprised our sample (N=683). Results showed that participants who reported health concerns as a reason for quitting were 1.27 times more likely to have quit during treatment (p=0.015) than those reporting health concerns affected quitting a little or not at all. Additionally, participants who reported that smoking cessation was part of their personal treatment plan during SUD treatment were 1.08 times more likely to have quit during treatment (p<0.001). Participants in methadone treatment were 49% less likely to report successfully quitting during treatment than those in outpatient treatment (95%CI: 0. 35-0.75, p<0.001). Leveraging health concerns about smoking and including smoking cessation in an individualized treatment plan may help increase smoking cessation during SUD treatment.

Use of multiple tobacco products in a national sample of persons enrolled in addiction treatment.

OBJECTIVE: To explore use of tobacco products in relationship to marketing exposure among persons in addiction treatment. METHOD: A random sample of treatment programs was drawn from the National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN). Participants in each program completed surveys concerning use of tobacco products (N=1113). Exposure to tobacco marketing and counter-marketing, advertising receptivity, and perceived health risks of smoking were tested for their association with use of multiple tobacco products. RESULTS: Prevalence of combustible cigarette use was 77.9%. Weekly or greater use of other products was: e-cigarettes (17.7%), little filtered cigars (8.6%), smokeless tobacco (5.2%), and standard cigars (4.6%) with 24.4% using multiple tobacco products. Compared to single product users, multiple product users smoked more cigarettes per day (OR=1.03, 95% CI 1.01-1.05, p<0.001), were more likely to have tried to quit (OR=1.41, 95% CI 1.02-1.96, p=0.041), reported greater daily exposure to advertising for products other than combustible cigarettes (OR=1.93, CI 1.35-2.75, p<0.001), and greater daily exposure to tobacco counter-marketing (OR=1.70, 95% CI: 1.09-2.63, p=0.019). CONCLUSION: Heavier smokers and those trying to quit may be more likely to use e-cigarettes, little filtered cigars, or smokeless tobacco and have greater susceptibility to their advertising. This highlights the importance of regulating advertising related to smoking cessation as their effectiveness for this purpose has not been demonstrated.

Barriers and Facilitators to Tobacco Cessation in a Nationwide Sample of Addiction Treatment Programs.

INTRODUCTION: Smoking rates among addiction treatment clients are 3-4 times higher than those of the general population. Recent studies indicate that ceasing tobacco use during treatment may improve recovery outcomes. Across the United States, publicly funded addiction treatment programs vary widely in terms of their tobacco policies and tobacco cessation services offered to clients. METHODS: The study reported here is the qualitative component of a larger study. Twenty-four programs were recruited from a random sample of publicly funded programs participating in the NIDA Clinical Trials Network. Semi-structured interviews were administered by phone to program directors. ATLAS.ti software was used to facilitate thematic analysis of interview transcripts. FINDINGS: While all directors expressed interest in helping clients to quit smoking, they cited numerous barriers to implementing tobacco policies and services. These included smoking culture, client resistance, lack of resources, staff smoking, and environmental barriers. Directors also cited several factors that they believed would support tobacco cessation. These included financial support, enhanced leadership, and state mandates against smoking in addiction treatment programs. CONCLUSION: Addiction treatment programs are beginning to place more emphasis on tobacco cessation during treatment. However, furthering this goal requires substantial infrastructural and cultural change. These qualitative study findings may help to inform Single State Agencies (SSAs) to support publicly funded addiction treatment programs in their tobacco cessation efforts. In order to maximize effectiveness, state-level policies regarding tobacco cessation during treatment should be informed by ongoing dialogue between service providers and SSAs.

A Pilot Study of a Readiness Group to Increase Initiation of Smoking Cessation Services among Women in Residential Addiction Treatment.

This study implemented a smoking cessation readiness group (RG) in two women-focused residential substance abuse treatment programs, with the aim of engaging women in smoking cessation services. The primary outcome was defined as attending at least one cessation group after the RG ended. The RG combined features of the Expert Systems (ES) approach with a practice quit attempt. ES is an interactive system which tailors intervention to the smokers' stage of change, while the practice quit attempt rehearses the process of quitting smoking. As a secondary aim we tested whether incentives, used to promote participation and engagement in the RG, would increase initiation of smoking cessation services. Participants (N=75) were women smokers enrolled in two residential programs, and intention to quit smoking was not required for participation. Twelve participant cohorts were randomly assigned to receive the RG with or without incentives. Following the RG intervention, 38.7% of participants (n=29) attended at least one smoking cessation session. Both the number of RG sessions attended and a successful practice quit attempt predicted the later use of cessation services, while incentives did not. From pre- to post-RG, participants reported decreased cigarettes per day (CPD: 11.8 vs. 7.6, p<.0001) and decreased nicotine dependence as measured by the Heaviness Smoking Index (HSI: 2.3 vs. 1.8, p<.001). The 3-session group-format RG intervention was associated with initiation of smoking cessation services and with changes in smoking behavior.

An international systematic review of smoking prevalence in addiction treatment.

AIMS: Smoking prevalence is higher among people enrolled in addiction treatment compared with the general population, and very high rates of smoking are associated with opiate drug use and receipt of opiate replacement therapy (ORT). We assessed whether these findings are observed internationally. METHODS: PubMed, PsycINFO and the Alcohol and Alcohol Problems Science Database were searched for papers reporting smoking prevalence among addiction treatment samples, published in English, from 1987 to 2013. Search terms included tobacco use, cessation and substance use disorders using and/or Boolean connectors. For 4549 papers identified, abstracts were reviewed by multiple raters; 239 abstracts met inclusion criteria and these full papers were reviewed for exclusion. Fifty-four studies, collectively comprising 37,364 participants, were included. For each paper we extracted country, author, year, sample size and gender, treatment modality, primary drug treated and smoking prevalence. RESULTS: The random-effect pooled estimate of smoking across people in addiction treatment was 84% [confidence interval (CI) = 79, 88%], while the pooled estimate of smoking prevalence across matched population samples was 31% (CI = 29, 33%). The difference in the pooled estimates was 52% (CI = 48%, 57%, P < .0001). Smoking rates were higher in programs treating opiate use compared with alcohol use [odds ratio (OR) = 2.52, CI = 2.00, 3.17], and higher in ORT compared to out-patient programs (OR = 1.42, CI = 1.19, 1.68). CONCLUSIONS: Smoking rates among people in addiction treatment are more than double those of people with similar demographic characteristics. Smoking rates are also higher in people being treated for opiate dependence compared with people being treated for alcohol use disorder.

Smoking Behaviors and Attitudes Among Clients and Staff at New York Addiction Treatment Programs Following a Smoking Ban: Findings After 5 Years.

INTRODUCTION: Addiction treatment clients are more likely to die of tobacco-related diseases than of alcohol or illicit drug-related causes. We aimed to assess smoking behavior, and smoking-related attitudes and services, in New York addiction treatment programs before a statewide smoking ban in treatment facilities was implemented (2008), 1 year (2009) and 5 years after implementation (2013). METHODS: We conducted surveys at each time point with clients (N = 329, 341, and 353, respectively) and staff (N = 202, 203, and 166, respectively) from five residential and two methadone maintenance programs in New York State. At each data collection wave, questionnaires measured smoking behavior as well as smoking-related knowledge, attitudes, and experiences with tobacco cessation services as part of addiction treatment. RESULTS: Staff smoking prevalence decreased from 35.2% in 2008 to 21.8% in 2013 (P = .005) while client smoking prevalence over the same period was unchanged (68.1% vs. 66.0%, P = .564). Among clients who smoked, mean cigarettes per day decreased from 13.7 (SD = 8.38) to 10.2 (SD = 4.44; P < .001). There were significant time-by-treatment-type interactions for client tobacco-related attitudes and cessation services received; and for staff self-efficacy and cessation services provided. In residential programs, scores for most items decreased (became less positive) in 2009 followed by a partial rebound in 2013. Methadone program scores tended to rise (become more positive) throughout the study period. CONCLUSIONS: Staff and clients may respond differentially to tobacco-free policies depending on type of treatment program, and this finding may help to inform the implementation of tobacco-free policies in other statewide addiction treatment systems.

Predictors of quit attempts among smokers enrolled in substance abuse treatment.

INTRODUCTION: This study investigates factors predicting past year quit attempts among smokers enrolled in substance abuse treatment in New York State. METHODS: Data were drawn from two prior cross-sectional surveys conducted among clients treated in 10 randomly selected substance abuse treatment programs. Among 820 clients recruited, 542 self-identified as current smokers, and 485 provided information about their quit attempts. The main outcome was reporting a quit smoking attempt in the past year, dichotomized as quit attempters or non-quit attempters. Univariate and multivariate logistic regression analyses were performed to explore predictors of attempting to quit. RESULTS: Half of substance abuse clients in treatment programs reported a past year quit attempt. Quit attempters were more likely to be in a preparation and contemplation stage of change (preparation: OR=2.68, 95% CI: 1.51-4.77; contemplation: OR=2.96 95% CI: 1.61-5.42), reported more positive attitudes toward quitting (OR=1.49; 95% CI: 1.11-1.99) and received more cessation services than non-quit attempters (OR=1.21; 95% CI: 1.11-1.99). CONCLUSIONS: Addressing patient attitudes about quitting smoking, having clinicians address smoking in the course of addiction treatment, and offering interventions to increase readiness to quit may contribute to increased quit attempts in smokers enrolled in addiction treatment programs.

The New York policy on smoking in addiction treatment: findings after 1 year.

OBJECTIVES: We assessed changes in smoking prevalence and other measures associated with the July 2008 New York Office of Alcoholism and Substance Abuse Services tobacco policy, which required that all publicly funded addiction treatment programs implement smoke-free grounds, have "no evidence" of smoking among staff, and make tobacco dependence treatment available for all clients. METHODS: In a random sample of 10 programs, staff and clients were surveyed before the policy and 1 year later. Measures included tobacco-related knowledge, attitudes, and practices used by counselors and received by clients. RESULTS: Client smoking decreased from 69.4% to 62.8% (P = .044). However, response to the policy differed by program type. Outpatient programs showed no significant changes on any of the staff and client survey measures. In methadone programs, staff use of tobacco-related practices increased (P < .01), client attitudes toward tobacco treatment grew more positive (P < .05), and clients received more tobacco-related services (P < .05). Residential clients were more likely to report having quit smoking after policy implementation (odds ratio = 4.7; 95% confidence interval = 1.53, 14.19), but they reported less favorable attitudes toward tobacco treatment (P < .001) and received fewer tobacco-related services from their program (P < .001) or their counselor (P < .001). CONCLUSIONS: If supported by additional research, the New York policy may offer a model that addiction treatment systems can use to address smoking in a population where it has been prevalent and intractable. Additional intervention or policy supports may be needed in residential programs, which face greater challenges to implementing tobacco-free grounds.

Addressing Tobacco Through Organizational Change (ATTOC) in residential addiction treatment settings.

BACKGROUND: Smoking prevalence among persons in addiction treatment is 3-4 times higher than in the general population. However, treatment programs often report organizational barriers to providing tobacco-related services. This study assessed the effectiveness of a six month organizational change intervention, Addressing Tobacco Through Organizational Change (ATTOC), to improve how programs address tobacco dependence. METHODS: The ATTOC intervention, implemented in three residential treatment programs, included consultation, staff training, policy development, leadership support and access to nicotine replacement therapy (NRT) medication. Program staff and clients were surveyed at pre- and post-intervention, and at 6 month follow-up. The staff survey measured knowledge of the hazards of smoking, attitudes about and barriers to treating smoking, counselor self-efficacy in providing such services, and practices used to address tobacco. The client survey measured knowledge, attitudes, and tobacco-related services received. NRT use was tracked. RESULTS: From pre- to post-intervention, staff beliefs became more favorable toward treating tobacco dependence (F(1, 163)=7.15, p=0.008), NRT use increased, and tobacco-related practices increased in a non-significant trend (F(1, 123)=3.66, p=0.058). Client attitudes toward treating tobacco dependence became more favorable (F(1, 235)=10.58, p=0.0013) and clients received more tobacco-related services from their program (F(1, 235)=92.86, p<0.0001) and from their counselors (F(1, 235)=61.59, p<0.0001). Most changes remained at follow-up. CONCLUSIONS: The ATTOC intervention can help shift the treatment system culture and increase tobacco services in addiction treatment programs.

Smoking prevalence in addiction treatment: a review.

INTRODUCTION: This review explores whether smoking prevalence in addiction treatment samples exceeds that shown in epidemiological data for persons with alcohol or other drug use disorders and whether smoking may have decreased over time in the addiction treatment population as it has done in the general population. METHODS: English language papers published between 1987 and 2009 were searched electronically. Forty papers reporting smoking prevalence for addiction treatment samples in the United States were identified, and key predictor variables were abstracted. Random logistic models were used to assess relationships between each individual predictor (year, treatment modality, primary drug treated, government status, and public/private funding status) and smoking prevalence. RESULTS: The lowest smoking prevalence aggregated for studies reported in any single year was 65%, well above epidemiological estimates reported among those with alcohol use and drug use disorders. The odds of smoking were higher in methadone maintenance programs (odds ratio [OR] = 2.25, CI = 1.08, 4.68) as compared with outpatient programs. No other variables in the model were significant. Reanalysis omitting recent studies that may represent outliers or confounding with type of treatment showed a small but significant decrease in smoking over time (OR = 0.9891, CI = 0.9888, 0.9893). CONCLUSIONS: The very high smoking rates reported in addiction treatment samples warrant significant, organized, and systemic response from addiction treatment systems, from agencies that fund and regulate those systems, and from agencies concerned with tobacco control.

Measuring smoking knowledge, attitudes and services (S-KAS) among clients in addiction treatment.

BACKGROUND: Addiction treatment programs are increasingly working to address prevalent and comorbid tobacco dependence in their service populations. However at present there are few published measurement tools, with known psychometric properties, that can be used to assess client-level constructs related to tobacco dependence in addiction treatment settings. Following on previous work that developed a staff-level survey instrument, this report describes the development and measurement characteristics of the smoking knowledge, attitudes and services (S-KAS) for use with clients in addiction treatment settings. METHOD: 250 clients enrolled in residential drug abuse treatment programs were surveyed. Summary statistics were used to characterize both the participants and their responses, and exploratory factor analysis (EFA) was used to examine the underlying factor structure. RESULTS: Examination of the rotated factor pattern indicated that the latent structure was formed by one knowledge factor, one attitude factor, and two "service" factors reflecting program services and clinician services related to tobacco dependence. Standardized Cronbach's alpha coefficients for the four scales were, respectively, .57, .75, .82 and .82. CONCLUSIONS: The proposed scales have reasonably good psychometric characteristics, although the knowledge scale leaves room for improvement, and will allow researchers to quantify client knowledge, attitudes and services regarding tobacco dependence treatment. Researchers, program administrators, and clinicians may find the S-KAS useful in changing organizational culture and clinical practices related to tobacco addiction, help in program evaluation studies, and in tracking and improving client motivation.

Adoption of motivational interviewing and motivational enhancement therapy following clinical trials.

The National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) is designed to test drug abuse treatment interventions in multisite clinical trials and to support the translation of effective interventions into practice. In this study, qualitative methods were applied to examine adoption of motivational interviewing and motivational enhancement therapy (MI/MET) in five clinics where these interventions were tested. Participants were clinic staff (n=17) who were interviewed about the MI/MET study, and about whether MI/MET was adopted after the study ended. Although clinics' participation in a clinical trial includes many elements thought to be necessary for later adoption of the intervention, we found that there was "adoption" in one clinic, "partial adoption" in one clinic, "counselor adoption" in one clinic, and "no adoption" in two clinics. These findings highlight a distinction between adoption at the organizational and counselor levels, and suggest that a range of adoption outcomes may be observed in the field. Findings are relevant to clinical staff, program directors, administrators and policy makers concerned with improvement of drug abuse treatment systems through adoption of evidence-based practices.

Staff Knowledge, Attitudes, and Practices Regarding Nicotine Dependence Differ by Setting.

This study examined smoking-related knowledge, beliefs, self-efficacy, smoking cessation practices, and barriers to providing smoking cessation services in a workforce sample. The 11 participating clinics (N=335 staff) included substance abuse treatment and HIV care clinics categorized into three types: Veterans Affairs Medical Center (VAMC) clinics, hospital-based clinics, and community-based clinics. Staff in both VAMC and hospital-based settings shared characteristics that may predict smoking-related knowledge, beliefs, and practices (higher education level, low smoking rates, fewer staff in recovery, and location in hospital-affiliated environments where there was greater emphasis on physical health). However, staff in VAMC settings outperformed those in both hospital-based and community-based clinic settings on measures of smoking-related knowledge, beliefs, self-efficacy, and practices. Well-developed procedures to support VAMC clinicians in addressing smoking may account for these findings. Findings suggest that both reductions in staff smoking, and development and implementation of smoking policy are needed to support staff in better addressing nicotine dependence in community-based treatment settings.

Development of the Smoking Knowledge, Attitudes, and Practices (S-KAP) Instrument.

This report describes the development and measurement characteristics of a new measure of smoking knowledge, attitudes, and practices (S-KAP) among treatment providers. Data are based on survey responses from 336 paid staff working in one of three drug abuse treatment or HIV care settings. Exploratory factor analysis, used to examine the factor structure, pointed towards five underlying factors: a single "knowledge" factor, three "attitude" factors ('treatment barriers,' 'counselor self-factor. The Knowledge scale had a standardized Cronbach's alpha coefficient of .85. The coefficients for Barriers, Self-Efficacy, and Attitudes were .81, .72, and .74, respectively. The Practice scale had a standardized Cronbach's alpha coefficient of .91. These results indicate that the proposed scales have reasonably good psychometric characteristics and will allow researchers to quantify staff knowledge, attitudes, and practices regarding smoking cessation treatments and issues.

Adoption of evidence-based practices among substance abuse treatment providers.

This research was conducted at a Substance Abuse Forum designed to address local community needs by focusing on Evidence-Based Practices (EBPs) in addiction treatment. The purpose of the study was to assess substance abuse treatment professionals' readiness to adopt EBPs, experience with EBPs, and attitudes toward EBPs, as well as agency support for EBPs. A total of 119 addiction treatment providers completed pre-test measures, and 82% completed a post-test. Eighty-three percent of participants reported using some EBPs in the past year, and 75% reported currently using EBPs. Participants who were currently licensed or certified in addictions had less negative attitudes toward EBPs than those without credentials. While respondents reported agency support for EBPs, most expressed interest in further training. This study underscores the movement toward EBPs in addiction treatment and the need for effective dissemination and training in this area.

The Place of Adoption in the NIDA Clinical Trials Network.

The National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) was established in 1999 to determine effectiveness of drug abuse treatment interventions among diverse client populations and settings. To address dissemination of research findings, the CTN also has as its mission the transfer of research findings to treatment providers. In a qualitative study of adoption of evidence based practice in the context of two CTN clinical trials, we interviewed 29 participants from seven organizational levels of the multisite study organization about post-trial adoption, their role in the clinical trial, and interactions between the research initiative and clinic staff and setting. Analysis of interview data revealed a range of opinion among participants on the place of adoption within the CTN. Innovation within the CTN to support adoption and further observational research on dynamics of adoption within the CTN can increase dissemination of evidence-based drug abuse treatment interventions in the future.

Strategies to encourage adoption in multisite clinical trials.

The goals of the National Institute on Drug Abuse Clinical Trials Network (CTN) are to test promising drug abuse treatment models in multisite clinical trials and to support the adoption of new interventions into clinical practice. Using qualitative research methods, we studied adoption in the context of two multisite trials, one outside the CTN and another within the CTN. Seventy-one participants representing eight organizational roles ranging from clinic staff to clinical trial leaders were interviewed about their role in the clinical trial, the trial's interactions with clinics, and intervention adoption. Drawing on the conceptual themes identified in these interviews, we report on strategies that could be applied in the planning, development, and implementation of multisite studies to better support the adoption of tested interventions in study clinics after trials had ended. Planning for adoption in the early stages of protocol development will enhance the integration of new interventions into practice.