Implementing a tobacco-free workplace program at a substance use treatment center: a case study.

BACKGROUND: People with substance use disorders smoke cigarettes at much higher rates than the general population in the United States and are disproportionately affected by tobacco-related diseases. Many substance use treatment centers do not provide evidence-based tobacco cessation treatment or maintain comprehensive tobacco-free workplace policies. The goal of the current work is to identify barriers and facilitators to a successful and sustainable implementation of a tobacco-free workplace program, which includes a comprehensive tobacco-free policy and evidence-based cessation treatment services, in a substance use treatment center. METHODS: This study is based on an ethnographic approach and uses a qualitative case study design. Data were collected via interviews with staff (n = 6) and clients (n = 16) at the substance use treatment center and site visits (n = 8). Data were analyzed using thematic analysis guided by the extended Normalization Process Theory designed to inform the implementation of innovations in healthcare practice. RESULTS: Staff at the substance use treatment center supported the implementation of the program and shared a good understanding of the purpose of the intervention and its potential benefits. However, the study identified significant challenges faced by the center during implementation, including widespread tobacco use among clients, contributing to attitudes among staff that tobacco cessation was a low-priority problem due to a perceived lack of interest in quitting and inability to quit among their clients. We identified several factors that contributed to changing this attitude, including provision of tobacco training to staff, active leadership support, low number of staff members who smoked, and access to material resources, including nicotine replacement products. The implementation and active enforcement of a comprehensive tobacco-free workplace program contributed to a gradual change in attitudes and improved the provision of evidence-based tobacco cessation care at the substance use treatment center. CONCLUSIONS: Substance use treatment centers can integrate tobacco cessation practices in their daily operations, despite multiple challenges they face due to the complex behavioral health and socioeconomic needs of their clients. With proper support, substance use treatment centers can provide much needed tobacco cessation care to their clients who are disproportionately affected by tobacco-related health conditions and systemic health inequities.

Smoking Intervention Practices in Texas Healthcare Centers with Sexual and Gender Minority Patients.

Objectives: This study evaluated the use of evidence-based practices (EBPs) for smoking cessation in centers providing behavioral healthcare for patient populations that included some proportion of sexual and gender minorities (SGMs). Methods: Healthcare providers from 75 healthcare centers across Texas serving SGMs with behavioral health needs participated in a survey assessing their center's tobacco control policies and practices. Results: Nearly half (N = 36) of participating centers had a comprehensive tobacco-free workplace policy, 30.67% employed ≥1 tobacco treatment specialist, 73.91% employed ≥1 prescriber, 80.82% mandated screening for patient tobacco use at intake, and 57.53% provided a template for tobacco use assessments. Overall, 70.67% of providers asked patients about smoking status, 69.33% advised patients to quit, 64.00% assessed patients' interest in quitting, 58.67% assisted patients with quit attempts, and 36.00% arranged follow-up. Providers' ability to tailor interventions for special populations like SGMs ranged from very low/0 to very high/10 (M = 4.63 ± 2.59). Conclusions: There are opportunities to improve policy implementation, standardization and usage of evidence-based interventions, and intervention tailoring within settings providing care to SGM patients in Texas to better address their tobacco use inequities.

Empowered Choices: African-American Women's Breast Reconstruction Decisions.

Objectives: Breast reconstruction (BR) potentially can improve quality of life in postmastectomy breast cancer survivors (BCS); however, African-American women are less likely to undergo BR than Caucasian women. This qualitative study was undertaken to explore individual, sociocultural, and contextual factors influencing African-American women's BR decision-making processes and preferences. Methods: Postmastectomy African-American BCS with and without BR participated in semi-structured interviews. We adopted a grounded theory approach using the constant comparison method to understand the contexts and processes informing participants' BR decision-making. Results: Twenty-three women participated, of whom 17 elected BR and 6 did not. Whereas women's primary reasons for deciding for or against BR differed, our core category, "empowered choices ," describes both groups' decision-making as a process focused on empowering themselves physically and/or psychologically, through self-advocacy, informed and shared decision-making, and giving back/receiving communal and spiritual support from church and African-American survivor groups. Socioeconomic factors influenced women's access to BR. Women preferred autologous BR and expressed the need for greater culturally-matched resources and support to inform treatment and shared BR decision-making. Conclusions: Understanding and supporting African-American women's BR preferences and empowerment is essential to ensuring equal access, and culturally-relevant, high-quality, and informed patient-centered care.

Perceptions and Barriers to Physical Activity in Childhood and Adulthood Among Latinas.

OBJECTIVE: The purpose of this qualitative study was to identify perceptions and barriers to physical activity in childhood and adulthood among Latina adults. METHODS: Three focus groups, 2 dyadic interviews, and an individual interview were conducted using semi-structured interview guides with 23 Latina women aged 21-35. A thematic analysis approach employing inductive and deductive coding was utilized to code, categorize, and summarize data into themes. RESULTS: The themes that emerged focused on: (1) physical activity is enjoyable; (2) family influenced physical activity; (3) different lifestyle in the US influenced physical activity; (4) physical activity is important for health; and (5) responsibilities (eg, work, caregiving) as barriers to physical activity in adulthood. CONCLUSIONS: Perceptions and barriers to physical activity experienced in both childhood and adulthood should be considered in the promotion of physical activity among Latinas.

Adapting and Evaluating Implementation of a Tobacco-Free Workplace Program in Behavioral Health Centers.

Objectives: State-administered community behavioral health centers (CBHCs) rarely treat tobacco dependence, despite high client tobacco use. Using a mixed-methods approach we examine the adaptation and implementation of an evidence-based tobacco-free workplace (TFW) program in 2 CBHCs (17 individual clinics). Methods: Varied data collection included pre- and post-implementation leader, clinician, and staff surveys; pre-, mid-, and post-implementation staff and client focus groups; and monthly implementation logs. The RE-AIM framework guided translation of behavioral interventions into sustainable practice. Results: Pre- to post-implementation increases were seen in training receipt among clinicians and employees. Both CBHCs adopted a 100% TFW policy, integrated tobacco screenings into routine practice, and delivered evidence-based practices (EBPs). Qualitative methods enlisted key stakeholders contributing towards adapting program strategies to local contexts, addressing barriers, adjusting tobacco screening administration, and understanding reasons for success or failure to implement specific components. Conclusions: Program implementation at both CBHCs increased organizational capacity in the provision of EBPs to treat tobacco dependence through successfully meeting the majority of our RE-AIM targets. Findings contribute to the development of flexible strategies and interventions responsive to variable implementation contexts and barriers; enhancing the effectiveness and sustainability of a TFW program.

Tobacco-free Workplace Program at a Substance Use Treatment Center.

Objectives: About 65%-87% of substance use disorder patients smoke cigarettes, compared to 14% of the general adult population. Few substance use treatment centers (SUTCs) have comprehensive tobacco-free workplace (TFW) policies or offer tobacco interventions. Taking Texas Tobacco Free (TTTF) implements an evidence-based TFW program in SUTCs, including at the Billy T. Cattan Recovery Outreach Center (BTC). We present a mixed methods case study of BTC's TTTF implementation, success factors, and challenges. Methods: TTTF provided policy development assistance, training, treatment resources, and technical assistance over ∼9 months. Implementation was tailored using mixed methods. Quantitative data included surveys to stakeholders (Nmax = 7), a pre- and post-training questionnaire assessing knowledge gain, and reported quantities of tobacco use assessments (TUAs) administered and nicotine replacement therapy (NRT) provided. Qualitative data included stakeholder focus groups and interviews (18 participants). Results: All employees reported TFW policy compliance. Employees exhibited a 20% knowledge gain. Clinicians increased self-report of NRT provision and tobacco cessation counseling. During implementation, BTC administered TUAs to 171 patients and dispensed NRT to 70 of 110 tobacco-using patients. Conclusion: Qualitative findings contextualized quantitative outcomes. TTTF implementation changed clinician attitudes, knowledge, and practices regarding tobacco treatment, facilitating patient quit attempts.

Clinician Training in the Adaptation of a Comprehensive Tobacco-Free Workplace Program in Agencies Serving the Homeless and Vulnerably Housed.

Tobacco use is exceedingly high among those who are homeless or at risk of homelessness but not commonly addressed by clinicians. Taking Texas Tobacco Free (TTTF) is a tobacco control program that addresses known clinician barriers to intervention (e.g., low training receipt, limited resources). Here, we examine the process and outcomes of TTTF's adaptation within four agencies that provide housing or other services to individuals who are homeless or vulnerably housed. Pre- and post-implementation data were collected from clinicians (N = 68) to assess changes in training receipt, knowledge, and intervention behaviors, relative to program goals. Results indicated significant gains in clinicians' receipt of training in 9 (of 9) target areas (p's ≤ 0.0042) and a 53% knowledge gain (p < 0.0001). From pre- to post-implementation, there were mean increases in the use of the 5As (ask, advise, assess, assist, and arrange) and other evidence-based interventions for tobacco cessation, with significant gains seen in assisting residents/clients to quit, arranging follow-ups, and providing or referring for non-nicotine medications (p's ≤ 0.0491). All program goals, except gains related to advising smokers to quit and the use of specific interventions (behavioral counseling), were met. Overall, TTTF improved clinicians' capacity to address tobacco use among homeless and vulnerably housed individuals and can serve as a model for tobacco control efforts in similar agencies.

Tobacco-related knowledge following a comprehensive tobacco-free workplace program within behavioral health facilities: Identifying organizational moderators.

OBJECTIVE: Although smoking prevalence rates among behavioral health consumers is nearly five times that of the general population, evidence-based policies and practices to address tobacco use are uncommon within behavioral health settings. This study assessed changes in non-clinical, general staff and clinician tobacco-related knowledge following brief education provided as part of a comprehensive tobacco-free workplace program implementation and explored organizational moderators of pre- to post-education knowledge change. METHODS: Fifteen behavioral health facilities, comprising hundreds of individual clinics in Texas, participated in a one (for general staff) or two (for clinicians) hour educational session. RESULTS: There were large effect sizes in general staff knowledge gain within each consortium, and large effect sizes in clinician knowledge gain in all but one consortium. Knowledge of the requirements for change, perceived availability of resources, and total number of client contacts moderated general staff knowledge gain. Value in the change and total number of client contacts moderated training effectiveness among clinicians. CONCLUSIONS: We conclude that a brief tobacco-related education for behavioral health employees was effective in increase attendee knowledge. PRACTICE IMPLICATIONS: Attention to organization-level factors moderating knowledge gain has the potential to guide and improve program implementation.

Advancing Health Behavior Research and Scholarship through Mentorship of First Generation, Underrepresented Undergraduate Students.

This article provides perspectives about mentorship of undergraduate mentees from directors of formal, externally-funded training programs within the context of the one of the most ethnically diverse national universities. The authors reflect about their mentorship of first generation and underrepresented undergraduate students and offer recommendations for others training similar students.