Introduction

Tobacco use remains the leading preventable cause of death in the U.S.; however, the devastating effects of tobacco do not equally impact all population groups. The proportion of people who use tobacco is dramatically elevated among people with substance use disorders (SUDs), who are also disproportionately affected by tobacco-related diseases. Despite this well-documented health disparity, many substance use treatment centers (SUTCs) fail to maintain comprehensive tobacco-free workplace (TFW) policies and provide evidence-based tobacco cessation treatment. Here we describe the implementation of a comprehensive TFW program at an SUTC in Texas that serves socioeconomically disadvantaged and medically underserved populations. This program, which is a part of the Taking Texas Tobacco Free (TTTF) project, includes a comprehensive TFW policy implementation, education and specialized training for staff, and provision of resources, including free nicotine replacement therapy (NRT), signage, and dissemination materials. The goal of the current work was to identify barriers and facilitators to successful integration of tobacco control and cessation services into an SUTC.

Methods

This study is based on an ethnographic approach and uses a case study design. Data were collected via interviews with staff (n=6) and clients at the SUTC (n=16) and site visits (n=8) between October 2021-August 2022. Audio-recordings of interviews were transcribed verbatim by a professional transcription service and analyzed using thematic analysis. To facilitate the analysis, the identified themes were applied to the concepts and categories of the extended Normalization Process Theory (eNPT) designed to inform the implementation of innovations in healthcare practice. 

Results

The main findings are summarized below following the eNPT categories:

Potential: Most staff shared a clear understanding of the purpose of the intervention and its potential benefits, evaluated the program as important, and reported commitment to support and motivate clients to quit tobacco use.

Capacity: Widespread tobacco use among clients and within their immediate environment presented a significant challenge, contributing to increased difficulties in quitting tobacco for clients and to attitudes among staff that tobacco cessation remained a low-priority problem due to a perceived lack of interest and inability to quit among their clients. Provision of tobacco trainings to staff and access to material resources, including free NRT products, contributed to changing these attitudes and increasing capacity to implement the program.

Capability: Implementation was facilitated by support provided by the TTTF program and the introduction of the local SUTC champion who served as the main point of contact for all aspects of the implementation process. New elements of the program were integrated into the existing routine workflow and were reported not to be disruptive or time consuming.

Contribution: Implementation of a comprehensive TFW program led to a gradual change of attitudes towards the importance of tobacco cessation and resulted in a better understanding of the needs of their clients and improved ability and readiness of SUTC staff to provide evidence-based tobacco cessation treatment. 

Conclusion

SUTCs can integrate tobacco cessation practices in their daily operations, despite facing multiple challenges due to complex behavioral health and socioeconomic needs of their clients. SUTCs need extensive support, including but not limited to material resources, informational support, assistance in preparing and maintaining local policies and regulations, and training provision to staff. With proper support, SUTCs can provide much need tobacco cessation care to their clients who are disproportionately affected by tobacco-related health conditions and systemic health inequities.