Presentation by: Joseph Guydish Catherine Saucedo University of California, San Francisco County Behavioral Health Directors Association of California September 25, 2019

1. SMOKINGAND TOBACCO-FREE POLICIES IN BEHAVIORAL HEALTH
Joseph Guydish
Catherine Saucedo
University of California, San Francisco
County Behavioral Health Directors Association of California
September 25, 2019

2. Smoking and Mental Illness
40% of all cigarettes smoked
are by individuals with
mental illness/substance use
disorder
(CDC. Morbidity and Mortality Weekly Report, 2008)

3. SMOKING AMONG PEOPLE WITH MENTAL ILLNESS
Lê Cook et al. (2014). Trends in Smoking Among Adults With Mental Illness and Association
Between Mental Health Treatment and Smoking Cessation. JAMA.
Smith et al. (2014). Smoking and mental illness in the US population. Tob Control.

4. Smoking and AddictionTreatment

5. Smoking Prevalence in the US, 2000 - 2017
0
10
20
30
40
50
60
70
80
90
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
Smokingrates
Year
Percent Adult Smokers in the US 2000-2017
US Adult Population (NHIS)
Serious Psychological Distress (NHIS)
Substance Use Disorder (NSDUH)

6. Oregon death rates due to tobacco use
0
10
20
30
40
50
60
<50 50-59 60-69 70-79 > 80
Percentage
Age
0
10
20
30
40
50
60
Overall
General population
Mental health only
Substance abuse only
Dual diagnosis

7. Tobacco cessation services in addiction treatment
National sample of specialty addiction treatment programs
• 86% of programs screened clients for smoking status at intake
• 40% reported that smokers were advised to quit
• 30-40% offered smoking cessation counseling
• 12-26% offered at least one smoking cessation medication
Knudsen. (2017). Implementation of smoking cessation treatment in substance use disorder treatment settings: a review. Am J Drug Alcohol Abuse

8. Barriers to integrating treatment of nicotine
dependence
• Lack of staff knowledge or training
• Lack of staff time
• Competing priorities
• Perceived risk to mental health / relapse to other substances
• Staff smoking
Guydish et al. (2007). Staff smoking and other barriers to nicotine dependence intervention in addiction treatment settings: A review. Journal of Psychoactive Drugs

9. Treating tobacco use in addiction treatment settings
Quitting smoking during addiction treatment à
greater likelihood of long-term abstinence from alcohol and other
drugs
Continued tobacco use is associated with...
• Greater odds of SUD relapse
• Increased depressive symptoms and suicidal risk behavior
• Prochaska et al. (2004). A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. J Consult Clin Psychol
• Weinberger et a. (2017). Cigarette Smoking is Associated with Increased Risk of Substance Use Disorder Relapse... J Clin Psychiatry

10. Treating tobacco use in addiction treatment settings
• Culture change
• Address staff smoking behaviors
• Prohibit staff and clients smoking together
• “No evidence of smoking” policy
• Increase access to smoking cessation services for clients

11. California Department of Health Care Services:
Mental Health and Substance Use Disorder Services
• Total of 1,920 licensed addiction treatment programs in California
• 195,000 unique individuals admitted to treatment in 2014-2015
• 70% of people in addiction treatment smoke
• Therefore, ~136,500 smokers per year enter into this treatment system
In 5 years this system will reach over 500,000 California smokers

12. Tobacco-free grounds policies
• Workplace smoking bans
• Increase smoking cessation
• Reduce cigarette consumption
• Complete bans reduce smoking more than partial
bans
• Bauer, J.E., et al. (2005). A longitudinal assessment of the impact of smoke-free worksite policies-on tobacco use. Am. J. Public Health
• Fichtenberg, C.M., Glantz, S.A. (2002). Effect of smoke-free workplaces on smoking behaviour: systematic review. Br. Med. J
• Tabuchi, T. et al. (2016). Are partial workplace smoking bans as effective as complete smoking bans? A national population-based study of smoke-free policy among Japanese employees. Nicotine Tob. Res.

13. Survey of clients in 24 SUD treatment programs

14. Tobacco-free grounds policies
• Compared 6 programs with tobacco-free grounds to 17 programs without
tobacco-free grounds...
• Clients smoked fewer cigarettes per day (9.7 vs 11)
• Lower prevalence of staff and clients smoking together (27% vs 51%)
• Compared 2 programs before and after tobacco-free grounds:
• Clients smoked fewer cigarettes per day (10.6 vs 8.2)
• Lower prevalence of staff and clients smoking together (36% vs 4%)
• Lower client smoking prevalence (93% vs 68%)
• Clients received more smoking cessation services
Guydish, J., et al. (2017). Smoking-related outcomes and associations with tobacco-free policy in addiction treatment, 2015–2016. Drug and alcohol dependence

15. State-wide implementation of tobacco policies in
behavioral health treatment
• New Jersey – residential addiction treatment facilities
1. Tobacco-free grounds
2. Required to provide tobacco dependence assessment and treatment
• New York – all public & private addiction treatment facilities
1. Tobacco-free grounds
2. Required to provide tobacco dependence treatment
• Oregon – community-based residential mental health and addiction treatment
facilities
1. Tobacco-free grounds
2. Must integrate smoking cessation into discharge planning
• Williams et al. (2005). The integration of tobacco dependence treatment and tobacco-free standards into residential addictions treatment in New Jersey. J Subst Abuse Treat
• Brown et al. (2012). Implementation of a tobacco-free regulation in substance use disorder treatment facilities. J Subst Abuse Treat
• Drach et al. (2012). Promoting Smoke-free Environments and Tobacco Cessation in Residential Treatment Facilities for Mental Health and Substance Addictions, Oregon, 2010. Prev Chronic Dis.

16. Survey of residential SUD programs in California
1921 SUD programs licensed
and/or certified with the DHCS
(as of May 2018)
389 residential programs
362 programs called
276 programs responded
-259 programs completed the
survey
-17 programs declined to
participate
86 programs did not respond
27 programs ineligible based on
phone call

17. Survey of residential SUD programs in California (n = 259)
• 11% (n=28) had tobacco-free grounds policies
• 35% (n=91) were interested in adopting tobacco-free grounds policies
• 23 of these programs had plans to adopt tobacco-free grounds policies
• 35% have scheduled breaks designated for clients to smoke
• 98% had a policy that limited the use of e-cigarettes
• 64% prohibited staff and clients from smoking together

18. California Tobacco Control Program
• Recruit up to 45 residential behavioral health programs
• Learning collaborative intervention
• Evaluation:
Cohort 1, 2, 3
Program 1
Program 2
Program 3
:
:
Program 15
3 DATA COLLECTION PERIODS PER PROGRAM:
Baseline à 12 month (interim) à 18 month (post-intervention)
v Director interview
v Staff surveys
v Client surveys
Contact: Catherine.Saucedo@ucsf.edu or Jessica.Safier@ucsf.edu

19. Joseph.Guydish@ucsf.edu
Catherine.Saucedo@ucsf.edu