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. 2017 Sep 19;20(11):1386–1392. doi: 10.1093/ntr/ntx211

Smoking and Tobacco-Free Policies in Women’s Residential Substance Use Disorder Treatment Facilities: A Community-Engaged Approach

Amanda Fallin-Bennett 1,✉, Kimberly A Parker 2, Alana Miller 1, Kristin Ashford 1, Ellen J Hahn 1
PMCID: PMC6154983  PMID: 29059449

Abstract

Introduction

The purpose of this study was to (1) describe the role of smoking in the lives of women in residential substance use disorder (SUD) treatment and (2) explore perceptions of the facilitators and barriers to tobacco-free policy among women in residential SUD treatment.

Methods

This was a community-engaged study using qualitative descriptive methods. We first recruited women in a residential SUD treatment facility to participate on a community research team. Interviews with staff (N = 10) and focus groups with clients (N = 42) were conducted using guides informed by the community research team. Interviews and focus groups were analyzed using content analysis.

Results

There were two themes related to the role of smoking in the women’s lives: (1) smoking facilitates socialization and (2) smoking as a coping mechanism. There were three themes related to the benefits of tobacco-free policy: (1) improved health, (2) support for continued abstinence from a previous tobacco-free placement (eg, prison), and (3) less grounds up-keep. Barriers to tobacco-free policy included (1) lack of an alternative coping mechanism to smoking, (2) fear that a tobacco-free policy would drive clients away, and (3) anticipation of implementation challenges.

Conclusions

Many women in residential SUD treatment smoke, which they attribute to the fact that smoking is used to facilitate socialization and cope with stress. Future research is needed to develop and test messages to counter the misperception that smoking is an effective method to cope with stress. Ultimately, evidence-based tobacco-free policies are needed to reduce tobacco-related disease among women with SUDs.

Implications

To promote smoking cessation among women with substance use disorders through evidence-based tobacco policy, it is necessary to first understand the role of smoking in their lives as well as facilitators and barriers to tobacco-free policy in residential treatment facilities. Participants reported that smoking facilitated socialization and served as a coping mechanism. Tobacco-free policies have many benefits, including improved health, support for continued abstinence from a previous tobacco-free placement (eg, prison), and less grounds up-keep. Barriers include the lack of an alternative coping mechanism, fear that a tobacco-free policy would drive away clients and anticipation of implementation challenges. To reduce the burden of tobacco-related morbidity and mortality among women and their children, it is necessary to catalyze a culture change in behavioral health settings to prioritize the treatment of tobacco alongside treatment of other addictions.

Introduction

Smoking is the leading cause of preventable death and disease nationwide, and a risk factor for cancer in nearly every organ of the body.1 Tobacco use disproportionately burdens disadvantaged groups, and thus, is a pressing public health and social justice issue.2 While smoking rates have dramatically decreased among the general population, they remain high among vulnerable women including women with substance use disorders (SUDs).3,4

The World Health Organization has highlighted the need for more research on tobacco use among women5 as well as the need for gender specific tobacco control policies.5,6 Lung cancer is the leading cause of cancer deaths among women, and since 1960, there has been a 10-fold increase in lung cancer among women. Smoking is also linked to a variety of women’s health issues, such as dysmenorrhea,7 rheumatoid arthritis,8 and breast9 and cervical cancer.10 Postmenopausal women who smoke have lower bone density and a higher risk of hip fracture.1

Smoking rates are highest among women of childbearing age, and smoking during pregnancy is associated with birth defects, sudden infant death syndrome, asthma attacks, and frequent ear infections.1 Further, the risks of maternal smoking to children continue beyond pregnancy. Among children, exposure to tobacco smoke further increases the risk of SIDS,1 as well as middle ear disease, impaired lung function, more frequent and severe asthma attacks, and attention deficit hyperactivity disorder.

Women addicted to alcohol or other drugs have particular challenges with tobacco treatment. Compared to men with SUDs, women are more likely to have co-occurring mood and anxiety disorders which can complicate tobacco dependence treatment.11 Further, women accessing SUD treatment face more barriers than men including more social stigma and a range of gender-specific complicating factors (eg, pregnancy and parenting issues).12

Given these challenges, it is critically important to tailor tobacco treatment programs for women with SUDs. People with alcoholism are more likely to die of tobacco-related disease than alcohol-related disease.13 Further, there is a body of literature indicating that nontobacco users have better SUD treatment outcomes.14–16 According to a meta-analysis, individuals in treatment for SUD who participate in smoking cessation have a 25% greater likelihood of long-term abstinence from alcohol and other drugs.17 Results of a recent study indicated that among individuals enrolled in intensive outpatient treatment for alcohol use who concurrently participated in a smoking cessation program, daily smoking abstinence was associated with same day reports of lower urge to drink and consume alcohol and greater alcohol abstinence self-efficacy.18 In addition, clients in SUD treatment facilities have reported interest in smoking cessation19 as well as the ability to be successful in smoking cessation.20,21

Smoking cessation has historically not been prioritized within the behavioral health system.22,23 This is in part due to the pervasive myth that smoking cessation will lead to SUD relapse, and the tendency among behavioral health professionals to compartmentalize different substances in their approach to treatment.23 Despite the widespread adoption of tobacco-free policies in other healthcare settings (eg, hospitals, health departments and clinics),24 SUD treatment facilities have lagged behind.

Tobacco-free policies are endorsed by the Centers for Disease Control and Prevention25 and the Substance Abuse and Mental Health Services Administration.26 Smoke and tobacco-free policies reduce exposure to secondhand smoke,27 smoking prevalence,28 and tobacco-related hospitalizations for heart attacks, and asthma and chronic obstructive pulmonary disorder exacerbations.29,30 Smoke-free policies are also linked to less relapse to daily smoking among former smokers.31 Five years after a statewide smoke-free policy for New York SUD treatment programs, the smoking prevalence declined among staff and led to a decrease in cigarettes per day among clients.32 To be more effective, tobacco-free policy adoption and implementation needs to be tailored to meet the needs of vulnerable individuals, including women with co-occurring SUDs.33

To promote smoking cessation among vulnerable women through evidence-based tobacco policy, it is necessary to first understand the meaning or role of smoking in their lives.34 The purpose of this community engaged study was to (1) describe the role of smoking in the lives of women in residential SUD treatment and (2) explore perceptions of the facilitators and barriers to tobacco-free policy among women in residential SUD treatment.

Methods

This community-engaged research study was approved by the University of Kentucky Institutional Review Board. The study setting was a residential SUD treatment facility that serves women with alcohol and other drug addiction. The facility, located in a southern, historically tobacco growing state, is licensed to provide care to women who are pregnant, and young children can live with their mother on site. This study was conducted through a partnership between the university research team and a community research team. Four community members (women living in the residential treatment facility) were on the community research team at any given time, and throughout the year there were a total of 11 members.

The university-community team developed focus group and interview guides with input from experts in tobacco control, tobacco use in behavioral health populations, and health communication/message design. The guides were further informed by the community research team through (1) regular meetings of the university and community research team members, (2) photo voice, and (3) social determinants mapping. For the photo voice project, the community research team members were given disposable cameras and asked to take photos of environmental triggers for smoking throughout the day. The community research team also participated in a social determinants mapping exercise. They drew a map of the places they went on a weekly basis, and identified places where they typically smoked (eg, smoking porch at the treatment facility) or engaged in health promoting activities (eg, walking path or the site of a support group meeting). These activities helped guide discussions about the role of smoking for women in the residential treatment program and inform the content for the interview and focus group guides.

Individual interviews with staff (N = 10) and 3 hour-long focus groups with clients (N = 42) were conducted in private, convenient locations at the SUD treatment facility. Clients were recruited from weekly wellness courses held at the treatment facility. Staff members who engaged directly with the clients on a regular basis were recruited, including those involved in treatment, admissions, case management, and peer support. Including the perspectives of both staff and clients in this study allowed for data triangulation. A trained research assistant (AM) and an expert in qualitative research methods (AFB) conducted the focus groups, and the research assistant conducted individual interviews. Staff and clients each received a $25 gift card as compensation for their time.

Measures

Interview and focus group guides with main questions and structured prompts were used; unstructured prompts were used to follow up on unexpected topics that arose. The interview and focus group guides included questions on the meaning of smoking in the clients’ lives (eg, with clients, “When you think about smoking cigarettes, what is the first thing that comes to mind for you?” and decision makers, “How would the women’s lives change if they quit smoking?”). In addition, the interview and focus group guides included questions on barriers and facilitators to smoking cessation (eg, with clients, “What would you need to quit smoking?” and “What are some of the reasons you have decided not to try [to quit smoking]?”; with decision makers, “What do you think would help women at [insert facility name] stop smoking?” and “What would motivate you to pursue a policy that prohibited tobacco use on the grounds?” and “What would stop you from pursuing a policy at the [insert name of facility] that prohibited tobacco use on the grounds?”

Following the focus groups, clients were asked to fill out a brief paper and pencil survey to assess participant demographics and tobacco use characteristics. We assessed the importance of smoking cessation to each client, as well as whether they felt confident they would quit smoking in the next month. The importance of smoking cessation was assessed by the question, “How important is stopping smoking to you on a scale of 0 to 10? (0 = not important at all; 10 = most important goal of my life).”35 Confidence was assessed with the question, “How confident are you that you will quit smoking in the next month? (0 = not confident at all; 10 = 100% confident).”

Data Analysis

Interviews and focus groups were voice recorded with participant permission and professionally transcribed verbatim. The transcripts were then checked against the recording by a research assistant (AM). A codebook was developed inductively from the data by the university research team, with feedback from the community research team. The data were analyzed using content analysis in MAXQDA. The research assistant (AM) and principal investigator (AFB) coded the first transcript together, and then coded subsequent transcripts separately until achieving over 90% inter-rater agreement. Once the data were coded and analyzed thematically, we engaged in member checking by presenting the results to the community research team for feedback.

Results

Clients (N = 42) lived in a residential SUD treatment facility for women. The clients were predominately white, non-Hispanic (76.2%). Six clients (14%) were pregnant, and 14 (33%) had small children living part-time or full-time with them in the facility. Median age was 31.5 years (range: 19–54 years). The vast majority of clients were seeking care for alcohol and other drug use (50%) or other drug use exclusively (47.6%). One client was seeking SUD treatment for exclusive alcohol use.

Nearly all (98%) of the clients reported smoking 100 cigarettes in their lifetime, and 93% reported past 30-day smoking. Lifetime past quit attempts ranged from 0 to 20 (median: 1). On a scale from 0 to 10, the median ranking of the importance of stopping smoking was 7. However, on a scale of 0–10, the median ranking of confidence in quitting in the next month was 2.

Themes

There were two themes related to the role of smoking in the women’s lives: (1) smoking facilitates socialization and (2) smoking as a coping mechanism. There were three themes related to the benefits of tobacco-free policy: (1) improved health, (2) support for continued abstinence from a previous tobacco-free placement (eg, prison), and (3) less grounds up-keep. There were three themes related to the barriers to tobacco-free policy: (1) lack of an alternative coping mechanism to smoking, (2) fear that a tobacco-free policy would drive clients away, and (3) anticipation of implementation challenges.

Smoking Facilitates Socialization

Clients and staff reported that smoking facilities socialization. Women described the role of smoking in their lives as a facilitator of socialization. A client explained, “I feel like it’s [smoking] kind of a positive thing because if I didn’t have to go outside to smoke, I probably would’ve never even talked to or got to know a lot of the girls because I’d stay in my room all the time.” Additionally, another client reported feeling left out when the other women went outside to smoke. “Especially here in this facility, smoking is sort of a social medium. I know that I sometimes feel left out because I’m the only female in this house who does not smoke cigarettes. So there’s like odd things that get discussed or decided while smoking.”

Other clients explained that the social benefits of smoking led them to consume more cigarettes. A client stated, “I know I’ll just go smoke, and then 20 minutes later somebody will be like, ‘Do you want to smoke?’ Yeah, I’ll go smoke, and like I know I don’t need it.” According to a staff member, “They’ll come in not wanting to smoke anymore and to stay quit and then they’re smoking because everybody else is doing it.” Another staff member explained, “We have a few clients that didn’t smoke and came here and sat outside with the girls and started smoking again.”

Smoking as a Coping Mechanism

In addition, clients and staff reported that smoking played a coping mechanism role for the clients. Women also described smoking while in residential SUD treatment as needed stress relief. “It’s part of my recovery. I need something to calm me down.” A client reported, “It is overwhelming to quit smoking on top of quitting everything else in such a stressful environment.” According to a staff member, the environment can be stressful, “We have a lot of women living together in home. Roommates and babies everywhere and I think we would have tense moments, tense days [without smoking on the grounds].” Staff members reported that smoking can reduce the initial anxiety of seeking SUD treatment, “They come in here and then the nervousness of walking through the door the first time and that’s the first thing they think of is, I need a cigarette.” The clients also reported feeling already overwhelmed by entering SUD treatment and fear that smoking cessation would be too much to handle. One client reported, “They [behavioral health staff] don’t typically want you to stop smoking right then and there because that’d be too overwhelming to stop everything at once.” According to a staff member, “The necessary coping skills just aren’t there yet. And so without the cigarette which becomes the outlet, I don’t know what we would have in place.”

Perceived Benefits of Tobacco-Free Policy

Despite tobacco use being historically overlooked in behavioral health settings, the perceived benefits of a tobacco-free policy included (1) improved health, (2) support for continued abstinence from a previous tobacco-free placement (eg, prison), and (3) less grounds up-keep. Staff and clients both reported the reduction of secondhand smoke exposure as a health benefit of a tobacco-free policy. “We have kids on site, it’s positive for them. We have women that have other health issues, so it would be good for them.” Another health benefit would be the promotion of smoking cessation. Staff perceive that the majority of women want to quit smoking, “I feel like most people I talk to who are active smokers, they’re not happy with it. They’re not content with being a smoker.” A client explained, “I feel like maybe I need to try to quit again because I’m all she [her daughter] has.” A tobacco-free policy would provide a supportive structure to empower the women to stop smoking. A staff member explained, “I think it would provide almost like a scaffolding kind of effect … we do a lot with low self-esteem and fear of failure. They’re not as apt to try something if they’re not sure they can be successful at it. And so I think the more we can put in place to ensure their success, the more likely they would be to participate.” Clients also reported that stopping smoking would be empowering. One client explained, “I think it [stopping smoking] would be just another accomplishment. Something else to make me feel proud of myself, and make other people proud of me as well.”

A second theme of the benefits of tobacco-free policy was support for women who enter the facility from a tobacco-free location (eg, in prison, a hospital, or another tobacco-free SUD facility) to remain smoke-free, and this was expressed by both staff and clients. Many of the women entered this residential SUD treatment from tobacco-free prisons. However, the clients and staff described a rapid relapse to smoking upon beginning residential treatment. One client explained, “I spent nine months in jail. When I got out, first thing I wanted to do was smoke a cigarette.” Another stated, “Because I went to prison, I stopped. And I started the day I got back out.” Members of the staff agreed that many women relapsed during residential treatment. One stated, “The ladies I work with, when they get here, they don’t smoke. And then everyone’s smoking around them so they start smoking again unfortunately.” Another staff member explained, “I’ve seen so many will have been in prison for years and not able to smoke, and they come out and they start smoking, and they’re like, ‘Why did I do that?’” A staff member also stated, “I think some of them would have a really good shot [of stopping smoking], particularly those who are coming out of institutions from being incarcerated because they’re not permitted to smoke when they’re there … I try really hard if I have a client who comes from prison to encourage her, just don’t pick back up, you’re already through the hard part.”

Finally, staff perceived a tobacco-free policy would be beneficial for grounds upkeep. One staff member stated, “It’d be good for our facilities; upkeep would be less of a challenge.” Another explained, “Somebody has to go out and pick up cigarette butts.”

Perceived Barriers to Tobacco-Free Policy

Despite the perceived benefits of a tobacco-free policy, decision makers at this residential treatment facility remain in early stages of contemplating policy adoption. The perceived barriers to tobacco policy included (1) lack of an alternative coping mechanism, (2) fear that a tobacco-free policy would drive clients away, and (3) anticipation of implementation challenges.

Clients and staff agreed that smoking is used as a coping mechanism in residential treatment facilities, and thus, the lack of an alternative was a barrier to tobacco-free policy. One client explained, “If we can’t smoke, we’ll be down each other’s throats all day.” A staff member stated, “We are the ones that really have to deal with all of the emotions, the different attitudes and adjustments and we have to deal with that. So we want to make it as comfortable for us as it is for them. If they need a cigarette, then by all means, go smoke.” There was a belief that smoking may be a necessary coping mechanism for women to engage in SUD treatment: according to a staff member, “The necessary coping skills just aren’t there yet. And so without the cigarette which becomes the outlet, I don’t know what we would have in place.”

Another barrier was the fear of driving away clients, and this was reported by clients and staff. A client stated, “When I was asked what rehab, I told them I didn’t want to go to one I couldn’t smoke at.” A staff member reported, “The first question a lot of people ask who were seeking the treatment out is, ‘Can I smoke?’” Another staff member explained, “I think we will lose a lot of clients.” A client described being previously kicked out while seeking SUD treatment. “I went to a detox that we couldn’t smoke at and I got kicked out of it. I got caught smoking twice and the second time they kicked me out.”

Although the clients largely agreed that they were concerned that a tobacco-free policy would dissuade people from seeking help, there were staff members with a dissenting opinion. A staff member reported that prior to arrival at the facility, “No one really asks that [if they can smoke]. Sometimes they ask when they come if they’re able to smoke but nobody asks that before … for the most part, when people call, they just really need help and I don’t think they care about all of that.” Another explained, “When they come in, they’re pretty okay with rules and following rules.”

Staff and clients also reported potential issues with compliance with a tobacco-free policy. A client predicted, “We’d probably be sneaking and smoking.” Another described an experience violating a tobacco-free policy at another residential SUD treatment facility, “We weren’t allowed to smoke on property so then when you’re sneaking off to the woods, we’re all getting covered in chigger bites and being late. It wasn’t good and then you’re forced to lie.” Another client reported violating a hospital tobacco-free policy. “In labor, going outside to smoke; I mean, it’s ridiculous in the winter. Before I got my epidural, I was going into the bathroom and smoking a cigarette.”

Discussion

To develop effective tobacco control policies for vulnerable women, it is necessary to first understand the role of smoking in their lives.34 This community-engaged study fills a gap in the literature by using participatory methods to gain an in-depth understanding of smoking in the lives of women in treatment for SUDs.33 Participants in this women’s residential substance abuse facility described smoking as a needed coping mechanism, as well as feeling overwhelmed by the idea of tackling smoking cessation while in treatment for their other addictions. This finding supports the existing literature that women in difficult life situations use smoking to relieve stress.36,37 In addition to serving as a coping mechanism, participants reported that smoking was a facilitator of socialization in residential SUD treatment facilities. This reinforces the need for tobacco-free policies in these facilities to change the social norm.

Lessons learned from tobacco-free campus policy implementation indicates that access to evidence-based tobacco treatment is critical for successful policy implementation.38 Tobacco treatment programs tailored for this population need to take into account the reliance on smoking as a coping mechanism and stress reliever. There is a longstanding misperception that smoking is an effective stress reliever, particularly for women with SUDs. Therefore, tailored tobacco treatment programs for this population need a strong emphasis on learning alternative, healthy coping mechanisms and building fellowship and social support for smoking cessation. Further, previous interventions developed to promote smoking cessation for women with SUDs have had little success, indicating the need to address smoking cessation in a holistic program that targets co-occurring stress.39

In addition to integrating stress and coping into tobacco treatment services, social marketing campaigns could be developed and tested for this client population to effectively combat the myths of tobacco use as a stress reliever and to promote tobacco cessation. Social marketing approaches draw upon sophisticated commercial marketing techniques to influence health behaviors and decision-making. Social marketing has been successfully incorporated into anti-smoking campaigns and smoking cessation programs around the world40–42 and in various populations, including pregnant women.43,44 The key to develop a social marketing campaign for this population would be to (1) focus on the needs and desires of the consumers and (2) link smoking cessation to something that is of value to the target audience. Therefore, a social marketing campaign could be used to promote a tobacco-free lifestyle as an empowering step toward overall health and emotional wellness, stress reduction, and a life in long-term recovery from all addictions.

Further, clients reported that tobacco-free policies at previous placements supported their continued abstinence while in those facilities (eg, prisons). Unfortunately, women in outpatient SUD treatment report relapse to smoking after leaving a tobacco-free environment.36 Being incarcerated in a smoke-free prison has little impact on long-term smoking cessation.45,46 Lessons learned from the literature on smoke-free prison policies indicate that tobacco-free policies need to be supported with evidence-based tobacco treatment for a long-term impact on smoking cessation. Findings from our study support that tobacco-free policies along with tobacco treatment in residential SUD treatment facilities could prevent relapse to smoking.

As rates of smoking fall in the United States, tobacco use is increasing concentrated among vulnerable groups,2 and smoking remains an epidemic in behavioral health settings.47 To reduce the burden of tobacco-related morbidity and mortality among women and their children, it is necessary to catalyze a culture change in behavioral health settings to prioritize the treatment of tobacco alongside treatment of other addictions.23,47,48

Evidence-based tobacco policies, supported by women-centered approaches to tobacco treatment, are also needed to address this pressing health disparity.33 To achieve widespread adoption of tobacco treatment and policy in SUD treatment facilities, organizational barriers need to be addressed. Behavioral health professionals with access to training and resources, who perceive support for smoking cessation from their managers and co-workers, are more likely to implement these programs.49

Limitations and Conclusion

One study limitation is that we collected data in one residential treatment facility located in a state with a historically high smoking rate.50 However, a key strength of this study is the innovative community engaged approach. By working with a community research team, we integrated feedback from community members on the role of smoking in the lives of participants, which we integrated into the development of the focus group and interview guides. Through this method, we collected rich, in-depth data on the role of smoking in the lives of the participants. To promote effective smoking cessation for disadvantaged smokers, a key first step is understanding the role of smoking in their lives.34 Another limitation of this study is that interviews and focus groups were conducted on site for convenience of the participants, and thus, may have been particularly susceptible to social desirability bias. However, interviews were conducted in a private location (eg, the staff member’s office) and facility staff did not attend the focus groups with the clients.

Results of this study indicate that many women in residential SUD treatment smoke, in part because smoking is used to facilitate socialization and cope with stress. Future research is needed to develop and test messages to counter the misperception that smoking is an effective method to cope with stress. In addition, tailored tobacco treatment services that incorporate healthy coping mechanisms and social support need to be developed and tested to support successful tobacco-free policy implementation in women’s residential treatment facilities. Evidence-based tobacco-free policies are needed to ultimately reduce tobacco-related death and disease among women with SUDs.

Funding

This work was supported by the Office of Women’s Health Research (K12 DA035150) and the National Institute on Drug Abuse at the National Institutes of Health, and the American Cancer Society Institutional Research (Grant IRG 85-001-25).

Declaration of Interests

None declared.

Acknowledgments

We would like to acknowledge the contributions of our community research team, participants, and the staff of the women’s residential treatment facility for collaborating with us on this project.

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