Substance abuse counselors, programs, and treatment systems are now carefully considering a general approach to address smoking and nicotine dependence in the populations they serve.

Most recently, the New York State Office of Alcoholism and Substance Abuse Services considered regulatory changes that would require all treatment programs to be smoke-free and to initiate services to help clients quit smoking (Join Together, 2007). This state mandate, if approved, echoes and surpasses other recent and similar broad policy initiatives. North Carolina was one of the first states to adopt a smoke-free grounds policy for its four residential addiction treatment programs (D. Ziedonis, personal communication), and the New Jersey Department of Health and Senior Services required “tobacco-free grounds” policies as well as assessment and treatment of nicotine dependence in all residential programs in 2001 (Williams, et al., 2005). The Colorado Legislature approved a constitutional amendment that raised taxes on tobacco and directed those funds to treating nicotine dependence in persons receiving substance abuse and mental health services (Colorado Department of Public Health, 2005). The Department of Veterans Administration (VA) Healthcare System implemented practice guidelines (supported by electronic record reminders and ongoing monitoring) requiring smoking veterans to receive brief smoking cessation counseling three times per year (Ziedonis et al., 2004).  

These policy initiatives, which directly influence the practice of substance abuse treatment in the states and systems where they have occurred, are driven by several key considerations:

• Persons in substance abuse treatment smoke at a higher rate than the general population (Sobell, Sobell & Agrawal, 2002; Kalman, 1998).  
• Persons with co-occurring nicotine and other substance dependence are more heavily addicted to nicotine than smokers not involved in other substance use (Sobell 2002; Hughes, 2002).  
• Persons with more severe substance dependence are less successful in
    attempts to quit smoking com-
    pared to smokers not involved in
    other substance use (Drobes, 2002;     Joseph, Nichol & Anderson, 1993).  
• By one estimate, persons with a current mental disorder (including substance abuse) consume 44 percent of all cigarettes smoked in the United States (Lasser et al., 2000).
• Persons with co-occurring nicotine dependence and other substance abuse are more likely to die from smoking-related causes than from other substance abuse-
related causes (Hurt et al. 1996; Hser, McCarthy & Anglin, 1994).

These findings point to smoking and nicotine dependence as prevalent comorbid health risks that disproportionately affect persons enrolled in substance abuse treatment, and negatively contribute to long-term health outcomes. Insofar as substance abuse treatment systems are concerned with addiction, and as they evolve toward behavioral health models with an increased focus on co-occurring conditions, they are increasingly encouraged to better address nicotine addiction.

Clinical Guidelines for Treating Tobacco Use and Dependence direct all healthcare professionals to address smoking in patients, and also to identify substance-abusing persons as a specific population in need of nicotine dependence treatment (Fiore, Bailey & Cohen, 2000). Research in this area has suggested the following:

• Clinical guidelines for smoking treatment should be disseminated to all certified substance abuse counselors.
• States should consider mandatory counselor continuing education on smoking cessation (Hahn, Warnick & Plemmons, 1999).
• Funding should be targeted to support reimbursement for smoking cessation intervention for clients • Resources should be developed to enable treatment of smoking among staff at drug treatment centers (McCool, Richter & Choi, 2005).
• Outdoor smoking on drug abuse treatment facility grounds should be restricted or banned (Richter, Choi & Alford, 2005).  

Such steps require not only the efforts of treatment programs and local treatment systems, but collaboration between state departments of alcohol and drug treatment, as well as national and professional organizations, in the development of policy guidelines for treatment of nicotine dependence in drug abuse treatment settings (Hahn, Warnick & Plemmons 1999; Walsh et al., 2005).

Still, many substance abuse counselors, programs and treatment systems do not address nicotine dependence in their service populations. In a recent review of papers reporting on barriers to providing smoking cessation in addiction treatment settings, three barriers emerged as most prominent: lack of staff knowledge or training related to nicotine dependence treatment; the belief that smoking cessation concurrent with other drug or alcohol treatment may create a risk to sobriety; and that many staff are themselves smokers (Guydish et al., in press). These barriers are widely reported and can be addressed. Studies found that increasing staff knowledge through training, resulted in a higher provision of smoking cessation treatment in agencies (Bobo, Slade & Hoffman, 1995), or a positive change in staff attitude towards smoking cessation (Gill & Bennett, 2000). A common belief among many in the addiction treatment field is that providing smoking cessation concurrently with other addictions treatment represents a risk to sobriety. This belief echoes the traditional treatment guideline that persons beginning sobriety should avoid other major life changes for at least one year.

However, Prochaska, Delucchi and Hall (2004) found that smoking cessation efforts, concurrent with addictions treatment, was associated with a 25 percent increase in long term abstinence from other drugs. Last, smoking in the substance abuse treatment workforce can be influenced through program policies like those in North Carolina, New Jersey and New York, and by providing support for smoking cessation directly to staff members.

Current study

This article reports on results from a survey of the National Drug Abuse Treatment Clinical Trials Network (CTN) that assessed whether the agency provided smoking cessation treatment as a part of their regular services. The survey also assessed the attitudes of staff regarding the feasibility of offering smoking cessation treatment.  Analyses explored those factors associated with whether or not smoking cessation services were provided, and factors that predict staff attitudes toward smoking cessation treatment in these drug treatment settings.

NIDA Clinical Trials Network

The CTN is an alliance of research centers and drug treatment programs sponsored by the National Institute on Drug Abuse (NIDA) to conduct randomized trials of drug abuse treatments. The CTN aims to improve drug abuse treatment by determining the effectiveness of promising substance abuse treatments, and to support the transfer of tested and effective interventions into clinical practice (Hansen, Leshner & Tai, 2002). The network includes 17 research centers with over 100 drug abuse treatment programs, and has enrolled more than 7,000 participants into 32 multisite research protocols in various stages of completion.

Surveys of the CTN

An early CTN protocol, the Baseline Study, surveyed the directors and staff members of the treatment programs that make up the research network (McCarty, Fuller et al. 2007). Three surveys were administered between February 2002 and August 2004. Organizational surveys were given to the president or the CEO of the program, and characterized funding sources, annual revenue, mission and number of full-time employees; 106 organizational surveys were collected from 112 eligible treatment programs. The Treatment Unit Survey was given to each program director and included additional items assessing patients served, services provided and program philosophy. The treatment unit survey collected data from 348 of 388 treatment units. Finally, the Workforce Survey was distributed to staff within each treatment unit and requested information on years of experience, education, training, licensing, credentials and job titles. For the workforce survey 3,786 individuals responded from 5,334 eligible respondents (71 percent of the eligible individuals).

Our analysis of these surveys was guided by two questions:

1) What were the characteristics of treatment units that had active smoking cessation programs compared to those who did not?
2) What characteristics of the employees working in substance abuse treatment programs predicted their attitudes toward integrating smoking cessation into substance abuse treatment?
Findings

To answer the first question we used data from the 344 treatment unit surveys and focused on an item that indicated whether or not the unit had a smoking cessation program. We found that of the 342 treatment units, 106 (31 percent) offered some kind of smoking cessation intervention; and 235 (69 percent) offered no treatment for nicotine dependence. A logistic regression found that the presence of smoking cessation at each treatment unit was positively related to three variables: the mean attitude of the staff supporting integration of smoking cessation treatment; the number of additional mental health and medical services offered at the clinic; and the presence of a residential detoxification program. Thus, the attitude of the staff is vitally important for a program to be established. Smoking cessation programs tend to be offered in clinics that include other ancillary services, and residential detoxification programs are likely to favor implementing such programs in their agencies.

Staff attitudes toward integrating smoking cessation interventions were measured on a one to five scale; one indicating that the person was not supportive, and five that the person was strongly supportive. We found that attitudes were more supportive in agencies that offered some kind of treatment for nicotine dependence (M = 3.7) compared with units that did not (M = 3.5). Treatment units providing smoking cessation interventions also provided more ancillary services (M = 8.2) compared with those clinics that did not (M = 5.8). Finally, residential detoxification facilities were more common among treatment units with smoking cessation services (36 percent with, versus 19 percent without).  

To answer the second question, we investigated the attitude item at an individual level, in order to determine which predictors differentiated em-ployees with a supportive attitude, as opposed to an unsupportive attitude. A multiple regression — using the attitude of the individual employee as a criterion and several measures from the treatment unit and workforce surveys, — found that employees were more likely to have a positive view of smoking cessation treatment if: the clinic provided smoking cessation interventions as part of treatment; admitted a higher number of women; admitted a higher number of pregnant women; was part of a VA Medical Center; and if the employee had a positive attitude toward evidence based practices; and familiarity with the American Society of Addiction Medicine (ASAM) Placement Criteria.

Staff was less supportive of smoking cessation treatment if the unit contained a residential detoxification service. The correlation between offering detoxification services and staff attitude toward smoking cessation programs was r = -.11 indicating that this inverse finding is not due to model specific effects (i.e., statistical suppression). However, it is interesting that it was contradictory to the previous findings for the first question. We discuss this odd finding below.

Discussion

Overall we found that smoking cessation treatment was more likely to be available in units that offered other ancillary services, including detoxification. Treatment units that provide multiple medical and mental health services appear to be more likely to offer smoking cessation interventions. Stand-alone drug abuse treatment programs were less likely to offer smoking cessation interventions. Treatment programs that provided a more comprehensive level of service were more likely to have the resources to provide nicotine dependence treatment. It is unclear whether the smoking cessation treatment was provided through ancillary services, such as primary medical care.

This might imply that smoking cessation was generally more acceptable in other health care settings but not yet in independent drug abuse treatment settings.

Clinics that provide smoking cessation care were more likely to have staff with a supportive attitude toward such services. This is consistent with previous findings (Hahn et al., 1999; Hurt et al, 1995; Williams, McGregor et al., 2005). Staff with a positive view toward smoking cessation may be more likely to refer patients to the program. This raises the question as to whether the presence of nicotine dependence treatment improves staff attitude or whether having a supportive staff increases the likelihood that a clinic would offer smoking cessation interventions. The association between staff attitude and the provision of smoking cessation treatment is likely bi-directional.

The results demonstrate that staff members who worked in clinics with a high number of pregnant women were more likely to support integrating smoking cessation into drug abuse treatment. This finding may reflect that individuals in clinics serving pregnant and perinatal women are more aware of the negative impacts of smoking on fetal development, and are more ready to integrate smoking cessation services in their clinics.  On the other hand, the proportion of youth admissions was neither a predictor for staff attitudes nor for the provision of smoking cessation services.

A curious finding is the negative relationship between staff attitudes toward smoking cessation treatment and residential detoxification services. Staff attitude toward smoking cessation interventions in detoxification settings may be negative because the staff are treating patients in withdrawal and may believe that removing smoking during this period will only make the patient more uncomfortable. This may contribute to the ideation that patients are likely to leave detoxification facilities prematurely because of cigarette cravings. Concerns such as these may lead staff to have more negative attitudes toward the use of smoking cessation treatment.

Employees working in VA Medical Centers tended to have more positive attitudes toward smoking cessation than the rest of the workforce, and may reflect governmental regulations requiring a smoke-free environment in VA hospitals (as well as most other health care facilities). Even though a small number of drug treatment clinics were a part of VA Medical Centers (n = 15) there was still a significant effect in the regression equation (confirmed by a significant univariate correlation).  
Respondents who valued evidence-based practices, and those who perceived themselves to be knowledgeable of the ASAM criteria, were also more likely to favor the integration of smoking cessation into drug treatment units. These staff may be more aware of both the importance and the current techniques of treating nicotine dependence.  

Staff surveys indicate that the lack of demonstrated efficacy and lack of client interest are big barriers for implementation of interventions for smoking reduction while in treatment (Walsh, Bowman, Tzelepis & Lecathelinais, 2005). The large proportion of the workforce who smokes cigarettes was less likely to suggest smoking cessation treatment to their clients (Bobo & Gilchrist, 1983). Some staff members believe that it is therapeutic to occasionally smoke with their clients (Walsh et al, 2005).

Research has indicated that nicotine dependence treatment does not jeopardize drug treatment and may actually help recovery (Burling, Marshall & Seidner, 1991; Hurt et al., 1994; Martin et al., 1997; Stuyt, 1997; Toneatto, Sobell, Sobell & Kozlowski, 1995).  Some research demonstrates that smoking cessation interventions do improve long-term abstinence from alcohol or drugs but not tobacco use (Bobo, et al, 1998; Prochaska, Delucchi & Hall, 2004). Even though smoking interventions started early in residential treatment have been shown to affect abstinence rates, these effects are largely short-term (Joseph, Willenbring, Ngent & Nelson, 2004). Studies examining the effectiveness of smoking cessation treatment in drug treatment show short-term (six month) reductions in cigarette use, but do not show long-term (18 month) effects (Prochaska, Delucchi & Hall, 2004). It is unclear to what extent treatment staff members are aware of these findings and how much this lack of evidence influences staff attitudes. Also inconclusive is how generalizable the current findings are when compared to treatment agencies not affiliated with the CTN. Although this is likely a good sample of treatment units, the CTN may have more multi-faceted clinics than a random sample of agencies would contain.

Conclusions

This study presents some challenges to the treatment field to focus on evidence-based services regarding smoking cessation treatment, and raises some ethical issues as well.  Pregnant clients who do not receive nicotine dependence treatment have limited ability to eliminate tobacco use, leading to more fetal complications. Treatment clinics for youth that ignore smoking cessation education do a disservice to a vulnerable population who may face a lifetime of tobacco addiction.

The incorporation of evidence-based practices can be enhanced by the adoption of concurrent tobacco cessation services during rehabilitation, clearly an asset to good health and client recovery. Research supports the efficacy of nicotine dependence to improve overall addictions treatment and thus, it appears that a major shift in how nicotine is treated in recovery is on the horizon. State Legislatures and Departments of Health will likely continue lead the way to mandate treatment for nicotine dependence and requiring smoke-free workplaces in agencies. It is also incumbent upon directors and counselors to ensure that evidence-based practices for the treatment of nicotine dependence be implemented in their agencies. Through a concerted effort in overcoming the barriers to implementing smoking cessation treatment, nicotine dependence treatment will likely be more prevalent in drug treatment centers across the nation. C

Acknowledgements: Cooperative agreements from the National Institute on Drug Abuse supported the design, distribution, collection and analysis of the organizational, treatment unit and workforce surveys within the CTN: Oregon Node (U10 DA13036), California-Arizona Node (U10 DA15815), Delaware Valley Node (U10 DA13043), Florida Node (U10 DA13720), Great Lakes Node (U10 DA13710), Long Island Node (U10 DA13035), Mid-Atlantic Node (U10 DA13034), New England Node (U10 DA13038), New York Node (U10 DA13046), North Carolina Node (U10 DA13711), Northern New England Node (U10 DA15831), Ohio Valley Node (U10 DA13732), Pacific Node (U10 DA13045), Rocky Mountain Node (U10 DA13716), South Carolina Node (U10 DA13727), Southwest Node (U10 DA15833), and Washington Node (U10 DA13714).  We appreciate the support and participation of executive directors, treatment unit directors, and the workforce in the participating clinics.

Bret E. Fuller, PhD spent six years at the Department of Public Health and Preventive Medicine at Oregon Health & Science University, as a part of the National Drug Abuse Treatment Clinical Trials Network. Currently he works at NPC Research in Portland, Oregon, where he investigates incentive-based funding structures in drug court treatment systems. He also is also a licensed psychologist in the State of Oregon.

Joseph Guydish, PhD, MPH, is Professor of Medicine and Health Policy at the University of California, San Francisco, and Associate Director of the California-Arizona node of the NIDA Clinical Trials Network. He has recently led studies evaluating San Francisco’s efforts to improve access to publicly-funded drug abuse treatment, and assessing federal policy to end drug addiction and alcoholism as an SSI disability category.

References

Bobo, J.K., McIlvain, H.E., Lando, H.A., Walker, R.D. & Leed-Kelly, A. (1998).  Effect of smoking cessation counseling on recovery from alcoholism: Findings from a randomized community intervention trial. Addiction 93(6), 877-887.
Bobo, J.K., Slade, J., & Hoffman, A.L. (1995). Nicotine addiction counseling for chemically dependent patients. Psychiatric Services 46, 945-947.
Burling, T.A., Marshall, G.D., & Seidner, A.L. (1991). Smoking cessation for substance abuse inpatients. Journal of Substance Abuse 3, 269-276.
Colorado Department of Public Health (2005). House Committee Approves Plan For Use of Tobacco Tax Revenue. Retrieved August 2, 2007, from http://
www.cdphe.state.co.us/release/2005/031105.html
Drobes, D.J. 2002. Cue reactivity in alcohol and tobacco dependence. Alcohol Clinical and Experimental Research 26 (12): 1928-1929.
Fiore, M.C., Bailey, W.C., and Cohen, S.J. (2000). Treating tobacco use and dependence: Clinical practice guideline.  U.S. Department of Health and Human Services: Rockville, MD.
Gill, B.S., & Bennett, D.L. 2000. Addiction professionals’ attitudes regarding treatment of nicotine dependence. Journal of Substance Abuse Treatment 19 (4): 317-318.
Guydish, J., Passalacqua, E.,  Tajima, B. & Turcotte Manser, S. (in press). Staff Smoking and Other Barriers to Nicotine Dependence Intervention in Addiction Treatment Settings: A Review.  Journal of Psychoactive Drugs.
Hahn, E.J., Warnick, T.A., & Plemmons, S. (1999). Smoking cessation in drug treatment programs. Journal of Addictive Diseases 18, 89-101.
Hansen, G.R., Leshner, A.I. & Tai, B. (2002).  Putting drug abuse research to use in real-life settings. Journal of Substance Abuse Treatment, 23, 69-70.
Hughes, J., (1996). Treating smokers with current or past alcohol dependence. American Journal of Health Behavior 20, 286-290.
Hughes, J.  (2002). Do smokers with current or past alcoholism need different or more intensive treatment? Alcoholism: Clinical and Experimental Research 26 ,1934-1935.
Hurt, R. D., Croghan, I. T, Offord, K.P, Eberman, K. M & Morse, R. M. (1995). Attitudes toward nicotine dependence among chemical dependency unit staff — before and after a smoking cessation trial. Journal of Substance Abuse Treatment 12, 247-252.
Hurt, R.D., Eberman, K.M., Croghan, I.T., et al. (1994). Nicotine dependence treatment during inpatient treatment for other addictions: a prospective intervention trial. Alcoholism: Clinical and Experimental Research 18, 867-872.
Hurt, R.D., Offord, K.P., Croghan, I.T. et al. (1996). Mortality following inpatient addictions treatment: Role of tobacco use in a community-based cohort. JAMA 275, 1097-1103.
Hser, Y.I.; McCarthy, W.J., & Anglin, M.D. 1994. Tobacco use as a distal predictor of mortality among long-term narcotics addicts. Preventative Medicine 23 (1): 61-9.
Join Together. (2007, July 25). NY Seeks Smoking Ban at All Addiction Treatment Programs. Retrieved August 2, 2007, from http://www.jointogether.org/news/headlines/
inthenews/2007/ny-seeks-smoking-ban-at-all.html.
Joseph, A.M., Nichol, K.L., & Anderson, H. (1993). Effect of treatment for nicotine dependence on alcohol and drug treatment outcomes. Addictive Behaviors 18, 635-644.
Joseph, A.M. Willenbring, M.L, Nugent, S.M., Nelson, D.B. (2004). A randomized trial of concurrent versus delayed smoking intervention for patients in alcohol dependence treatment. Journal of Studies on Alcohol, 65, 681-91.
Kalman, D. (1998). Smoking cessation treatment for substance misusers in early recovery: a review of the literature and recommendations for practice. Substance Use and Misuse 33, 2010-2047.
Lasser, K., Boyd, J.W., Woolhandler, S., Himmelstein, D.U., McCormick, D., and Bor, D.H., Smoking and mental illness: A population-based prevalence study. JAMA, 2000. 284(20): p. 2606-2610.
McCarty, D. J., Fuller, B.E. Arfken, C., et al, (2007).  Direct Care Workers in the National Drug Abuse Treatment Clinical Trials Network: Characteristics, Opinions, and Beliefs. Psychiatric Services, 58, (2). 1 - 10.
McCool, R.M.; Richter, K.P., & Choi, W.S. 2005. Benefits of and barriers to providing smoking treatment in methadone clinics: findings from a national study. American Journal on Addictions 14 (4): 358-366.
Martin, J.E., Calfas, K.J., Patten, C.A., et al. (1997). Prospective evaluation of three smoking interventions in 205 recovering alcoholics: one-year results of Project SCRAP-Tobacco. Journal of Consulting and Clinical Psychology 65, 190-194.
Prochaska, J. J., Delucchi, K., & Hall, S. M. (2004). A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology, 72(6), 1144-1156.
Sobell, M.B. (2002). Alcohol and tobacco: Clinical and treatment issues. Alcoholism: Clinical and Experimental Research 26, 1954-1955.
Sobell, L.C.; Sobell, M.B., & Agrawal, S. 2002. Self-change and dual recoveries among individuals with alcohol and tobacco problems: current knowledge and future directions. Alcohol Clinical and Experimental Research 261: 1936-1938.
Stuyt, E.B. (1997). Recovery rates after treatment for alcohol/drug dependence — Tobacco users vs. non- tobacco users. American Journal on Addictions 6, 159-167.
Richter, K.P. Choi, W.S., & Alford, D.P. 2005. Smoking policies in U.S. outpatient drug treatment facilities. Nicotine and Tobacco Research 7 (3): 475-480.
Toneatto, A., Sobell, L.C., Sobell, M.B., & Kozlowski, L.T. (1995). Effect of cigarette smoking on alcohol treatment outcome. Journal of Substance Abuse, 7, 245-252.
Walsh, R.A.; Bowman, J.A.; Tzelepis, F., & Lecathelinais, C. (2005). Smoking cessation interventions in Australian drug treatment agencies: a national survey of attitudes and practices. Drug and Alcohol Review 24 (3): 235-244.
Williams, J.M., Foulds, J., Dwyer, M., Order, O’Connors, B., Springer, M., Gadde, P. & Ziedonis, D. (2005). The integration of tobacco dependence treatment and tobacco-free standards into residential addictions treatment in New Jersey. Journal of Substance Abuse Treatment, 28, 331-340.
Williams G. C., McGregor, H., Borrelli, B., Jordan P.J. & Strecher, V.J. (2005). Measuring tobacco dependence treatment outcomes: a perspective from the behavior change consortium. Annals of Behavioral Medicine Apr, 29 Suppl:11-9.
Ziedonis, D., Williams, J.M., Steinberg, M.L., Smelson, D., Krejci, J.,Sussner, B.D., Violette, N. & Foulds, J. (2004). Addressing tobacco dependence among veterans with a psychiatric disorder: A neglected epidemic and public health concern. In S.L. Isaacs (Ed.). VA in the Vanguard: Building on Success in Smoking Cessation

Comments

Add New Search RSS

Write comment
Name:
Email:	do not notifynotify
Title:
	Please input the anti-spam code that you can read in the image.

Powered by !JoomlaComment 3.26

3.26 Copyright (C) 2008 Compojoom.com / Copyright (C) 2007 Alain Georgette / Copyright (C) 2006 Frantisek Hliva. All rights reserved."

---