TOOLKIT: Implementing Tobacco-Free Environments in Behavioral Health Settings

Developing and implementing a tobacco-free environment policy can be a major organizational change. Facilities should first asses their readiness for implementing a tobacco-free environment policy to explore areas on which to engage and focus. It is important to understand the beliefs and behaviors that contribute to support for or resistance to a tobacco-free environment across facility stakeholders. For example, how important is it to leadership to realize a tobacco-free environment? How is a tobacco-free environment consistent with the mission and values of the facility? Assessment of beliefs of clinicians, clients, leadership, referring providers, and the community provides direction about how to move forward.

Use the Tobacco-Free Environment Agency Assessment TOOL below to identify strengths and areas of ambivalence or resistance to change. Use the Tobacco-Free Environment Decisional Balance Exercise TOOL to consider the various aspects of implementing a tobacco-free environment policy at your facility. Additional TOOLS to reduce ambivalence and prepare for change are located throughout the toolkit.

• TOOL: Tobacco-Free Environment Agency Assessment
• TOOL: Tobacco-Free Environment Decisional Balance Exercise

Tobacco addiction is the leading cause of preventable morbidity and mortality in the United States.¹ People who live with a behavioral health condition are two to four times more likely than those without such conditions to smoke cigarettes.² One study found a smoking prevalence rate of more than 90% among rural-dwelling people who inject drugs,³ compared to a rate of 12.5% in the general US adult population in 2020.⁴ As a result, individuals with a behavioral health condition are more likely to die from their tobacco use than of their primary behavioral health condition.⁵  People with a behavioral health condition die 5-25 years prematurely,^6,7 often from diseases caused or worsened by tobacco use.

Tobacco addiction has a significant impact on mental health, wellness, and other addictions. Recovery from tobacco addiction has been shown to:

• Decrease symptoms of depression and anxiety^8,9
• Decrease stress⁸
• Increase positive affect and quality of life
• Increase long-term abstinence from all substances^9,10
• Increase confidence and self-efficacy
• Increase social networks¹¹

Creating a tobacco-free environment is one of the best ways to create a safer and healthier environment and support efforts to address the tobacco use by your clients. Tobacco-free environments have been shown to effectively motivate and support people who use tobacco to reduce or stop using tobacco products.¹²

Tobacco and other substances, particularly alcohol, demonstrate strong behavioral and neurochemical links to one another. Using, smelling, or seeing tobacco can be a trigger not only for tobacco use but for other substances that are frequently used in the same environment. Exposure to these cues can make it more difficult for your client to recover from their other addictions. Co-treatment of tobacco use does not interfere with substance use disorder (SUD) treatment. In fact, research shows co-treatment of tobacco use can increase likelihood of long-term abstinence from all substances by up to 25%.^10,13

• VIDEO: Behavioral Health Clients Discuss How the System Fosters Smoking, How it Can Help
• VIDEOS: Clinicians on how and why to treat tobacco

Written policies provide clarity and guidance; support consistent provision of treatment and interventions for unsupportive behaviors; and increase accountability among staff and clients. A strong tobacco-free environment policy can change the culture and increase efficiency of the policy and related efforts, while the process is important for increasing awareness and buy-in.

• FACT SHEET: Benefits of tobacco-free environment policy

The process of developing a policy and getting client and staff support to implement the policy takes time. Plan for a 6-9 month timeframe, from the decision to go tobacco-free to the policy launch. Some agencies may need more time depending on existing resources and culture. However, delaying a launch date may decrease momentum and permit staff concerns to persist unnecessarily. Research shows that employee and supervisor perspectives can improve following policy implementation as fears are alleviated.¹⁴

Although phasing in a tobacco-free environment policy may seem appealing, it can draw out the process and create confusion. This can lead to challenges with enforcing the policy. It is recommended to provide clear and consistent expectations for all impacted parties with a single launch date.

Consistency is an essential element to effective implementation. Varying policies by program or setting can lead to concerns and complaints, be more challenging to enforce, and are less effective in achieving its purpose. Establishing a universal policy for the entire facility reinforces consistent treatment and support of tobacco recovery as clients move through the continuum of care. This said, the specifics of a treatment setting may constrain aspects of the tobacco-fee policy. For example, an outpatient clinic that shares a parking lot with other businesses may not be able to prohibit tobacco use in the parking lot.

Many people who use tobacco perceive smoking as a stress reducer and a way to cope with negative affect, low mood, or anxiety. It is important to discuss stress and smoking with clients and share how nicotine affects the body. Nicotine withdrawal often occurs right before someone smokes. Withdrawal symptoms (like anxiety, irritability, mood swings, and difficulty concentrating) mirror symptoms of stress. Once someone smokes, they relieve the nicotine withdrawal, and within seconds feel more relaxed. Educate clients to better understand how smoking relieves nicotine withdrawal and while it may appear to reduce stress, can increase stress in the long-term. These discussions present an opportunity for clients to identify other healthy and more effective ways to cope with stress.

Timing is important to ease staff and clients into the new policy. Be sure to give adequate time before the policy is implemented to allow for input, feedback, and preparation for the change. It is helpful to have both staff and client involvement when developing and implementing the new policy. Be transparent when sharing overall goals of the policy and anticipated outcomes. Provide education to clients around tobacco use, concurrent cessation, recovery benefits, and available resources and support. Ultimately, an employee may choose not to work in a facility that does not permit tobacco use and prospective clients may choose not to receive treatment from a program that is tobacco-free.  Fortunately, there are not many such individuals.

Neighbors can be a key stakeholder in the implementation process. Inform them of the policy change and garner their support for enforcement. Encourage them to revisit their own tobacco-free policies. When educating clients on the new policy, request that clients be considerate of neighboring landowners and avoid trespassing, littering, and the creation of secondhand smoke for others nearby.

Tobacco-free policies are legal and do not discriminate against people who smoke. Tobacco-free policies do not limit whether an individual uses tobacco, but where they use tobacco. A tobacco-free environment policy prohibits the use of tobacco products in the same way as other substance use policies, by setting a rule for activities prohibited on the property for the wellness of the clients and others around them.

There is no legal right to smoke. In addition to decreasing exposure to second-hand smoke, a tobacco-free environment policy decreases risk of accidental fire, burns, and death from fire. Of relevance, the United States Department of Housing and Urban Development (HUD) now prohibits smoking in all its residences.

No, clients and staff are not required to stop using tobacco products. However, they must comply with the tobacco-free environment policy while on facility grounds.

There is no evidence that tobacco-free environment policies adversely impact client census rates or early discharges. The predicted loss in business simply has not materialized. When comprehensive tobacco-free policies are implemented, client knowledge and motivation about tobacco recovery improve and intent to remain tobacco-free both during and after treatment increase.¹⁴

There is no evidence to support losing staff because of implementing a tobacco-free environment.

It is important to design a policy based on the needs and existing practices at a facility. Facilities may already have a wellness committee established. It is recommended that the existing wellness committee engage in the tobacco treatment policy work rather than creating a new tobacco-free environment policy specific committee. Including a tobacco-free environment policy in the broader wellness goals of the facility supports integration and long-term sustainability of all wellness initiatives. Add tobacco-free environment policy implementation as a standing agenda item. Additional interim or tobacco-focused meetings may be necessary.

For facilities that do not have an existing committee, recruit wellness champions and other action-focused members that represent a cross-section of your facility. Plan an initial meeting to determine committee processes and individual roles and responsibilities. Set a regularly scheduled meeting time, every 2-4 weeks, depending on the size of your committee.

A wellness committee is responsible for:

• developing and implementing a tobacco-free environment policy
• communicating the policy and implementation plan
• reviewing existing practices and policies for consistency
• receiving input from staff, clients, and other stakeholders
• evaluating the implementation process as well as the outcomes of policy implementation

While the committee develops the implementation plan and troubleshoots challenges that arise, all staff and clients at the facility play a role in policy implementation.

Whether or not a facility has an existing wellness committee, incorporating tobacco into a broader wellness framework better supports integration into the practices and culture of the facility. Therefore, the wellness committee may be responsible for additional initiatives in addition to creating a tobacco-free environment policy and environment.

One of the first steps in developing wellness committee is to identify one or more “Tobacco Cessation Champions.” Often a clinical representative, the tobacco champion is committed to leading the effort and serves as an advocate for the policy and any associated treatment efforts. Engagement of wellness or tobacco champions is a widely recognized best practice for wellness programs and initiatives. The role of a tobacco champion is to engage in two-way communication with leadership and the community; assist with planning and implementing tasks; and to provide progress reports on policy development and implementation. Champions serve as an ambassador to communicate key messages and help navigate challenges or gaps as they arise.

Tobacco cessation champions may emerge naturally or may be assigned. It may be helpful to provide identified champions with relevant resources and expert contacts as they prepare for their role. Champions may also be identified through organizational self-assessments. Engage additional champions who represent various groups within the facility as they emerge over time.

Start by convening a group of people that represent the various groups at your facility such as clinical staff, leadership, clients, administration, pharmacy or other prescribing representative, facility staff, facility or grounds staff, security, and quality improvement staff. Consider including people who currently use tobacco and/or have differing views to the policy on the committee. This demonstrates consideration of varying perspectives and opens the door to build rapport with people who express opposition, as well as providing the opportunity to account for and address concerns early in the process. The size of the wellness committee will depend on the size of the facility. Smaller agencies may not have representatives from all suggested groups.

Obtain commitment to serve on the wellness committee from each member. Clarify general roles and responsibilities for each committee member at the initial meeting. Further delegate task responsibilities for each member during timeline development.

• TOOL: Wellness Committee Contact List

Health care is increasingly moving towards a holistic or whole-person approach in providing care. Tobacco use significantly impacts all aspects of wellness and tobacco-free policies should be included in any wellness initiative. Take time to understand how a tobacco-free environment policy initiative aligns with other wellness activities at your facility. As you plan wellness activities, consider how each can have a tobacco-free aspect or dimension.

One of the first steps of the wellness committee is to create a timeline with a launch date. Set a policy launch date, between 6-9 months out, and work backwards to fill in the rest of the timeline. When selecting a launch date, consider important facility dates, holidays, and other local events. Use the Policy Implementation Timeline TOOL to assign individuals to each important task, identify target completion dates, and track progress.

• TOOL: Tobacco-Free Environment Policy Implementation Timeline

There have been many early adopters in Wisconsin who have successfully integrated tobacco-free policies at their facilities. According to SAMHSA’s NSSATS 2020 survey, 40.1% of substance use treatment facilities in Wisconsin reported a tobacco-free environment policy not permitting smoking anywhere outside or within any building.¹⁸

Learn about the work Wisconsin clinicians are doing:

• CASE STUDY: Journey Mental Health
• VIDEO: E. Phillips Libertas
• VIDEO: Meta House (residential program)
• VIDEO: Mac on Tobac, An Addiction Treatment Breakthrough (inpatient rehab program)

After the wellness committee is established, begin drafting the new policy. Start by listing goals and intended outcomes of a tobacco-free environment policy. Goals may be to reduce tobacco use and improve health outcomes, or creating a cleaner, safer space. Describe both short and long term intended outcomes. Integrate intended outcomes into a logic model detailing facility resources, strengths, and specific activities. The logic model will illustrate the process to effecting the changes described in your goals. It provides a road map to demonstrate how implementation will lead to the intended outcomes and may highlight barriers to address.

• TOOL: Tobacco-Free Environment Policy Implementation Logic Model

Then begin writing the policy. Have leadership and HR review the policy, then obtain feedback from employees and clients. Incorporate appropriate feedback while maintaining strength of the policy to reach intended goals.

As you draft your tobacco-free environment policy, consider how it is consistent with your policy regarding use of other addicting substances (drugs and alcohol) in the facility and on facility grounds, Also, consider how other existing policies might apply. For example, a current fragrance policy may be in effect for those sensitive to such fragrances. Might such a policy also apply to the smell of tobacco that might be a trigger for relapse? As another example, an existing policy about possession and display of drug paraphernalia might apply to the presence of lighters, cigarettes, ashtrays, etc.

All tobacco-free policies should, at a minimum, clearly define the following components:

• Purpose and rationale for policy
• Scope of policy
• Statement of prohibited products and behaviors
• Definition of physical grounds and facilities
• Compliance and enforcement guidelines
• Date the policy is effective

Tobacco use in all forms pose significant health risks. A smoke-free policy only prohibits use of combustible tobacco products such as cigarettes, pipes, and cigars. It does not address types of tobacco products such as chew, spit, snus, dissolvables, and e-cigarettes. Whereas this approach focuses on reducing second-hand smoke exposure, which is an important goal, a tobacco-free environment policy takes overall health and wellness into account. It prohibits the use of all tobacco products, including smokeless tobacco. It exempts medicinal FDA-approved nicotine products (patches, gum, etc.) used for treatment. Some treatment programs exempt e-cigarettes from the tobacco-free environment policy but doing so is not recommended as most e-cigarettes contain nicotine or other drugs and they are not currently approved as a tobacco cessation device. Some programs prefer to refer to their tobacco-free policy as a nicotine-free policy.

A comprehensive tobacco-free environment policy covers all buildings and grounds on the property of the facility. This covers the parking lot and facility/personal vehicles on the property. Incorporating all areas of facility property decreases exposure to second-hand smoke, limits exposure to smells and visual cues, and shifts culture.

All persons on facility grounds are expected to adhere to a tobacco-free environment policy to support tobacco-free recovery. This includes clients, staff, visitors, and volunteers. Policy enforcement may have to be different for these groups of individuals (see “enforcement” below). Policy adherence is an endorsement of wellness and is consistent with the mission and values of the facility.

Yes. Tobacco products and related paraphernalia (items that are needed to use tobacco), such as lighters or rolling papers, should not be permitted on campus to reinforce the policy. Advise visitors they may not possess any tobacco products or related paraphernalia on the property but may keep those items in a personal locked vehicle.

The smell of tobacco smoke can be a strong trigger and may contribute to cravings to those in recovery. Strengthen your tobacco-free environment policy by incorporating language prohibiting tobacco odors. This can be included in any existing fragrance policy that covers colognes, perfumes, or other fragranced products.

A tobacco-free environment policy cannot forbid the use of tobacco products off facility grounds before or after a treatment session, particularly in outpatient settings. But the policy can forbid someone from smelling like smoke or bringing cigarettes and paraphernalia onto the facility property. Smelling cigarette smoke or seeing the bulge from a pack of cigarettes in a pocket can make it difficult for some individuals trying not to smoke.

• EXAMPLE: Outpatient Tobacco-Free Environment Policy
• EXAMPLE: Residential Tobacco-Free Environment Policy

Inform all clients, staff, volunteers, and visitors about the policy and expectations. Develop a communication plan for clinical and non-clinical staff, clients, volunteers, visitors, referral sources and other stakeholders such as board members.

Provide clear and concise messaging on policy changes and rationale. Key points to communicate can include but are not limited to: the reasons for implementing or changing a tobacco-free environment policy; the implementation process and associated timeline; enforcement procedures; where to find educational and support materials for people who use tobacco products; and how individuals can participate in the process.

Begin the communication process as soon as the policy has been drafted and messages have been defined. Allow adequate time to answer questions, address concerns, and for people to make individual adjustments. Include information on the policies – both treatment and tobacco-free policies – in orientations as soon as materials are developed but before the policy goes into effect so new clients, staff, volunteers, and visitors are aware of the upcoming changes.

Use a multimedia approach and a variety of channels to communicate your plan. Communication should include an explanation of the policy but also provide an opportunity for education.

• Email or letters: Mail an initial announcement from leadership detailing your plan.
• In-person: Hold in-person meetings to allow for two-way dialogue and all voices to be heard. Clearly explain how the policy will be implemented. While this is not an opportunity to challenge the policy, input on the transition process is desirable. Respond to questions and concerns. Incorporate feedback into your plan to make the transition as easy as possible for everyone.
• Print materials: Provide fact sheets and handouts on tobacco use, benefits of recovery from tobacco, and information on how to access support and treatment. Review free print materials in the Additional Client Resource section at the end of the toolkit.
• Signage: Post announcements and posters around the building that celebrate the commitment to wellness and recovery. Hang signs and make a display with a countdown to launch date.

• • EXAMPLE – Agency Announcement Clients

There will likely be many questions during the implementation process. Anticipate questions concerns clients, staff, visitors, and volunteers will have and develop responses that pertain specifically to your facility. Share the responses through written documentation or posting on your website. Consider adding to the document as additional questions arise.

• EXAMPLE: Tobacco-Free Environment FAQs page

Consider developing a tobacco-free agreement for clients, staff, and volunteers. A signed agreement indicates understanding and acknowledgement of the policy.

Inform new clients and staff about the policy during admission and orientation. Obtain a signed agreement from all new clients and staff.

• EXAMPLE: Tobacco-Free Environment Agreement

Resistance, particularly on behalf of staff, can be a barrier to implementation of a tobacco-free environment policy and staff support is critical for success. The Tobacco Resource Exchange Toolkit provides documents and handouts for building staff support of a tobacco-free environment policy.

• TOOLKIT: Building Buy-In

Referring and affiliated providers – It is important to communicate with any referring and affiliated providers. Inform other clinicians on your clients’ health care teams of the transition and reasons for doing so.

Neighbors – If applicable, contact neighboring facilities and property owners. Educate them on your reasons for going tobacco-free. Address concerns on how this may impact their property. For example, there may be individuals moving to the edge of the property to use tobacco. If interested assist neighboring facilities in creating a tobacco-free environment.

New employees – Inform prospective employees and volunteers of the tobacco-free environment policy during their first interview and again during the orientation process. Have new employees sign an employee agreement during onboarding.

It is important to provide educational materials on recovery from tobacco. Create sample materials in multiple languages that reflect the client population served. A list of educational materials can be found in the Additional Client Resources section.

• FACT SHEET: Nicotine Addiction and Behavioral Health: Why is it hard to quit smoking?
• FACT SHEET: Quit Tips
• FACT SHEET: Vital Signs Smoking and Mental Illness

Hold a celebration on launch day to recognize the commitment to recovery and wellness. Staff and clients should already be aware of the policy provisions. Use the opportunity to celebrate by having leadership speak to the excitement for the transition and ask individuals to share stories about how they quit tobacco. Consider inviting local media or prepare media releases.

• Install signage at entrances and exits, parking lots, lobbies, and places people typically use tobacco at the facility. In addition to tobacco-free language, display positive and motivational messaging. Post signage prior to your launch date.
• Remove and replace smoking-related items (receptacles, ashtrays, garbage can that include ashtrays, smoking-area signage) of receptacles and replace garbage cans that include ashtrays.
• Redesign or repurpose old smoking areas into healthy break areas. For outdoor spaces, redesign the space by planting new plants, creating a walking path, or other adding a new recreational space.
• Review other organizational practices and policies for inconsistencies with the new policy. For example, breaks in the schedule are frequently used to smoke or use tobacco products and often referred to as “smoke breaks.” Shift to language that reflects the focus on wellness to “wellness breaks” or “fresh air breaks” in written and verbal communications. Additionally, provide appropriate materials or activities that can be used during break, such as new sporting equipment or games, or areas for practicing meditation. For certain settings, it may be appropriate to go on group walks.

Tobacco dependence treatment incorporates screening, skills-based counseling, medication, and motivational interventions. Clinicians trained in behavioral health services are skilled at providing the counseling and supportive therapies necessary for tobacco dependence and tobacco use disorder treatment. Increase capacity to utilize these clinical skills and knowledge in the context of treating tobacco use through regular trainings on evidence-based treatments for tobacco. Training may include in-service training, evidence-based conference training, self-study, teleconference, webinars and/or other e-learning activities.

• TOOLKIT: Integrating Tobacco Dependence Treatment in Behavioral Health Settings

With the understanding that tobacco dependence is an addiction, assistance should be provided to staff who use tobacco. Staff are not required to abstain from using tobacco products completely, but they must comply with facility policies while at work.

• Ensure staff have knowledge of and access to treatment services and policy through new staff and volunteer orientations
• Cover/offer discounted tobacco cessation benefits found to be most effective: counseling and medications, multiple counseling sessions, counseling services (including telephone, individual, and group), all 7 FDA-approved cessation medications
• Consider how employee assistance programs and employee wellness programs can support staff who use tobacco
• Consider the chronic nature of tobacco dependence. Offer and cover the cost of a variety of treatment options and at least two courses of treatment per year
• Offer alternative activities for break time while on campus property like walking trails, books, magazines, puzzles, or games in the breakroom

Like any policy, it is critical to have guidelines on policy violations that are applied fairly and consistently. The absence of enforcement guidelines undermines the policy and associated efforts. It is important that the enforcement policy is clear. Be sure to illustrate what constitutes a violation and the resulting consequences for each violation. Align consequences for tobacco use with consequences for using other prohibited substances.

Tobacco dependence is a chronic, unremitting illness. Like any addiction, relapse, especially early during treatment is expected. Policy violations may reflect need for additional therapeutic support. On the other hand, repeated policy violations negatively affect morale and treatment. Most enforcement policies balance these conflicting concerns by prescribing a clinical response for initial violations and escalating to punitive consequences for repeated violations. Initial policy violations may suggest the need for more intense tobacco dependence treatment. Punitive consequences for repeated violations can conclude with discharge or transfer to another facility as the only way to maintain treatment integrity.

Staff should present the tobacco-free environment policy and its enforcement to clients at the time of admission. Clients should sign that they received notification of the policy.

Clients – It is crucial to develop and follow a protocol for addressing violations when they occur. Be consistent with enforcing predetermined consequences. Consequences should be escalating in nature and consistent with responses to other policy violations. Initial violations should begin with therapeutic interventions and progress up to a transfer to a different level of care or discharge from treatment. While it is a rare occurrence, if clients continue to violate the policy, there may be a need to discontinue services for that client or work to transfer the client to another facility.  Consequences will likely vary between inpatient/residential and outpatient treatment settings. If an outpatient setting does not have a policy regarding the use of other prohibited and addictive substances, it should develop a tobacco-specific policy. Accommodations may be necessary for clients with cognitive impairments in an outpatient setting.¹⁷

Staff – There should also be an enforcement procedure for employees who violate the tobacco-free environment policy. Enforcement for employees might best be administrated by HR and be consistent with the enforcement procedures it has for other employee policies.

Volunteers and Visitors – Enforcement for volunteers and visitors might be different from that for clients, but also escalating in nature. Initial responses could begin with reminders of the policies and handouts for local resources such as the Wisconsin Tobacco Quit Line. Repeated violation could result in expulsion from the premises.

• EXAMPLE: Nonsmoking Procedure

All employees are expected to be familiar with and responsible for monitoring compliance. Equip staff with language to feel comfortable enforcing the policy as well as support from management for enforcing the policy. Enforcing the policy is an opportunity to respectfully support the whole-health or wellness approach of the organization. For clients, view the compliance issue as a therapeutic opportunity.

Provide staff training on policy rules, consequences, and how to respond to specific examples of violations and specific procedures to follow once a violation has been observed. Provide language that can be used in a variety of potential scenarios. Staff should begin using the language before the policy is launched to make the transition smoother. It is everyone’s responsibility to contribute to a healthy work environment that supports client recovery and wellness.

Tips for addressing a compliance issue:

1. Remain calm and polite
2. Remind them about the policy
3. Share information on available resources

Include the tobacco-free environment policy in your quality assessment efforts to determine if the policy is impacting the target group and if the policy met implementation goals. Begin the policy evaluation process as early as possible to identify barriers as they occur and make appropriate adjustments.

The wellness committee should develop assessment questions and related performance measures that reflect the goals and outcomes listed in the logic model. Include staff and clients in the process in order to create a more equitable, effective, and accurate evaluation plan. Assessment questions include:

• Were clients and staff adequately aware of and prepared for the policy before it took place?
• Were the policy and expectations clear?
• Were the reasons for it compelling?
• Was it implemented as described?
• Was it implemented too rapidly or too slowly?
• Have violations gone undetected?
• Have violations been responded to consistently and fairly?
• Has ongoing support been sufficient?
• Are there opportunities for improvement?

Your wellness committee should have a structured method to solicit feedback from stakeholders, especially staff and clients. These questions can be collected via a survey, individual or group meetings with employees/clients, and/or electronically through a chat room following a presentation about evaluating the policy.  Collected information should be shared with management and feedback given to staff.

TOOLKIT: Evaluation toolkit for Smoke-Free Policies

The information collected above will help you evaluate the outcomes of your tobacco fee policy.  In addition, a periodic review and analysis of policy violations will be instructive and help indicate areas to be improved. Consider asking clients about how the policy affected them. Expect unanticipated positive consequences but be sensitive to negative impacts as well. Make a periodic inspection of signage to ensure that all signs remain appropriately in place.

TOOLKIT: Developing and Effective Evaluation Plan

• Include a description of policy and consequences for violations into orientation for new clients
• Include policy language in HR materials: new employee training, job postings, employee handbook
• Review other policies for consistency with tobacco-free policy and environment
• Provide ongoing treatment training for staff and train new staff on tobacco treatment protocol
• Maintain a wellness committee for ongoing policy review and evaluation. Continue to monitor enforcement and compliance of policy and address challenges or barriers for the organization
• Include regular communication and reminders to staff/clients/visitors regarding expectations and approaches to support policy
• Maintain tobacco-free environment signage
• Keep educational materials on hand for visitors and new clients and staff

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15. SAMHSA, CBHSQ. National Survey of Substance Abuse Treatment Services (N-SSATS): 2020 Data on Substance Abuse Treatment Facilities ii. Accessed March 14, 2022. https://www.samhsa.gov/data/.
16. Wisconsin Nicotine Treatment Integration Project. Recommendations and Guidelines for Tobacco-Free Behavioral Health Facilities & Services. Accessed March 31, 2022. https://uwmadison.app.box.com/s/zftsvlz967d5a330zuspf63va6ppso72