Frequently Asked Questions

NC Standard and Tailored Plans Tobacco Related Policy Requirements for Organizations that Serve People with Intellectual/Developmental Disabilities (IDD) or Traumatic Brain Injuries (TBI)

See the original provider memo on NC Medicaid’s blog here.

Click here for PDF of this FAQ

Questions about Tobacco Related Policies and Treatment

Why is North Carolina implementing a tobacco-free policy requirement through the Standard and Tailored Plans?

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.

 Learn more about what policy is required for your program from the two questions below.

Who does the policy requirement affect?

The 100% tobacco-free policy requirement applies to medical and behavioral health providers and non-residential IDD and TBI service providers contracted with Standard and Tailored Prepaid Health Plans to provide services to people who receive Medicaid or are uninsured. The only Standard or Tailored Plan contracted programs not required to become 100% tobacco-free at this time are retail pharmacies and Intellectual and Developmental Disabilities residences and intermediate care facilities. For more information on tobacco policies in these residential IDD settings see the next question.

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

I’m a provider who offers intermediate care facility services for people with IDD (ICF-IID) services or residential services covered by the Home and Community Based Services (HCBS) final rule. What are the policy requirements for my services?

In these types of settings:

  • Indoor use of tobacco products is prohibited.

For outdoor areas of campus, providers shall:

  • ensure access to common outdoor space(s) that are free from exposure to tobacco products/use; AND
  • prohibit staff/employees from using tobacco products anywhere on campus.

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.

How many people with IDD or TBI use tobacco products?

According to North Carolina’s National Core Indicators data, about 5% of people using IDD services report using tobacco products.(6) However, some research shows that people who have both IDD and substance use disorders have a high rate of tobacco use, with more than 80% smoking.(7)

People with lifetime history of a traumatic brain injury might be somewhat more likely to smoke than those who do not.(8) More research is needed in this area. One possible reason for this is that traumatic brain injury puts people at increased risk for behavioral health conditions.(8) People with behavioral health conditions are much more likely to smoke.(9)

Why might people with IDD or TBI who have behavioral health conditions be more likely to use tobacco? Learn more from our FAQs about tobacco’s impact on people with behavioral health conditions here.

What is the impact of tobacco use on people with IDD or TBI?

Tobacco is the number one preventable cause of death and disability in the United States and North Carolina.(1,2) The most common causes of death among individuals with intellectual and developmental disabilities are heart disease, respiratory illness, and cancer, all conditions that can be influenced or caused by smoking or secondhand smoke.(7) People with IDD use tobacco at a lower rate than the population overall, so most of these deaths are not caused by smoking.(7) People with TBI are more likely to use tobacco and tobacco use prior to a traumatic brain injury impairs recovery. (10)

Tobacco use is harmful; it can cause heart attacks, strokes, and many types of cancer. Everyone should have the same access to tobacco use treatment and tobacco-free environments to support them when they set a goal of becoming tobacco-free.(3,7)

What are the risks from secondhand smoke and e-cigarette chemical emissions?

Secondhand tobacco smoke is dangerous; it increases risk for lung cancer, heart attacks, stroke, and lung illness.(5) For people with asthma or COPD, just a few minutes of breathing secondhand smoke can trigger an asthma attack.(5) Some studies have found that secondhand smoke increases the risk for triggering a seizure in people with epilepsy.(11) There is no safe level of secondhand smoke.(5)

Secondhand aerosol is the cloud of chemicals that comes from e-cigarettes or vapes.(9) The U.S. Surgeon General warns e-cigarette aerosol can have harmful chemicals, including nicotine and cancer-causing chemicals.(9) Children especially can be harmed because their lungs are still growing—and nicotine is always harmful to teen and fetal brain development.(9)

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.(4,10)

 

How does having a tobacco-free campus policy benefit clients and staff?

Many research studies have looked at the effects of tobacco-free policies at healthcare programs. All North Carolina behavioral health hospitals became 100% tobacco-free campuses in 2014. This policy was implemented after piloting tobacco-free campuses at psychiatric and a substance use treatment hospital and collecting data on the outcomes (12). Here are some of the things that happened:

  • 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 (12)

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.

Tobacco Products and Nicotine

What is a tobacco product?

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.

What is the difference between commercial and traditional tobacco?

Commercial tobacco is manufactured by companies for recreational and habitual use in the form of cigarettes, smokeless tobacco, pipe tobacco, cigars, hookahs, and other products. Commercial tobacco is mass-produced and sold for profit.(25) It contains thousands of chemicals and produces over 7,000 chemical compounds when burned, many of which are carcinogenic, cause heart and other diseases, and premature death.(25)

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.

Why does a tobacco-free policy not allow the use of e-cigarettes and smokeless tobacco?

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.(14)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.(14) 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.(16)

Smokeless tobacco products like chew, dip, snus, and many more have been proven to be harmful and addictive.(3,17)Also, the spitting involved with some smokeless products can spread disease.(18) 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. To provide tobacco use treatment, the program’s campus needs to be tobacco free.

Will the nicotine patch, gum, or lozenge be allowed?

YES! The nicotine patch, gum, and lozenge are not tobacco products.

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.

Questions About Rights and Personal Freedom

Why can’t we do what we want like other people in the community?

A tobacco-free policy makes IDD, TBI, and behavioral health services more like other community settings.(1,3,4,21) Doctor’s offices and hospitals are all generally tobacco-free, because of the dangers of secondhand smoke and the need to have an environment where people can quit. Schools are tobacco-free, many workplaces are tobacco-free, and a lot of apartment complexes are tobacco-free.(1) People with IDD, TBI, or behavioral health conditions deserve the same rights to clean air and support when they try to quit as anyone else in the community.

Smoking is a personal choice. How can you take this choice away?

Allowing secondhand smoke and e-cigarette emissions in healthcare settings hurts everyone’s right to breathe clean air.(5) Secondhand smoke and vape chemicals prevent people who are pregnant or people who have asthma, COPD, and heart disease from safely getting healthcare or being in public spaces. Just a few minutes of secondhand smoke can be enough to trigger an asthma attack.(5)

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.

Must clients, staff, and visitors quit using tobacco products?

No, the policy only asks individuals to avoid using any tobacco while on a program’s property.

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.

Is a tobacco-free policy person-centered?

Yes. Most people who use tobacco want to quit.(19) Most people who use tobacco try to quit each year, yet without a tobacco-free environment and evidence-based treatment, few are successful.(19) Tobacco-free policies in healthcare protect people’s right to decide what to put into their own bodies by providing an environment that supports their ability to quit tobacco use, while not taking away anyone’s ability to use tobacco while off campus. Taking a person-centered approach means offering tobacco use treatment to people with IDD or TBI who want to quit.

Questions about quitting

I want to quit. How can I be successful?

You can DOUBLE your chances of quitting for good by using counseling and medication to treat nicotine withdrawal.(30)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. Let your health and behavioral health providers know you are interested in quitting, and they can help you as well. Learn more about medications like the nicotine patch, gum, and lozenges from these flyers in English and Spanish.

I am a staff member who uses tobacco. What resources are there to help me quit?

You can DOUBLE your chances of quitting for good by using counseling and medication to treat nicotine withdrawal.(30)The good news is that the Affordable Care Act requires health insurance plans to cover tobacco use treatment counseling and medications. Talk with your employer and your health plan to find out what resources there are to help you. Let your health and behavioral health providers know you are interested in quitting, and they can help you as well.

You can also get free help TODAY from QuitlineNC. 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.

How can I deal with stress without smoking, vaping or using tobacco?

Though it feels like a relief for a short time, the body actually goes through withdrawal– physically and mentally–between cigarettes, because it’s addicted.(30) Quitting smoking will actually lower one’s overall stress after about 1-3 weeks, with effects similar to an anti-depressant.(18)

In the meantime, it’s important to get quit coaching and medication that will lessen your stress and make it 2x more likely that you will be able to quit for good.(30) 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.

You can also learn more about medications like the nicotine patch, gum, and lozenges from these flyers in English and Spanish.

Supporting people to quit

What is evidence-based tobacco use treatment and how can I integrate it into my program?

Evidence-based tobacco use treatment is a combination of FDA-approved cessation medications and counseling.(19)The NC Division of Public Health promotes the NC Standard of Care for tobacco use treatment. This is based on Treating Tobacco Use and Dependence: 2008 Update—Clinical Practice Guideline(16), as well as more recent research on tobacco use treatment. Standard of care tobacco use treatment is also provided by QuitlineNC; learn more about how to refer clients by clicking here.

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 all of the treatment and policy implementation resources that are evidence-based.
You can also learn more about medications like the nicotine patch, gum, and lozenges from these flyers in English andSpanish.

It has been my experience that clients don’t want to quit. Does anyone want to quit using tobacco?

Yes. The majority of people who smoke report wanting to quit, and more than half of the people who smoke make a quit attempt every year.(19) However, less than a third of the people who try to quit receive evidence-based treatments that can double or triple their chances of success.(19) As a healthcare provider you have the power to change that by offering your clients evidence-based treatment. A tobacco-free policy creates a positive environment that supports clients and staff in successfully quitting tobacco use.

But… why does it SEEM like no one wants to quit then?

One reason why healthcare professionals sometimes perceive a lack of motivation to quit is the way people are screened. A common screening method is to ask, “Do you smoke cigarettes?” and if the answer is yes, the next question is “Are you ready to quit?” This is a screening method that will probably yield a lot of “no” answers.(23) Desire to quit is not a yes or no question. Just like with any other substance use disorder, there is ambivalence: reasons clients want to continue using and reasons clients want to quit. Meet the client where they are by exploring if tobacco use conflicts with their values and goals. You may be able to set smaller, achievable goals and provide evidence-based treatment to reach those goals. Smaller goals include making the home tobacco-free, staying tobacco-free while at the program, experimenting with cutting down using medications & counseling. You can learn more about evidence-based counseling strategies on this page.

 

Lastly, once your organization starts the process of going tobacco free, you may find that more clients are interested in quitting.(4) This is because clients come to your organization as 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.(19)

Guidance on Policy implementation and Promoting Adherence

When are campuses expected to be 100% tobacco-free or to implement other tobacco related policy requirements?

December 1st, 2022.

NC Standard and Tailored Prepaid Health Plans must require contracted medical and behavioral health providers, and some IDD/TBI service providers to furnish a 100% tobacco-free campus starting December 1st, 2022. Intermediate care facilities for people with IDD or residential services covered by the Home and Community Based Services (HCBS) final rule will be required to adhere to a different set of requirements by December 1st, 2022. Learn more about those requirements from this question above: I’m a provider who offers intermediate care facility services for people with IDD (ICF-IID) services or residential services covered by the Home and Community Based Services (HCBS) final rule. What are the policy requirements for my services?

While the requirement goes into effect December 1st 2022, 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.

What comprises a 100% tobacco-free policy?

A tobacco-free policy applies to all the property under the program’s control (rented, leased or owned). All of the property (buildings, grounds, including the parking lots and vehicles) is tobacco-free.

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.

How do I implement a 100% tobacco-free campus policy?

There are several essential components and processes to implementing a 100% tobacco-free policy. The process of implementation can take six months to a year. Check out the Tobacco-Free Road Map for details and resources. Contact your regional or local tobacco control staff to help your organization have a positive and smooth implementation process.

A few other useful resources are:
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.
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 all of the treatment and policy implementation resources that are evidence-based.

For sample policies click here.

An important piece of this planning process is conducting listening sessions well in advance with clients and separately with staff. This gives clients and staff the opportunity to express any concerns and give their input on how the policy should be implemented, making for a smooth implementation process. Your regional or local tobacco control staff and You Quit, Two Quit are experienced with this process and can help you plan a listening session. Check out our Listening Session Guide and Sample Agenda as well. Learn more about how to build support and communicate your policy here.

I rent my space; how do I adhere to this requirement?

Ensure the policy applies to whatever space and property that is under your program’s control. For example, if your program is in a strip mall and you have control over the interior space, the storefront, the sidewalk in front, and a couple parking spaces, then the policy applies to all of that space. If you rent a building and you have control over the front and backyard of that building, the parking lot, and vehicles for your program, the policy should apply to all that property. For assistance with writing a policy that covers the appropriate property to adhere to this requirement, contact your regional or local tobacco control staff and check out the sample policy provided here.

How can I promote client adherence to a tobacco-free policy at my program?

Ensuring adherence to a tobacco-free policy is the responsibility of everyone at the organization, particularly staff.(21) If only a few people promote adherence, the policy will not be effective. Clear tobacco-free campus policy signs and other resources are important tools.(21) The response to any problem someone has with not using tobacco on campus should be compassion and working with that person to find ways that work for them to adhere to the policy on campus. It is the responsibility of behavioral health programs to offer clients the tools they need to be successful in avoiding using tobacco on campus, and to be respectful in promoting the policy. It is the responsibility of clients to let staff know what support they need to be successful avoiding using tobacco on campus, and then do their best to respect the policy.

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.(19) 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 or local tobacco control staff for help.

For sample policies click here.

How can I promote staff adherence to a tobacco-free policy at my program?

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.(21) 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 or local tobacco control staff.

For sample policies click here.

Would employees, clients or visitors be allowed to smoke in their car while it’s parked on property covered by the 100% tobacco-free policy?

No. The policy prohibits smoking and tobacco use on ALL agency property, which includes inside parked and moving vehicles on the property. It also prohibits tobacco use inside agency owned vehicles.

How do I address concerns about people who go to smoke on my neighbor’s property?

An important part of the implementation process is reaching out to your neighbors. Let them know you will be implementing a tobacco-free campus policy and have a discussion ahead of time about how you can work together if individuals from your campus use tobacco on your neighbor’s property. Communicate with clients and staff about these discussions. Offer compassion, evidence-based treatment, and collaborate with the client to find ways to prevent use on campus, as well as any encroachment on neighbors’ space.

References

  1. North Carolina Tobacco Prevention and Control Branch. Vision 2020 North Carolina’s Strategic Plan to Reduce the Health and Economic Burdens of Tobacco Use [Internet]. 2016 [cited 2021 May 18]. Available from: www.tobaccopreventionandcontrol.ncdhhs.gov
  2. Centers for Disease Control and Prevention. Tobacco Use [Internet]. 2020 [cited 2021 May 18]. Available from: https://www.cdc.gov/chronicdisease/resources/publications/factsheets/tobacco.htm
  3. U.S. Department of Health and Human Services. The Health Consequences of Smoking – 50 Years of Progress: A Report of the Surgeon General [Internet]. 2014 [cited 2021 May 18]. Available from: www.cdc.gov/tobacco
  4. Centers for Disease Control and Prevention. Smokefree Policies Reduce Smoking [Internet]. 2020 [cited 2021 May 18]. Available from: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/protection/reduce_smoking/index.htm
  5. Centers for Disease Control and Prevention (US), U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General [Internet]. Publications and Reports of the Surgeon General. Centers for Disease Control and Prevention (US); 2006 [cited 2021 May 18]. 727. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44324/
  6. National Core Indicators. Does this person use nicotine or tobacco products? North Carolina [Internet]. 2018 [cited 2021 May 25]. Available from: https://www.nationalcoreindicators.org/charts/2017-18/?i=77&st=NC
  7. Steinberg ML, Heimlich L, Williams JM. Tobacco use among individuals with intellectual or developmental disabilities: A brief review [Internet]. Vol. 47, Intellectual and Developmental Disabilities. NIH Public Access; 2009 [cited 2021 May 25]. p. 197–207. Available from: /pmc/articles/PMC4451812/
  8. Bogner J, Corrigan JD, Yi H, Singichetti B, Manchester K, Huang L, et al. Lifetime history of traumatic brain injury and behavioral health problems in a population-based sample. Journal of Head Trauma Rehabilitation [Internet]. 2020 Jan 1 [cited 2021 May 25];35(1):E43–50. Available from: https://pubmed.ncbi.nlm.nih.gov/31033748/
  9. Prochaska JJ, Das S, Young-Wolff KC. Smoking, Mental Illness, and Public Health. Annual Review of Public Health [Internet]. 2017 Mar 20 [cited 2021 May 18];38:165–85. Available from: https://pubmed.ncbi.nlm.nih.gov/27992725/
  10. Sivandzade F, Alqahtani F, Cucullo L. Traumatic brain injury and blood–brain barrier (BBB): Underlying pathophysiological mechanisms and the influence of cigarette smoking as a premorbid condition. International Journal of Molecular Sciences [Internet]. 2020 Apr 1 [cited 2021 May 25];21(8). Available from: https://pubmed.ncbi.nlm.nih.gov/32295258/
  11. Rong L, Frontera AT, Benbadis SR. Tobacco smoking, epilepsy, and seizures [Internet]. Vol. 31, Epilepsy and Behavior. Epilepsy Behav; 2014 [cited 2021 May 25]. p. 210–8. Available from: https://pubmed.ncbi.nlm.nih.gov/24441294/
  12. North Carolina Department of Health and Human Services. Report on the Pilot to Establish a Tobacco Free Environent in State Operated Healthcare Facilities: Broughton Hospital and Walter B. Jones ADATC. 2011.
  13. National Native Network. Commercial Tobacco | Keep It Sacred [Internet]. 2015 [cited 2021 May 18]. Available from: https://keepitsacred.itcmi.org/tobacco-and-tradition/commercial-tobacco/
  14. U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA; 2016.
  15. National Native Network. Traditional Tobacco | Keep It Sacred [Internet]. 2015 [cited 2021 May 18]. Available from: https://keepitsacred.itcmi.org/tobacco-and-tradition/traditional-tobacco-use/
  16. US Department of Health and Human Services. Treating Tobacco Use and Dependence: 2008 Update [Internet]. Rockville, MD: US Department of Health and Human Services; 2008 [cited 2021 Jun 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK63952/
  17. Siddiqi K, Shah S, Abbas SM, Vidyasagaran A, Jawad M, Dogar O, et al. Global burden of disease due to smokeless tobacco consumption in adults: Analysis of data from 113 countries. BMC Medicine [Internet]. 2015 Aug 17 [cited 2021 May 18];13(1):1–22. Available from: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0424-2
  18. Gaunkar RB, Nagarsekar A, Carvalho KM, Jodalli PS, Mascarenhas K. COVID-19 in Smokeless Tobacco Habitués: Increased Susceptibility and Transmission. Cureus [Internet]. 2020 Jun 25 [cited 2021 May 18];12(6). Available from: /pmc/articles/PMC7384704/
  19. U.S. Department of Health and Human Services. Smoking Cessation: A Report of the Surgeon General. Atlanta, GA; 2020.
  20. Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: An overview and network meta-analysis [Internet]. Vol. 2013, Cochrane Database of Systematic Reviews. John Wiley and Sons Ltd; 2013 [cited 2021 Jun 15]. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009329.pub2/full
  21. National Association of State Mental Health Program Directors. Tobacco-Free Living in Psychiatric Settings A best-practices toolkit promoting wellness and recovery [Internet]. 2007 [cited 2021 May 19]. Available from: www.nasmhpd.org
  22. Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P. Change in mental health after smoking cessation: Systematic review and meta-analysis. BMJ (Online) [Internet]. 2014 Feb 13 [cited 2021 May 18];348. Available from: http://www.bmj.com/content/348/bmj.g1151?tab=related#datasupp
  23. Greenberg MR, Greco NM, Batchelor TJ, Miller AHF, Doherty T, Aziz AS, et al. Physician‐directed smoking cessation using patient “opt‐out” approach in the emergency department: A pilot program. Journal of the American College of Emergency Physicians Open [Internet]. 2020 Oct [cited 2021 May 19];1(5):782–9. Available from: https://pubmed.ncbi.nlm.nih.gov/33145519/