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Policy Innovation Profile

State-Mandated Tobacco Ban, Integration of Cessation Services, and Other Policies Reduce Smoking Among Patients and Staff at Substance Abuse Treatment Centers


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Snapshot

Summary

The New York State Office of Alcoholism and Substance Abuse Services requires the 1,300 addiction treatment centers that it regulates to take the following steps to reduce tobacco use among patients, staff, and volunteers: institute and enforce a ban on the use or presence of tobacco products and paraphernalia, train staff and volunteers how to integrate smoking cessation into the treatment of other addictions, and include tobacco addiction in the treatment plans of patients who smoke. The office gave facilities 1 year to comply with these requirements and supported them in doing so in a variety of ways. The policies have generated high levels of compliance among State facilities, enhanced access to smoking-cessation education and treatment for patients who previously had little or no ability to receive such services, encouraged many patients and staff to quit smoking, and generated smoking-related cost savings at the treatment centers.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on compliance rates among regulated treatment facilities, patient access to cessation education and services, and the number and/or proportion of patients able to quit smoking, along with anecdotal reports from treatment facilities about staff who have quit smoking and cost savings generated as a result of the policies.
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Developing Organizations

New York State Office of Alcoholism and Substance Abuse Services
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Use By Other Organizations

Staff within the Office of Alcoholism and Substance Abuse Services have consulted with several other states about implementing similar tobacco-free initiatives.

Date First Implemented

2008
The regulation was enacted in 2008; enforcement began in 2009.

Problem Addressed

Tobacco use remains common, particularly among those with substance abuse disorders. It is the leading cause of preventable death in the country, and it contributes to increased risk of disease and disability and to higher health care costs. When smoking is combined with substance abuse, risks of illness, disability, and death rise even higher. Many coaddicted individuals express interest in quitting smoking, but they often need help to do so, and very few treatment facilities attempt to address smoking addiction at the same time as other addictions.
  • High rates of smoking, especially among substance abusers: Although smoking in the general population has declined in recent decades, just under 1 in 5 individuals (19 percent) still smokes in the United States.1 Rates among substance abusers are two to four times higher.2
  • Risk of significant health consequences rises when combined with substance abuse: Smoking causes cancer, heart disease, stroke, and lung diseases. Tobacco use is responsible for one in five deaths annually in the general population.1 Combining tobacco use with other addictions such as alcohol or drug abuse substantially increases the risk of disease and death even further. For example, the odds of developing esophageal cancer are twice as high among heavy drinkers than nondrinkers who don't smoke. However, those who smoke and drink are seven times as likely to develop this type of cancer.2
  • Many desire to quit, but receive little support for doing so: As many as three-fourths of patients in addiction treatment programs express an interest in quitting smoking. To succeed, they often need additional support, such as nicotine-replacement therapy and other therapeutic methods. Although many addiction treatment facilities now recognize the interconnectedness of addictions, most have not integrated tobacco addiction treatment into their programs. Reasons for this include a lack of staff training, concerns that stopping smoking may jeopardize recovery from other addictions, and the mistaken belief that patients do not want to quit.2

What They Did

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Description of the Innovative Activity

The New York State Office of Alcoholism and Substance Abuse Services requires the 1,300 addiction treatment centers that it regulates to take the following steps to reduce tobacco use among patients, staff, and volunteers: institute and enforce a ban on the use or presence of tobacco products and paraphernalia, train staff and volunteers how to integrate smoking cessation into the treatment of other addictions, and include smoking addiction in the treatment plans of all patients who smoke. The office gave facilities 1 year to comply with these requirements, and supported them in doing so in a variety of ways. Key elements of the policies and associated implementation support are outlined below:
  • Multiple requirements designed to reduce tobacco use: The Office of Alcoholism and Substance Abuse Services put in place multiple requirements for the 1,300 addiction treatment centers it regulates, as outlined below:
    • Requirement that facilities ban tobacco use: The cornerstone of the program is a mandate requiring all State-regulated addiction treatment centers to ban tobacco use, with no smoking or smoking paraphernalia allowed on the grounds, including outside buildings and in cars parked on the property. The regulation requires facilities to notify patients, staff, volunteers, and visitors of this policy, with the notice spelling out the specifics of the ban, including what products and paraphernalia are not allowed and the areas where smoking is prohibited. Facilities must provide copies of the notice to anyone who asks.
    • Mandatory training on integrating smoking cessation into treatment: The regulated treatment centers must also train their staff and volunteers on how to integrate tobacco education and smoking cessation services into the context of treating other chemical dependencies. Although the policy did not outline the content of such training programs, the Office of Alcoholism and Substance Abuse Services staff offered support to help facilities in designing a training program. (See bullet below on training and technical support for more details.)
    • Mandatory inclusion of smoking addiction in treatment plans: Treatment facility staff must include goals and action steps related to quitting in the treatment plan of any patient who smokes and uses alcohol or other addictive drugs.
  • Time for implementation, along with extensive training and technical support: Although the agency enforces most regulations from their enactment date, officials decided to give facilities 1 year before they began enforcing the ban and related policies. This delay gave facilities time to develop and implement the policies gradually, and to take advantage of a variety of optional training and technical support offered by the agency to assist with the effort, as outlined below:
    • Online webinars and tutorials: The agency offered a wide array of webinars and tutorials (known as “Knowledge Workbooks”) in the Tobacco Independence section of its Web site. These materials cover the science of smoking addiction, along with strategies for implementing smoke-free policies in the addiction treatment environment and for integrating smoking addiction treatment into the treatment of other addictions. To encourage use of the workbooks, counselors who complete them receive credit toward the 60 credit hours needed every 3 years to maintain their credentials. Some of the materials can also be adapted for use in patient education.
    • Educational forums: Agency staff hosted hundreds of educational forums in different regions of the state, presenting information on the science and philosophy behind the policies and answering questions. These forums reached about 10,000 individuals.
    • Advice via telephone or e-mail: Agency staff established a special e-mail account for inquiries about the tobacco-free program. Facility staff could also call for advice.
    • Press releases and other announcements: Agency staff developed press releases and other announcements to let State residents, patients, and other interested individuals know about the tobacco-free program and related policies.
    • Free nicotine-replacement therapy: Since the program's inception in 2008, patients and staff who smoke have received free nicotine-replacement therapy. Initially, State funds paid for the therapy, but, as those funds ran out, the agency assisted facilities in locating other sources, including Medicaid coverage (for patients who qualify) and other New York State programs.

Context of the Innovation

The New York State Office of Alcoholism and Substance Abuse Services plans, develops, and regulates chemical dependence treatment facilities in New York. It operates 12 addiction treatment centers and licenses, funds and supervises 1,300 community-based programs that serve about 110,000 people a day. The office also provides substance abuse awareness, education, and prevention programs in schools and communities and oversees the credentialing of alcoholism and substance abuse counselors and prevention specialists.

The impetus for this initiative began in 1996, when leaders of two residential addiction treatment centers run by the Office of Alcoholism and Substance Abuse Services became aware of new evidence showing that smoking addiction can be effectively treated at the same time as other addictions, and consequently decided to implement a ban on smoking and tobacco use in their facilities. Staff in the two facilities worked with other providers, including nearby outpatient and detoxification programs, to coordinate the effort. While not a pilot program, the experiences of these two treatment centers formed the basis for the later agency-wide initiative, which did not begin in earnest for another 7 years. Although many in the addiction community supported a state-wide tobacco-free policy earlier, agency leaders did not feel they had adequate support from State officials until 2003, when a change in administration created an opening for them to push for the ban and related policies.

Did It Work?

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Results

The policies have generated high levels of compliance among state-regulated facilities, enhanced access to smoking cessation education and treatment for patients who previously had little or no opportunity to receive such services, allowed many patients and staff to quit smoking, and generated cost savings at the treatment facilities.
  • High compliance: Recertification inspections conducted by the Office of Alcoholism and Substance Abuse Services found that more than 90 percent of the treatment facilities complied with the agency’s tobacco-free regulations.
  • Enhanced access to cessation education and services: Agency-regulated facilities treat more than 250,000 unique individuals each year. All those who smoke receive some level of cessation education and treatment as part of their treatment plan. As noted earlier, before implementation of this program, few treatment facilities offered such services. In addition, facility staff have received training on effective smoking cessation techniques. Patients and staff who smoke have received on request nicotine-replacement therapy at no cost.
  • Many patients and staff able to quit: The program has helped many patients and staff to quit smoking, as outlined below. (New York State’s ban on smoking in public places presumably contributed to these improvements as well.)
    • Many patients quit during treatment: In the first 2 years after the regulations went into place, 23,000 patients who entered treatment using tobacco were no longer smoking at discharge. Those completing the addiction treatment program were more likely to quit.
    • Many patients remain smoke-free after discharge: During a 4.5-year period (April 2007 to October 2011), 50,079 patients who received treatment for smoking and other addictions in regulated facilities ended up being readmitted for treatment. Of these, between 13 and 36 percent remained smoke-free at readmission. Those treated in community residential settings were most likely to be smoke-free (36 percent), presumably because they went into outpatient programs that reinforced their nonsmoking status. (The program did not track patients who did not return for treatment after discharge.) By comparison, the successful quit rate among smokers is estimated at 7 percent while those who use nicotine replacement or other medicine to quit have success rates of 25 percent.3
    • Staff able to quit as well: Although the program does not track the smoking status of facility staff, anecdotal reports suggest that many staff who formerly smoked quit after implementation of the tobacco-free policy. At one facility, for example, the majority of staff smoked before implementation, but only one staff member remains a smoker.
  • Associated cost savings: Facilities report that costs for cleaning, replacing furniture, and repainting have declined since implementing the policies. Although hard data are not available, overall health care and disability-related costs should fall as a result of the decline in smoking rates among patients and staff.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on compliance rates among regulated treatment facilities, patient access to cessation education and services, and the number and/or proportion of patients able to quit smoking, along with anecdotal reports from treatment facilities about staff who have quit smoking and cost savings generated as a result of the policies.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Creation of planning workgroup: In 2004, the Office of Alcoholism and Substance Abuse Services convened a workgroup to discuss the implementation of an agency-wide tobacco-free initiative. Representatives from different agencies and organizations involved in addiction treatment discussed how best to go about instituting the policy and how to obtain buy-in from key partners. Participating agencies and organizations initially included the New York State Department of Health, the American Cancer Society, and the New York Association of Alcohol and Substance Abuse Providers (an association representing chemical dependency treatment providers in New York). Other agencies and organizations joined the effort over time.
  • Decision to “level playing field”: To increase the chances of success and widespread implementation, the workgroup decided to pursue a mandatory tobacco-free policy at all treatment facilities. They felt this approach would ensure that all patients benefit from the smoking addiction treatment and would prevent patients from choosing a facility based on its smoking policy.
  • Consultation with treatment community: The workgroup convened a series of community forums to educate the addiction community about the effort and elicit their feedback and support. The forums addressed three fundamental questions: What is the benefit of going tobacco-free? What is the downside? What strategies should be employed in implementing the policy? The feedback made it clear that the Office of Alcoholism and Substance Abuse Services should educate and support providers in implementing the policies, and provide free nicotine-replacement therapy.
  • Securing funding: The Office of Alcoholism and Substance Abuse Services did not have funds to provide nicotine-replacement therapy, but the Department of Health agreed to provide funding through its Tobacco Prevention Bureau.

Resources Used and Skills Needed

  • Staffing: The program was implemented by existing staff. No new staff or consultants were hired to develop materials for educating the staff at the treatment facilities.
  • Costs: During the first year, the program earmarked $4 million for nicotine-replacement therapy and $4 million for educating and supporting the treatment facilities in implementing the policies. Since that time, funding has fallen steadily, with $600,000 allocated in 2012. Funding for the program is scheduled to end in 2013.
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Funding Sources

New York State Department of Health
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Tools and Other Resources

The following program-related tools and instructional materials are available on the Office of Alcoholism and Substance Abuse Services Web site.

Adoption Considerations

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Getting Started with This Innovation

  • Address facility concerns upfront: When the agency first introduced the idea, many facility representatives supported the purpose of the ban and related policies, but worried that they would lose patients and undermine the state's successful treatment addiction system. The forums held around the state allowed facility staff to articulate what they needed to overcome these concerns and successfully implement the policies—notably education and support, along with free nicotine-replacement therapy. Finding a way to address these concerns and provide this support helped ensure successful implementation.
  • Provide facilities with access to guidance and advice: As noted, program leaders participated in hundreds of presentations and conference calls, and made themselves available by e-mail and telephone for technical support.
  • Recognize and address need for cultural change: Many medical providers and members of the addiction community do not adequately understand the role that tobacco can play as a gateway to other addictions or how continued tobacco use can complicate addiction treatment. Addressing these misconceptions and changing attitudes takes time, leadership, and education. To assist in this process, conduct surveys on current attitudes and beliefs about smoking, and ensure that these beliefs are addressed in training.
  • Make public aware of efforts: When the program launched in 2008, the agency held a press conference and otherwise made information available to the public on the role of smoking addiction in other substance use disorders. The press conference featured patient stories that proved quite effective in conveying key information. One patient described smoking as the "pilot light" for his other addictions, noting that extinguishing that light made him better able to overcome them.
  • Consider appropriate forms of nicotine-replacement therapy: At first, many facilities handed out free nicotine lozenges. However, the vials that hold these lozenges are considered hazardous waste, with special requirements for disposal that drive up facility costs. As a result, the program switched to other forms of nicotine-replacement therapy that do not impose such costs.

Sustaining This Innovation

  • Address differences between outpatient and residential facilities: Different types of facilities face different challenges when implementing a smoke-free ban. Patients visit outpatient facilities for only a few hours a day, leaving them free to smoke the rest of the day. As a result, these facilities will have a tougher time helping patients quit. In contrast, patients in residential facilities stay there 24 hours a day, and hence will have to quit once the policies are implemented. These facilities must be prepared to deal with patient complaints, serious withdrawal symptoms, and attempts to sneak in cigarettes.
  • Do not expect success on the first try: Just like any other addiction, the first attempt at quitting smoking may not be successful. It will be at least as difficult to quit for patients trying to address other addictions at the same time.
  • Provide support to staff, recognizing they must start anew with each patient: With each admission, addiction treatment counselors must start the process again, explaining the smoke-free policy, the reasons for it, and what support is available to assist in quitting. To support these staff, teach them to use motivational interviewing techniques and to exhibit patience when helping patients understand and comply with the policy, and provide them with support in dealing with difficult patients.
  • Educate offsite providers: Medicaid beneficiaries often have to get a prescription for nicotine-replacement therapy from an offsite provider. However, some of these providers may advise patients to hold off on trying to quit smoking until they have addressed their other addiction(s). To deal with these situations, program leaders drafted a letter that facilities can give to patients with Medicaid coverage, who in turn can give it to their offsite providers. The letter explains the initiative and the need to address multiple addictions concurrently, outlining the evidence supporting this approach.

Use By Other Organizations

Staff within the Office of Alcoholism and Substance Abuse Services have consulted with several other states about implementing similar tobacco-free initiatives.

More Information

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Contact the Innovator

Steven Kipnis, MD, FACP, FASAM
Medical Director, Office of Health, Wellness, and Medical Direction
New York State Office of Alcoholism and Substance Abuse Services
1450 Western Avenue
Albany, NY 12203
(845) 680-7633
E-mail: steven.kipnis@oasas.ny.gov

Innovator Disclosures

Dr. Kipnis reported that the Office of Alcoholism and Substance Abuse Services received funding for several years from the State Department of Health to support the provision of free nicotine-replacement therapy to facility patients and staff; in addition, information on funders is available in the Funding Sources section.

References/Related Articles

Kalman D, Kim S, DiGirolama G, et al. Addressing tobacco use disorder in smokers in early remission from alcohol dependence: the case for integrating smoking cessation services in substance use disorder treatment programs. Clin Psychol Rev. 2010:30(1):12-24. [PubMed]

Footnotes

1 Centers for Disease Control and Prevention. Smoking and Tobacco Use: Fast Facts. Available at: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/.
2 Kalman D, Kim S, DiGirolama G, et al. Addressing tobacco use disorder in smokers in early remission from alcohol dependence: the case for integrating smoking cessation services in substance use disorder treatment programs. Clin Psychol Rev. 2010:30(1):12-24. [PubMed]
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Original publication: February 27, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 11, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.