Initiation of a tobacco treatment program within an inpatient substance use treatment facility: A case study

Abstract

Tobacco use prevalence is disproportionately high among individuals with mental health conditions, including substance use disorders. Clinical practice guidelines recommend tobacco treatment for those receiving treatment for substance use given the health and psychosocial benefits from tobacco cessation. Despite this, there are several barriers to the provision of tobacco treatment in substance use treatment settings, and many patients in these settings do not receive treatment. This case study describes the acquisition of an inpatient substance use treatment facility by a major hospital system and the subsequent integration of a tobacco treatment service within this setting. In this case, we describe barriers, such as initial staff and patient hesitance toward the service, logistical challenges in service provision, and policy issues that needed to be addressed within the setting. Data derived from medical chart reviews of admitted patients show that following the introduction of the program, engagement with tobacco cessation pharmacotherapy and counseling substantially increased, which suggests acceptability and integration of the services. This case serves as a model of the adoption process of a comprehensive tobacco treatment program in substance use treatment settings as a way to reduce tobacco-related disparities in this priority population.

This case study illustrates how expanding a hospital-based tobacco treatment program into a substance use treatment facility was accepted by staff and patients and increased engagement with tobacco cessation support.

Implications.

Practice: This case study describes how a structured tobacco treatment program was integrated within a substance use treatment facility, which over time was well received by patients and improved engagement with tobacco cessation efforts.

Policy: This case describes how a smoke-free policy was newly instituted within an existing substance use treatment facility, and how the subsequent provision of tobacco treatment to patients supported this policy.

Research: Future studies should evaluate the long-term impact of tobacco treatment programs in substance use treatment facilities by evaluating cessation outcomes, as well as researching means to improve treatment delivery to increase tobacco cessation among this priority population.

Introduction

Tobacco use prevalence in the USA has been decreasing, which is a critical milestone for public health. However, tobacco use remains to be one of the leading causes of death and disability, partially as a result of exacerbating existing disparities among those disproportionately affected tobacco use [1]. For instance, individuals who have been diagnosed with psychiatric disorders, including substance use disorders, smoke at nearly twice the rate of the general population [2], with some estimates suggesting that about 70% of cigarettes smoked are by those with a co-occurring psychiatric diagnosis [3]. Despite recommendations [4] and Clinical Practice Guidelines [5], individuals with psychiatric diagnoses and substance use disorders often do not receive support for smoking cessation as a part of their care and are less likely to quit smoking than the general population [6]. This may be due to providers having negative views about smoking cessation and permissive attitudes about smoking, such as believing that smoking cessation is too much for patients to take on [7]. Institutional barriers include the culture of the setting being unsupportive for tobacco cessation and well as limited resources, such as medications [8, 9]. Despite these barriers, prior research has shown that integrating smoking cessation into substance use treatment organizations can improve staff knowledge and have a positive impact on recovery [10].

Widespread dissemination of tobacco treatment resources is critical so that all individuals are able to access treatment in a variety of settings. For this reason, many healthcare settings have taken steps to incorporate tobacco treatment into standard clinical care. Tobacco treatment programs (TTPs) embedded in medical settings, including healthcare systems with psychiatric and substance use treatment programs, have demonstrated the ability to reach a significant number of patients who smoke and connect them with cessation resources [11]. That is when the assessment of tobacco use and referrals to treatment are standard care for all patients, individuals who might otherwise not engage in smoking cessation leave the hospital with exposure to cessation resources, which may prompt future cessation attempts.

One example of such a program is the TTP at the Medical University of South Carolina (MUSC)/Hollings Cancer Center. The MUSC TTP utilizes an opt-out protocol with all admitted patients, such that any patient who reports tobacco use is referred to the program [11–13]. The MUSC TTP serves all hospitals at the main MUSC campus in Charleston, SC, which is a smoke-free campus. The program extends to the MUSC Institute of Psychiatry, which consists of inpatient units for general psychiatric care as well as a substance use disorder treatment unit. Trained inpatient counselors visit all referred patients, provide bedside counseling, and pend medication orders to the patients’ care team. Upon discharge, all patients are enrolled in an automatic phone system that collects smoking status and refers to the MUSC TTP or state Quitline. Long-term follow-up data from the MUSC TTP shows reductions in future healthcare costs [14] and fewer readmissions [15] among individuals treated through these interventions.

Recently, the MUSC Health system acquired two regional hospitals, expanding services into Florence, SC and Lancaster, SC. As a result, the MUSC TTP expanded into these regional health networks, providing tobacco treatment in largely rural areas that have been historically underserved [13]. Included into the expansion of the Florence site was an inpatient substance use treatment, rehabilitation, and detox facility. Prior to being acquired by MUSC, the detox facility permitted smoking by residents and did not provided tobacco cessation services. The subsequent case study describes how the detox facility evolved into a smoke-free facility with the routine provision of smoking cessation services for residents.

Methods and Results

This case study is presented through the perspective of the MUSC TTP counselor of the regional hospital to describe the initial integration of the TTP as well as the implementation of a smoke-free policy. Initial staff responses and patient reactions to the changes are examined, including a description of methods used to address barriers to treatment delivery such as working with detox staff, seeking input from patients, and involvement of hospital leadership. A chart review of patient data is also presented related to examine trends in TTP participation and prescriptions for stop-smoking medications. Using these data to support this manuscript was approved by the MUSC Institutional Review Board (IRB). Based on lessons learned throughout this experience, future directions for other programs and evaluations are discussed.

Patient population

The detox facility provides substance use detoxification, most commonly from alcohol, benzodiazepines (Xanax, Klonopin, Valium, etc.), or opioids (heroin, oxycodone, hydrocodone, etc.) alongside mental health care treatment for patients. The annual patient population is about 300–400 patients/year and includes both men and women, ranging from 18 to 65 years of age. Data were obtained from medical charts of all patient admissions. Table 1 shows patient demographics of all admissions within the detox unit at the time of acquisition to 2022 (the time period immediately following the establishment of the program). Overall, these demographics are reflective of the geographical region.

Table 1.

Patient demographics by year

	1 September 2019–31 August 2020	1 September 2020–31 August 2021	1 September 2021–31 August 2022
Admitted patientsa	N = 254	N = 342	N = 306
Age: M (SD)	43.69 (13.66)	42.49 (14.06)	45.36 (15.46)
Sex: n (%)
Male	138 (54.3%)	178 (52.0%)	157 (51.3%)
Female	116 (45.7%)	164 (48%)	149 (48.7%)
Race: n (%)
Black/African American	57 (22.4%)	78 (22.8%)	73 (23.9%)
White	186 (73.2%)	256 (74.19%)	220 (71.9%)
Otherb	6 (2.4%)	5 (1.5%)	7 (2.3%)
Unknown	5 (2.0%)	3 (<1%)	6 (1.9%)
Ethnicity: n (%)
Hispanic/Latinx	1 (<1%)	5 (1.5%)	3 (<1%)
Non-Hispanic/Latinx	251 (98.8%)	330 (96.5%)	294 (96.1%)
Unknown	2 (<1%)	7 (2.0%)	9 (2.9%)

Data from 4/4/2020 to 9/30/2020 are missing due to Covid-19.

^aRepresents the number of unique patients per year (individuals who were admitted multiple times throughout the year were only counted once).

^bRepresents patients who identify as Asian, Native American/Alaska Native, or another race.

Initial acquisition phase

The detox unit was a subunit of Carolinas Hospital System—Florence (a private hospital system), yet its physical location is a few miles from the main hospital campus. Prior to its acquisition by MUSC the detox facility was a free-standing facility consisting of seven inpatient beds and was part of a private hospital system. Patients in the facility were allowed to smoke in a designated smoking area but prohibited from smoking in the adjacent main hospital. Patients who identified as tobacco users were not administered nicotine replacement therapy (NRT) unless requested. Some staff were former or current tobacco users. There were no tobacco cessation programs systematically incorporated into treatment services.

Upon acquisition on 1 March 2019 and integration into the MUSC Health enterprise a hospital-wide inpatient TTP began to be implemented [11, 13]. However, the statewide tobacco-free policy was yet to be implemented until the unit itself was fully subsumed under MUSC. The MUSC TTP hired a master’s level social worker in January 2021 to serve as a tobacco treatment specialist (TTS) assigned to the Florence area to provide bedside counseling for all inpatients. This TTS underwent TTS training (accredited by the Council for Tobacco Treatment Training Programs). Following completion of this training, the TTS was trained on the day-to-day procedures of the MUSC TTP by the doctoral level TTS already established at MUSC TTP.

During the first few months of program implementation at the facility in April 2021, time was spent with introductions to the detox unit staff and giving more details of the role, as the unit initially questioned the necessity of adopting tobacco treatment services. An additional goal was to give the TTS access to the patients in the unit to begin to provide counseling to any patients interested in tobacco cessation. It took several attempts to master a convenient framework for establishing these procedures. To start, the detox unit leadership agreed to contact the TTS when there was an interested patient. Unfortunately, there was no voluntary participation by patients. Next, a proposal was made to meet with an “interest group” of patients. An allotted 15–25 minutes was designated to meet with patients interested in tobacco cessation using a group format. This approach resulted in improved participation because patients were motivated to attend a group session, either to address their tobacco use or gather information to assist the family. Tobacco history was discussed, common questions were answered, NRT use was explained, and cessation resources were disbursed. However, engagement by patients still remained low. In this setting, the TTS opted to prioritize the use of NRT given the ability to start working quickly (relative to prescription medications such as varenicline or bupropion) to alleviate nicotine withdrawal in the moment. NRT is also easily accessible, either over the counter or through state quitlines, without a prescription; therefore, it is the first-line treatment recommendation [5].

Leadership involvement

The TTS described some of the challenges faced to the MUSC TTP Director, who initiated a meeting with the MUSC Florence Chief Medical Officer and the Medical Director. In discussions, leadership was enthusiastic about the inclusion of tobacco cessation services. Prior to acquisition by MUSC, the medical center did not have tobacco cessation resources for inpatients nor its numerous clinics. An opportunity to include a tobacco cessation clinic wherein patients have access to services including treatment was appealing. Due to the immediate barriers presented with onboarding the detox unit, leadership was integral in bridging hospital policy and a new tobacco cessation program for the detox program. There was an assurance of full cooperation from the leadership with assistance in any needs from both the detox unit and the TTS. This resulted in the TTS feeling supported in finding ways to collaborate with staff on the best way to integrate tobacco cessation services within the detox unit. For example, prior to the initiation of the TTS, staff were only able to pend orders for NRT to physicians if patients specifically asked for it. With the help of leadership, procedures were revised such that there was a standing order for NRT for all admitted patients who were using tobacco, thus facilitating staff provision of medication.

A larger meeting was held with staff and leadership to communicate the need and benefits of tobacco cessation, as well as a discussion to work collaboratively to establish a workflow. Initially, staff were apprehensive of adding tobacco cessation and did not engage with efforts to provide these services. Staff endorsed concern that patients would turn down the detox unit because of the smoke-free policy, which might lead to a loss of funding and possibly their jobs. Staff also reported they were not optimistic that patients had an interest in quitting tobacco. Overall, fear and pessimism were overarching themes among the staff. However, after a few weeks of observing the TTS interactions with patients, they noticed that patients were responding positively to the newly implemented tobacco cessation program and group sessions. In fact, some patients were beginning to inquire to staff about NRT independently. These observations, coupled with encouragement from hospital leadership, prompted a shift in the perception of tobacco cessation services amongst staff.

Establishment of procedures and maintenance

The detox unit administrators and staff reported to the TTS that they believed the tobacco cessation groups to be well received by patients, and therefore, an agreement was made to designate two days of the week for the TTS to meet with interested patients in the dayroom for an hour. This method created an opportunity for patients to have an informal conversation with TTS. Patients could get a snack or enjoy a favorite TV show while engaging in conversation about their tobacco history. Patients were given brief counseling from the TTS and provided resources such as information about the Tobacco Quitline. Additionally, many interested patients requested NRT during these meeting times.

A few months after the establishment of these procedures, the detox unit was relocated to the main campus of MUSC Florence, and thus the full statewide smoke-free policy applied to this unit. Staff worked with the TTS to implement a weekly group session in which patients could learn more about tobacco cessation as well as obtain resources. If patients were too sick to be seen during weekly group sessions, then the TTS returned to visit patients individually later in the week. Additionally, nursing staff at the main campus requested assistance adequately providing the correct NRT dosage for patients. The TTS provided NRT dosage education for nurses to assist with the appropriate nicotine patch, lozenge, and gum based on patient’s reported nicotine intake of cigarettes, cigars, and e-cigarettes. Over time, staff needed less consultation from the TTS to integrate these changes into the workflow and began to provide tobacco cessation medications at higher frequencies.

Table 2 shows data related to patient tobacco use estimates, provision of NRT, and engagement in tobacco cessation services. Overall, admissions and prevalence of tobacco use remained stable throughout the time course of the acquisition and integration of the TTP in the facility, indicating that the new smoke-free policy did not deter any patients from seeking care. The provision of NRT and counseling for smoking cessation substantially increased following the collaborative efforts of the TTS and facility staff to integrate these services into the existing workflow, illustrated by Fig. 1.

Table 2.

Assessment of tobacco use status and provision of NRT by year

	1 September 2019–31 August 2020	1 September 2020–31 August 2021	1 September 2021–31 August 2022
Admitted patientsa	N = 254	N = 342	N = 306
Total admissions	N = 269	N = 382	N = 350
	N (%)	N (%)	N (%)
Tobacco use documentation: n (%)
Documented	220 (86.6%)	292 (85.4%)	236 (77.1%)
Not Assessed	34 (13.4%)	50 (14.6%)	70 (22.9%)
Tobacco use estimateb: n (%)
Cigarettes—current	162 (63.8%)	228 (66.6%)	166 (54.2%)
Cigarettes—past	17 (6.7%)	26 (7.6%)	28 (9.1%)
Smokeless—current	10 (3.9%)	24 (7.0%)	21 (6.9%)
Smokeless—past	5 (1.9%)	8 (2.3%)	8 (2.6%)
Smokeless—not assessed	13 (5.1%)	25 (7.3%)	13 (4.2%)
Vapingc		2 (<1%)	18 (5.8%)
NRT provision: n (%)
Number of patientsd	5 (1.9%)	16 (4.7%)	203 (66.33%)
Number of admissionse	6 (2.2%)	30 (7.8%)	314 (89.7%)
Received counseling: n (%)
Number of patientsd		11 (3.2%)	110 (35.9%)
Number of admissionse		11 (2.8%)	111 (31.7%)

Data from 4/4/2020 to 9/30/2020 are missing due to Covid-19.

^aRepresents the number of unique patients per year (individuals who were admitted multiple times throughout a year were only counted once).

^bRepresents the proportion who had documented tobacco use out of the unique patients admitted. Cigarettes, smokeless tobacco, and vaping are not mutually exclusive.

^cVaping status was not a part of the medical chart until late 2021 and is separate from the tobacco use documentation. These data are obtained from notes in the tobacco use documentation.

^dRepresents the proportion of unique patients who had received this treatment during any admission.

^eRepresents the proportion of admissions in which patients received this treatment (includes repeat patient admissions).

Figure 1.

Treatment services provided

Dates of years are from admissions beginning 1 September of prior year to 31 August of latter year. Data from 4/4/2020 to 9/30/2020 are missing due to Covid-19. The Y axis represents the number of unique patients per year (individuals who were admitted multiple times throughout a year were only counted once).

These data are consistent with the narrative report of increased patient acceptability and participation in services provided. Patients reported that prior to the smoke-free transition and establishment of tobacco cessation services, smoking while detoxing was an added incentive to come to the detox unit. Following the policy transition, patients were surprised at the introduction of a TTS as well as adherence to the tobacco-free policies. However, staff reported to the TTS that despite initial fears, the transition to a smoke-free facility had not slowed patients from choosing the detox unit for care. In fact, some individuals have undergone frequent inpatient admissions at the detox unit and adjusted to the tobacco-free environment well. During group sessions, patients reported gaining more knowledge than they previously had about quitting tobacco and appreciating the resources provided. Even if not ready to quit, patients are open to reducing tobacco use, which they had not previously considered. In the case of patients leaving detox to long-term treatment, they report the cessation services are a great educational transition into life without smoking. Although not all patients participate in services, overall, the established tobacco cessation services at this inpatient substance detox facility are now recognized as a standard practice by patients and staff with the support of the TTS.

Discussion

Individuals undergoing inpatient treatment for substance use disorders often lack support and resources for tobacco treatment [3]. Indeed, stigma remains among both patients and providers that smoking cessation is a much lower priority than other treatment goals, which may reduce interest and engagement in cessation attempts. This case study describes how, over time, tobacco cessation treatments were integrated in a substance use treatment facility. Data clearly illustrate that the prevalence of tobacco use and assessment did not change in the facility, but there was a significant and substantial increase in the provision and acceptance of tobacco cessation treatment once these services were being formally offered.

Prior to its acquisition by MUSC, there was no established tobacco treatment protocol in the detox unit and as a result, the delivery of tobacco cessation treatments was minimal. Thus, there are several important insights that can be gained from this case study. To begin, the increase in service utilization from the TTS demonstrates that there was a significant need for these tobacco cessation support in this facility that provides substance use treatment to underserved communities. Given what is known about the high rates of smoking among psychiatric populations [2], this high smoking prevalence could be addressed through an integrated TTP. For this reason, implementing tobacco treatment within these settings should be a high priority.

Initially, there was hesitance toward the TTP at the onset, which has validity given the previously established culture of the facility. However, though the work of the MUSC team at large alongside MUSC Florence leadership, multiple barriers were overcome and the program was integrated into the existing system. The case of the detox unit described in this paper demonstrates the power of having a tobacco treatment “champion” who is skilled in the assessment of the environment, validating staff concerns, facilitating procedural changes, and reinforcing cultural changes to adhere to statewide policies for smoking. In this case, the TTS showed persistence working within the facility and generated changes with staff input through a collaborative process. Additionally, the hands-on collaborative support of key leaders (e.g. setting up and attending group meetings related to the service) aided the efforts of the champion to work alongside healthcare staff to implement an acceptable treatment delivery protocol. For these reasons, the utilization of the program into the facility has been maintained and continues to grow and expand, as evidenced by patients and staff proactively seeking services and consultation with the TTS. Although several challenges were faced, this case study illustrates the integration of an established program into a setting that had not previously had a rigorous approach to tobacco use, which resulted in high acceptability and utilization. This case may function as a roadmap for other programs wishing to expand in a similar manner.

Implications for behavioral medicine

Outcomes from the integration of this program support the following recommendations for substance use treatment facilities interested in initiating tobacco treatment services: (i) The individual providing services should be trained as TTS through an accredited program. TTS trainings provide the clinician with comprehensive knowledge and skills to address tobacco use among a variety of populations, which increases confidence as a provider [16]. In this case, the certification also bolstered trust in the TTS among staff in the facility, and the TTS became an expert resource for those supporting the new smoke-free policy. (ii) Key partners, such as institutional leaders and staff members with leadership positions, should be visibly involved and supportive of the initial integration and adaptation of these programs. In this case study, the participation of the hospital leadership likely further encouraged staff to implement the new procedures and provided positive reinforcement for implementing the changes. Additionally, the adherence to a smoke-free policy ensured that all members of the hospital upheld this standard of care. Key personnel (such as administrators) can continue to support such programs through financial support, as it has been demonstrated that such programs save on future patient costs (post-discharge) and healthcare system costs (such as readmissions) [14, 15]. (iii) Whether a program is newly established or longstanding, TTPs should consistently evaluate outcomes from services. Program evaluation data could be used to support continued funding, which is critical to the maintenance of tobacco treatment services [11]. Additionally, program data evaluations can identify areas in which there is room for improvement in the provision of services. For instance, assessing differences in treatment responses or outcomes among various sociodemographic groups or diagnoses may help to elucidate individuals who are in need of additional support and resources.

Limitations and future directions

Given the nature of the setting, most patients were asked only about the most common tobacco products (combustible products and vaping) upon admission. Additionally, there are clear guidelines for recommending NRT doses based on cigarette smoking level and dependence which further supported this practice. However, oral products were not consistently documented. As the landscape of available nicotine and tobacco-containing products continues to expand (e.g. nicotine pouches, vaping), documentation of tobacco use status should be improved. Finally, this case study did not include formal analyses (e.g. theory-driven qualitative methodology) of the perceptions of the staff, administrators, and other involved parties described. Future research may consider utilizing these strategies to gain a richer understanding of the perceptions and processes involved when integrating tobacco treatment into similar settings.

In conclusion, tobacco treatment is a high priority for individuals undergoing inpatient treatment for substance use disorders. Despite this priority, many psychiatric treatment facilities do not offer smoking cessation treatment [17]. Substance use treatment facilities, especially those that serve under-resourced communities, should consider integrating tobacco treatment into their standard care protocols. The integration of the MUSC TTP in a substance use treatment facility illustrates ways in which barriers to implementing a TTP were overcome favorably for both staff and patients. Future work within this domain should track and evaluate long-term outcomes following the integration of the TTP in this setting.

Funding Sources

This publication was supported by the Hollings Cancer Center (P30 CA138313) and South Carolina Clinical and Translational Research (SCTR) Institute (UL1 TR001450), both with an academic home at the Medical University of South Carolina. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Conflicts of Interest

K.M.C. and B.A.T. testify on behalf of plaintiffs who have filed litigation against the tobacco industry.

Human rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required. MUSC IRB Pro00107000.

Transparency Statement

Neither this study nor the analysis was pre-registered. Data were derived from medical chart reviews and therefore are not publicly shared.