Discussion
Smoking prevalence in this sample, following the intervention, was 31.1% among staff and 70.7% among clients. This compares with a California smoking prevalence of 8.9% in 2020 [Pre—post intervention comparisons, with programs collapsed across condition, showed decreased staff and client smoking prevalence, and decreased client receipt of cessation medication at post-intervention. However, sensitivity analyses eliminating Program 5 found only decreased staff smoking and decreased client receipt of cessation medication. A randomized trial design is scientifically more rigorous than a pre-post design. This leads us to the conservative conclusion that the multi-component intervention did not reduce staff or client smoking, and did not increase client receipt of tobacco-related services.The reported pre-post intervention decrease in staff smoking may be associated with the COVID pandemic. Available data do not suggest a population-level decrease in smoking associated with the pandemic [These findings may speak to what is required to implement or strengthen tobacco-related practices in SUD treatment. While the multi-component intervention did not show significant change in smoking prevalence, is it possible that the dose of the components was insufficient, or that these components would be effective if modified. For example, if incentives were required to be used for NRT, or if programs were required to incorporate further tobacco-related staff training or policy change. Other interventions, however, have demonstrated such change. Statewide implementation of tobacco free policies, as in New York and New Jersey, enlisted program licensing or certification requirements [Findings may also speak to the importance of comparison conditions in studies of tobacco interventions in SUD treatment. Many such studies have used pre-post designs without comparison conditions [Study limitations include limitations on statistical power. The cluster-randomized trial was designed to include 10 programs (5 intervention and 5 control programs). However, as given in Supplemental Figure We conducted a cluster-randomized trial of a brief multi-component intervention to reduce smoking among staff and clients and increase client receipt of tobacco-related services. The intervention in this trial did not show significant impact on staff or client smoking behavior, or on tobacco-related services received by clients. To reduce smoking among staff and clients in SUD treatment, interventions should be supported by tobacco free grounds policies, regulatory or contractual requirements to provide tobacco services, programmatic funding to support those services, and/or access to NRT or other cessation medications.