Inpatient Substance Use Treatment Smoking Bans: What We Learn By Listening to People Who Use Drugs

Background and Purpose: While rates of cigarette smoking are on the decline, they remain high for those with behavioral health disorders. Concerns about the long-term impacts of smoking has prompted a focus addressing cigarette smoking within this population. One approach has been to integrate smoking cessation programs into inpatient substance use treatment. In 2019 one northeastern city integrated smoking cessation into their inpatient treatment programs along with a ban on smoking cigarettes. This occured during a period when overdose deaths in the city were labeled as a public health crisis. Outpatient treatment providers and individuals with substance use disorders publicly expressed concern over the ban and anecdotal evidence suggested the ban was serving as a barrier to treatment during this public health emergency. The ban only pertained to individuals receiving Medicaid, thus creating the social justice concern that only poor people would be impacted by this ban and potential barriers it might create.

Method: A local researcher and small non-profit collaborated to create a mixed-method survey about the extent to which the smoking ban was impacting individuals' decisions to go into treatment or to leave treatment early. They used a critical participatory action research (CPAR) framework. CPAR intentionally shifts the research focus from those who have experienced harm to the policies and structures that can the perpetrators of that harm. They co-created a survey containing thirteen close-ended questions and one open-ended question. They utilized the non-profits's facebook page and their mobile syringe exchange to recruit participants. Participants were screened for being residents of that city, English speaking, over eighteen, currently smoking cigarettes, and currently identified with a substance use disorder. They had a final sample size of 112 participants. The sample was 71% male, 29% female (none identifying as non-binary), and 68% White, 20% Black and 12% as multi-racial or another race. Forty-one percent of the sample size identified as being unhoused.

Results: The survey indicated that for those who left treatment early, 85% said that smoking was part of the reason. Of those considering entering treatment in the next 3 months, 45% said that smoking would be a factor in their decision to go inpatient. Of those that responded to the open-ended question, 72% expressed opposition to the ban, 10% expressed mixed opinions, and 18% expressed support for the ban.

Conclusion: Through the participatory action approach, findings from this study were used to roll back the smoking ban in this city. While there was a relatively small sample size, the findings indicated that the smoking ban may have been acting as a deterrent to enter and stay in inpatient treatment. These findings suggest policy makers consider short-term consequences of smoking bans in tandem with concerns about the longterm harms of smoking. Additionally, it highlights the importance of meaningfully including the perspectives services users in initial policy development.