Implementation and outcomes of a comprehensive tobacco-free workplace program in agencies serving women with unmet social, economic, and behavioral health needs in Texas
Introduction
Despite cessation gains in recent decades, tobacco use remains a prominent cause of cancer incidence and mortality in the United States (U.S.). Unfortunately, tobacco use disproportionately affects certain subgroups in the U.S., calling for targeted efforts to address tobacco use among these groups. Women with unmet social, economic, and behavioral health needs experience myriad disadvantages that place them at heightened risk for tobacco use and which lead to lower rates successful quitting. Comprehensive tobacco-free workplace programs (TFWPs) are evidence-based interventions that reduce tobacco use through policy and provider behavior change. To effectively bring tobacco dependence care to women with diverse needs, TFWPs are needed within trusted healthcare and community settings. Accordingly, this work presents outcomes from the implementation of a TFWP called Taking Texas Tobacco Free (TTTF) within agencies serving women.
Methods
From 2017-2019, TTTF enrolled four women-serving agencies (six clinics; three substance use treatment centers [SUTCs], one non-profit organization providing education, housing, and counseling services) for program implementation (hybrid type II design), which lasted 16 months on average (range: 9-23). Together, the four agencies with 344 employees (209 client-facing service providers) serve 3,462 women annually through >24,500 contacts across five Texas counties. The women served had multiple and intersecting needs, including high rates of smoking (between agency range: 65-75%), unemployment (84-100%), unstable housing (50-100%), criminal justice involvement (33-74%), active child protective status (32-45%), intimate partner violence history (66-95%), behavioral health needs (27-100%), and persistent poverty (64-100%). TTTF implementation goals and outcomes are presented according to the RE-AIM: Reach, Effectiveness, Adoption, Implementation, and Maintenance framework.
Results
Reach: TTTF provided tobacco education to 185 employees (53.8%; >60% goal not met) and motivational interviewing training to 23 providers (11.0%; >60% goal not met), and sent 10 providers to tobacco treatment specialist training (>1 per agency goal met). Effectiveness: Tobacco education facilitated a significant (p<.0001) knowledge gain of 36.2% (>50% goal not met). Adoption: Each (100%) enrolled agency completed the TTTF implementation (100% goal met). By post-implementation, all SUTCs had an enforceable and comprehensive tobacco-free workplace policy, the non-profit did not (100% SUTCs goal met, goal was N/A for non-SUTC agencies). Implementation: By post-implementation, providers increased delivery of screening and intervention practices (goal >65% each partially met); 57.9-76.0% (all ps<.02) reported delivering each of the 5As (Ask, Advise, Assess, Assist, Arrange); 27.2% (p<.04) provided behavioral counseling; 54.3% provided nicotine replacement therapies (NRT; p<.03); and 3.7% provided non-nicotine medication or referral (n.s.). Maintenance: All (100%) agencies were compliant with screening/intervention (>80% goal met) during the six-month sustainment period post-TTTF implementation (249 tobacco use assessments delivered, 352 boxes of NRT distributed).
Conclusion
TTTF’s implementation within women-serving agencies affected both policy and provider behavior change consistent with best practices for tobacco control and intervention, despite that only some program goals were achieved. These results demonstrate that when provided with training and access to evidence-based tobacco interventions, trusted healthcare and community settings that serve women with unmet economic, social, and behavioral needs can both adopt and maintain delivery of these interventions to prevent tobacco-related cancers. Results suggest that TTTF is a feasible model for future implementation in similar settings and point to areas that can be improved in those efforts.