Population health examines the health outcomes of groups and the disparities in health among subgroups. This issue of the NCMJ illustrates population health efforts in the areas of obesity prevention, tobacco cessation, and clean water. Articles in this issue also discuss community health needs assessments, integrated health improvement, social determinants of health, and the Healthy North Carolina 2020 program.
Adopting a Tobacco-Free Campus Policy at a Substance Abuse Treatment Center
The Walter B. Jones Alcohol and Drug Abuse Treatment Center (ADATC) in Greenville is a 66-bed inpatient psychiatric hospital operated by the North Carolina Division of State-Operated Healthcare Facilities, and it specializes in the treatment of patients with co-occurring substance abuse and mental health problems. Five years ago, the leadership team at Walter B. Jones ADATC accepted an invitation from the North Carolina Department of
Health and Human Services (DHHS) to participate in a pilot program that would involve making the campus tobacco-free; under the new policy, both staff members and patients would be prohibited from using any tobacco products.
In making this transition, an important consideration was that a tobacco-free environment would have a direct impact on the men and women who are admitted to the center for treatment. A 2000 study by Lasser and colleagues  analyzed result of a national survey and found that 44.3% of all cigarettes smoked by survey respondents were consumed by individuals who had had a mental health disorder within the past month, and 41% of those with past-month mental illness were current smokers. Indeed, smoking rates among patients at the Walter B. Jones ADATC can be as high as 75%—more than triple the overall smoking rate for adults in North Carolina, which is currently 20.2% .
A major concern in adopting a tobacco-free campus was that a majority of our patients are smokers, and we would be requiring them to quit using tobacco for the length of their hospitalization. This was a considerable change for facilities such as ours, where tobacco use has often been viewed as a lesser problem compared to alcohol or illegal drug abuse. However, smoking kills more people than alcohol or other drugs, and this is true even among clients being treated for substance abuse [3, 4].
Thus the medical staff at the Walter B. Jones ADATC prepared for an uphill battle with the center’s patients. Prior to admission, the center notified patients that tobacco products were no longer allowed on campus. The ADATC has voluntary admissions, yet there was no substantial change in the number of patients admitted. The first couple of months were a challenge for the clinical staff; they not only had to add tobacco cessation counseling to their regular workload, but they also had to promote compliance with the new policy. Clear communication from staff members about the policy and the offer of assistance with tobacco cessation were keys to increasing compliance. Although some patients were concerned or even resistant to the new policy, the majority of patients who used tobacco products took this as an opportunity to see how successful they could be with tobacco cessation treatment.
Staff also adapted to the change. The ADATC made arrangements with the North Carolina Tobacco Prevention and Control Branch (which is part of DHHS) to provide nicotine replacement therapy for patients, and the Tobacco Prevention and Control Branch worked with the center’s medical staff to adopt new tobacco cessation treatment protocols for inpatients. We learned through experience that the center’s patients preferred face-to-face counseling about tobacco addiction during their stay, rather than using the state’s toll-free telephone counseling service, QuitlineNC. In addition to counseling, educational groups were formed that focused on nicotine addiction and the medical impact of tobacco use. In the end, patients came to realize that they could stop smoking, at least for a few days. Although some patients continued to feel that they should be allowed to smoke, many others welcomed the tobacco-free environment and planned to remain tobacco-free when they returned home.
QuitlineNC has played an important role in helping patients remain tobacco-free during their transition back into the community. When patients are discharged, they are informed that they can call QuitlineNC (1-800-QuitNow) for ongoing counseling and nicotine replacement therapy. Over a 2-year period from June 2010 through May 2012, QuitlineNC shipped nicotine replacement therapy in bulk to 926 tobacco users for use during their stay at the ADATC, and during that same period QuitlineNC provided services to 101 patients after their discharge from the center. The majority of patients served by the ADATC are connected with Alcoholics Anonymous or Narcotics Anonymous after discharge from the facility, and QuitlineNC is now also part of the discharge protocol.
The Walter B. Jones ADATC compared patient behavioral outcomes before and after implementation of the tobacco-free campus policy; pre-implementation surveys conducted from December 2009 through March 2010 were compared with post-implementation surveys conducted from October 2010 through December 2010. This assessment found that the implementation of a tobacco-free campus had no effect on elopements, assaults, injuries, or the use of restraints. Reports of contraband increased during the month of implementation; following an emphasis on facility policy and procedures, however, instances of contraband fell to below-average rates. There was also a sustained reduction in verbal assaults, which is consistent with reports from other behavioral health facilities that have implemented tobacco-free campuses.
After the success of the pilot program at the Walter B. Jones Center and that of a similar pilot program at Broughton Hospital, the North Carolina Commission for Mental Health, Developmental Disabilities, and Substance Abuse Services amended a rule requiring state-operated health care facilities to provide smoking areas for patients. As of July 1, 2014, the Division of State-Operated Healthcare Facilities implemented tobacco-free campus policies in all state health care facilities that treat adults and children with mental illness, developmental disabilities, and substance use disorders. This change will help reduce the disparately high rates of tobacco use in this high-risk North Carolina population.
Potential conflicts of interest. B.G. is an employee of the Walter B. Jones Alcohol and Drug Abuse Treatment Center.
1. Lasser K, Boyd W, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: a population-based prevalence study. JAMA. 2000;284(20):2606-2610.
2. North Carolina State Center for Health Statistics (SCHS). Behavioral Risk Factor Surveillance System Survey Results: North Carolina. Tobacco use. Current smoker. NCSCHS Web site. http://www.schs.state.nc.us/data/brfss/2013/nc/risk/_rfsmok3.html. Accessed September 10, 2014.
3. North Carolina Institute of Medicine (NCIOM). Healthy North Carolina 2020: A Better State of Health. Morrisville, NC: NCIOM; 2011. http://publichealth.nc.gov/hnc2020/docs/HNC2020-FINAL-March-revised.pdf. Accessed October 24, 2014.
4. Adams D, Bornemann A, Condojani M, et al; Tobacco Use Recovery Now! Advisory Committee and Project Team. Tobacco Treatment for Persons with Substance Use Disorders: A Toolkit for Substance Abuse Treatment Providers. http://smokingcessationleadership.ucsf.edu/Downloads/Steppsudtoolkit.pdf. Accessed October 24, 2014.
Ben Gregory, MS facility director, Walter B. Jones Alcohol and Drug Abuse Treatment Center, Greenville, North Carolina.
Address correspondence to Mr. Ben Gregory, Walter B. Jones Center, 2577 West 5th St, Greenville, NC 27834 (email@example.com).