Total versus Partial Workplace Tobacco Use Bans in Texas Behavioral Health Centers and their Associations with Employees’ Report of Clear Signage, Policy Enforcement, Policy Awareness, and Their Beliefs, Training, and Practices Conducive to Addressing Clients’ Tobacco Use

Abstract

Objectives:

Adults with behavioral health needs exhibit elevated tobacco use rates. Tobacco-free workplace policies (TFWPs) at behavioral health treatment centers can effectively curb clients’ tobacco use and secondhand smoke/vape exposure. However, there is little extant observational research about how total versus partial workplace tobacco use bans are associated with employee’s perceptions of signage clarity, consistency of enforcement, and stakeholders’ policy awareness in behavioral health centers. Additionally, little is understood about the relations of total or partial TFWPs with other factors that may affect evidence-based client care provision including employees’ beliefs and their tobacco treatment practices. This study examined these associations within Local Mental Health Authorities (LMHAs) providing behavioral healthcare throughout Texas.

Methods:

Employees from 30 of 39 LMHAs (covering >75% of Texas’ statewide service area) responded to a 2021 survey on their TFWP characteristics, communication, awareness, enforcement, and other tobacco-related factors. Associations between the TFWP (total vs partial) and variables of interest were explored using independent proportions tests (p<0.10).

Results:

Relative to their counterparts, LMHAs with total TFWPs reported clearer signage; more consistent enforcement; and greater client, contractor, and visitor awareness (ps=.013–.078). They were also more likely to offer tobacco screening training, promote the Quitline, and believe in the benefits of concurrent treatment of behavioral health needs and tobacco use (ps=.024-.079).

Conclusions:

LMHAs with partial TFWPs had weaknesses in communication, enforcement, awareness, and greater barriers to tobacco use care provision. There are opportunities for collaboration between LMHAs to share policies and care-facilitation practices to reduce the research-to-practice gap and resultant tobacco use inequities statewide.

INTRODUCTION

Tobacco use is associated with an increased risk of multiple forms of cancer, stroke, and other chronic diseases leading to premature death.¹ Despite a significant reduction in the use prevalence since the 1960s, 19% of adults in the United States still used tobacco in 2020. ² Individuals with behavioral health conditions (BHCs), including those living with mental health and substance use disorders, are disproportionately affected by tobacco-related diseases as their tobacco use rates are significantly higher compared to the general population, with multiple studies showing that over 50% of people living with BHCs smoke cigarettes or use other forms of tobacco.^3–5 Consequently, further efforts are needed to address the existing disparities in tobacco use and improve health outcomes among these individuals.

People living with BHCs often want to stop using tobacco, but they face additional barriers to quitting compared to the general population. These barriers to quitting include high levels of nicotine dependence, fears of behavioral health symptom exacerbation during nicotine withdrawal, and changes in the effectiveness of their medications.^6,7 Fortunately, evidence-based treatment for tobacco use – primarily, a combination of brief counseling and nicotine- or non-nicotine-based medications – exist and are potentially effective for all tobacco users.⁸ However, adults with BHCs often have limited access to evidence-based treatment to support their quit attempts and prevent relapse.^9–11 For example, a 2016 study found that tobacco cessation programs were only offered in 37.6% of mental health clinics and 47.4% of substance use treatment centers in the United States.⁹ Further, in study conducted in 2021, only 48.9% of respondents representing a diverse range of healthcare centers that serve adults with BHCs in Texas reported that they screened patients for tobacco use and fewer provided counseling (47.4%) or nicotine replacement therapy (26.2%).¹² Common barriers to the provision of evidence-based tobacco cessation care in behavioral healthcare settings include lack of training, misconceptions about benefits of concurrent treatment and patient compliance, and lack of knowledge about referral resources.^10,13 While these barriers are commonly reported, there is also evidence that healthcare settings serving individuals with BHCs can accommodate changes to provide better tobacco cessation services to their clients by directly addressing these barriers.^14,15

Implementation of tobacco-free workplace policies (TFWPs) is an evidence-based practice which significantly contributes to changing social norms around acceptability of smoking, promoting delivery of tobacco cessation services, and reducing tobacco use, while at the same time decreasing exposure to secondhand smoke and vapor among non- and former smokers as well as those trying to quit,^9,16–20 including within behavioral healthcare settings.^21–24 A “total” TFWP would disallow tobacco use in any form anywhere on the property; these are recommended over “partial” (those with designated use areas on site and/or are limited to certain tobacco products) policies. Although data are from observational versus experimental designs, prior research suggests that total TFWPs are about two times more effective than partial policies in reducing tobacco consumption and prevalence.²⁵ The lower effectiveness of partial policies may be due to the mixed message that they convey about the ubiquity of tobacco use and the importance of tobacco cessation.²⁶ Moreover, evidence suggests that TFWPs are most effective when they are explicitly communicated to clients, employees, and visitors and are strictly enforced; partial TFWPs may be associated with lower awareness of them, making compliance and enforcement more troublesome.^14,27,28

In Texas, there are no laws governing tobacco-free workplace policies in behavioral healthcare centers. State-supported behavioral healthcare contracts, however, mandate that these centers need to be a “Tobacco-Free Workplace.” Despite this, their contracts do not include that they have to ban tobacco product use for all tobacco products and everywhere on the property; enforcement requirements are not detailed; and mandates for things conducive to the provision of tobacco use care for clients are not included (e.g., training of providers on evidence-based care and referrals). Consequently, there is some variation in the approach to this contractual mandate between behavioral healthcare centers. However, there is a paucity of data on how total versus partial TFWPs may differ in their visibility and enforcement, as well as how they may relate to myriad tobacco care-facilitating practices in Texas.

The current study redresses this gap in the literature by addressing how total versus partial TFWPs were associated with employees’ perceptions of signage clarity, consistency of enforcement, and policy awareness within behavioral healthcare centers in Texas. Additionally, it explores the association of total vs partial TFWPs with employee’s tobacco treatment beliefs, exposure to training on screening for tobacco use, familiarity with and use of referrals to the state Tobacco Quitline, and billing practices for cessation care provision. We hypothesized that behavioral healthcare settings with total TFWPs would evince greater employee perceptions of signage clarity, consistent policy enforcement, stakeholder policy awareness, and other evidence-based care-facilitating factors than would settings with partial TFWPs.

METHODS

Participants and Procedures

Electronic survey data were collected from April to December 2021 as part of a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis of Local Mental Health Authorities (LMHAs) in Texas. LMHAs offer low-cost behavioral health care for a range of conditions with a focus on addressing mental health needs; there are 39 LMHAs covering all areas of the state.²⁹ The aim of the SWOT was to understand current tobacco control policies within these healthcare centers and develop a roadmap to inform future efforts in providing support to Texas’ LMHAs.³⁰

Survey solicitations were sent via email to leadership (e.g., CEOs, Executive Directors) at each of the 39 LMHAs by collaborators (coauthors) who were affiliated with Austin Travis County Integral Care (a Texas LMHA), including its CEO. Recipients were encouraged to forward the solicitations to an individual within their LMHA who was best placed know how tobacco use was being addressed to complete the survey on behalf of the LMHA. Only 1 survey per LMHA was requested. Multiple reminders for survey completion were sent over a 5-month period.

Overall, there were 56 completed surveys during our data collection period and 8 partially completed surveys. Of the partially completed surveys, 7 respondents were from the same 3 LMHAs, for which we already had at least 1 completed survey. Therefore, incomplete data from these 7 respondents were withdrawn from the dataset. The remaining incomplete survey had ~58% of the survey items completed. Given that there was no complete survey from that LMHA in our records, partially completed survey data were maintained in our analysis. Consequently, there were 57 responses received from 30 unique LMHAs (30/39=76.92% of LMHAs). There were 9 respondents from a single LMHA and 20 respondents from another. Interrater reliability of a selection of factual (i.e., not opinion/attitude based) survey items amongst the LMHAs providing >1 complete survey was moderate or high (0.52–1.00). A single survey for each of the 2 LMHAs was retained in the analytic dataset; the respondent who also completed an individual interview on behalf of their LMHA (as part of the qualitative procedures of the SWOT analysis, data not presented herein) was selected for inclusion. The final sample of respondents (n=30) represents the 30 unique LMHAs. Conjointly, these LMHAs served the entirety of Texas, with their service areas spanning all 11 public health regions.

According to the University of Houston’s IRB, this study did not meet the definition of human subject research. Despite this, to provide full transparency, each employee was provided with a cover letter detailing study aims and key elements of informed consent prior to being provided access to the Qualtrics survey. Each respondent received a $20 Amazon e-gift card as remuneration for their time and participation in the study.

Measures

The items administered and described below were investigator-generated, face-valid items designed to gather information on various factors that may serve as barriers or facilitators to the delivery of evidence-based tobacco cessation interventions (including TFWPs) as informed by theory, practicality, and the team’s extensive experience working in or with behavioral health treatment centers on tobacco initiatives.

LMHA characteristics

LMHA characteristics included: (1) the number of clients treated annually (later categorized ≤1600 vs. ≥1601), (2) number of full-time employees (later categorized as <100, 101–200, 201–300, 301–400, 401–500, vs. ≥501), (3) inclusion of an on-site pharmacy (yes vs. no), (4) presence of at least one Certified Tobacco Treatment Specialist (CTTS; yes vs. no/I don’t know), and (5) provision of telehealth services (yes vs. no).

Independent variable

Respondents were queried on whether their LMHA implemented a total tobacco-free workplace program (TFWP), defined as those that prohibit all tobacco use and e-cigarette use/vaping in all buildings and on the outside LMHA property in its entirety (yes vs. no/I don’t know).

Dependent variables

Respondents were asked to indicate their level of agreement or disagreement on the following statements: (1) “My LMHA has clear signage regarding our tobacco use policy”; (2) “Our tobacco use policy is consistently enforced”; (3) “Our clients are aware of our tobacco use policy”; (4) “Our contractors are aware of our tobacco use policy”; (5) “Our visitors are aware of our tobacco use policy”; (6) “My organization suggests that we refer smokers and other tobacco users to the Texas Tobacco Quitline.” Each item was rated along a 5-point Likert scale. For analysis, endorsements of strongly disagree, disagree, and neither agree nor disagree were compared against endorsements of agree or strongly agree.

Additionally, participants were queried for their beliefs regarding concurrent treatment for tobacco and illicit drug use, which are common client comorbidities in behavioral health settings. Specifically, they were asked: “For clients who use illicit drugs and tobacco products (and are open to any of the options below), which should come first?”. Options included: (1) “Quit using drugs”; or (2) “Quit using drugs and tobacco at the same time.” Responses of quit using drugs first were considered relative to quit using drugs and tobacco concurrently; the latter is considered a belief conducive to addressing clients’ tobacco use whereas the former is not. An additional item assessed agreement with “People with mental and/or non-nicotine substance use disorders who quit smoking may experience concurrent improvements in some mental health symptoms and/or reductions in non-nicotine substance use.” This item was rated along a 5-point Likert scale; for analysis, endorsements of strongly disagree, disagree, and neither agree nor disagree were compared with endorsements of agree or strongly agree. Agreeing/strongly agreeing with this item is a belief considered conducive to addressing clients’ tobacco use.

Lastly, employees indicated their agreement or disagreement (yes vs. no/I don’t know) with the following: (1) “Does your organization receive/offer training to direct service providers on how to screen clients for tobacco use ”; (2) “Does your organization encourage you to seek reimbursement for smoking cessation counseling from clients’ private or public insurance coverage?”; and (3) “My LMHA is familiar with the Texas Tobacco Quitline.”

Statistical Analysis

Whether the center characteristics differed between those LMHAs with a total TFWP and their counterparts with a partial TFWP were investigated using chi-square tests. Independent proportions tests were used to determine associations between the independent variable (having a total vs. partial TFWP) and dependent variables (TFWP communication, enforcement, and awareness efforts; employee’s beliefs about treating client’s tobacco use; and the LMHA’s tobacco-related practices). Due to a small sample size of 30, p <.10 was used to assess significance. Analyses were conducted using SAS version 9.4.

RESULTS

Descriptive Statistics

Approximately half (53.3%) of respondents were direct service providers who treated LMHA clients. Overall, 70% of responding LMHAs had a total TFWP. More than half (65.5%) of responding LMHAs indicated that they serve ≥1601 clients annually; 20.0% of LMHAs reported ≥501 fulltime employees. LMHAs with a total TFWP tended to have more full-time employees relative to LMHAs with a partial TFWP (X²=12.09, p=0.03). See Table 1.

Table 1.

Descriptive Statistics of Responding Local Mental Health Authorities (LMHAs; N=30 employees representing 30 LMHAs).

Variable of interest
Type of tobacco-free workplace policy	All	Total (n=21, 70%)	Partial (n=9, 30%)	X 2	p
	%
Number of full-time employees				12.09	0.03
<100	10	0	33.3
101–200	13.3	9.5	22.2
201–300	16.7	23.8	0
301–400	23.3	23.8	22.2
401–500	16.7	23.8	0
≥501	20	19.1	22.2
Number of clients treated annually				0.01	1.00
≤1600	34.5	35	33.3
≥1601	65.5	65	66.7
Presence of on-site pharmacy				0.52	0.69
Yes	43.3	47.6	33.3
No/I don’t know	56.7	52.4	66.7
Presence of a Certified Tobacco Treatment Specialist				0.52	0.69
Yes	43.3	47.6	33.3
No/I don’t know	56.7	52.4	66.7
Provides telehealth services				2.41	0.30
Yes	96.7	100	88.9
No	3.3	0	11.1

Communication, Enforcement, and Visibility of Tobacco-free Workplace Policies

Relative to their counterparts, employee representatives at LMHAs with partial TFWPs were less likely to report clear tobacco-free signage; consistent TFWP enforcement; and client, contractor, and visitor awareness of their TFWP than LMHAs with total TFWPs. See Table 2.

Table 2.

Communication, Enforcement, and Awareness of Total versus Partial Tobacco-free Workplace Policies at Texas Local Mental Health Authorities (LMHAs; N=30 employees representing 30 LMHAs).

	Type of Tobacco-Free Workplace Policy (TFWP)
	Total n=21, 70.0%	Partial n=9, 30.0%
	%	%	p value
Communication
LMHA has clear tobacco-free signage	95.2	71.4	.078
Enforcement
LMHA consistently enforces the TFWP	95.2	71.4	.078
Awareness
Clients are aware of the TFWP	95.2	71.4	.078
Contractors are aware of TFWP	95.2	71.4	.078
Visitors are aware of the TFWP	95.2	57.1	.013

Note. % = valid percent of centers endorsing neither agree or strongly agree to the associated statement; Due to a limited sample size, p < .10 was considered significant.

Employee Beliefs on Tobacco and Behavioral Health Co-treatment

Having a partial TFWP was associated with a greater likelihood of the representative employees reporting a belief that clients should stop using drugs before quitting tobacco, a lower likelihood of believing that clients should quit drugs and tobacco simultaneously, and a lower likelihood of believing that concurrent improvements in mental health symptomatology could be attained with concurrent treatment. See Table 3.

Table 3.

Employee Beliefs on Tobacco and Behavioral Health Co-treatment in Local Mental Health Authorities (LMHAs) with Total versus Partial Tobacco-free Workplace Policies (N=30 employees representing 30 LMHAs).

	Type of Tobacco-Free Workplace Policy (TFWP)
	Total n=21, 70.0%	Partial n=9, 30.0%
	%	%	p value
Employee believes clients should stop using drugs before they quit tobacco use.†	42.9	77.8	.079
Employee believes that clients should stop using drugs at the same time they quit using tobacco.†	52.4	11.1	.035
Employee believes that people with mental health and/or non-nicotine substance use disorders may experience concurrent improvements in their symptoms if they quit smoking.	85.7	55.6	.074

Note. %

^†= valid percent of centers endorsing the associated statement, or % = endorsing agree or strongly agree to the associated statement; Due to a limited sample size, p < .10 was considered significant.

Center Practices on Tobacco Treatment

LMHAs with a partial TFWP were less likely to provide tobacco use screening training, have state Quitline familiarity, and encourage Quitline referrals. However, they were more likely to promote insurance reimbursement for tobacco services. See Table 4.

Table 4.

Center Practices on Tobacco Treatment in Local Mental Health Authorities (LMHAs) with Total vs. Partial Tobacco-free Workplace Policies (N=30 employees representing 30 LMHAs).

	Type of Tobacco-Free Workplace Policy (TFWP)
	Total n=21, 70.00%	Partial n=9, 30.00%
	%	%	p value
LMHA provides training on screening clients for tobacco use.	80.9	37.5	.024
LMHA promotes insurance reimbursement for tobacco services.	9.5	37.5	.075
LMHA is familiar with the Quitline.	90.5	62.5	.075
LMHA encourages Quitline referral.	78.9	42.9	.077

Note. % = valid percent of centers endorsing yes to the associated statement; Due to a limited sample size, p < .10 was considered significant.

DISCUSSION

While previous research has explored the impact of implementing total TFWPs in various settings,^27,31–36 few studies, to our knowledge, have examined how total versus partial TFWPs within similar state-supported behavioral healthcare centers are related to employees’ reports of signage clarity, policy enforcement, client and contractor policy awareness, and their beliefs, training, and practices conducive to addressing clients’ tobacco use.^37–40 This study found lower likelihood of signage clarity, enforcement, and awareness; endorsement of the benefits of concurrent treatment of tobacco use and behavioral health needs; and center practices conducive to the provision of tobacco dependence care in LMHAs that had partial (vs. total) TFWPs based on the report of a knowledgeable/representative employee. Consequently, results contribute to improving the understanding of how TFWPs are associated with center practices and employees’ perspectives related to policy enforcement and the provision of tobacco treatment.

At LMHAs with partial TFWPs, the representative employee was less likely to report clear tobacco-free signage at their centers, consistent TFWP enforcement, and perceived client, contractor, and visitor awareness of their TFWP compared to their employee counterparts at LMHAs with a total tobacco use ban. Previous studies have found that clear and direct signage is an important factor that contributes to increased awareness and understanding amongst individuals regarding existing tobacco-free policies and practices, as well as a better implementation of a TFWP, through passively addressing and preventing violations.^41,42 In addition to enhanced communication via tobacco-free signage, enforcement of the TFWP is required to maintain an honest tobacco-free culture within settings.⁴³ For example, a previous study conducted on a college campus found that compliance with a campus-wide TFWP increased with in-person intervention via campus ambassadors, who were trained to approach violators using scripted messages.⁴⁴ The use of clear signage and policy enforcement can contribute to greater stakeholder awareness of TFWPs, compliance with them, and ultimately may contribute to reduced tobacco usage when consistently employed at worksites. In our sample, best practices for TFWP communication (clear signage) and enforcement (consistency) aligned with greater perceived stakeholder awareness when the TFWP was total versus partial. Although the future research will be needed to ascertain mechanisms that underlie these associations, results may reflect that a total TFWP may be more definitive and easier to convey to and enforce with stakeholders than a partial TFWP, which allow exceptions for tobacco use in certain areas in the workplace or the use of certain tobacco products on the grounds of the workplace.

One of the barriers to the provision of evidence-based tobacco cessation care in behavioral healthcare settings is the misconception amongst employees (both providers and administrative staff) that concurrent treatment for tobacco and other substance dependencies hinders substance use recovery, and that concurrent treatment of mental health needs and tobacco use can improve mental health symptoms.^45,46 This misconception persists despite empirical evidence to the contrary.^47,48 Our findings suggest that LMHAs with a total TFWP were more likely to endorse understanding the benefits of concurrent treatment relative to LMHAs with a partial TFWP. Employees at LMHAs with partial TFWPs may be less likely to be aware of positive effects of concurrent treatment, possibly due to a lack of continuing education on the topic; this may result in the lower likelihood of concurrent tobacco cessation care delivery to clients while in substance use treatment. Overall, results may suggest the importance of educating employees at LMHAs about the benefits of concurrent tobacco use treatment on other behavioral health outcomes as a mechanism to increase their care provision for tobacco use.

Limited provision of evidence-based tobacco cessation care in behavioral healthcare settings has been discussed in prior research, which identified multiple barriers to improving and expanding these services.^13,49,50 Lack of organizational policies, leadership support, and funding for tobacco cessation care stagnates the goal of reducing tobacco use in these settings where the implementation of TFWPs and provision of concurrent tobacco and behavioral health treatment often remain low priorities. The current study supported that representative employees at LMHAs with total TFWPs were more likely to report the receipt/availability of training on how to screen clients for tobacco use, more likely to be familiar with the state tobacco Quitline, and more likely to refer clients to the Quitline than their counterparts at LMHAs with partial TFWPs. These results may suggest that LMHAs implementing total TFWP policies are also engaging in other practices conducive to providing tobacco cessation care for their clients, including but not limited to referral to the Quitline, which can be done quickly and without taking significant time away from the presenting problem. Future work should seek to understand what contributes to the alignment (or lack thereof) of evidence-based tobacco-related policies and practices in LMHAs, which may have implications for further reducing the research-to-practice gap for tobacco care in these settings.

A potentially surprising finding is that the representative employees at LMHAs with total TFWPs were less likely to endorse that their LMHA promoted insurance reimbursement for tobacco screening and cessation services than at LMHAs with partial policies. The reasons for this are unknown; however, it may be that the provision of tobacco cessation services at LMHAs with partial TFWPs are more closely linked with the ability to be compensated for those services than at LMHAs with total TFWPs. Alternatively, it may also reflect a systematic lack of understanding about billing codes in some versus other LMHAs, or may reflect differences in the type of insurance carried by most clientele (or uninsurance rates) in some settings. Further research is necessary to explain this finding.

Limitations and Strengths

The current study has limitations and strengths. One potential limitation of our study is that it was conducted solely in Texas, and as such, its applicability to behavioral health treatment centers throughout the country is unknown. Future research should investigate this topic in different regions and contexts to determine if the results are consistent across diverse settings. Additionally, the current study was observational and cross-sectional and thus can only describe associations between variables and not causal processes. Future work would benefit from a longitudinal design and investigation of other potential factors that could impact how TFWPs affect employee beliefs and behaviors (e.g., center size and location, funding, and demographics of clients and employees). These data could provide a more nuanced understanding of how total TFWPs can be most effectively implemented in LMHAs. Additional limitations include that although respondents hailed from each of the public health regions across Texas, their combined service area coverage was not statewide; thus, results do not represent all Texas LMHAs. Reasons for non-response are unknown but could include the perception that the purpose of the survey, to inform future efforts in providing support to Texas’ LMHAs, was perceived as unnecessary or unwelcome. Finally, the respondents may have provided data that was not truly representative of practices across the LMHA within which they were employed. Similarly, the respondents who completed the surveys may have had varying familiarity about their LMHA policies and practices; it is unknown whether having a partial TFWP was systematically associated with the veracity of the other data reported. Likewise, the current work relied on employees’ perceptions of their workplace policy; policies were not reviewed independently to ascertain congruence with the employee reports.

Strengths of this study include its focus on the type of TFWPs (total versus partial) that exist within state-supported behavioral healthcare centers, which has not been previously explored in the literature, and its association with several variables that are conducive to the provision of tobacco cessation care. These findings might have implications for policy mandates, including but not limited to providing guidance for the development of more extensive TFWPs that encourage comprehensive and unified approaches to tobacco cessation care within behavioral healthcare settings across Texas.

Conclusion

This study addressed the association of total TFWPs with other factors that are conducive to the provision of tobacco cessation care to clients of behavioral health treatment centers in Texas. Findings supported that LMHAs with total TFWPs were more likely than those with partial TFWPs to have their representative employee report clear tobacco-free signage; engagement in consistent TFWP enforcement; employee, client, and visitor awareness of the policy; the benefit of co-treatment of nicotine and other addictions and mental health symptomatology; and other center practices conducive to the provision of tobacco dependence care (i.e., training on how to screen clients for tobacco use, awareness of and referrals to the state Quitline). At a minimum, this work supports the existence of variation within state-supported LMHAs with regard to their TFWPs. Consequently, results may suggest the potential utility of mandating that state-supported behavioral healthcare centers implement total TFWPs (an evidence-based tobacco control intervention that may be more likely than a partial TFWP to affect stakeholder tobacco use) to align their approach to tobacco control across the state for the overall health of Texans. Of course, it would be ideal to align policy mandates with resources for policy communication and enforcement, employee training on treating tobacco use, instructions for how and when to bill for cessation care, and information about tobacco cessation care referral sources. Alignment of policies across the state could better facilitate resource-sharing between LMHAs that might enhance their tobacco care provision to clients. Alternatively, factors that facilitate the treatment of tobacco use (e.g., training of providers on evidence-based interventions) could be incentivized within the LMHA state contract to increase their use. Although more research is needed, these findings may suggest that the implementation of total TFWPs in LMHAs may help to facilitate the development of more integrated care and effective intervention strategies to enhance the well-being of clients receiving behavioral healthcare services in Texas.

IMPLICATIONS FOR HEALTH BEHAVIOR OR POLICY.

1. Total Workplace Tobacco Use Bans (TFWPs)

• Further research is needed to explore the impact of total TFWPs in diverse settings to determine the consistency of results across different regions and contexts.

• State-supported behavioral healthcare centers might consider mandating total TFWPs to align their approach statewide with this evidence-based approach to tobacco control.

2. Signage and TFWP Enforcement

• Practitioners should focus on implementing clear signage for the TFWP and engage in consistent enforcement, as these measures contribute to greater stakeholder awareness and compliance.

• Policymakers should provide resources for policy communication and enforcement to employees to ensure the effective implementation of total TFWPs.

3. Addressing Misconceptions About Concurrent Treatment

• Practitioners should invest in continuing education to help employees understand the benefits of concurrent treatment for tobacco and behavioral health needs.

• Policymakers should encourage and support educational programs that address common provider misconceptions, emphasizing the positive effects of concurrent treatment.

4. Provision of Evidence-Based Tobacco Cessation Care

• Practitioners should adopt total TFWPs and prioritize best practices recommended for improving tobacco cessation care, including training on how to screen, refer, and treat clients who use tobacco.

• Further research is necessary to explain the finding that total TFWPs are less likely to promote insurance reimbursement for tobacco screening and cessation services.

5. National and International Health Priorities

• Alignment with WHO and Healthy People Initiatives: The study’s recommendations align with the World Health Organization’s priorities for tobacco control and the goals outlined in Healthy People 2020 and Healthy People 2030 in the United States. Some of these objectives include:

  • Increase the proportion of worksites with policies that ban indoor smoking – ECBP-D06
  • Increase the proportion of adults who get advice to quit smoking from a healthcare provider – TU-12
  • Increase use of smoking cessation counseling and medication in adults who smoke – TU-13

In sum, this study provides valuable insights into the significance of total TFWPs in behavioral health treatment centers (i.e., LMHAs) in Texas. Mandating total TFWPs across the state could lead to more effective tobacco control and enhanced well-being for clients. However, to ensure success, policymakers should align total TFWP implementation with resources for policy communication and enforcement, employee training, and cessation care referral sources. Further research is essential to validate these findings in various settings and to explore potential factors that may influence employee beliefs and behaviors related to TFWPs and other factors conducive to the provision of evidence-based tobacco use care. Results suggest that more work is needed to ensure the absence of a research-to-practice gap in tobacco control and intervention in Texas’ LMHAs, which can ultimately translate into a reduction in tobacco-related disparities for clients in behavioral health treatment centers.