Inpatient Treatment Smoking Ban: A Barrier to Treatment Amidst an Overdose Crisis

Overview: Using a participatory action research approach, a university researcher partnered with a group providing outreach to individuals with substance use disorders to examine how a recently enacted inpatient treatment smoking ban impacted individual's willingness to go to inpatient treatment as well as their leaving treatment early.Proposal text: While rates of cigarette smoking are on the decline, they remain high for those with behavioral health disorders (Weinberger et al., 2018; Parker et al., 2019). Concerns about the long-term impacts of smoking has prompted a focus addressing cigarette smoking within this population (Cooperman et al., 2018; Marynak et al., 2018). One approach has been to integrate smoking cessation programs into inpatient substance use treatment (Kelly et al., 2020). In 2019 one northeastern city integrated smoking cessation into their inpatient treatment programs along with a ban on smoking cigarettes. They simultaneously declared overdose deaths in the city to be 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. 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.

A local researcher and small non-profit collaborated to create a mixed-method survey about the extent to which, if at all, the smoking ban was impacting individuals' decisions to go into treatment or to leave treatment early. The survey contained 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. 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.

While there was a relatively small sample size, the findings indicate 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 (particularly in the midst of an overdose crisis) in tandem with concerns about the harms of smoking. Additionally, it highlights the importance of meaningfully including the perspectives services users in initial policy development.

Through the participatory action approach, findings from this study were used to rollback the smoking ban in this city. This study has teaching implications in terms of the highlighting the potential power of participatory action research, shedding light on including cigarette smoking in our discussions about harm reduction, and demonstrating the consequences of how we weigh "expert" opinions and that of those with lived experience when making policy decisions.