In California, 27.7% of people who experienced serious psychological distress in the last year (2011–2012) reported smoking, compared with 12.6% of the general population (1). To address the needs of this at-risk population, the California Tobacco Control Program (CTCP) surveyed county and private behavioral health care programs to assess their readiness for adopting tobacco control strategies at behavioral health treatment facilities. Themes that emerged from surveys of key informants guided 2012 regional behavioral health care trainings. Training provided evidence-based guidelines, and participating agencies created rapid improvement plans for implementing tobacco control strategies.

In 2011, CTCP conducted key informant interviews by telephone with 17 CTCP grantees, all of whom ran county or private behavioral health care programs. We selected key informants who reported plans to use state tobacco control funds to address the cessation needs of people with mental illnesses or addictions. Qualitative data were obtained on current practices to address nicotine dependence, established treatment relationships, current policies, expected challenges, needed educational materials, and buy-in from local decision makers regarding implementation of tobacco-free policy and systems change. Additionally, we asked key informants whether they were aware that Mental Health Services Act grant funds were available through the California Mental Health Services Act for innovative cessation projects for people in need of behavioral health treatment. A brief 9-item interview, which included open-ended items and in-depth probes, was created with input from tobacco control and behavioral health county partners. For analysis, CTCP used an inductive qualitative approach to code emergent interview themes.

Subsequently, in 2012, we chose 4 locations from the 17 originally surveyed, and regional trainings were conducted by the University of Colorado Behavioral Health and Wellness Program (BHWP). Participating community agencies in Sonoma, Shasta, Santa Cruz, and San Diego were selected on the basis of local decision makers’ buy-in for implementing systems change and tobacco-free policy strategies to support people in need of the behavioral health treatment. Each training session had an average of 50 participants with the exception of the training at Sonoma County, which received special permission to have 100 participants. During trainings, participants learned evidence-based strategies for integrating tobacco cessation and tobacco-free policies into daily behavioral health treatment. Participants further engaged in strategic planning and developed rapid improvement plans by using an established plan-do-study-act (PDSA) model to articulate short- and long-term tobacco control goals. In 2013, BHWP conducted follow-up interviews by telephone with the participating agencies to determine outcomes for their system change goals.

Emergent themes were identified from baseline key informants (n = 17, Table 1): staff ambivalence, system challenges, insufficient resources, and tobacco’s lack of priority status, effective strategies, and creation of a movement. During the 4 regional trainings, attendees reported needing both county and organizational policies but noted lack of implementation and enforcement of tobacco-free policies due to inadequate time and resources. Legal guidance and health educational tools were requested. Attendees asserted that policies are possible but take time and multilevel buy-in. To increase buy-in from agencies, attendees proposed a top-down approach combined with a bottom-up approach, which required that all decision makers, staff, and clients be involved in tobacco-free policy development, implementation, and enforcement to ensure success. To aid policy implementation, attendees asked that health department champions be intermediaries between facilities and their decision-making boards.

Most agencies were in early stages of policy implementation and planned to focus on staff and leadership awareness regarding the benefits of tobacco-free policies. Also, 15 county agencies requested and received additional technical assistance in the months following trainings.

Follow-up interviews with 3 county agencies and 7 nongovernment organizations showed that trainings identified specific achievable objectives (n = 10, Table 1, bottom section). Heightened resistance to policies was reported for addiction treatment centers and trauma agencies. Agencies accomplished about 50% of their goals, such as recruiting members for tobacco coalitions and educating decision makers. Progress is evidenced by growing community partnerships, increased tobacco-free policies (n = 2), and provision of cessation services (n = 2) (Table 1). County public health agencies in Sonoma, Monterey, Santa Cruz, Watsonville, Shasta, and San Diego partnered with behavioral health agencies to build coalitions. BHWP conducted trainings in these counties and others to implement train-the-trainer tobacco use cessation programs. We also found a decrease in the proportion of agencies in early stages of change (Table 2) because they had moved to a later stage. Organizations at the action and maintenance stages (Table 2) doubled from baseline to follow-up.

California has been effective in helping the behavioral health care system to address the health disparities experienced by smokers with behavioral health issues. Training participants expanded their knowledge and outlined concrete plans for transitioning to tobacco-free environments.

Obstacles to implementing policy still remain. Specifically, many agencies treating trauma and addictions continue to have concerns about going tobacco-free. In part, this reluctance reflects a long-held perspective that other issues are more important and that clients cannot or do not desire to quit smoking (2). Future training should acknowledge providers’ competing demands but also refute common misinformation that has reinforced inaction.

Building on the gains from statewide trainings, California is funding 4 additional county health departments to increase the number of smoke-free health care campuses (El Dorado, Lake, Mariposa, Placer), and 2 county health departments (Humboldt, Sonoma) are being funded to adopt or implement behavioral health care treatment programs.

CTCP held another series of regional trainings in 2014. The trainings have led to collaboration between the California Department of Public Health (CDPH) and the California Department of Health Care Services (DHCS). DHCS is currently implementing the Affordable Care Act (ACA) and the Medi-Cal expansion that supports comprehensive tobacco cessation programs for beneficiaries. The Medi-Cal expansion focuses on creating a plan of care that treats the whole person, including mental health and alcohol and drug services. CDPH and DHCS are working together to determine how best to integrate tobacco control activities into state Medicaid benefits and how to strengthen systemwide tobacco control policies.