Pre-implementation Assessment of Tobacco Cessation Interventions in Substance Use Disorder Residential Programs in California

Abstract Background Across the United States, substance use disorder (SUD) treatment programs vary in terms of tobacco-related policies and cessation services offered. Implementation of tobacco-related policies within this setting can face several barriers. Little is known about how program leadership anticipate such barriers at the pre-implementation phase. This study used the Consolidated Framework for Implementation Research (CFIR) during the pre-implementation stage to identify factors that may influence the implementation stage of tobacco-related cessation policies and services in residential SUD programs. Methods We conducted semi-structured qualitative interviews with sixteen residential treatment program directors in California. The analysis was guided by a deductive approach using CFIR domains and constructs to develop codes and identify themes. ATLAS.ti software was used to facilitate thematic analysis of interview transcripts. Findings Themes that arose as anticipated facilitators for implementation included the relative advantage of the intervention vs. current practice, external policies/incentives to support tobacco-related policy, program directors’ strong commitment and high self-efficacy to incorporate cessation into SUD treatment, and recognizing the importance of planning and engaging opinion leaders. Potential barriers included the SUD recovery culture, low stakeholder engagement, organizational culture, lack of workforce expertise, and lack of reimbursement for smoking cessation services. Conclusion To support successful implementation of tobacco-related organizational change interventions, staff and clients of residential SUD programs require extensive education about the effectiveness of evidence-based medications and behavioral therapies for treating tobacco dependence. Publicly funded SUD treatment programs should receive support to address tobacco dependence among their clients through expanded reimbursement for tobacco cessation services.


Introduction
Smoking prevalence remains disproportionately high among populations affected by substance use disorders (SUDs) (Weinberger et al., 2018). Among people in SUD treatment programs, the smoking prevalence is 2 to 4 times higher than the general population (Guydish, Passalacqua, et al., 2016). Those seeking SUD treatment also experience greater smoking-related health disparities as compared with the general population (Bandiera et al., 2015). Given the high prevalence of smoking and the deleterious effect that tobacco can have on long term substance use, integration of smoking cessation services into SUD treatment is needed (Baca & Yahne, 2009;Weinberger et al., 2017).
Prior research examining the impact of organizational change interventions in SUD treatment programs highlight the potential benefits of integrating tobacco-related services and tobacco-free grounds policies (Asamsama et al., 2019;Conrad et al., 2018;Richey et al., 2017;Romano et al., 2019). States such as New York, New Jersey, Oregon, Utah, and Texas have introduced statewide policies that support the integration of smoking cessation services into SUD treatment (Brown et al., 2012;Correa-Fernández et al., 2019;Drach, 2011;Marshall, 2015;Williams et al., 2005). In California, a branch of the department of public health, the California Tobacco Control Program (CTCP) has supported tobacco cessation among people with SUD by offering grant funding to treatment programs to implement tobacco free policies (CTCP, 2018). Despite the efforts of these programs, challenges remain that can influence successful integration of smoking cessation services.
A 2017 systematic review examined the barriers and facilitators to smoking cessation for people in SUD treatment including populations within Veterans Health Administration programs (Gentry et al., 2017). Results suggested that many persons with SUDs were motivated toward smoking cessation but were not offered support. Some people with SUD felt interventions should be delivered subsequent to SUD treatment while others felt simultaneous interventions would be beneficial, due to strong associations between smoking and other substances use. Elements of the organizational and SUD community culture were identified as barriers. Treatment providers' also felt they lacked training and resources to support smoking cessation. They were further concerned about the potential impact of smoking cessation on mental health outcomes among clients (Gentry et al., 2017).
A qualitative study conducted with a national sample of 24 directors of SUD treatment programs (i.e., outpatient, residential, and methadone clinics) also revealed several barriers to implementing tobacco-related policies and integrating tobacco cessation services . The directors noted that a traditional lack of focus on smoking cessation services within SUD treatment, client resistance, lack of financial support and resources, staff smoking rates, and environmental factors all served as barriers. These barriers hold potential to complicate successful integration of smoking cessation services into SUD treatment. It is important to note that these studies present data that were collected post-implementation. While post-hoc assessments of implementation are valuable, the use of an implementation evaluation assessment model during the pre-implementation stage would allow researchers and program directors to identify and address factors that could impact implementation before project implementation (English, 2013;Robins et al., 2013;VanDevanter et al., 2017).
Further exploration of the barriers and facilitators, which may impact effective implementation, is key for successful integration of evidence-based practices in SUD treatment settings. Often in SUD treatment programs, organizational factors that impact implementation remain unaddressed, despite evidence that they can be detrimental (Damschroder & Hagedorn, 2011). Thus, gaining a better understanding of the challenges faced by SUD treatment programs prior to implementation of a tobacco-related policy could serve as a method for facilitating the integration of tobacco cessation services. Guided by the Consolidated Framework for Implementation Research (CFIR), this study aimed to identify factors that could impact the implementation of tobacco cessation policies and services prior to integration in residential SUD treatment facilities.

Program selection and recruitment
This study analyzed baseline interview data collected among residential SUD programs directors who were participating in three studies described in detail elsewhere . The first study was designed to promote the adoption of tobacco-free grounds and other wellness initiatives. Programs applied to participate in an 18-month policy development intervention led by the UCSF Smoking Cessation Leadership Center, who provided tailored feedback and support as programs developed and implemented tobacco free grounds . The second study focused on improving tobacco intervention services (including facilitating a smoking cessation group) within four residential SUD treatment programs in San Francisco, CA (Guydish, Gruber, et al., 2016). The third study was designed to examine the impact of a staff training intervention on increasing implementation of tobacco-free grounds policies and reducing client smoking. All programs participating across the three studies had expressed interest in developing or improving strategies to address tobacco use among clients, and all programs received incentives to offset costs of study participation (ranging from $15,000 to $24,000 per program per year) (CTCP, 2018). Across the three studies, 16 programs were enrolled. The 16 programs were located in 11 of California's 58 counties, from Lake County in the north to San Diego County in the south, spanning a distance of over 500 miles. Data included in the current study are from pre-intervention interviews with program directors, prior to the delivery of any intervention, support, or education within the respective programs. Prior to their participation in this study, two programs had voluntarily implemented tobacco-free grounds policies prohibiting use of all tobacco products on all facility premises. Data collection occurred in 2019.

Data collection, procedures, and measures
Using a purposeful sampling approach, 16 SUD residential program directors completed key-informant interviews between January and December 2019 during the pre-implementation stage of their respective smoking cessation intervention. Interviews were conducted by Zoom videoconferencing and lasted approximately 60 min. The interview covered topics within five CFIR domains as they related to tobacco policies and the integration of smoking cessation into SUD treatment (see Supplemental Materials which shows the interview guide).
Directors also completed an online survey to gather demographic information and assess organizational policies, which support tobacco-free grounds (TFG) and smoking cessation services provided in their respective programs. Demographic questions asked about race/ethnicity, gender, age, year of service in SUD treatment, smoking status, and personal SUD recovery status. The organizational characteristics of the SUD treatment programs were assessed using six salient items drawn from prior research concerning implementing policies to support tobacco free grounds such as provision of nicotine replacement treatment (NRT) products, assessing smoking among clients, smoking among staff, staff and clients smoking together and tobacco screening and counseling options (Campbell et al., 2022;Guydish et al., 2017Guydish et al., , 2020. Greater endorsement of these policies indicates higher likelihood of reduced use of tobacco products among clients and staff. The survey can be accessed at https://tinyurl.com/2br7xkus. Seven of the interviews were conducted by two of the authors (CMa and ES) and other research staff conducted the rest. All interviewers were female and trained in qualitative interviewing. Interviews were digitally recorded and professional transcribed. Interviewees received a $50 gift card for their time. All participant information was de-identified to ensure confidentiality. Research procedures were approved by the Institutional Review Board of the University of California San Francisco.

Qualitative coding and data analysis
Interviews transcripts were integrated into ATLAS.ti, a qualitative data management software program. Thematic analysis of interview transcripts was informed by grounded theory (Boyatzis, 1998;Glaser & Strauss, 2009). Thematic analysis was also guided deductively by the CFIR model (Damschroder et al., 2009). The CFIR synthesizes 18 existing implementation theories and evidence-based factors into a single taxonomy. The CFIR model includes five domains: (i) the intervention characteristics (ii) the outer setting, (iii) the inner setting, (iv) the characteristics of the individuals involved, and (v) the process of implementation. Thirty-nine constructs are then organized within these five domains, all of which interact with one another to impact implementation. The model can be used to evaluate implementation, explain research findings, or assess context prior to implementation (Damschroder et al., 2009). The CFIR model has been used with interventions spanning several different topics, including mental health and physical health conditions, though, few studies have employed the CFIR model to explore factors at pre-implementation stage (Kirk et al., 2016). Studies that have used the CFIR pre-implementation were able to identify and address factors that could potentially impact implementation (English, 2013;Robins et al., 2013;VanDevanter et al., 2017).
Members of the research team (KF, CMc, JW, CMa, and ES) initially each read four transcripts independently identifying preliminary codes and subthemes. The first author then read all transcripts and, informed by the existing literature and the preliminary analysis of interviews, developed the initial codebook. Researchers met weekly over three months to compare preliminary coding choices, suggest possible codes and provide code definitions for the codebook. Differences between the coders were resolved by team discussion. Major themes were then mapped onto the domains and constructs of the CFIR. The relative importance (Ri) of CFIR constructs was determined by of two criteria (1) the relative frequency (%) of a construct being reported across all interviews and (2) the degree of emphasis placed on a single theme by an interviewee within the given interview. Two members of the research team independently coded a random sample of 20% of transcripts, which they had not previously coded, to establish 81% inter-rater agreement on parent (i.e., domain) codes. Finally, the first author selected passages that exemplified the themes, which mapped onto the CFIR constructs and domains.
Members of the coding team were also part of the larger research teams and therefore worked extensively with several of the agency directors represented in this sample. Therefore, the members of the coding team had an understanding of the workflow and current policies at several of the agencies and could therefore speak to the quality of the data.

Participants and program characteristics
The participants were mostly female and most reported over ten years of experience within the SUD treatment industry (Table 1).
Almost half of the directors identified as persons in recovery from SUD, and half reported being former smokers. Organizational TFG related policies and services of the 16 participating programs appear in Table 2. Only eight programs (50%) endorsed four or more supporting policies at pre-implementation. Over half of this sample (75%) allowed their clients to smoke nicotine products outdoors, and half of the programs (50%) allowed clients to smoke during designated smoking breaks on campus or on off-campus walks. Half of the sample (50%) allowed staff to smoke nicotine products outdoors, and a few programs (31%) permitted their staff and clients to smoke together. The majority of the programs provided their clients with access to NRT products (63%) and provided tobacco screenings and/or counseling for smoking cessation (88%).
We present findings within each of the five CFIR domains evaluated. Domains are in bold, CFIR constructs appear in italics, and themes are underlined. Example quotes exemplifying each theme are displayed in Table 3.

Domain I: Intervention characteristics
Intervention characteristics include key aspects of the intervention that could influence successful implementation   You know, i would say challenges occur as part of the culture, in -i don't want to say a field of addiction, but in the field of recovery -for many, many years, and if you think of the image of a smoked-filled alcoholics anonymous meeting, or smoking and addiction to alcoholism seem to have gone hand in hand -and part of it is the culture surrounding that. Program Director #8 barrier Organizational culture P: Putting a smoke-free campus is gonna pretty much take that away (smoke break), and so this is gonna be one barrier for our staff, who can rely on that as kind of a tool to calm people down or to take a break, or to connect with someone, this is gonna be taking that away from them as well. Program Director #1 barrier ambivalence P: [….] if they want to smoke a cigarette, i was okay with them smoking, even though i knew it was a habit that was unhealthy and could lead to other things, but i know that they were dealing with some real tough decisions in their life at that specific moment in time, and it was better -it was like the lesser of two evils, i guess. Program Director #1 barrier culture change even the people that came to meetings on the outside, they were just like, oh, okay, it's nonsmoking now, i can go an hour and a half and not smoke. and then people started to realize -in a short amount of time -just how much cleaner it was here, and -people were like, okay. and then here in town, other meetings started having their meeting spaces be nonsmoking, and then society slowly started changing and -so i thought i was gonna get all kinds of push-back […] and it wasn't. Program Director #4 (Continued) barrier culture change My experience with the (nicotine) ban - […] it was very, very challenging. Lots of people started smoking inside the building.
[…] and that really started to become a safety hazard. everyone was stressed out. i mean, i work with our clients -a lot of them have very severe mental illness, and i mean, the incidence of people with schizophrenia who smoke is very, very high, and so it's challenging, […] People were trying to find ways to get around the smoking -people would go out on appointments that didn't actually exist so they could go smoke, people would say they were having panic attacks and needed a stress walk so they could go smoke -the term "stress walk" became a code word that people would try to use to go smoke, and it really -it put the staff in a tough position, because they kind of became cops and had to police something that really didn't feel that necessary. So yeah, it was very tense. and i don't know -later that year, or whenever it was, when we were told that we could actually walk that policy back and implement smoking breaks -i remember going into a morning meeting with all the clients and letting them know, and it really felt like a weight had been lifted off everyone when i said that, because it was very, very unpopular, and it frankly wasn't working. increased health, more long-term sobriety. 'cause that's what we're looking -we don't want to just get 'em clean for two or three months that they're with us. We want 'em to be clean and changed forever now, afterwards. and i think that these policies and this program that we're gonna put in place is really gonna help that. Program Director #13 Facilitator Leadership commitment if we're saying we're assisting them to have better lives and we're working on the whole-person education, but yet we're still allowing a substance that ultimate kills people, too, then i think that we need to really figure out how we can assist them in quitting that, too. Program Director #10 Facilitator Leadership commitment You know, i just decided one day, we're going nonsmoking, and that was it. i literally came to work one day and said, this is too much. this is too much energy, too much of their lives, too much "can i go smoke," and i thought, we're goin' nonsmoking.   (Damschroder et al., 2009). Within the current study, the following findings emerged.
Relative advantage (Ri = 75%). Participants expressed an interest in developing and implementing smoking cessation policies and services within their residential treatment program, highlighting a perceived need to address smoking among their clients and to obtain smoking cessation resources. They acknowledged the potential reduction in smoking rates among clients through organizational-level interventions as an advantage over the current practice.
Evidence strength and quality (Ri = 68%). There was uncertainty about whether residential treatment programs should permit e-cigarettes use (which have mixed evidence of effectiveness for tobacco product cessation) (Kalkhoran & Glantz, 2016) as a form of harm reduction. Some directors perceived e-cigarettes as a tool to help smokers quit combustible tobacco products. These perceptions were reflected in organizational-level policies, in which a few programs encouraged the use of e-cigarettes among clients and staff while others prohibited use due to the products visual similarity to cannabis vaporizers.

Domain II: Outer setting
The outer setting includes the larger context (e.g., political, social, economic) in which the organization resides (Damschroder et al., 2009). Themes related to the outer setting are identified below.

Patient needs and resources (Ri = 94%).
All the participants described a degree of concern about residents' reaction to tobacco free grounds policies. Some directors believed clients did not have an interest in smoking cessation. Directors highlighted the prominent role that smoking can play within the SUD recovery culture. According to directors, the SUD recovery culture often allows the use of tobacco products to facilitate the cessation of other substances. Directors further raised the concern within the organizational culture that prohibiting smoking in residential settings would interfere with rapport building between staff and clients. Directors therefore expressed some ambivalence toward removing smoking from residential treatment programs.
Directors of the two programs which had previously adopted and sustained tobacco-free policies and tobacco related services discussed their anticipated fears related to enforcing quit mandates, particularly as it related to client and staff resistance. However, they both reported that culture change was easier than they had initially anticipated. However, culture change was reportedly more challenging for other programs. Four directors described previous attempts to implement tobacco-free grounds that resulted in clients leaving treatment early and the dismissal of clients for violation of the policy. According to one director, implementation of tobacco-free policies was a challenge, partially due to client's use of tobacco to cope with comorbid mental health disorders. An additional challenge was the added workplace burden on barrier Financial reimbursement system i would allow every client to have gum or a patch or a lozenge if they wanted to quit smoking. However, all of those are looked at and considered a medication, and per our state licensing regulations, we can't just hand that out to clients. they have to have a prescription.
[…] -that's a challenge. For sure. it would be -so even if a client -identifies that they want to quit smoking, they would need to have somebody bring in those tools to them. We could not provide it for them. Program Director #8 CFIR Domain IV: Characteristics of individuals Self-efficacy 56% Facilitator Self-confidence i would like to move forward with addressing it [smoking cessation] from a whole health perspective. i do think it's important, and so now that i'm in a director position, i'm moving it that way.
[…] We're used to barriers, so as a small nonprofit, what i'll say, is that the team is great at stepping up and accomplishing whatever needs to be accomplishing, and coming together as a team. So we're used to barriers and overcoming them, and so i'm not too concerned about that. Program Director #3 Facilitator Personal-motivation One of our staff members had a medical issue, and we felt tobacco played a role in his health issues and his ability to heal from his health problems, so we just -we thought -we didn't want to be the enabler,  staff (who may themselves be smokers) to ensure clients adhere to the policy. Negative consequences also included clients smoking tobacco in high fire risk places (e.g., in their bedroom or bathrooms). Within ten months of implementation two program directors reported that the policy was amended to permit designated smoke breaks for clients. External policy and incentives (Ri = 81%). Many directors were aware of current government mandates (e.g., city, county, state, federal) related to nicotine products. However, they reported a lack of mandate adherence. For example, in 2018, San Francisco County passed the ban of flavored tobacco products including menthol products (Vyas et al., 2021;Yang & Glantz, 2018), however several program directors reported that they would still permit their clients to smoke menthols while in the program. Program directors also remarked that while they ensured their clients followed public no-smoking rules when participating in program activities off campus (e.g., no smoking in public areas when going on a walk), lack of adherence to public policies from other community members may pose a barrier for encouraging clients to remain smoke-free.
Directors reported that external incentives, including a need for grant funding, were important factors in their motivation to integrate tobacco cessation services in SUD treatment. The majority of directors stated they were able to provide partial support for NRT and smoking cessation services to their clients through partial funding from grants or private donations. A few directors stated they were able to fully provide those services through the financial reimbursement system of their affiliated federal qualified health center.

Domain III: Inner setting
The inner setting includes factors of the program (e.g., structural, cultural contexts) that may be associated with implementation (Damschroder et al., 2009). The following themes emerged related to the inner setting.
Implementation climate (Ri = 81%). Residential directors believed that the implementation climate of their programs was compatible with smoking cessation interventions, and that tobacco-related services were a priority in SUD treatment. Directors believed that smoking cessation was a priority because of the impact of smoking on their clients' overall health. They reported using a holistic approach to providing SUD treatment, and acknowledged the health risks associated with smoking. Some directors demonstrated strong leadership commitment to enforce an institutional smoking ban.
Readiness for implementation (Ri = 87%). Despite directors' expressed strong commitment to develop and implement smoking cessation policies, they also noted major reasons why they had not offered treatment for clients. Directors reported low staff training/knowledge about tobacco-related services. They also stated that SUD counselors smoking status was also a barrier, which seemed to send a "mixed message" to clients. Most programs did not require staff to be nicotine-free nor did they provide smoking cessation services for staff. Directors expressed a desire to aid employees in achieving better health outcomes (e.g., referral to an EAP) but did not find it appropriate to impose smoking cessation mandates for their employees. Workforce resources are further discussed under the CFIR construct, Planning and Engaging. Most programs screened clients for nicotine use disorders and some occasionally provided informal smoking cessation counseling as part of wellness process groups. However, several directors mentioned that smoking cessation counseling services are not reimbursed under the current public financial reimbursement system. Although clients may buy NRT products over-the-counter, directors acknowledged the cost of smoking cessation medications as a barrier for clients. Therefore, programs sought public health grant funding to subsidize NRT for clients unable to pay. Programs unable to obtain funding used a referral to NRT approach, by referring residents to local clinics and national quit lines. Directors recognized workflow as a viable concern in the implementation process. Directors noted that the structure of their programs does not have workflow processes and services such as onsite healthcare services that would allow medical personnel to prescribe and dispense NRT.
Directors reported that they anticipated state policy makers would eventually impose smoking-free campus mandates. Thus, many expressed being highly motivated to participate in this research study simply because the project provided access to smoking cessation services and training. Others expressed the need for treatment standardization of tobacco cessation policies across all facilities providing SUD treatment services.

Domain IV: Characteristics of individuals
Characteristics of individuals in an organization include factors of the individual's beliefs, knowledge, self-efficacy, and personal attributes that may be associated with implementation (Damschroder et al., 2009).
Self-efficacy (Ri = 56%). Despite the challenges of service and policy integration, all directors expressed self-confidence and optimism that they could successfully incorporate smoking cessation interventions into SUD treatment curricula. Many reported a personal motivation to integrate smoking cessation interventions within their treatment programs and acknowledged the potential health benefits for clients and staff.

Domain V: Process of implementation
The process of implementation includes stages of implementation such as planning, executing, reflecting and evaluating, and the presence of key intervention stakeholders and influencers including opinion leaders, stakeholder engagement, and project champions (Damschroder et al., 2009). The following theme emerged related to the process of implementation.
Planning and engaging (Ri = 73%). Directors conducted planning activities that included assessing their settings and making environmental plans and assessing workforce needs to identify potential barriers to implementation. Directors also recognized the need for the active resident inclusion in policy development. SUD residential program directors discussed that executive committees developed policies, most often without client input, which were communicated to residential clients via a meeting (e.g., "a house meeting"). Client reactions to policies served as a catalyst for policy amendments that had occurred in some programs. Some directors therefore suggested that residents should be engaged in the process of developing policies and services, while another suggested that the implementation approach should be gradual and repetitive.

Discussion
This study applied the CFIR framework to identify anticipated barriers and facilitators that could influence the implementation of tobacco policies and services in residential SUD treatment programs during the pre-implementation stage of a tobacco free policy intervention. At the pre-implementation stage, the majority of the programs lacked supportive policies to implement tobacco free grounds and smoking cessation services. Programs with four or fewer policies supporting tobacco free grounds and smoking cessation services reported higher barriers within CFIR domains. All five CFIR domains emerged from the analysis: intervention characteristics, outer setting, inner setting, characteristics of individuals, and the process of implementation. However, the outer setting and inner setting domains were represented both as barriers and facilitators at pre-implementation. Leadership engagement and commitment to adopting tobacco cessation policies and services were key facilitators. Across all participating programs, directors were engaged, motivated, and reported self-efficacy to implement tobacco cessation policies and services. Integrating smoking cessation policies and services in residential SUD programs was viewed as compatible with a holistic approach to the treatment of SUDs, superior to current practices, and facilitated by local government mandates and incentives. However, important barriers to implementation were identified within several CFIR domains: the intervention characteristics, outer setting, inner setting, and process of implementation.
In the inner setting, directors reported the complexity of implementation of smoking cessation treatment services within their settings. Directors emphasized that existing resources were insufficient to support implementation of comprehensive smoking cessation policies. Program directors cited a number of barriers related to the inner setting that impacted the extent to which they could change policies, services, and practices including the resources available to treat tobacco use disorder, financial costs of NRT medications, and the ability to be reimbursed for smoking cessation services. They also cited the SUD recovery culture as an important barrier to adopting tobacco cessation policies. According to directors, the SUD recovery culture was connected to both staff and client resistance to tobacco-free grounds. They further explained the organizational culture that permitted clients to smoke on the premises was used to facilitate prosocial behaviors and that smoking played an important role in helping clients to cope with stress and build provider rapport. Other barriers specific to the inner setting centered on the organizational culture: ambivalence about imposing tobacco-free grounds, uneven attention given to staff smoking, and the view that promoting smoking cessation among staff was not part of their role. Prior research has documented these barriers to the integration of smoking cessation care within SUD treatment programs (Fallin-Bennett et al., 2018;Guydish et al., 2007;Knudsen, 2017;Laschober et al., 2015;Pagano et al., 2016). In SUD residential treatment, rapport is a critical skill and clients perceive supportive staff as motivators for their personal tobacco cessation efforts (Gentry et al., 2017). Despite these barriers, directors reported high commitment to implementing these policies and services. Directors collectively identified nicotine as a harmful substance, which negatively impacts their clients' health. The finding shows that directors regard smoking cessation services as a priority in residential treatment settings. They reportedly believe allowing nicotine use in residential treatment settings goes against their values of client-centered and holistic recovery.
In the current study, directors discussed their reluctance to address smoking among their workforce. However, to increase the success of tobacco cessation policy interventions, it is critical to address staff smoking. Staff smoking is common in SUD treatment and could reinforce client tobacco use (Baca & Yahne, 2009). A recent study, found that higher rates of SUD treatment program staff and clients smoking together was associated with lower rates of client intent to quit smoking in the next 30 days, more negative client attitudes toward quitting smoking, and with clients receiving fewer tobacco services (Guydish et al., 2017). This finding highlights the importance of addressing staff smoking in SUD treatment programs and provides support for a policy to prohibit staff smoking together with clients.
The successful implementation of tobacco services in residential SUD treatment programs would require organizational culture change interventions. Interventions would include program wide staff and client training and workshops on the long term effectiveness of tobacco cessation services, policies to prohibit staff and clients from smoking together and, provide holistic avenues for staff to build rapport with clients, such as gardening or sports (Guydish et al., 2007(Guydish et al., , 2012(Guydish et al., , 2017. Organizational change interventions have been associated with increased favorable attitudes toward treating tobacco use disorder in SUD treatment programs, use of NRT medications, client receipt of services from their programs or counselors, and a reduction client smoking prevalence and cigarettes smoked per day (Guillaumier et al., 2020;Guydish et al., 2012).
Furthermore, funding streams may serve as a barrier to the availability of smoking cessation services in SUD treatment programs (Knudsen, 2017). The expansion of Medicaid under the Affordable Care Act (ACA) has allowed for increased coverage of smoking cessation treatments. However, in the state of California, from where the study sample was selected, Medi-Cal, currently covers SUD treatment and tobacco-related cessation counseling and medications for clients receiving outpatient and inpatient hospitalization services. Presently, residential SUD treatment programs are not Medi-Cal-recognized practitioners of tobacco related cessation services and SUD providers' services are not reimbursed in residential settings. In California, the Department of Health Care Services (DHCS) has sole authority to license nonmedical SUD treatment facilities and does not consider tobacco-related services within its scope. Therefore, SUD program directors have no regulatory or financial incentive to provide tobacco-related cessation services for their clients. Unfortunately, this gap in clinical care has a negative impact on the prevalence of smoking among residential clients and its associated health comorbidities . Clients are more likely to have a quit smoking attempt when they have health coverage, and are three times more likely to quit smoking while they participating in SUD treatment (Yip et al., 2020). Therefore, there is a critical need for the allocation of resources dedicated to build SUD programs' capacity to provide smoking cessation services including expanded insurance coverage of counseling-based smoking cessation programs.
Directors reported implementing changes to the program's smoking policies using a top-down approach where client input or participation in policymaking was not taken into consideration. Engaging clients as stakeholders early in the design of interventions is essential for implementation success (Pronovost et al., 2008). Clients could provide an insider perspective on the acceptability of specific policies or intervention components that could enhance buy-in. Furthermore, implementation will be more effective when all key stakeholders are involved (e.g., leadership, external change agents, clients) (Greenhalgh et al., 2004). A communication strategy should be in place before implementation to educate both providers and clients about the value of tobacco-free grounds and smoking cessation services.

Limitations
Although the findings of this study are comparable to past systemic reviews, this study focused on SUD residential treatment programs in California, and the factors influencing adoption of tobacco cessation policies and services may be different in outpatient settings or in other geographic locations. Our analysis relies on self-report from program directors, and does not take into account the views of clients or other staff members. Obtaining the perspective of other key stakeholders would increase understanding about barriers and solutions from multiple perspectives. Furthermore, it is unclear whether participation in the pre-implementation interview may have influenced ongoing implementation for this study. Future research should consider exploration of participant perceptions before, during, and after implementation. Finally, the residential treatment programs that participated in this study responded to a call for applications for SUD treatment programs willing to participate in implementing tobacco policy interventions. Thus, residential programs that had an investment in and a higher level of motivation to participate in this study may be over-represented.

Conclusions
Guided by the CFIR model, that current study illuminates anticipated barriers and facilitators to the implementation of tobacco policies and services in residential SUD treatment. Study findings indicate that challenges related to reimbursement for smoking cessation services persist in the context of SUD treatment programs. To increase adoption of tobacco policies and services in SUD treatment settings, it is essential to dedicate funding to increase training capacity, but also to expand reimbursement of smoking cessation-counseling services in SUD treatment.

Ethics approval and consent to participate
The Institutional Review Board of the University of California San Francisco approved this manuscript's research procedures.

Author contributions
We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We confirm that this publication is not under review-and will not be under review-by another publication while it is being considered by Substance Use & Misuse. JKF contributed to the conception of this manuscript's research hypothesis, design, analysis, interpretation, drafting and revision of the manuscript. CMc contributed to the design, analysis, data interpretation, drafting and revision of the manuscript. CMa contributed to the design, analysis, data interpretation, drafting and revision of the manuscript. VG contributed to the data analysis, data interpretation and revision of the manuscript. ES and JW contributed to data collection, data analysis and provided revisions to the manuscript. JG contributed to study design and revision of the manuscript. All authors provided critical feedback and helped shape the research, analysis and manuscript.

Declaration of interest
We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that there are no known potential competing interests.

Funding
This work was supported by the California Tobacco Control Program (18-10025), by the California Tobacco Related Disease Research Program (TRDRP 27IR-0040, 28CP-0038), and by the National Institute on Drug Abuse, Award Number T32DA007250. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The abovementioned funding sources played no role in the design of the study, data collection, analysis, and interpretation of data; and they did not play a role in writing the manuscript.