How Triple Care Farm introduced a smoke-free policy

About the service

Operated by Mission Australia, Triple Care Farm is a residential rehabilitation and treatment program for 16−24 year-olds experiencing substance abuse, homelessness, mental illness and acute behavioural problems.

Triple Care Farm’s 12-week program involves therapeutic group work and counselling, educational programs, life skills and leisure activities. For the first four weeks at Triple Care Farm the students remain on-site, except for organised community outings. For the remaining eight weeks they may take weekend leave every second week.

Students are not permitted to use tobacco or any other substance while engaged in the program, including while off-site participating in a Triple Care Farm outing or activity.

What was the problem?

Before Triple Care Farm introduced its smoke-free policy, students were permitted to smoke in outside areas. The perceived wisdom was that coming off drugs and other substances was hard enough—asking people to stop smoking at the same time was just a bridge too far.

But it bothered the program’s manager that they were meant to be a helping service, yet they were effectively enabling young people to continue using the substance most likely to cause death, ill health and financial hardship—tobacco.

“We had, for a long time, been really challenged by not addressing smoking for the young people that we work with. I was thinking about how you can provide a safe smoking environment. Well, you can’t. Then one day, when I looked around and one of my colleagues, who was pregnant at the time, was surrounded by young people who were smoking, I thought, “This isn’t okay.” I said, “no, we need to change this. We need to do something different.”

What did they do about it?

Getting to the smoke-free policy took a few years and a process of incremental shifts and trial and error.

First they tried making only one of the houses completely smoke-free, but this created placement difficulties because of greater demand for the smoking houses. They decided the best path forward was to go completely smoke-free.

To start making the change, the Triple Care Farm leadership team worked with the Tackling Tobacco team at Cancer Council NSW to identify a model that would work for them. They took a highly consultative route to change, involving:

• a literature review to identify good practice in comparable environments
• a staff survey
• focus groups with staff and students
• stakeholder discussions
• establishing a Smoke-Free Working Group, with staff and student sub-groups to work on specific aspects of the policy.

The policy they ended up with was collaboratively developed by the staff, students and external stakeholders, and was built on a solid foundation of research.

In December 2012 they introduced the smoking ban, timed for the new intake in January 2013. They also obtained a $5,000 grant from the Cancer Council NSW to provide free Nicotine Replacement Therapy (NRT, e.g. patches) to any student who wanted it.

Tackling Tobacco organised training for all Triple Care Farm staff. This was critical as the training helped to debunk myths about NRT and give staff the confidence to administer it.

The policy was supported by a three-strikes system of escalating consequences: first strike, students were given extra chores; second strike, they were suspended from the program for three days; third strike, they were suspended for a week and their participation in the program was reviewed at their next progress meeting.

The policy was a good start, but problems soon emerged. Struggling to keep track of strikes, staff implemented the policy inconsistently and documented breaches haphazardly. Meanwhile, some students quickly learned how to work the system as it was commonly known that they had two chances before they were asked to leave. Some would even deliberately time their second strike suspension to occur on a Friday so they could go home for the weekend.

That’s when the Triple Care Farm team decided the three-strikes system had to go.

Everybody wanted to give young people that opportunity to change, but they saw it as three opportunities to smoke, not three opportunities to change.

Working as a team, Triple Care Farm revised the policy to make it simple and direct. If students were caught smoking, they would leave and go to the bottom of the waiting list. This policy was easier for staff to track and implement, and it was easier for them to support. They knew the young people weren’t kicked out and cut off from treatment; they just had to wait to get back in. Instead of creating a complex policy for students to follow, the staff created a single rule with a clear consequence.

What was the result?

As with any big change, the early stages of implementation were daunting. Adopting a smoke-free policy was a major shift that came with serious concerns that the change might reduce referral and retention rates and jeopardise positive impact of the program.

But disaster didn’t occur. In fact, over the next 12 months, participation and retention rates remained the same, while referrals increased. On all of the program’s outcome measures, including accommodation, education and training and employment, achievement rates increased. Follow-up with students found that after six months back in the community, 21% described themselves as a non-smoker and another 9% said they had reduced their cigarette use or were attempting to quit.

Compared with other programs, this is a high success rate.

The smoke-free policy also had some unexpected positive effects, including:

• increased attention spans in group counselling, education and training groups
• completion of accredited training courses in a shorter period of time
• more money at students’ disposal
• reduced interpersonal difficulties between students over tobacco products.

What factors made it work?

• Triple Care Farm gained a clear understanding of the literature, where each aspect of the new policy was backed up by research evidence
• They had strong leadership from the executive team to drive the changes, and clear deadlines for each stage.
• Staff, students and stakeholders were all involved in designing the policy, so everyone was brought along on the journey.
• Triple Care Farm is able to provide free NRT, which is offered to all smokers on intake and is critical to the program’s ability to manage the effects of nicotine addiction. A grant from Cancer Council NSW funded NRT for the first six months, and then a private donor, the Key Foundation, agreed to increase their donation to cover the cost.
• Their new policy targets staff as well as students. If staff members wish to smoke, they need to walk or drive off the property and must take steps to ensure they do not smell of tobacco on their return.
• Triple Care Farm learned from their process of trial and error. At first the staff members weren’t comfortable with an instant-exit policy, but when the flaws in the three-strikes system became apparent, everyone was ready to make a change.
• The Tackling Tobacco team provided guidance, training and resources for every step of the process.