Evaluating Healthcare Center Staff Attitudes Toward Adoption of Tobacco-Free Policies and Concurrent Tobacco Use and Behavioral Health Treatment in Rural and Medically Underserved Areas of Texas

Background: People with behavioral health conditions (BHCs), including substance use disorders (SUDs) and mental health conditions, use tobacco at elevated rates, yet tobacco management is often overlooked during healthcare visits. Tobacco-free workplace policies (TFWPs) effectively reduce tobacco use in healthcare centers (HCs), but staff valuation is key to successful adoption. Little is known about the factors influencing staff (providers’ and managers’) value of TFWPs, especially in HCs serving rural or medically underserved areas (MUAs). This study examined associations between healthcare providers’ attitudes toward treating tobacco and BHCs simultaneously and their valuation of TFWPs in HCs serving patients in rural/MUAs of Texas. Methods: HCs were enrolled continuously from August 2021 through January 2024, a timespan that primarily fell within the COVID-19 pandemic period (January 2020–May 2023). Generalized linear mixed models assessed links between treatment attitudes and perceived value of TFWPs among 347 providers across 19 HCs serving over 100,000 patients annually, controlling for existing TFWPs in 10 HCs. Rapid qualitative analysis of 16 individual (n = 2) and group (n = 14) interviews from 12 HCs, including 5 medical healthcare centers and 7 substance use treatment centers, was conducted. Results: Quantitative findings indicated that providers who believed concurrent treatment improved BHCs were more likely to endorse TFWPs as promoting clean and safe environments (OR = 3.81, CI: 2.31–6.28) and as helping staff and patients quit smoking (OR = 3.04, CI: 1.90–4.87). Providers who supported concurrent quitting were also more likely to agree that TFWPs support smoking cessation (OR = 1.77, CI = 1.08–2.92), but this attitude was not associated with endorsing TFWPs as promoting clean and safe environments (OR = 1.25, CI = 0.74–2.11). Qualitative themes: (1) prioritization of “harm reduction” strategies, (2) limited support for tobacco use screening and tobacco cessation services, and (3) hesitation to integrate tobacco-free workplace programs. Integrative findings revealed ambivalent support for concurrent treatment amidst limited resources, provider concerns about concurrent treatment jeopardizing BHC recovery, and mixed reactions to TFWP implementation, particularly concerning patient autonomy, stigma, and practicality. Conclusions: Findings highlight structural and attitudinal barriers to treating tobacco use and BHCs and implementing TFWPs in rural/MUA HCs. Improving providers’ access to tailored education, evidence-based tools, and organizational support can enhance tobacco use treatment and TFWP implementation in rural and MUAs of Texas.