Individuals with a substance addiction and/or mental illness use tobacco at rates much higher than the general population. Approximately 21% of the U.S. population smokes, yet 40%-80% of substance abuse and mental health patients smoke and consume more than 44% of all the cigarettes sold in the United States each year. As a result, these individuals experience increased tobacco related morbidity and mortality. Tobacco use is common and accepted within this population, and has become a norm even within treatment programs. Only 30%-40% of treatment facilities offer smoking cessation resources, and many organizations are hesitant to address cessation or to adopt a tobacco-free campus policy. This toolkit addresses the unique barriers and challenges that a residential substance addiction facility will face when adopting a tobacco-free policy. A tobacco-free campus policy protects all individuals from dangerous secondhand smoke and promotes the health and recovery of clients from all addictions, including nicotine. This toolkit provides step-by-step information and resources to allow a facility to become tobacco-free and implement a full smoking cessation program over a six month time period. This project helps fill a need for specific resources related to concurrent smoking cessation and substance abuse/mental health treatment. This resource will be made available to residential substance abuse facilities in Georgia and will be provided to the Substance Abuse and Mental Health Service Administration’s Smoking Cessation Leadership Center.

This study was the first to examine the effect of tobacco policies in prisons on the health of inmates. Kentucky has two types of tobacco policies in its 16 state prisons: indoor smoke-free policies, where smoking is allowed outdoors and tobacco-free policies, in which no tobacco of any kind is allowed on the grounds of the prison. The smoking rate of inmates is three times higher than that of current smokers in the non-incarcerated population which results in high rates of tobacco-related health conditions such as heart disease and lung cancer. A literature review discussed the evolution of tobacco policies in prisons , the motivations for strengthening policies in prisons and the unintended consequences. Health outcomes in the non-incarcerated population on the benefits to cardiovascular and respiratory health following passage of smoke-free laws in public places were reviewed. No studies have been found on the health outcomes of inmates with varying degrees of smoke-free or tobacco-free policies. The first study was a time series analysis comparing the frequency of medication refills for asthma and/or COPD before and after a tobacco-free policy was implemented. Short-acting inhaler refills decreased in the first few months following the tobacco-free policy date but returned to baseline within 12 to 15 months. Rapid turnover of inmates, minimum security status of the prisons, and possible loosening of enforcement may have been related to the gradual increase in use. The second study was a survival analysis on the time to an inmate’s first acute myocardial infarction (AMI) with tobacco policy status (tobacco-free or smoke-free) of the prison as the primary predictor variable. Controlling for the multiple movements over time, facilities, co-morbidities, past smoking history, age and race, there was a 2.87 hazard for AMI for time spent in a smoke-free (indoors) prison compared to a tobaccofree prison. This finding may be due to the fact that tobacco is considered contraband after prisons become tobacco-free and inmates risk disciplinary action by smuggling or using tobacco in the prison, thereby reducing secondhand smoke for non-smokers and probably reducing the consumption of current smokers.

Tobacco use and secondhand smoke exposure are leading causes of preventable morbidity and mortality in the United States. Outdoor tobacco smoke exposure conveys many of the same risks as indoor secondhand smoke exposure. Tobacco-free campuses policies are an intervention to promote a positive social norm that encourages smoking cessation, as well as reduces exposure to outdoor tobacco smoke. This dissertation contains a review of the policy implementation literature; findings from a psychometric analysis of the newly developed Tobacco-free Compliance Assessment Tool (TF-CAT) to assess compliance with tobacco-free campus policies; and results of a campus intervention study to promote compliance. The TF-CAT protocol is designed to count cigarette butts, observe smokers, and use GIS mapping to display hot spots. A total of 413 observations in primary and secondary campus locations yielded compliance data on both the academic healthcare and main campuses. Results show support for the concurrent validity of the TF-CAT. Inter-rater reliability of the measure is strong, and the tool is feasible, though time- and resource-intensive. The intervention study tested the effects of an efficacy-based messaging campaign on the number of cigarette butts observed on campus. After distributing 6,000 message cards in high-traffic areas over three days, there were fewer cigarette butts per day per site post-intervention compared to pre-intervention (n = 312 observations; median = 4.7 vs. 1.9; U=2239, p=.004). It is crucial for tobacco control advocates to ensure implementation effectiveness of tobacco-free policies. Future research needs to refine methods to measure policy implementation effectiveness. In addition, interventions need to be developed and tested to promote policy implementation effectiveness.

The implementation of a tobacco-free policy is the leading recommendation among health institutes for reducing the harms associated with tobacco exposure–for both smokers and nonsmokers–on college campuses. Despite the health benefits associated with tobacco-free policies, compliance with these policies remains a serious challenge on college campuses. Interventions aimed at increasing smokers’ willingness to comply with tobacco-free policies are essential for improving public health. Guided by the theory of planned behavior (TPB), the purpose of this study was to (a) investigate the factors associated with tobacco-free policy compliance among undergraduate students and (b) design and evaluate a theory-based campaign aimed at increasing compliance with a tobacco-free campus policy. To achieve these aims the current study was conducted in two phases. Phase One was a qualitative investigation that analyzed focus group data related to messaging strategies for increasing tobacco-free policy compliance. Phase Two was a quantitative investigation that used survey data to explore variables associated with tobacco-free policy compliance and to test the effectiveness of a campus-wide print-based campaign. Results from Phase One suggest various ways to target the TPB variables in messages in order to improve tobacco-free policy compliance. Results from Phase Two suggest the psychological variables and the physical variable of nicotine dependence are not related to tobacco-free policy compliance behaviors; however, social variables, quit attempts, and daily cigarette use are predictors of compliance behaviors. Similarly, the TPB variables had mixed results for relating to tobacco-free policy compliance behaviors. In addition, the campaign materials were supported as effectively improving tobacco-free policy compliance behaviors, both through individual level survey reports of compliance and observed compliance behaviors on campus. Although the campaign materials were designed around the TPB variables and were supported for improving compliance behaviors, above average campaign exposure was only found to improve normative beliefs from pre- to post-intervention. In addition to theoretical and practical implications offered from this study regarding tobacco-free policy compliance behaviors, this study also provides critical insight into the current compliance behaviors on the University of Kentucky’s campus.

Background: Tobacco-free campus policy is identified as an effective means to address tobacco use on college campuses; however, the prevalence of tobacco-free policies (TFPs) in the United States remains low. This study explores college tobacco users' support for a university's TFP and tobacco-free campuses (TFCs) in general. Methods: A standardized and structured questionnaire was administered to 790 college tobacco users recruited in a university located in a tobacco-growing region of the United States, during April-May 2011, to collect information on support for TFPs and TFCs and sociodemographic-political characteristics. Descriptive and multivariable logistic regression analyses were conducted to identify key factors associated with support for TFPs and TFCs. Results: Approximately 2 of 5 tobacco users favored TFPs and TFCs. Multivariable logistic regression models showed that demographic factors were mostly not significantly associated with attitudes of the college tobacco users. Instead, while knowledge about harmful effects of exposure to secondhand tobacco smoke significantly increased support for both TFPs and TFCs, parental and peer smoking and exposure to tobacco industry promotions significantly decreased the likelihoods of support compared with respective referent groups. Conclusion: Study findings suggest that campus advocacy and education campaigns for campus tobacco policies to pay attention to tobacco use behavior of familial relations, tobacco industry activities, and other political determinants of tobacco users' attitudes. Thus, this study should inform national initiatives to promote TFPs nationwide such as the Tobacco-Free College Campus Initiative.

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