An investigation of an organisational change approach for smoking cessation in the alcohol and other drug treatment setting

Tobacco smoking among persons receiving treatment in the alcohol and other drug (AOD) setting is highly prevalent. The health, social, and economic costs of tobacco smoking are profound for this group, who also have lower quit rates. Despite the presence of effective treatment for tobacco smoking, translating such interventions into clinical practice has been slow and limited in the AOD setting. Organisational barriers to care and a culture permissive of smoking have led to calls for an organisational change intervention to integrate smoking cessation care into routine delivery in the AOD setting. An organisational change intervention in relation to the tobacco control context can be defined as multicomponent strategies that target the system, culture, policies, and individuals, with the aim of integrating the identification of smoking and ensuring the treatment of tobacco smoking. Organisational change interventions aim to transform the culture so that it supports rather than conflicts with the goal of smoking cessation. In addition, such interventions aim to address identified barriers and ensure smoking cessation is routinely addressed in an ongoing sustainable manner. Importantly, the US Public Health Service Clinical Practice Guidelines recommend organisational change to facilitate the implementation of smoking cessation care into usual care within the health care setting. Also known as the Health Systems Change approach by Fiore et al., the organisational change strategies include the following: Strategy 1: Implement a system for identifying smokers; Strategy 2: Provide education, resources and feedback to promote smoking cessation care; Strategy 3: Dedicate staff to provide smoking cessation care and assess its delivery in staff performance evaluations; Strategy 4: Promote smoke-free policies that support and include the provision of smoking cessation care; Strategy 5: Include smoking cessation care (both counselling and pharmacotherapy) identified as effective as paid or covered for by the service; Strategy 6: Reimburse staff members for the delivery of effective smoking cessation care and include these interventions among the defined duties of staff members. Models of organisational change for smoking cessation in the AOD setting have been proposed; common to these interventions are: developing organisational commitment from management and staff; implementing systems to identifying smoking status; designating support champions; training; resources; smoke-free policy; and evidence based tobacco dependence treatments. International research provides some preliminary evidence that organisational change interventions are feasible and acceptable to the staff and clients of the AOD setting. Further research to elucidate the barriers and facilitators to implementing these interventions is important to ensure sustainable changes in the AOD setting. The aim of this thesis is to explore the opportunities for and barriers to the introduction of smoking cessation care in the AOD setting.