The United States (U.S.) has experienced a substantial decline in tobacco use over the last decade, with national smoking prevalence decreasing from 16.8 % in 2014 to 11.5 % in 2021 (CDC, 2023, Jamal et al., 2014). However, declines in smoking prevalence are not experienced equally across the U.S., as marginalized communities continue to experience high smoking prevalence. One such population is people who are accessing substance use disorder (SUD) treatment. While recent literature suggests that smoking prevalence among people with SUD may be decreasing (from 46.5 % in 2006 to 35.8 % in 2019) (Han et al., 2022), these data still represent a smoking prevalence more than three times that of the national average. When considering smoking prevalence within SUD treatment settings, the smoking prevalence is higher, estimated at 53–85 %, (Baldassarri et al., 2019, Gass et al., 2018, Guydish et al., 2019, Hunt et al., 2013, Min et al., 2022, Smith et al., 2020) which represents a smoking prevalence more than five times that of the national average.

Smoking among people in SUD treatment is associated with higher rates of medical problems compared to SUD treatment seekers who are non-smokers (Patkar et al., 2002), and tobacco-related deaths among individuals who access SUD treatment surpass tobacco-related deaths of the general population (Bandiera et al., 2015). In addition to the health consequences of high smoking prevalence among individuals in SUD treatment, smoking is also related to poorer treatment outcomes. While causality cannot be determined, individuals who smoke are more likely to report an associated return to use three years after SUD remission (Weinberger et al., 2017).

Despite the disparately high rates of smoking in SUD treatment compared to the general population, few SUD treatment settings across the U.S. currently offer smoking cessation services (Marynak et al., 2018). In 2016, only 64 % of SUD treatment facilities screened for tobacco and fewer offered smoking cessation counseling (47 %) or nicotine replacement therapy (NRT; 26 %) (Marynak et al., 2018). This lack of smoking cessation services could be due to a combination of issues, including a culture that promotes smoking behavior, elevated smoking rates among program staff (Guydish et al., 2007), concern that smoking cessation will distract from other substance use reduction goals, or apprehension regarding how implementing tobacco-free policies may impact the client census (Fokuo et al., 2022, Pagano et al., 2016).

One method of supporting SUD treatment programs to offer more smoking cessation services is through the implementation of tobacco-free grounds (TFG) policies (e.g., no smoking on program property). Several states (New York, New Jersey, Oregon, and Oklahoma) have implemented policies that require SUD treatment programs to be tobacco-free (Brown et al., 2012, Drach et al., 2012, Marynak et al., 2018, Williams et al., 2005). Utah extended their TFG policy to both mental health and SUD treatment programs (Marshall et al., 2015). Through an academic-community partnership, Texas also supported Local Mental Health Authorities to implement TFG via the Taking Texas Tobacco Free Initiative (Correa-Fernández et al., 2019). Several of these statewide efforts were associated with increased tobacco screening and access to cessation services (Brown et al., 2012, Correa-Fernández et al., 2019, Drach et al., 2012, Williams et al., 2005). These findings were based on program administrator report (Brown et al., 2012, Drach et al., 2012), changes in employee training, education, and practices (Correa-Fernández et al., 2019), and admission and discharge data (Williams et al., 2005). However, few studies have investigated whether such initiatives are associated with a reduction in client smoking prevalence.

In 2019, the California Tobacco Control Program (CTCP) launched the Tobacco-Free for Recovery Initiative (CTCP, 2020a, CTCP, 2020c), which targeted smoking cessation among people in residential SUD treatment programs. The first cohort of the initiative included seven SUD treatment programs across California. The programs partnered with the Smoking Cessation Leadership Center (SCLC) (Schroeder et al., 2018) to receive targeted support in developing and implementing a TFG policy and to support other wellness activities. An evaluation including these 7 residential SUD treatment programs found that the initiative was associated with a significant decrease in client smoking prevalence (54.2 % to 26.6 %; p < 0.0001) and an increase in client receipt of NRT (11.9 % to 25.2 %; p = 0.015) from pre to post intervention (McCuistian et al., 2021). While these results are promising, additional study may support generalizability of findings and reinforce the potential benefit of this program-level intervention in reducing smoking prevalence among people accessing SUD treatment.

The current study examined data from 11 additional programs to assess whether the Tobacco Free for Recovery Initiative was associated with changes in client-level smoking prevalence, other tobacco use behaviors, or increased tobacco-cessation services, as was found in a previous study (McCuistian et al., 2021).