Tobacco and behavioral health: Can government agencies successfully collaborate with behavioral health facilities to implement system-wide tobacco control policies?

Smoking rates for behavioral health populations are least twice that of the general population, yet few behavioral health facilities have successfully implemented smoke-free policies. The California Mental Health Services Act (MHSA) eliminated state department oversight of county MHSA funds, giving authority to each county's board of supervisors to oversee work plan implementation. Qualitative analyses were conducted using guided interviews with 17 county-level project directors, most of whom utilized tobacco control funds for behavioral health activities. Participant observations took place at four regional meetings (Sonoma, Shasta, Santa Cruz, San Diego) in June 2012 with regionally-defined key stakeholders (n=50 participants). An inductive approach was used for data analysis. A key theme identified was adoption of several county-level and organizational policies, but lack of implementation/enforcement due to inadequate time/resource commitment. A frequently cited obstacle to a systems-level approach was buy-in from counselors and administrative managerial staff. A top-down approach was proposed by respondents as a solution to obtain buy-in from all levels. Significantly, each project director identified a local health department champion who could serve as a crucial intermediary for successful policy implementation. There appeared to be a lack of understanding regarding the ability of local ordinances to trump state ordinances (i.e., Title 22). Participants commonly requested legal and educational fact sheets as health educational tools. Most participants felt that system-level tobacco policy changes were possible but would take time. The systematic adoption and implementation of policies will heighten awareness of enabling legislation, and encourage uptake of behavioral health system-wide policies.