Participants and Program Characteristics
The participants were mostly female, with an average of over ten years of experience within the SUD treatment industry (Table 1). Half of the directors identified as persons in recovery from SUD. Program characteristics showed over half of this sample (75%) allowed their clients to smoke nicotine products outdoors, and some programs (44%) 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 (25%) permitted their staff and clients to smoke together. See Table 2 for program characteristics.
We present findings within each of the five CFIR domains evaluated. Domains are in bold, CFIR sub-constructs are 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.19 Within the current study, the following findings emerged.
Relative advantage. Participants expressed an interest in developing and implementing smoking cessation policies and services within their residential treatment program. They saw the potential reduction in smoking rates among clients through organizational-level interventions as an advantage over the current practice. Evidence strength and quality. There was uncertainty about whether residential treatment centers should permit e-cigarettes use (which have mixed evidence of effectiveness for tobacco product cessation).28 Some directors perceived e-cigarettes as a tool to help smokers quit combustible tobacco products. These perceptions were reflected in organizational-level policies, which encouraged the use of e-cigarettes among clients and staff.
Domain II: Outer setting
The outer setting includes the larger context (e.g., political, social, economic) in which the organization resides.19 Themes related to the outer are identified below. Needs and resources of those served by the intervention. 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 SUD recovery culture. According to directors, the SUD recovery culture often times prohibits the use of tobacco products to help ease the cessation of other substances. Directors further raised the concern with the organization culture, that prohibiting smoking in residential settings would change rapport 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 voluntarily leaving 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 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, the policy was amended to permit designated smoke breaks for clients. External policy and incentives. Many directors were aware of current government mandates (e.g., city, county, state, federal) related to nicotine products. However, they reported their programs did not enforce such mandates. For example, in 2018, San Francisco County passed the ban of flavored tobacco products including menthol products.29,30 Program directors remarked 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).
Directors reported external incentives such as grant funding, were important factors in their motivation to integrate tobacco cessation services in SUD treatment. Some directors stated they were able to provide nicotine replacement options and smoking cessation services to their clients through partial funding from grants or private donations.
Domain III: Inner setting
The inner setting includes factors of the program (e.g., structural, cultural contexts) that may be associated with implementation.19 The following themes emerged related to the inner setting. Implementation climate. Residential directors believed that the implementation climate of their programs was compatible with smoking cessation interventions and, 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. 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 including: the lack of available resources such as, workforce expertise and therapeutic interventions (pharmacotherapy and psychotherapy), financial reimbursement and SUD counselors smoking status. Directors reported low staff training/knowledge about tobacco-related services. 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 forms of nicotine replacement treatment (NRT) 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 do not have workflow processes and services such as onsite healthcare services that would allow medical personnel to prescribe and dispense NRT.
With respect to staff smoking status, 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., refer to an EAP) but did not find it appropriate to impose smoking cessation mandates for their employees.
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 standardized or uniform tobacco cessation policies across all facilities providing SUD treatment services.
Domain IV: Characteristics of Individuals
Characteristics of individuals in an organization includes factors of the individual’s beliefs, knowledge, self-efficacy, and personal attributes that may be associated with implementation.19Self-efficacy. Despite the challenges of service and policy integration, all directors expressed self-efficacy and optimism that they could successfully incorporate smoking cessation interventions into SUD treatment curricula. They all reported a strong commitment to integrating 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.19 The following theme emerged related to the process of implementation. Planning and engaging. Directors conducted planning activities that included assessing their environmental settings, and workforce knowledge to identify potential barriers to implementation. Directors also recognized the need for client champions and stakeholders.
SUD residential treatment 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”). Clients’ 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.