Frequently Asked Questions

North Carolina is committed to protecting the health of all North Carolinians. Tobacco-related illness is the number one preventable cause of death and disability in North Carolina.(1,2) A 100% tobacco-free campus is an essential part of offering evidence-based tobacco use treatment services.(3,4) The U.S. Surgeon General states there is no safe level of secondhand smoke.(5)  No one should be exposed to secondhand smoke when they access care or on the job.

A little more than 1 in 5 people in North Carolina use any tobacco products.(7) People with behavioral health conditions are much more likely to use tobacco. (6)  Among people with intellectual or developmental disabilities (IDD) the rate of tobacco use is much lower.(8) However, people with IDD and a substance use disorder are much more likely to smoke.(9)People with traumatic brain injuries (TBI) may also have higher rates of tobacco use and behavioral health conditions, compared to those without TBI.(10)

Among people in North Carolina who are uninsured or have Medicaid, more than half of people who used mental health services use tobacco and more than 2 out of 3 of people who use substance use treatment services use tobacco.(11)

Studies have observed 5%-15% of people in substance use treatment starting to smoke in treatment. (12–15)

Here are some examples of the impact of tobacco use on people with behavioral health conditions:

• In the US, folks with a behavioral health condition who use tobacco lose 25 years of life, on average(6)
• Life expectancy 14.5 years lower for people with schizophrenia and this is largely attributable to higher rates of tobacco use(16)
• One large, long term study found that over half of people who went to substance use treatment died from an illness caused by tobacco use (17)

• Quitting smoking lowers overall stress after about 1-3 weeks with effects similar to an anti-depressant.(18)
• For someone who wants to quit using other substances, getting treatment for tobacco use at the same time makes them 25% more likely to avoid substance use in the future.(19)

Withdrawal from nicotine makes people feel anxious, angry, sad, irritable, and  more.(3) The cycle of withdrawal happens throughout the day between the times you smoke, vape, or use tobacco. Exiting the stressful cycle of nicotine highs and lows, along with having more energy because you can breathe better may explain why quitting is good for long-term mental health.(18) For people with a substance use disorder, using tobacco often happens along with drinking alcohol or using other drugs.(19) One can be a trigger for the other.

For these reasons, treating tobacco use is a key part of evidence-based behavioral healthcare. Interested in quitting? QuitlineNC offers free help with quitting that really works via phone, web, or text. Register online, call 1-800-QUIT-NOW, or text READY to 200-400 to get started.

Secondhand aerosol is the cloud of chemicals that comes from e-cigarettes or vapes.(21) The U.S. Surgeon General warns e-cigarette aerosol can have harmful chemicals, including nicotine and cancer-causing chemicals.(21) Children especially can be harmed because their lungs are still growing—and nicotine is always harmful to teen and fetal brain development.(21)

One more risk from smoking, vaping, or dipping on site: kids who see adults that they look up to using tobacco are more likely to use tobacco in the future.(4,22)

Social Determinants of Health

• Social determinants of health are the conditions in which people are born, grow, live, work, and age.(23)
• Social determinants within each of these broad areas, such as poverty, housing, social support, discrimination, quality of schools, health care access, and transportation, influence tobacco-related disparities. For example, people that lack quality housing may be at greater risk of exposure to secondhand smoke, and people with limited health care access may lack information about the dangers of tobacco use and available cessation options.(23)

Tobacco Industry Influence:

• The tobacco industry has used multiple strategies to market cigarettes to populations with behavioral health conditions.(24) The Centers for Disease Control’s Best Practices User Guide: Health Equity in Tobacco Prevention and Control, notes that the tobacco industry heavily markets its products to populations affected by tobacco-related disparities. Marketing, advertising, and promotional strategies are often directed at low-income, minority, and young adult populations. Historically, the industry has also funded groups that work with communities affected by tobacco-related disparities. (23)

Lack of Comprehensive Policies 

• Inconsistent adoption and promotion of adherence to tobacco control policies, like tobacco-free policies, create disparities in protections from secondhand smoke exposure and support for people trying to quit.(23)

Changing U. S. Population

• The population of adults living in poverty is more likely to forego needed medical care, experience psychological distress like hopelessness and anxiety, and smoke cigarettes.(23)

Breathe Easier – Become Tobacco-free

• Offering a 100% tobacco-free environment with tobacco-use treatment is the first step towards health equity for people with behavioral health conditions. Not only that, but it is an important part of treatment because becoming tobacco free is associated with improved mental health and substance use recovery outcomes.(6)
• CDC’s Overview of Tobacco Use and Quitting Among Individuals with Behavioral Health Conditions click here.

Tobacco products include

• Products you light, like cigarettes, cigars, little cigars, hookah.
• Electronic products like e-cigarettes or vapes
• Heated products such as IQoS
• Smokeless tobacco products like dip, chew, snuff, and snus. Also dissolvable oral products like orbs, sticks, and pouches.
• Nicotine products that are not approved by the FDA as tobacco treatment medications

There is a difference between commercial tobacco products and traditional tobacco used by some American Indians and Alaska Natives. For more about commercial vs. traditional tobacco click here.

Electronic cigarettes or vapes are a newer category of commercial tobacco products that are also known to contain and release potentially harmful chemicals.(21)

Traditional tobacco is tobacco and/or other plant mixtures grown or harvested and used by many American Indians and Alaska Natives for ceremonial or medicinal purposes.(26) Traditional tobacco has been used by American Indian nations for centuries as a medicine with cultural and spiritual importance.(26)

While burning or using commercial tobacco products on campus is prohibited by the 100% tobacco-free policy requirement, service providers should work collaboratively with tribal people that they serve to respect tradition and find ways for people to engage in sacred practices that both adhere to the requirement and meet the needs of clients. Reach out to North Carolina DHHS’s American Indian Tobacco Coordinator and your regional commercial tobacco control manager for assistance in doing this.

For more information on commercial vs. traditional tobacco and resources for American Indian North Carolinians, click here.

E-cigarettes and smokeless tobacco are tobacco products. E-cigarettes are a delivery system for nicotine, which is a highly addictive substance. Electronic cigarettes are considered a tobacco product by the FDA and North Carolina law.(21) Nicotine can cause an increase in blood pressure, heart rate, flow of blood to the heart and a narrowing of the arteries (vessels that carry blood).(3) As well as being addictive, nicotine is harmful to fetal and adolescent brain development.(21) Withdrawal symptoms from nicotine include anxiety, anger, sadness, and many more.(3) It is important to treat nicotine withdrawal with medications that really work and are safe.(27)

Smokeless tobacco products like chew, dip, snus, and many more have been proven to be harmful and addictive.(3,28) Also, the spitting involved with some smokeless products can spread disease.(29) The use of smokeless tobacco products on campus in front of another client who is trying to quit could be a trigger for that person to use tobacco. It also models tobacco use for children and teens who may be on campus.  A tobacco-free campus enables effective tobacco use treatment.

Nicotine replacement therapies like the patch, gum, lozenge, inhaler, and nasal spray are all FDA approved safe medications that are shown to help people quit.(30) They treat nicotine withdrawal so you can focus on using the services you receive to reach your goals. Nicotine replacement therapy is an important part of tobacco use treatment and a successful tobacco-free policy.(30) This is because using nicotine replacement therapy combined with counseling makes it 2x more likely that someone will finally be able to quit.(27)

Sometimes people who try the nicotine patch, gum, or lozenge don’t know how to use them or that they can be used together. Combining the patch and gum or lozenge is much more effective than either by itself.(31) Learn more about nicotine replacement therapy and  how to use it from these flyers in English and Spanish.

• Studies have observed 5%-15% of people in substance use treatment starting to smoke in treatment.(12–15)
• One large, long term study found that over half of people who went to substance use treatment died from an illness caused by tobacco use.(17)
• For years, tobacco companies gave cigarettes away to psychiatric hospitals, causing many to start using tobacco or become more addicted. As a result, smoking is now common in treatment centers.(6,32)
• Yet for people who want to stop using other substances, getting treatment for tobacco use at the same time increases their chances of maintaining recovery by 25%. (19)

Tobacco-free policies in healthcare settings also protect people’s ability to quit tobacco use.(4) Many people receive all the healthcare services they need in tobacco-free environments, like their doctors’ office or at the hospital. These environments support people when they set a goal to quit smoking.

Also, a tobacco-free policy doesn’t restrict people from using tobacco while they are not on a property covered by the policy. Similar to how not allowing alcohol use at a workplace, campus, or healthcare setting doesn’t take away anyone’s right to drink alcohol off campus, a tobacco-free policy does not take away people’s ability to use tobacco off campus.

Breathing secondhand smoke day in and day out is what causes heart attacks, lung disease, cancer, and strokes for people who live with someone who smokes in their home or in their porch or yard.(5) No one should have to accept the health risks from secondhand smoke to get the support they need in their home to reach their goals. This is why so many landlords have tobacco-free policies.(1,33)

Tobacco-free policies in housing, such as apartments or group homes, protect people’s right to clean air and support their ability to quit tobacco use. It is extremely hard to quit when the people who live with you often use tobacco products in front of you.  It is important to note that a tobacco-free policy does not take the ability to use tobacco off campus away from anyone. People who need housing supports have the right to breathe clean air and to reach their goals, as well as broad rights to decide what to put in their body. Tobacco-free policies protect those rights, without harming the rights of others.

The goal is a tobacco-free environment that supports success in quitting tobacco use–not to force people to quit or stigmatize clients or staff who use tobacco. This protects the safety of clients, staff, and visitors and their freedom to breathe clean air. A behavioral health, IDD, or TBI program should offer the full range of services to support you, partner with you to set goals, and help you achieve them. Staff might respectfully explore with you if you are interested in quitting and how smoking fits with your other goals. If your goal is quitting smoking that is great, but it is your choice.

This policy gives people who want to quit tobacco a real chance at making the choice to live life tobacco free. For example, we wouldn’t expect clients who are trying to quit alcohol use to be successful in a treatment environment with a bar in the backyard. It is unfair to ask people with Medicaid or who are uninsured who want to quit to get treatment in environments that allow tobacco use.

• Clients were much more successful becoming tobacco-free themselves.
• Fewer staff sick days
• Less conflict among clients
• Better focus on treatment
• Same number of people were admitted to treatment showing that people still sought help in crisis
• A cleaner environment that saved money and staff time that would’ve been spent cleaning up cigarette butts.
• Discharges did not increase (36)

If you are wondering where to start with implementation, the good news is you do not have to do this by yourself. Reach out to your regional tobacco control manager for support. They have the experience to help your organization have a smooth and positive policy implementation process. Also, check out this Road Map to a Tobacco-Free Policy.

For technical assistance with integrating tobacco use treatment, as well as free training, you can contact:

Regional and local tobacco control staff

You Quit, Two Quit provides free technical assistance on policy implementation and tobacco use treatment for programs that work with reproductive-aged or pregnant people.

Tobacco use treatment integration toolkits:

Dimensions: Tobacco-Free Policy ToolKit is a step-by-step resource for implementing a policy.

Million Hearts Tobacco Cessation Change Package is a compilation of treatment and policy implementation resources that are evidence-based.

Lastly, once your organization starts the process of going tobacco-free, you may find that more clients are interested in quitting.(4) Clients come to your organization because they trust you to help them reach their goals and take care of their health. Research shows that health professionals communicating the message to clients that quitting will benefit their physical and mental health increases quit attempts.(30)

There are resources for uninsured people who cannot afford to buy over-the-counter nicotine replacement therapies or pay out of pocket for a prescription of FDA-approved cessation medication.

Here are some examples:

• QuitlineNC offers up to eight weeks of combination nicotine replacement therapy for uninsured callers. Learn how to refer clients here.
• Several health departments offer nicotine replacement therapy to county residents; check with your local health department.
• Many community health centers or free clinics offer free or reduced-price nicotine replacement therapy or medications to uninsured people.
• Check out this list of prescription assistance programs for prescription tobacco use treatment medications.

For in-patient and residential programs, these resources are useful but do not provide nicotine replacement or other medications for the immediate need on-site when someone is admitted to the program. For these settings, it may be necessary for the program to provide the nicotine replacement until clients are connected to another resource, learn more about how to do this on our medications page.

The 100% tobacco-free policy requirement applies to most service providers (including residential substance use disorder treatment providers) contracted with Standard Plans and LME/MCOs. For providers subject to the 100% tobacco-free policy, the policy applies to everyone at all times on a program’s property: clients, staff, contractors, vendors, and visitors. This requirement starts July 1, 2024.

Some provider settings are not required to become 100% tobacco-free after July 1, 2024. These include:

1. Settings not required to become tobacco-free: retail pharmacies; properties where no direct clinical services are provided; non-emergency medical transport; alternative family living settings; manufacturing sites that employ people who receive adult developmental vocational program services; or manufacturing sites that employ adults who receive other group day services.
2. Settings where a partial tobacco-free policy is required: Intermediate care facilities for adults with intellectual disabilities (ICF-IID), adult I/DD residential services subject to the Home and Community Based Final Rule, adult mental health group homes, adult care homes, family care homes, residential hospices, skilled nursing facilities, and long-term nursing facilities. For details on the partial policy requirement, see the next question: “What is the partial tobacco-free policy requirement and where does it apply?”

Need help implementing a tobacco-free policy? Click here to find out who is assigned to your region to assist you.

Starting July 1, 2024, the following partial tobacco-free policy shall be required in Intermediate care facilities for adults with intellectual disabilities (ICF-IID), adult I/DD residential services subject to the Home and Community Based Final Rule, adult mental health group homes, adult care homes, family care homes, residential hospices, skilled nursing facilities, and long-term nursing facilities:

1. Use of tobacco products is prohibited indoors when the building or home in which the provider operates is under the provider’s control as owner or lessee.
2. Outdoor areas of the property under the provider’s control as owner or lessee must:
   1. Ensure access to common outdoor space(s) free from exposure to tobacco use; and
   2. Prohibit staff/employees from using tobacco products anywhere on the property.

Providers subject to the above-referenced partial tobacco-free policy requirement retain the option to implement a one hundred percent (100%) tobacco-free campus policy for the safety of clients and staff.

Wondering how to implement your agency’s policy? Luckily you don’t have to do this by yourself, for help creating a policy that adheres to these standards at your organization contact your regional commercial tobacco control manager. 

Yes. The following are exempt:

• retail pharmacies;
• properties where no direct clinical services are provided;
• non-emergency medical transport; alternative family living settings;
• manufacturing sites that employ people who receive adult developmental vocational program services;
• or manufacturing sites that employ adults who receive other group day services.    

Long term services and support such as adult mental health group homes, adult care homes, family care homes, residential hospices, skilled nursing facilities, and long-term nursing facilities have a different requirement, to learnmore see the question above: “What is the partial tobacco-free policy requirement and where does it apply?”

Tobacco refers to commercial tobacco products and includes the use of combustible, electronic, heated, and smokeless tobacco products. For more on the difference between commercial and traditional tobacco products, click here.

There are no designated areas for tobacco use indoors or outdoors.

Programs do not purchase, accept as donations, or distribute any tobacco products.

For sample policies click here.

A 100% tobacco-free policy applies to everyone at all times on a program’s property: clients, staff, contractors, vendors and visitors.

July 1, 2024.

Click here for the updated Medicaid Bulletin.

In the meantime, organizations are highly encouraged to implement a 100% tobacco-free policy well in advance and to take the time (usually months) necessary to implement the policy in a thoughtful, transparent, and evidence-based way. Reach out to your regional or local tobacco prevention and control staff for assistance.

For sample policies click here.

Yes.  

PSRs, ADVPs, and other group day services have an important role to play in facilitating clients or members in leading meaningful lives of their choice in the community. No one should ever have to choose between participating in these services and their goal of living life tobacco-free. By providing a tobacco-free environment, these services both support people who want to quit and prevent new clients or members from ever starting, while not stopping anyone who wishes to continue from using tobacco when they are off-campus. 

You don’t have to do this alone! Your regional tobacco prevention manager is here to help you take your campus tobacco-free. 

To learn more about how to take your PSR program tobacco-free, check out this recorded training: 

Taking Psychosocial Rehabilitation Services Tobacco-Free: A Success Story from Maryland. 

Support might look like:

• Offering nicotine patches, gum, and lozenges for relief from cravings (you can use these, even if you are not ready to set a goal of quitting!)
• Identifying smoking triggers and finding ways to plan for or avoid them
• Offering toothpicks, hard candy, and water to give folks things to do with their hands and mouth when not smoking
• Working together to find other ways to socialize on campus that do not involve tobacco use

Tobacco use disorder is a substance use disorder–a chronic condition; recovery is possible and happens every day.(30)However, slips and returns to use are a normal part of the recovery process. Difficulty not using a substance is one of the symptoms of a substance use disorder. Programs should respond to difficulties with adhering to the policy by offering compassion, evidence-based treatment, and collaborating with the client to find ways to prevent future use on campus.

For help creating a policy that adheres to the NC Managed Care Tobacco-Free Policy requirement and is individualized to fit your organization, reach out to your regional and local tobacco control staff.

For a sample policies click here.

Start by taking the time to build buy-in for the policy from staff prior to implementation. Staff should receive training on the policy and how to address it when someone is not adhering to the policy as a part of implementation, orientation, and ongoing training. Employee handbooks should detail the policy and the response if employees have trouble adhering to it.

A tobacco-free policy is one of the most effective ways to support employees to quit, but it is just the first step.(32)Educate employees about the tobacco use treatment benefits offered by employee healthcare coverage. Ensure that those benefits provide the NC standard of care for tobacco use treatment with no barriers and no co-pays. Refer employees to health insurance’s quit resources, QuitlineNC, community resources, or offer tobacco use treatment over-the-counter medications and counseling for employees onsite.

For help creating a policy that adheres to the NC Managed Care Tobacco-Free Policy Requirement and is individualized to fit your organization, reach out to your regional and local tobacco control staff for help.

Wondering how to build support among staff and clients for a tobacco-free policy? This free online self-paced training can help! Justice in the Air: Framing for Tobacco-Free Behavioral Health Initiatives.

For sample policies click here.

Yes.

Anyone who has tried to quit smoking, drinking alcohol, or using any other drug knows from experience that staying away from triggers to use substances and having a supportive environment are key to success. Part of that supportive environment is not having substances, including legal ones like alcohol and tobacco, onsite.

Inpatient and residential treatment programs can treat nicotine withdrawal quickly using medications (such as nicotine patches, gum/lozenges) that are safe, fast, and effective. Clients may or may not set a goal of quitting smoking during their stay and that is ok. In the meantime, clients and staff are safe from secondhand smoke/aerosol, and clients’ withdrawal symptoms are adequately treated.

The response to someone who brings tobacco products on campus is compassion and collaboration with that person to find ways that work for them to adhere to the policy, as well as removing the tobacco products from campus. To learn more about how to promote adherence see How can I promote client adherence to a tobacco-free policy at my program?