The question of how nicotine dependence should or should not be addressed within the context of addiction treatment has been a controversial issue from the inception of addiction treatment in the United States. Many nineteenth-century inebriate asylums and private addiction- cure institutes demanded cessation of smoking as a condition of treatment for other drug dependencies. Bottled and boxed miracle cures for the “tobacco habit” were promulgated alongside cures for alcoholism and morphine addiction. The first textbooks on addiction (then referred to as inebriety) included chapters on “tobaccoism,” and intense debate raged in the first addiction medicine journal—the Journal of Inebriety, 1875–1914—on the relationship between nicotine addiction and other addictions and how and when it could be best treated (White, 1998). The debate continues more than a century later, but accumulating scientific findings, shifts in cultural attitudes toward smoking and growing clinical experience within addiction treatment are tipping the scales of this debate.
Smoking Cessation and Addiction Treatment: Current Context
Cigarette smoking remains one of the largest causes of premature death in the United States (Centers for Disease Control and Prevention, 2008). Individuals seeking addiction treatment are far more likely to smoke than the general adult population. About 21 percent of American adults smoke, but rates of smoking for clients in treatment range from 70 to 80 percent (McCarthy, Collins, & Hser, 2002; Richter, Ahluwalia, Mosier, Nazir, & Ahluwalia, 2002; Teater & Hammond, 2010; Williams & Ziedonis, 2004). Furthermore, people with substance use disorders (SUDs) consume more cigarettes per day, which further increases the risks to their health (Sussman, 2002). Long-term studies have shown that cigarette smoking is more likely to result in premature death for individuals with SUDs than their alcohol or drug use (Hser, McCarthy, & Anglin, 1994; Hurt et al., 1996).
There is a growing body of research examining how smoking impacts recovery after treatment as well as the effectiveness of smoking cessation interventions for people with SUDs. Quitting smoking in the first year of SUD treatment increases clients’ likelihood of achieving recovery, even nine years after treatment (Tsoh, Chi, Mertens, & Weisner, 2011). Continuing to smoke after treatment is actually a risk factor for relapse (Kohn, Tsoh, & Weisner, 2003; Satre, Kohn, & Weisner, 2007). Strengthening the case for the importance of smoking cessation interventions is a meta-analysis by Prochaska and colleagues (2004). They reviewed the existing research and concluded that these interventions increase the likelihood of short-term smoking cessation and improve the chances of long-term SUD recovery. Other recent reviews have also concluded that smoking cessation is an important clinical goal for SUD treatment (Baca & Yahne, 2009; Prochaska, 2010; Schroeder & Morris, 2010).
Clinical practice guidelines also call for the integration of smoking cessation services into SUD treatment. Most notably, the U.S. Public Health Service has published the clinical practice guideline Treating Tobacco Use and Dependence: 2008 Update, which recommends that all healthcare providers counsel their patients about tobacco use and provide interventions—ranging from counseling to medications—to help patients quit smoking (Fiore et al., 2008). The guideline specifically addresses SUD treatment providers, recommending that they deliver smoking cessation interventions to their clients. These interventions are also recommended in the National Institute on Drug Abuse (NIDA) guideline Principles of Drug Addiction Treatment: A Research-Based Guide (NIDA, 2009).
Smoking Cessation and SUD Treatment Programs: New Scientific Findings
In 2006, we began a study at the University of Georgia that sought to increase knowledge about the adoption and implementation of smoking cessation interventions in SUD treatment programs. Our interests were twofold: first, to learn about how many treatment organizations offered counseling programs and medications for smoking cessation, while identifying the types of organizations more likely to offer these services. Second, to collect innovative data from counselors about implementation, meaning how routinely counselors delivered smoking cessation interventions as part of their everyday work. By gathering information from both administrators and counselors, we sought to conduct one of the most comprehensive studies about smoking cessation services in addiction treatment centers throughout the United States.
Our research methodology built upon the National Treatment Center Study (NTCS), which is a large-scale health services research project that recruited administrators from more than 1,100 treatment organizations to participate in face-to-face interviews from 2002 through 2004. More information about the larger NTCS can be found in publications by Dr. Paul Roman and colleagues; see Roman, Ducharme & Knudsen (2006) and Dye et al. (2009). The NTCS included nationally representative samples of publicly funded treatment agencies and privately funded treatment organizations and therapeutic communities, which were recontacted by telephone in 2006 through 2008. About 86 percent of these programs participated in telephone interviews about smoking cessation services. After the interview, we invited administrators to provide lists of counselors working at their treatment programs. Counselors were mailed surveys, and we received more than 2,100 surveys from counselors across the United States.
The Adoption of Smoking Cessation Services in SUD Treatment
One goal of the study was to document the extent to which treatment organizations had adopted smoking cessation services (Knudsen, Studts, Boyd, & Roman, 2010). Adoption refers to the availability of these services. We focused on three types of services: brief interventions delivered during intake, counseling-based smoking cessation programs, and medications to treat nicotine dependence. The brief intervention of asking new clients if they currently smoked had been adopted by nearly all programs (86 percent), but far fewer programs (35 percent) helped motivated clients to develop a quit plan.
The three samples of treatment organizations differed in their rates of offering smoking cessation programs and medications. About 71 percent of publicly funded treatment programs and 65 percent of therapeutic communities did not offer a counseling-based smoking cessation program or any medications, such as over-the-counter nicotine replacement therapy (NRT) or prescription medications (e.g., varenicline (Chantix); sustained-release bupropion). Programs that relied on private sources of funding, like insurance and self-paying clients, were more likely to offer services, but the predominant approach offered by 41 percent of private programs was smoking cessation medications without a formal counseling program.
We sought to identify the types of treatment organizations that were more likely to offer comprehensive smoking cessation services, meaning both a counseling-based program and medications. This type of comprehensive approach is highly consistent with current clinical practice guidelines, although it was only adopted by 11 percent of programs. Statistical models compared programs offering comprehensive services to those that offered neither a counseling program nor medications. Comprehensive services were more likely to be found in hospital-based programs, larger treatment organizations, and those offering only inpatient/residential levels of care. There were three cultural barriers to comprehensive services: programs reporting that smoking was not important in treating SUDs, that there was no time to integrate smoking cessation into their existing treatment protocols and that staff did not have smoking cessation counseling skills.
The larger NTCS had previously collected information about the adoption of nicotine replacement therapy (NRT), so we compared rates of NRT adoption from 2002 through 2004 and 2006 through 2008 (Knudsen & Studts, in press). There was a small decrease over time, from 38 percent to 34 percent of programs offering NRT. While that seems like a very modest change, it actually does not fully capture the changes that occurred within these programs over time. About 16 percent of programs discontinued using NRT between the two time periods, while 12 percent of the sample started using NRT by the 2006 through 2008 time period. We found that 21 percent of the programs used NRT during both time periods, indicating sustained adoption within these programs.
Implementation of Smoking Cessation Interventions
While adoption of a service reflects organizational decisions about offering a given service, counselors play a central role in the actual delivery of psychosocial interventions, such as smoking cessation counseling. In other words, counselors are the drivers of implementation. They can influence whether smoking cessation counseling becomes a routine part of addiction treatment. Surveys from more than 2,100 counselors measured the extent to which they were delivering brief interventions and counseling sessions dedicated to smoking cessation.
Many counselors are making a concerted effort to ask new clients about whether they use tobacco products, but counselors less frequently implement other brief interventions such as advising smokers to quit, assessing willingness to quit and trying to increase motivation to quit (Knudsen & Studts, 2010). Delivery of counseling sessions that are dedicated to smoking cessation are rare (Knudsen, Studts, & Studts, in press), which is not surprising given the small number of organizations offering a counselingbased smoking cessation program.
We sought to better understand the factors related to higher levels of implementation for both brief interventions and counseling sessions (Knudsen & Studts, 2010; Knudsen, et al., in press). Three key factors were identified. First, counselors who reported that program managers were supportive of smoking cessation services more frequently delivered brief interventions and counseling sessions dedicated to smoking cessation. Second, counselors who reported greater knowledge about the PHS guideline Treating Tobacco Use and Dependence, engaged in greater implementation. Finally, counselors who believed that smoking cessation would improve clients’ chances of recovery reported greater implementation of both brief interventions and counseling sessions focused on smoking cessation.
One issue that has been discussed in the literature is the role of counselors’ personal tobacco use as a factor in their implementation of smoking cessation counseling (Guydish, Passalacqua, Tajima, & Manser, 2007). In our sample, about 20 percent of counselors were current tobacco users. Our findings about the implications of counselor tobacco use were mixed. On the one hand, current tobacco users implemented brief interventions less frequently than counselors with no history of tobacco use (Knudsen & Studts, 2010). However, there was no difference in the implementation of counseling sessions between current tobacco users and counselors who had never been tobacco users (Knudsen, et al., in press).
Having been involved in documenting the history and evolution of smokingrelated practices within the field, we would offer the following six predictions regarding the future of this issue within the field.
Addiction counselors are speeding the advent of these changes through their personal advocacy, refinement of their counseling practices and, in increasing numbers, severing their own relationship with nicotine.
Acknowledgments: The authors gratefully acknowledge research support from the National Institute on Drug Abuse (NIDA; R01DA020757, R01DA13110, R01DA14482 and R01DA14976). Research collaborators on the national study of smoking cessation practices included Dr. Paul M. Roman from the University of Georgia and Dr. Jamie L. Studts, Dr. Tina R. Studts, and Ms. Sara Boyd from the University of Kentucky. The opinions expressed are those of the authors and are not intended to represent the official position of NIDA.
Baca, C. T., & Yahne, C. E. (2009). Smoking cessation during substance abuse treatment: What you need to know. Journal of Substance Abuse Treatment, 36, 205–219.
Centers for Disease Control and Prevention (2008). Cigarette smoking among adults— United States 2007. MMWR Morbidity and Mortality Weekly Report, 57, 1221–1226.
Dye, M. H., Ducharme, L. J., Johnson, J. A., Knudsen, H. K., & Roman, P. M. (2009). Modified therapeutic communities and adherence to traditional elements. Journal of Psychoactive Drugs, 41, 275–283.
Fiore, M. C., Jaen, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Curry, S. J., et al. (2008). Treating tobacco use and dependence: 2008 update. Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service.
Guydish, J., Passalacqua, E., Tajima, B., & Manser, S. T. (2007). Staff smoking and other barriers to nicotine dependence intervention in addiction treatment settings: A review. Journal of Psychoactive Drugs, 39, 423–433.
Hser, Y. I., McCarthy, W. J., & Anglin, M. D. (1994). Tobacco use as a distal predictor of mortality among long-term narcotics addicts. Preventive Medicine, 23, 61–69.
Hurt, R. D., Offord, K. P., Croghan, I. T., Gomez-Dahl, L., Kottke, T. E., Morse, R. M., et al. (1996). Mortality following inpatient addictions treatment: Role of tobacco use in a community-based cohort. Journal of the American Medical Association, 275, 1097–1103.
Knudsen, H. K., & Studts, J. L. (2010). The implementation of tobacco-related brief interventions in substance abuse treatment: A national study of counselors. Journal of Substance Abuse Treatment, 38, 212–219.
Knudsen, H. K., & Studts, J. L. (in press). Availability of nicotine replacement therapy in substance use disorder treatment: Longitudinal patterns of adoption, sustainability, and discontinuation. Drug and Alcohol Dependence.
Knudsen, H. K., Studts, J. L., Boyd, S., & Roman, P. M. (2010). Structural and cultural barriers to the adoption of smoking cessation services in addiction treatment organizations. Journal of Addictive Diseases, 29, 294–305.
Knudsen, H. K., Studts, J. L., & Studts, T. R. (in press). The implementation of smoking cessation counseling in substance abuse treatment. Journal of Behavioral Health Services & Research.
Kohn, C. S., Tsoh, J. Y., & Weisner, C. M. (2003). Changes in smoking status among substance abusers: Baseline characteristics and abstinence from alcohol and drugs at 12-month follow-up. Drug and Alcohol Dependence, 69, 61–71.
McCarthy, W. J., Collins, C., & Hser, Y. I. (2002). Does cigarette smoking affect drug abuse treatment? Journal of Drug Issues, 32, 61–80.
National Institute on Drug Abuse (NIDA). (2009). Principles of drug addiction treatment: A research-based guide. Rockville, MD: NIDA.
Prochaska, J. J. (2010). Failure to treat tobacco use in mental health and addiction treatment settings: A form of harm reduction? Drug and Alcohol Dependence, 110, 177–182.
Prochaska, J. J., Delucchi, K., & Hall, S. A. (2004). A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology, 72, 1144–1156.
Richter, K. P., Ahluwalia, H. K., Mosier, M. C., Nazir, N., & Ahluwalia, J. S. (2002). A population-based study of cigarette smoking among illicit drug users in the United States. Addiction, 97, 861–869.
Roman, P. M., Ducharme, L. J., & Knudsen, H. K. (2006). Patterns of organization and management in private and public substance abuse treatment programs. Journal of Substance Abuse Treatment, 31, 235–243.
Satre, D. D., Kohn, C. S., & Weisner, C. (2007). Cigarette smoking and long-term alcohol and drug treatment outcomes: A telephone follow-up at five years. American Journal on Addictions, 16, 32–37.
Schroeder, S. A., & Morris, C. D. (2010). Confronting a neglected epidemic: Tobacco cessation for persons with mental illnesses and substance abuse problems. Annual Review of Public Health, 31, 297–314.
Sussman, S. (2002). Smoking cessation among persons in recovery. Substance Use Misuse, 37, 1275–1298.
Teater, B., & Hammond, G. C. (2010). Exploring smoking prevalence, quit attempts, and readiness to quit cigarette use among women in substance abuse treatment. Social Work in Health Care, 49, 176–192.
Tsoh, J., Chi, F. W., Mertens, J. R., & Weisner, C. M. (2011). Stopping smoking during first year of substance use treatment predicted 9-year alcohol and drug treatment outcomes. Drug and Alcohol Dependence, 114, 110–118.
White, W. (1998). Slaying the dragon: The history of addiction treatment and recovery in America. Bloomington, IL: Chestnut Health Systems.
White, W. (2008). Alcohol, tobacco and drug use by addiction professionals: Historical reflections and suggested guidelines. Alcoholism Treatment Quarterly, 26, 500–535.
Williams, J. M., & Ziedonis, D. (2004). Addressing tobacco among individuals with a mental illness or an addiction. Addictive Behaviors, 29, 1067–1083.