The committee should be made up of administrators, staff, and consumer/client representative(s) who will be responsible for creating and implementing the tobacco-free policy. Key members of the committee are:

• The human resources director
• Facilities director
• Environmental services representative
• The clinical and/or medical director
• Key employee groups
• Key client groups
• Security representative
• Pharmacy representative
• Health education representative
• Public affairs representative

Tip: Include those who may be nay-sayers, like a staff member/counselor who smokes and believes it is more important to address a client’s alcoholism because “cigarettes are their last freedom”. Including these people who feel negatively toward the initiative in the beginning and giving them a voice on the committee will likely bring an otherwise unheard perspective to the endeavor. It will also show them that their opinion is valued and give them time to, hopefully, come around. Their experience will then be more compelling when they interact with clients. 

To adequately prepare your organization for becoming tobacco-free, a 6-12 month planning and implementation timeline is preferable.

Download the Model Tobacco-Free Policy Timeline also in the Downloadable Resources section below 

Explain why you want to address tobacco-use in your facility. Talk about what you want to accomplish.

Key messages may include:

• “We are developing this policy to provide a healthy and safe environment for employees, clients, and visitors and to promote positive health behaviors.”
  
   
• “Persons with behavioral health conditions die up to 25 years younger than the general population due largely to conditions caused or worsened by smoking.”
  
   
• “Tobacco acts as a cue for other drug use and maintains drug-related coping styles.”
  
   
• “Policies that discourage smoking can improve health outcomes: Smoking slows wound healing, increases infection rates in surgeries and is the most common cause of poor birth outcomes.”
  
   
• “We are not saying you must quit smoking, but we are saying you cannot use tobacco while you are at work. If you are ready to quit, we want to support your efforts.”
  
   
• Starting [DATE], we will no longer permit use of tobacco products on our campus.
  
   
• [Name of a trusted staff manager/ HR director/ tobacco-free program coordinator] will be responsible for this initiative. Please contact her/him if you have suggestions to improve our process or if you have questions or concerns.

An effective tobacco-free policy will provide a clear rationale that cites the documented health risks that tobacco use poses to clients and staff. The tobacco-free wellness policy is most effective when created in consultation with members of staff and clients. It will acknowledge the right of employees to work in a tobacco-free environment and to not subject clients, or anyone else, to second hand smoke.

Download the Model Tobacco-Free Policy also below in the Downloadable Resources section

*THERE ARE A NUMBER OF COMMON CONSIDERATIONS WHEN WRITING A TOBACCO-FREE POLICY*:

Understanding your state’s tobacco-free policies for mental health and substance use facilities As of March 15, 2020, eleven (11) states require tobacco-free grounds for most mental health facilities. Five (5) states require tobacco-free grounds for most substance use facilities.

Public Health Law Center has posted a detailed summary of these laws

Determining the reach of tobacco-free areas It is recommended that all indoor and outdoor facility areas be tobacco-free, if possible. For those facilities that allow clients to leave the premises, a 100% tobacco-free environment is the healthiest and most easily-enforced policy.

It is recommended that human resources policies are revised to reflect the tobacco-free policy. Dress code (scent of smoke) issues can be included in policy changes. For example, if employees come to work smelling strongly of smoke, they would be considered in violation of the tobacco-free policy. Provision of cessation medications Sites should offer or facilitate access to nicotine replacement therapy (NRT) or other FDA-approved cessation medications and behavioral counseling to clients and staff members who require assistance refraining from smoking while onsite. This assistance should begin at least one month before the tobacco-free policy goes into effect and last at least 3 months post implementation, if not longer. Your facility’s Human Resources department should communicate to staff about cessation medication benefits offered by their health insurance plans.

TIP: Using terms that are more familiar to behavioral health clinicians can help encourage tobacco dependence treatment. NRT is similar to MAT (medication-assisted treatment).

Inform employees and clients of the tobacco-free policy timeline as early as possible. Tobacco users will need time to get used to the idea of a tobacco-free campus. Tobacco users who want to quit will also be more successful if they have time to adjust and potentially begin to prepare for this significant life change.

Download Sample Staff Announcement also below in the Downloadable Resources section

Download Sample Letter to Clients also below in the Downloadable Resources section

Offer educational events for staff and clients. Staff should be encouraged to learn more about tobacco cessation through continuing education and supervision. Such training should include:

• The association between mental illnesses, substance use and tobacco dependence
• Evidence based pharmacotherapy and counseling for tobacco cessation
• Brief screening and assessment tools
• Practical strategies for inclusion of tobacco cessation into treatment planning
• Community referral resources

There are a number of resources to assist agencies in accomplishing training goals. The Resources section at the end of this toolkit refers to relevant content. We also encourage you to visit the Behavioral Health section of our website or call us toll-free at 1-(877)509-3786.

Regardless of patients’ stage of readiness for cessation attempts, staff should be trained to utilize the “5 A’s” (Ask, Advise, Assess, Assist and Arrange). Similar to SBIRT (Screening Brief Intervention and Referral to Treatment), clinicians are encouraged to “Ask” all patients at every visit if they smoke. If they do smoke the clinician should “Advise” them in a personalized manner to quit. Providers are then directed to “Assess” patients’ willingness to make quit attempts over the next month, “Assist” in setting quit dates and obtaining services (e.g., Quitline, agency groups), and “Arrange” for follow-up contacts to determine if quit attempts were successful. For agencies that lack the necessary resources to perform the “5 A’s”, an abbreviated model may be used which is referred to as “AAR”. In this model, providers “Ask” all patients if they use tobacco, “Advise” tobacco users to quit through personalized messages, and then “Refer” tobacco users to appropriate community cessation services (including Quitlines).

Agencies that are going tobacco-free should provide counseling opportunities and tobacco cessation medication to both staff and clients. Nicotine dependence is a chronic, relapsing disorder often requiring multiple attempts before individuals quit for good. Only 4-7% of unaided quit attempts are successful, but proven treatments exist that significantly enhance those odds. Combining counseling and nicotine replacement therapy (NRT) or other FDA-approved smoking cessation medications is the most effective option. Staff and clients will need these cessation aids to prevent or alleviate withdrawal symptoms while at work.

TOBACCO RAPID IMPROVEMENT ACTIVITIES
Meet to assess strategies for integrating tobacco screening, assessment, treatment, and referral into policies and procedures. Here are common steps that a policy committee or organization can take:

• Include tobacco use and cessation questions on intake and assessment forms
• For medical personnel, add tobacco-use status to vital signs at every visit
• Add chart stickers documenting tobacco usage
• Create a policy that tobacco usage must be included in treatment planning
• Consider wellness incentives for employees and clients

Download Tobacco Use Assessment (TUA)

TOBACCO CESSATION COUNSELING
Effective tobacco cessation counseling includes individual, group, and telephone sessions. Regardless of the treatment modality, the Stages of Change Model can be utilized to gauge individuals’ readiness for treatment. In this model, motivational interviewing allows providers to tailor interventions to shifting stages of change, and assists patients to become autonomously motivated and competent to make cessation attempts. Individual or group treatment should include practical counseling (e.g., problem solving, skills training), and social support. Cognitive behavioral therapy (CBT) will also help accomplish reduction and cessation goals by changing the dysfunctional thoughts, emotions, and behaviors that often accompany tobacco dependence. Be prepared to address and support clients’ reasons and motivations for quitting. Have materials to provide to clients that make the case for the importance of cessation.

Download Substance Abuse and Mental Health Services (SAMHSA) flier on Benefits and Tips for Quitting for Good

Along with improving physical and mental health, quitting smoking can improve one’s financial health. Use the cost calculator link to help clients figure out how much money they can save by quitting.

QUITLINES
Quitllines are a tobacco cessation resource with demonstrated effectiveness, doubling a smoker’s chances of quitting successfully. These telephonic services are widely available to all tobacco users in the U.S. and Canada, and community organizations should readily utilize them.41, Quitlines generally offer some combination of counseling and cessation medications. This video on the CDC website demonstrates what happens when someone calls a quitline. 1-800-QUIT-NOW (also at https://smokefree.gov) is a toll-free number operated by the National Cancer Institute (NCI) that will connect you directly to your state’s tobacco quitline Some states’ helplines offer tailored services for the behavioral health population and offer to providers and clients bi-directional services using clients’ electronic health records.

Garner support from local and state health departments and tobacco-free coalitions. They are often able to provide resources, including signage, technical assistance, and educational materials in multiple languages that can be used when engaging the community. There are a variety of national events that can be used to showcase local initiatives such as:

The Great American Smoke Out on the 3rd Thursday of every November 
Mental Health Awareness (May)
No Menthol Sunday in mid-May each year
World No Tobacco Day on May 31st each year
National Recovery Month (September)
National Addiction Treatment Week (October)

Before the policy implementation date, ensure that all needed agency and campus signage is posted. Your local and state health department will be an invaluable resource in providing direction. Signage should be placed at building entrances and in key locations around the property perimeter, particularly where staff and clients congregate to smoke. Signage should also be in the different languages representing your clients.

Download Sample Signage also below in the Downloadable Resources section

Visitors will need to be informed both directly and indirectly about the new tobacco-free policy. Staff will appreciate cards or brochures they can give to a client, visitor, or co-worker who is violating the tobacco-free policy. These usually include a message about the policy with information about how to quit, including the Quitline phone number. Subtle messages include removal of smoking shelters and cigarette receptacles. These areas can be turned into recreational spaces or serenity gardens. On the day of the policy implementation, hold a kick-off event to celebrate the tobacco-free policy and your organization’s commitment to wellness. Invite community partners and local media to cover the event.

Anticipate negative reactions by some staff and clients. Staff members may express concerns that the policy will have a negative impact on the organization. Staff may cite smoking as a means to establish a therapeutic relationship with patients or to reward desired behavior. Studies show that smoking bans do not increase aggression, use of seclusion, discharge against medical advice, or use of as needed medication. Staff may also report that they do not want to be responsible for “policing” clients, visitors, and co-workers. Agency leadership must make it clear that it is everyone’s job to create a healthy work environment, which includes respectfully enforcing the policy. Staff should not be confrontational, but should provide information regarding the policy, and information about how to quit, and then inform the relevant agency personnel or treatment teams if individuals refuse to comply with the policy. If a violation poses a risk, security or police should be notified.