During 1 year following implementation of the New York tobacco policy, client smoking prevalence in the programs studied decreased significantly (69.4% to 62.8%), and this is consistent with data for the entire New York treatment system.33
This finding is consistent with, although less dramatic than, the New Jersey findings that 41% of smokers did not smoke in residential treatment after implementation of tobacco-free grounds.25
We also found a nonsignificant decrease in staff smoking (34.5% to 31.2%). From a staff perspective, the move to tobacco-free grounds is similar to a workplace smoking ban, and such bans are shown to reduce workforce smoking.34
Some of the decrease in smoking was likely attributable to the policy, independent of taxation. During the study period, New York statewide smoking prevalence decreased by 1.2% (from 18% to 16.8%),32,35
and this amount of decrease may be associated with increased taxation or other tobacco control measures. A recent review of smoking rates among clients in addiction treatment found a 0.7% annual decrease in smoking when they reviewed published papers, and a 0.4% annual decrease in smoking when they reviewed National Survey on Drug Use and Health data.36
In the absence of the New York policy, then, staff and client smoking rates may be expected to decrease over the study period within the range of 0.4% to 1.2%. However, staff smoking in the present study decreased by 3.3% and client smoking decreased by 6.6%. Furthermore, analysis of persons who, at follow-up, reported quitting smoking while in treatment, showed that residential clients were nearly 5 times more likely to quit compared with outpatients. When asked the reasons for quitting, the majority of residential quitters said they quit because of the policy and not because of the tax increase.
Response to the New York policy differed by type of treatment. In outpatient programs, no significant pre–post policy changes were observed. That the policy had little impact in outpatient settings is supported by administrator reports of few difficulties in adapting to the policy. In methadone programs, staff use of tobacco-related practices increased, and client attitudes toward tobacco treatment grew more positive and clients reported receiving more tobacco-related services. These findings are consistent with the intended effects of the policy. Some impact of taxation is also seen, as quitters in methadone treatment were more likely to quit because of the tax increase than because of the policy. Residential clients, compared with outpatients, were almost 5 times more likely to quit smoking while in treatment, and those quitters were more likely to quit because of the policy than because of tax increases. However, residential staff reported decreased self-efficacy to address tobacco dependence over time, and decreased use of practices to address tobacco. Residential clients reported less-favorable attitudes toward treatment of tobacco dependence, and received fewer tobacco-related services.
Outpatient findings may be taken at face value, as the policy required few changes in these settings. Policy impacts may have been stronger in methadone programs because smoking rates among staff were lower than those of other programs. Methadone programs also include more medically trained staff, and previous studies of addiction treatment have shown a relationship between medical staffing and both increased availability of cessation medications for clients20
and sustained use of NRT.37
In methadone clinics, the combination of lower staff smoking, medically trained staff, and access to NRT as part of the tobacco policy may overcome frequently reported barriers to treating tobacco dependence.38
In residential settings, the demands of the policy were greater. Clients live in these programs and often for the first 1 to 2 weeks cannot leave program grounds. Those able to leave the grounds may find that opportunities to smoke are infrequent and inconvenient, and may stop smoking while in the program. This may account for the higher probability of quitting among those in residential treatment.
As to why counselor tobacco-related efficacy and practices, as well as tobacco services received by clients, would decrease in residential programs, we offer 3 possibilities. First, residential administrators reported preparing for the policy before implementation. This could elevate baseline scale scores, with later regression to the mean. This would be consistent with higher levels of program and clinician services reported by residential clients at baseline (). Second, residential administrators reported more implementation challenges, consistent with earlier reports of implementing tobacco-free grounds in residential treatment.25
Residential programs may have initiated more tobacco-related training or services in advance of the policy, and then relaxed efforts as they confronted difficulties. Third, residential program clients were much more likely to quit smoking, and did so in response to the policy. Clients who continued to smoke in residential treatment may be more resentful of the policy and less interested in tobacco-related services. This could account for decreases in client tobacco-related attitudes and services, along with decreases in staff self-efficacy to address, and practices used to address, tobacco dependence.
The small number of clinics and the replacement of sampled clinics with another clinic in the same agency limit generalizability. The sample was randomly selected from among those meeting eligibility criteria, all programs in the sample were invited to participate, and all of those expressing interest were enrolled until time available before policy implementation was exhausted. We allowed replacement of a selected program with another program in the same agency, as replacement programs would be subject to the same organizational approach to tobacco dependence as the selected program. Comparison of admissions data for programs included (n = 10) with those invited but not included (n = 31) enables assessment of generalizability. In terms of client demographic characteristics and self-report smoking status, the sample of programs in the study was representative of all those invited to participate. As those invited were randomly selected from 610 eligible programs, findings may reasonably generalize to those programs, representing more than one third of the New York State addiction treatment system. However, there may be other program characteristics that made sites more or less willing to participate in the study, and more or less open to the New York tobacco policy. Such program features may include, for example, attitudes of the leadership toward smoking and the tobacco initiative, and smoking prevalence among program staff.
We collected data in 3 clinics shortly after the policy implementation date. Baseline data for those clinics do not offer a “true” prepolicy baseline. This can be addressed by using the available data to represent true baseline, or by using imputation methods to estimate what the baseline data may have been approximately 1 month before the data were collected. Preliminary analyses found little evidence of confounding associated with the before-or-after timing of baseline data collection. That is, the pattern of change over time for outcome measures did not differ according to whether baseline data were collected before or after the policy implementation date. Absent evidence of before-or-after confounding, our approach was to let baseline data stand as the best estimate of a true prepolicy baseline. Our assumption is that the change 1 year after implementation is greater than that 1 month after implementation, or, stated another way, change over time may be observed over 1 year even where baseline data were collected shortly after the implementation date.
Clients were selected within programs systematically, rather than randomly. Client sampling procedures likely achieved good representation in residential programs, where all clients present on a given day were invited and incentivized to participate. Recruitment in out-patient settings occurred during specified times when clients were present and used strategies acceptable to participating clinics. It is possible that outpatient clients were not representative of all clients, particularly if smokers more often self-selected into the study. If smokers were overrepresented among outpatient clients at both time points, this would not influence estimates of change over time.
It is possible that clients underreported smoking, particularly for residential clients and if they thought that smoking status would have consequences for their treatment. Future research would be strengthened through the use of biochemical verification of client smoking status. Reported decreases in client smoking may have been short-lived, as Tesiny et al. found that clients who left programs as non-smokers often identified as smokers when they returned for a new treatment episode.33
These limitations notwithstanding, we are aware of no other data reflecting tobacco-related client-and staff-level measures, collected in the same set of clinics before and after the New York policy intervention, and there is only 1 articles to date reporting on policy efforts to address tobacco dependence in a state addiction treatment system.25