Implementing Trauma-Informed Training for Tobacco Use for Health Care Professionals in Two California Counties

Abstract

Tobacco use remains a leading cause of preventable death in the United States, and smoking is disproportionately concentrated among individuals who have experienced trauma. Trauma-informed care offers a framework for addressing tobacco use in this population, yet few training programs provide guidance on integrating trauma-informed principles into cessation treatment. To address this, our team added a tobacco treatment module to the Trauma, Addictions, Mental Health, and Recovery (TAMAR) training for behavioral health providers in two California counties. We conducted semi-structured qualitative interviews with seven community-based providers who completed the training and analyzed them using inductive thematic analysis. Participants described the module as relevant and actionable. Participants reported changes in practice after the training, including adding tobacco questions to intake workflows, incorporating mindfulness strategies to help clients manage cravings, and integrating cessation goals into treatment planning. Participants viewed trauma-informed cessation care as requiring empathy, cultural humility, nonjudgment, and an understanding of the role of trauma in tobacco use. Barriers included limited time, staffing constraints, insufficient cessation training, rigid workflows, and a lack of physical space to deliver the training. Facilitators included organizational support, leadership buy-in, and access to professional development in providing cessation care. Participants emphasized that one-time trainings are insufficient to sustain trauma-informed tobacco treatment. Effective implementation requires organizational infrastructure, repeated reinforcement of skills, and materials that support real-time application. Findings highlight the need to align trauma-informed cessation curricula with the realities of diverse community settings and to expand training opportunities for professionals serving populations experiencing trauma.

Tobacco use is the leading preventable cause of death in the United States (U.S. Department of Health and Human Services, 2024). Individuals with Adverse Childhood Experiences (ACEs) and those who experience trauma bear disproportionate tobacco-related harm (Abufarsakh et al., 2024). Among these populations, an estimated 27% of people with posttraumatic stress disorder (PTSD) smoke cigarettes compared with 9.9% of the general population (Agaku, 2026), and people with multiple ACEs report heavier tobacco use (Abufarsakh et al., 2024).

Trauma-informed care provides a framework for recognizing and responding to the impact of trauma in health care delivery (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). However, few programs offer guidance on applying these principles to tobacco cessation treatment. To address this, we integrated tobacco treatment into the Trauma, Addictions, Mental Health, and Recovery (TAMAR) program (National Association of State Mental Health Program Directors [NASMHPD], 2023). TAMAR is a nationally recognized, trauma-specific group intervention that trains providers working with clients who have experienced trauma across justice, behavioral health, and community settings (NASMHPD, 2023). The TAMAR manual for providers comprises a 16-module psychoeducational curriculum that combines education about trauma’s impact with examples of self-regulation techniques, including mindfulness and creative expression, that can be used with clients (NASMHPD, 2023). In 2023, we added a tobacco treatment module to the TAMAR manual that covers the relationship between trauma and tobacco use, misconceptions about cessation, and practical cessation guidance, including the 5As (Ask, Advise, Assess, Assist, Arrange) and pharmacotherapy (NASMHPD, 2023). The tobacco treatment module is included in the standard TAMAR curriculum used nationally across health care and correctional settings.

In 2023 and 2024, we trained 82 public health professionals in two California counties. We invited the 64 individuals who completed the post-TAMAR evaluation survey to participate in qualitative interviews. Seven individuals representing program coordinators, tobacco treatment specialists, public health administrators, and research staff working with clients who had experienced trauma agreed to participate. In this Practice Note, we describe applications and lessons learned from the TAMAR tobacco treatment module, as experienced by the seven participants. Our objective was to understand participants’ perspectives on essential components of trauma-informed cessation care to inform curricula and best practices for tobacco treatment. The study was considered exempt by the University of California, San Francisco Institutional Review Board (IRB#-23-40523). We conducted semi-structured qualitative interviews lasting approximately 45 minutes (August–October 2024, 9–12 months after the training). Interviews were audio-recorded and transcribed verbatim by a professional transcription service. The study team coded transcripts in Excel and Atlas.ti.v.24 using inductive thematic analysis, iteratively developing codes and organizing them into themes. The semi-structured interview guide is available as supplementary material. Participants received a US$50 gift card for their contribution. We present participant demographics and professional roles with quotes emblematic of themes in Table 1.

Table 1

Key Themes, Subthemes, and Emblematic Quotes

Themes	Subthemes	Quotes
Reflections on the TAMAR training	Understanding trauma helped them be trusted by clients/patients	“I personally think it’s had positive impact in the sense of it allows us, I always say this, to be the trusted partner that when I as a provider, am recognizing, acknowledging what has gone on in their life or what is going on in their life” 38 year-old White female; Program coordinator
	Add tobacco questions	“Ever since the meeting, we did add as our one of our questions in our application for the families, if they have, if they smoke or chew tobacco themselves or someone in the household, and we have been keeping track of those.” 42 year-old Hispanic/Latine female; Community relations coordinator
	Mindfulness	“I think the mindfulness activities really resonated with me because they felt accessible. I felt like anyone could do them, and any client, or nearly any client that I’m working with, we could adapt, if needed, any of those activities to support them. I also think the explanations and like how the curriculum went through what is trauma like, and explained it at a very approachable, like level. I really like that component of it.” 38 year-old White female; Program coordinator
Attitudes and practices toward trauma-informed tobacco treatment	Attitudes	“I think that when anyone experiences trauma, our brain and our body gets into this mode of survival, and anything that I can find to make that feel better, to either take away the negative feelings or boost what I feel are those positive feelings, I think can become a vicious cycle for someone who’s experienced trauma. So I definitely think . . . there’s a connection between addiction and trauma. I think a lot of it, too, is oftentimes people who have suffered trauma have also been in a situation where they weren’t able to learn healthy coping skills, and so smoking addiction of any kind is an unhealthy coping skill, but it’s the only one they might have come across.” 38 year-old White female; Program coordinator
	Building trust	“I have to listen to what their experience has been, and then, you know, expressing a lot of empathy, being sympathetic to the situation, making the correlation between their substance abuse or tobacco behavior with those traumas.” 44 year-old Hispanic/Latine female; Tobacco treatment specialist
	Responding rather than reacting	“It really also means being responsive, not reactive . . . . Typically, many of us hear something challenging that’s happened in someone’s life and create trauma, and there’s this reaction to fix and trauma informed care, for me is, don’t do that. We’re not their fixer, also understanding that their trauma could potentially link to any and all of their behaviors moving forward . . . for me, trauma informed care is about not downplaying anyone’s experience and supporting them through the recovery of whatever that looks like.” 38 year-old White female; Program coordinator
Barriers to integrating trauma-informed cessation care	Limited time for in-depth counseling	“I would not be able to let you know about how much we’re able to access the trauma level, because we really don’t have time to sit with them, to get into the depth of the counseling sessions, but we are most of the time able to to know that they’re going through something. But these are the patients who are the most resistant. They will fight us until we, you know, started changing our approach. So, yeah, we don’t, sometimes we don’t even mention that we’re smoking counselors.” 49 year-old Asian female; Respiratory care practitioner
	Lack of funding	“I think number one, like, part of the answer is, if we had funding, we would provide that care as well, right? Like, that’s a huge that’s just one of the huge barriers is the staff time.” 38 year-old White female; Program coordinator
	Lack of space	“I also think it’s space right that seems, sometimes seems insignificant, but like finding space to hold things such as this, you have in communities, especially, I’m in a very rural community, finding a space that’s accessible to many, that can hold people comfortably, that doesn’t feel like I’m going to for example, we have a probation office that we use that who wants to go to probation if they’re not on probation. So space is a is a barrier . . . . So lack of like community rooms, where these types of programming can happen.” 38 year-old White female; Program coordinator
	Lack of resources in rural areas	“I’m in a relatively rural county. We have to depend on our partner agencies a lot, because we don’t have a lot of the massive resources like a San Francisco has, or a South San Francisco, or a Phoenix, or whatever you you’ve got a lot of small, little independent medical providers you.” 62 year-old White female; Program specialist
Facilitators of trauma-informed cessation care	Leadership-organizational buy-in	“As far as leadership support that provides financing for our program, a lot of it is grant based. So we do depend on grant funding, but it’s not the sole source of the financing for the tobacco program. Our organization has a commitment to provide this service regardless of grant funding.” 44 year-old Hispanic/Latine female; Tobacco treatment specialist
	Interest and buy-in from colleagues	“So my colleagues . . . we’re very interested in the trauma informed training that I received, and quickly incorporated them and wanted to know a lot, I shared the materials that I brought back . . . . So yes, a lot of buy in from the colleagues . . . it’s 100% buy in.” 44 year-old Hispanic/Latine female; Tobacco treatment specialist
	Structured guide (TAMAR) is a facilitator	“I think, like, the TAMAR curriculum, I think overall it is very organized and structured, like I have a plan for here’s what I do. So I think that’s really helpful when, when I’m not sure where to start, it tells me where to start. So, so I really like that component.” 38 year-old White female; Program coordinator
Lessons learned	Decision support tool	“I think what would help would be, I know that, can access the stuff online, but almost like a shorthand version of everything, kind of like a say, like a Wikipedia or, like an easy, like a cliff notes version, or even just putting in scenarios through, an AI, that’s meant for this specifically, and it shows you like, the different situations and outcomes that you should take” 29 year-old Asian female; Community research coordinator
	Offering routine and extended training	“I liked all of them. I would have loved two full days to just go over TAMAR. I love the way our setup was to kind of getting the background, and then going in depth into the into the curriculum the next day. But I really would have loved to have even spent more time going more in depth, because I just it was one of the best curriculums I’ve run across in my decades, and I spent over almost 25 years in social services . . . ” 62 year-old White female; Program specialist
	Training materials	“And I also feel like the classes were more for the outpatient world, where we have a lot of time to attend to a patient and be able to effectively do the counseling sessions I do. I do have an interest in developing something [for] inpatients as well, where we have a time constraint, and how do we utilize the 30 minute time window to effectively be involved in a patient’s lives and be able to make a difference to them.” 49 year-old Asian female; Respiratory care practitioner
		“I think there are ways to think about . . . merging sections . . . . I do remember that it felt towards the end like we were starting to squeeze things . . . and it was important . . . to get all that . . . information in there . . . if we could integrate other pieces together, so you’re covering them in six sections, I think that that might be beneficial.” 42 year-old White female; Community research coordinator

Reflections on the TAMAR Training

Participants described the tobacco module in the TAMAR training as relevant, engaging, and practical (Table 1). Several said it reinforced their understanding of trauma and introduced new ways to integrate tobacco-related content into client care. As a result of the training, participants added tobacco-related questions to intake forms, started using mindfulness exercises to help clients manage cravings, and integrated tobacco cessation as a client goal in treatment planning. Participants said TAMAR helped normalize conversations about trauma and tobacco use within professional teams and fostered shared understanding of the importance of professional development in trauma-informed care to support tobacco cessation.

Attitudes and Practices Toward Trauma-Informed Tobacco Treatment

Participants reported their clients used tobacco to regulate trauma-related distress, especially when lacking healthy coping skills (Table 1). They reported helping clients make the connection between tobacco use and stress, anxiety, and traumatic events. Participants viewed trauma-informed tobacco treatment as a process of building trust, being empathetic, listening, having cultural humility, and avoiding judgment. They talked about trauma-informed care as recognizing the role of trauma in tobacco use behaviors, using client-centered communication, and avoiding triggering language.

Barriers to Implementing Trauma-Informed Cessation Care

Some providers described limited time or staffing to provide cessation support beyond brief advice (Table 1). Others worked in clinical settings such as cancer care centers or inpatient hospitals and found it difficult to approach patients being treated for chronic illnesses until they had built rapport. Some spoke of the difficulty in providing cessation support when clients were not ready to quit and said they lacked training in tobacco cessation. Participants reported organizational workflows that lacked prompts or forms to assess tobacco use, making it harder to initiate conversations. Others reported fewer resources in rural communities compared with urban areas. Participants emphasized that infrastructure must align with the realities of their work settings, and a lack of mobile outreach, private space for conducting assessments, and limited physical spaces for holding classes and trainings were barriers to providing trauma-informed care.

Facilitators of Trauma-Informed Cessation Care

Organizational support and leadership buy-in facilitated the integration of trauma-informed cessation care (Table 1). In some settings, trauma-informed care was already part of the organizational culture, which made it easier to apply these principles to tobacco use. Participants described how training and professional development, including the TAMAR training, gave them language and tools to feel more confident addressing trauma and tobacco use with their clients.

Lessons Learned

Participants emphasized the need for regular opportunities to reinforce trauma-informed practices (Table 1). While the TAMAR training provided valuable tools, several noted that a single training was not enough to sustain long-term changes in practice, highlighting the need for ongoing professional development in trauma-informed principles and cessation treatment. Materials need to align with learners’ practical needs, including quick-reference guides or visual tools to support application in community settings during real-time client interactions. Curricula must align with specific work settings, such as inpatient hospital units and community-based research roles.

Implications for Practice

Integrating trauma-informed principles into tobacco cessation treatment requires infrastructure and training approaches that align with diverse community and clinical settings. Ongoing training opportunities in trauma-informed cessation care for behavioral health and other health care professionals, including extended and recurrent training formats, could align cessation services with the needs of behavioral health populations.

Supplemental Material

sj-pdf-1-hpp-10.1177_15248399261449740 – Supplemental material for Implementing Trauma-Informed Training for Tobacco Use for Health Care Professionals in Two California Counties

Supplemental material, sj-pdf-1-hpp-10.1177_15248399261449740 for Implementing Trauma-Informed Training for Tobacco Use for Health Care Professionals in Two California Counties by Mark R. Hawes, Jessica Safier, Brian Clark, Maria Pamatmat, Catherine Bonniot, Christine Cheng, Raul Almazar, Joan Gillece and Maya Vijayaraghavan in Health Promotion Practice