Tobacco use is causally related to multiple cancers and 30% of cancer deaths. Population-level tobacco control initiatives have successfully reduced smoking, the most common form of tobacco use, in Texas. However, women experience an ever-increasing disproportionate burden of tobacco-related health consequences; e.g., from 1959 to 2010 women's risk of developing lung cancer increased tenfold. Moreover, the burdens of these health consequences are exacerbated among women with intersecting social, economic/housing, and behavioral health (mental health and/or substance dependence) needs, who turn to community agencies for services to address these myriad issues, that jointly contribute to...

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Tobacco use is causally related to multiple cancers and 30% of cancer deaths. Population-level tobacco control initiatives have successfully reduced smoking, the most common form of tobacco use, in Texas. However, women experience an ever-increasing disproportionate burden of tobacco-related health consequences; e.g., from 1959 to 2010 women's risk of developing lung cancer increased tenfold. Moreover, the burdens of these health consequences are exacerbated among women with intersecting social, economic/housing, and behavioral health (mental health and/or substance dependence) needs, who turn to community agencies for services to address these myriad issues, that jointly contribute to high tobacco use rates and greater difficulty quitting. Yet, the agencies providing their care rarely screen for and address tobacco dependence. Consequently, these women constitute a priority group for tobacco intervention efforts. In our prior work (PP170070), we implemented Taking Texas Tobacco Free (TTTF), a multi-level, evidence-based comprehensive tobacco free workplace (TFW) program, in 4 women-serving agencies (WSAs) with 6 clinics total (3 substance use treatment centers [5 clinics] and 1 non-profit care organization that assists single-mother families). WSAs adopted a TFW policy, their employees showed significant knowledge gains following tobacco dependence intervention training, and their service providers significantly increased their screening (tobacco use assessments; TUAs) and intervention provision with clients. Our work, however, suggested that women have unique needs (e.g., high rates of co-occurring depression and trauma) that require women-tailored tobacco cessation interventions (e.g., focus on peer support). Furthermore, adapted implementation strategies (e.g., training content) will be needed to maximize uptake and adoption by providers in WSAs. Here, we propose an expansion and adaptation of TTTF that will leverage our prior work with WSAs to meet these needs. Overall Project Strategy. A mixed methods formative evaluative process will guide program adaptation and implementation in WSAs, with an emphasis on capacity building for sustainment beyond the project period. Through various implementation strategies, TTTF will work with WSAs to: 1) implement or refresh TFW policies with sustainable plans for enforcement (adoption); 2) train employees to increase knowledge and regular provision of tobacco dependence interventions, including TUAs, at the point-of-care through developing embedded expertise (penetration); 3) provide resources to support TFW program implementation (e.g., nicotine replacement therapies) and change clinical workflows to facilitate regular tobacco intervention (e.g., via provider tools and nudges; fidelity); and 4) establish systems, practices, and policies to maintain this service delivery after active program implementation (sustainability), ultimately achieving a reduction of tobacco use rates among engaged employees and the women they serve over time. This work addresses women's issues and needs affecting tobacco use including pregnancy/postpartum, menopausal, and behavioral health issues; program implementation will incorporate peer support, use a trauma-informed approach to care, and be sensitive to prominent social justice issues. This expansion will capitalize on prior successful implementations within behavioral healthcare facilities, substance use treatment centers, community-based non-profit centers, healthcare centers, and agencies serving adults experiencing homelessness, providing an excellent background for our work with agencies serving women with intersecting social, economic/housing, and/or behavioral health challenges. Specific Goals. Goals are to: 1) adapt the program for WSAs as evidenced by acceptability, appropriateness, and feasibility; 2) achieve successful adoption of the program in 36 WSAs with evaluation of penetration and fidelity of the implementation; and 3) achieve program sustainability and engage in statewide program dissemination. Our website and dissemination strategies promise broad reach, as supported by data from prior CPRIT awards. Based on these data, 497,905 people will be reached, 111,084 people will be served through?144,188 direct educational, navigation, and clinical services. Significance and Impact. TTTF will increase tobacco abstinence by enhancing tobacco treatment capacity via policy, education, specialized provider training, routine TUAs, and regular point-of-care intervention on tobacco use in 36 WSAs. Ultimately, the impact of this proposal will include a reduction in tobacco use and environmental tobacco smoke exposure among employees and the women served in these settings. Therefore, the expansion of the TTTF program as proposed will have a tremendous impact on tobacco-related cancer prevention among women in Texas through its statewide reach and focus on an underserved and at-risk group.

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