Urging the alcoholic client to quit smoking cigarettes

Psychopharmacology of Tobacco and Alcohol Comorbidity: a Review of Current Evidence

Purpose of the Review

Comorbidity of alcohol and tobacco use is highly prevalent and may exacerbate the health effects of either substance alone. However, the mechanisms underlying this comorbidity are not well understood. This review will examine the evidence for shared neurobiological mechanisms of alcohol and nicotine comorbidity and experimental studies of the behavioural consequences of these interactions.

Recent Findings

Studies examining the shared neurobiology of alcohol and nicotine have identified two main mechanisms of comorbidity: (1) cross-reinforcement via the mesolimbic dopamine pathway and (2) cross-tolerance via shared genetic and nAChR interaction. Animal and human psychopharmacological studies demonstrate support for these two mechanisms of comorbidity.

Summary

Human behavioural studies indicate that (1) alcohol and tobacco potentiate each other’s rewarding effects and (2) nicotine reduces the sedative and intoxication effects of alcohol. Together, these findings provide a strong evidence base to support the role of the cross-reinforcement and cross-tolerance as mechanisms underlying the comorbidity of alcohol and tobacco use. Methodological concerns in the literature and recommendations for future studies are discussed alongside implications for treatment of comorbid alcohol and tobacco use.

An international systematic review of smoking prevalence in addiction treatment

AIMS

Smoking prevalence is higher among people enrolled in addiction treatment compared with the general population, and very high rates of smoking are associated with opiate drug use and receipt of opiate replacement therapy (ORT). We assessed whether these findings are observed internationally.

METHODS

PubMed, PsycINFO and the Alcohol and Alcohol Problems Science Database were searched for papers reporting smoking prevalence among addiction treatment samples, published in English, from 1987 to 2013. Search terms included tobacco use, cessation and substance use disorders using and/or Boolean connectors. For 4549 papers identified, abstracts were reviewed by multiple raters; 239 abstracts met inclusion criteria and these full papers were reviewed for exclusion. Fifty-four studies, collectively comprising 37,364 participants, were included. For each paper we extracted country, author, year, sample size and gender, treatment modality, primary drug treated and smoking prevalence.

RESULTS

The random-effect pooled estimate of smoking across people in addiction treatment was 84% [confidence interval (CI) = 79, 88%], while the pooled estimate of smoking prevalence across matched population samples was 31% (CI = 29, 33%). The difference in the pooled estimates was 52% (CI = 48%, 57%, P < .0001). Smoking rates were higher in programs treating opiate use compared with alcohol use [odds ratio (OR) = 2.52, CI = 2.00, 3.17], and higher in ORT compared to out-patient programs (OR = 1.42, CI = 1.19, 1.68).

CONCLUSIONS

Smoking rates among people in addiction treatment are more than double those of people with similar demographic characteristics. Smoking rates are also higher in people being treated for opiate dependence compared with people being treated for alcohol use disorder.

The implementation of smoking cessation counseling in substance abuse treatment

Research on the implementation of smoking cessation counseling within substance abuse treatment organizations is limited. This study examines associations among counselors' implementation of therapy sessions dedicated to smoking cessation, organizational factors, and counselor-level variables. A two-level hierarchical linear model including organization- and counselor-level variables was estimated using survey data collected from 1,794 counselors working in 359 treatment organizations. Overall implementation of smoking cessation counseling was low. In the final model, implementation was positively associated with counselors' knowledge of the Public Health Service's clinical practice guideline, perceived managerial support, and belief that smoking cessation had a positive impact on recovery. Private versus public funding and presence of a formal smoking cessation program were organization-level variables which interacted with these counselor-level effects. These results highlight the importance of organizational contexts as well as counselors' knowledge and attitudes for effective implementation of smoking cessation counseling in substance abuse treatment organizations.

Measuring smoking knowledge, attitudes and services (S-KAS) among clients in addiction treatment

BACKGROUND

Addiction treatment programs are increasingly working to address prevalent and comorbid tobacco dependence in their service populations. However at present there are few published measurement tools, with known psychometric properties, that can be used to assess client-level constructs related to tobacco dependence in addiction treatment settings. Following on previous work that developed a staff-level survey instrument, this report describes the development and measurement characteristics of the smoking knowledge, attitudes and services (S-KAS) for use with clients in addiction treatment settings.

METHOD

250 clients enrolled in residential drug abuse treatment programs were surveyed. Summary statistics were used to characterize both the participants and their responses, and exploratory factor analysis (EFA) was used to examine the underlying factor structure.

RESULTS

Examination of the rotated factor pattern indicated that the latent structure was formed by one knowledge factor, one attitude factor, and two "service" factors reflecting program services and clinician services related to tobacco dependence. Standardized Cronbach's alpha coefficients for the four scales were, respectively, .57, .75, .82 and .82.

CONCLUSIONS

The proposed scales have reasonably good psychometric characteristics, although the knowledge scale leaves room for improvement, and will allow researchers to quantify client knowledge, attitudes and services regarding tobacco dependence treatment. Researchers, program administrators, and clinicians may find the S-KAS useful in changing organizational culture and clinical practices related to tobacco addiction, help in program evaluation studies, and in tracking and improving client motivation.

Structural and cultural barriers to the adoption of smoking cessation services in addiction treatment organizations

Few studies have examined associations between the availability of smoking cessation services in addiction treatment organizations and specific cultural, staffing, and resource barriers. Telephone interviews were conducted with administrators of 897 addiction treatment organizations in the United States. These data revealed that few programs had adopted the full bundle of five recommended tobacco-related intake procedures, and that less than half of programs offered any smoking cessation services. Barriers to adoption of the intake bundle and availability of services included organizational culture and low levels of staff skills. Adoption of cessation services was associated with center type, location in a hospital setting, levels of care, and organizational size. Although a substantial proportion of organizations offer smoking cessation services, expansion of these services and greater adoption of tobacco-related intake procedures are needed to address the needs of nicotine-dependent individuals in addiction treatment.

The implementation of tobacco-related brief interventions in substance abuse treatment: a national study of counselors

Most individuals receiving substance abuse treatment also use tobacco, which suggests that smoking cessation is an important clinical target for most clients. Few studies have measured the extent to which addiction treatment counselors address clients' tobacco use. In this study, we examined counselors' implementation of brief interventions that are consistent with the U.S. Public Health Service's (PHS) clinical practice guideline, Treating Tobacco Use and Dependence, when counselors are engaging new clients in treatment. We hypothesized that counselors' implementation of tobacco-related brief interventions is associated with organizational and counselor-level factors. Data were collected from 2,067 counselors via mailed surveys. Implementation of recommended brief interventions during intake was significantly lower among counselors reporting greater barriers to smoking cessation services within their organizational context. Perceived managerial support for smoking cessation services was positively associated with implementation. Counselors with greater knowledge of the PHS guideline and who believed in the positive impact of smoking cessation interventions on sobriety reported greater implementation. Relative to counselors who have never been tobacco users, current tobacco users reported significantly lower implementation of these brief interventions. These findings suggest that attempts to increase the implementation of best practices in substance abuse treatment may require attention to organizational contexts and the individuals responsible for implementation.

Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings

This article reviews the research on the treatment of cigarette smoking in individuals who have comorbid mental illnesses or non-nicotinic addictions. The prevalence of smoking in mentally ill and substance-abusing populations is presented, as well as reasons for this high prevalence. The historical role of cigarettes and tobacco in mental illness and addiction is reviewed to help the reader better understand the pervasiveness of smoking in these disorders and the relative absence of intervention efforts in mental heath and addiction treatment settings. The article then discusses the several reasons for integrating smoking treatment into mental health and addiction settings. The outcome research for adult and adolescent comorbid smokers is reviewed, and barriers to treatment are discussed. The review closes with a brief discussion of models of integration and thoughts about prevention.

The adoption of tobacco dependence treatment by rehabilitation clinicians

PURPOSE

Individuals with disabilities tend to smoke at rates that surpass those of the general population. The Pubic Health Service Guideline on the treatment of tobacco dependence suggests that all smokers be screened at every health care visit and counselled regarding how best to quit smoking. We review the literature on the adoption of tobacco dependence treatment by rehabilitation clinicians working with disabled individuals. Despite the deleterious health effects of smoking on individuals with disabilities, the limited data suggests that rehabilitation clinicians rarely encourage their clients who smoke to quit.

METHOD

Studies were collected using various computerized databases from 1980 to the present. Because of the paucity of literature on tobacco dependence treatment utilization among rehabilitation clinicians, we also examine research on the use of tobacco dependence treatment by health care providers in the general population and in substance abuse treatment settings.

RESULTS

Despite the efficacy of tobacco dependence treatment in smokers with disabilities, tobacco dependence treatment appears to be underutilized by rehabilitation clinicians.

CONCLUSIONS

Interventions that have successfully increased adoption by the two other clinician groups should be utilized to increase tobacco dependence treatment provision by rehabilitation clinicians. Additional research is warranted to determine how to overcome obstacles to adoption.

Where there's smoke, there's fire: high prevalence of smoking among some sub-populations and recommendations for intervention

In Australia, the prevalence of smoking is higher among certain sub-populations compared to the general population. These sub-populations include Aboriginal and Torres Strait Islander people, people from culturally and linguistically diverse backgrounds, as well as people with mental and substance use disorders and prisoners. The aims of this paper are to: describe the high prevalence of smoking among these particular sub-populations and harms associated with smoking; explore possible reasons for such high prevalence of smoking; review the evidence regarding the efficacy of existing smoking cessation interventions; and make recommendations for smoking interventions and further research among these groups. In addition to low socio-economic status, limited education and other factors, there are social, systems and psychobiological features associated with the high prevalence of smoking in these sub-groups. General population-based approaches to reducing smoking prevalence have been pursued for decades with great success and should be continued with further developments that aim specifically to affect Aboriginal and Torres Strait Islander people and some cultural groups. However, increasing attention, more specific targeting and flexible goals and interventions are also required for these and other distinct sub-populations with high smoking prevalence. Recommendations include: more funding and increased resources to examine the most appropriate education and treatment strategies to promote smoking cessation among people from Aboriginal and Torres Strait Islander and some culturally and linguistically diverse backgrounds; larger and better-designed studies evaluating smoking cessation/reduction interventions among distinct sub-groups; and system-wide interventions requiring strong leadership among clients and staff within mental health, drug and alcohol and prison settings.

Smoking cessation interventions in Australian drug treatment agencies: a national survey of attitudes and practices

A cross-sectional survey was mailed to all Australian drug and alcohol treatment agencies to assess their smoking cessation policies and practices and related staff attitudes. Barriers to smoking cessation interventions were also examined. Completed questionnaires were returned by 213 managers and 204 other staff representing 260 agencies (59.8% consent rate). Approximately one-quarter of agencies have smoking cessation intervention policies and one-third of clients receive adequate smoking advice. Of 12 intervention strategies, only the recording of smoking status on file occurs in a majority of cases. Concerns about the potential negative impact of smoking interventions and lack of client interest were endorsed as very important barriers by the highest percentage of respondents. 12.6% of managers and 16.5% of other staff agreed that it is occasionally useful for staff to smoke with a client. Smoking cessation receives little systematic attention from drug and alcohol agencies. Training and policy initiatives are needed urgently to address negative staff attitudes impeding progress in this area.

Tobacco-related practices and policies in residential perinatal drug treatment programs

Despite serious health consequences from high rates of smoking among perinatal women, smoking cessation and/or nicotine treatment practices have yet to be broadly adopted into perinatal substance abuse treatment settings. This correlational cross-sectional survey examined tobacco-related policies, practices, knowledge, and attitudes of 31 directors of perinatal residential substance abuse treatment programs in California. We found that the directors' programs had limited on-site adoption of evidence-based practices for smoking cessation, and that directors had gaps in their knowledge of perinatal tobacco effects. Implications for tobacco policy initiatives in perinatal substance abuse treatment are discussed.

Staff Knowledge, Attitudes, and Practices Regarding Nicotine Dependence Differ by Setting

This study examined smoking-related knowledge, beliefs, self-efficacy, smoking cessation practices, and barriers to providing smoking cessation services in a workforce sample. The 11 participating clinics (N=335 staff) included substance abuse treatment and HIV care clinics categorized into three types: Veterans Affairs Medical Center (VAMC) clinics, hospital-based clinics, and community-based clinics. Staff in both VAMC and hospital-based settings shared characteristics that may predict smoking-related knowledge, beliefs, and practices (higher education level, low smoking rates, fewer staff in recovery, and location in hospital-affiliated environments where there was greater emphasis on physical health). However, staff in VAMC settings outperformed those in both hospital-based and community-based clinic settings on measures of smoking-related knowledge, beliefs, self-efficacy, and practices. Well-developed procedures to support VAMC clinicians in addressing smoking may account for these findings. Findings suggest that both reductions in staff smoking, and development and implementation of smoking policy are needed to support staff in better addressing nicotine dependence in community-based treatment settings.

Adolescent tobacco use and substance abuse treatment outcomes

This study investigated the relationship between cigarette-smoking status and 12-month alcohol and marijuana treatment outcomes in a sample of 1,779 adolescents from the Drug Abuse Treatment Outcomes Study for Adolescents. Participants were classified into four groups based on change in cigarette-smoking status from intake to the 12-month follow-up: persistent smokers, nonsmokers, quitters, and smoking initiators. Logistic regression was used to predict likelihood of relapse to alcohol, marijuana, and other drugs after controlling for intake levels and demographic/treatment characteristics. Results found persistent smokers and smoking initiators to have significantly greater odds of alcohol and marijuana relapse compared with quitters. Furthermore, persistent smokers and smoking initiators were also found to have distinctively shorter periods to marijuana relapse at follow-up. Implications for the implementation of tobacco cessation treatment in the context of substance abuse treatment for adolescents are discussed.

Survey of clinician attitudes toward smoking cessation for psychiatric and substance abusing clients

The current study examined mental health clinician attitudes regarding smoking cessation for psychiatric and substance abusing patients. Participants included n = 15 never smokers, n = 12 former smokers, and n = 7 current smokers. There was a trend (p = 0.08) for current smokers as compared to former and never smokers to be less likely to encourage their clients to stop smoking. Overall, clinicians strongly agreed that an individual's motivation is the most important determinant of success in quitting. Clinicians were concerned that smoking cessation would initiate a relapse to substance abuse. We suggest that mental health clinicians can be instrumental in providing information, encouragement, and opportunities for their patients to attempt smoking cessation.

Staff smoking and other barriers to nicotine dependence intervention in addiction treatment settings: a review

The aims of this review were to assess smoking prevalence among drug abuse treatment staff and summarize the range of barriers to provision of nicotine dependence intervention to clients receiving addictions treatment. A systematic literature search was conducted to identify publications reporting on workforce smoking prevalence, attitudes toward smoking, and perceived barriers to providing smoking cessation treatment in drug abuse treatment settings. Twenty papers met study inclusion criteria. Staff smoking prevalence estimates in the literature ranged from 14% to 40%. The most frequently reported barriers to providing nicotine dependence intervention in addiction treatment settings were lack of staff knowledge or training in this area, that smoking cessation concurrent with other drug or alcohol treatment may create a risk to sobriety, and staff are themselves smokers. Staff smoking is not uniformly elevated in the drug abuse treatment workforce. Smoking prevalence may be lower where staff are more educated or professionally trained, and may be higher in community-based drug treatment programs. Barriers to treating nicotine dependence may be addressed through staff training, policy development, and by supporting staff to quit smoking. State departments of alcohol and drug programs, and national and professional organizations, can also support treatment of nicotine dependence in drug abuse treatment settings.

Smoking among adolescents in substance abuse treatment: a study of programs, policy, and prevalence

The study was designed to: (1) identify smoking policies and interventions in adolescent residential treatment settings; (2) examine the prevalence of smoking among adolescents in these settings; and (3) assess relationships between program-level smoking policies and client-level smoking. The Center for Substance Abuse Treatment funded 17 sites to evaluate the effectiveness of Adolescent Residential Treatment (ART) programs for substance abuse. To describe program smoking policies and interventions, we conducted phone interviews with one key informant at each program (N=12). To describe client smoking behaviors, we conducted a secondary data analysis of baseline data for adolescents (N=912) entering ART programs. All sites had no smoking indoors and 75% of the site had tobacco-free grounds for adolescents. Forty-two percent provided their youth with nicotine replacement therapy, and 42% provided counseling for smoking cessation. Also, 33% did not allow staff smoking on and off campus. The prevalence of any smoking in the past month was 66%, and 22% of current smokers were daily smokers at admission. Where smoking was allowed on grounds, adolescents more often reported recent smoking. Smoking behavior is prevalent among adolescents in residential drug treatment, and should be addressed in all such programs through policy implementation and client-level smoking cessation intervention.

Long-term behavior in treated alcoholism: Evidence for beneficial carry-over effects of abstinence from smoking on alcohol use and vice versa

Co-dependence of alcohol and nicotine is quite frequent. Research results on the mutual influence one drug has on the other - i.e., on the further course of the dependence - has been inconclusive. Our primary aim is to investigate the natural course of smoking behavior in a long term follow-up study with alcohol-dependent patients who completed an inpatient treatment program. A sample of 139 out of originally 190 patients was successfully followed up 7 years after index alcohol treatment. After 7 years, 56% of patients (total surviving sample: 46%, 21 [11.1%] patients deceased during the follow-up time interval) were abstinent. Our results show that being a non-smoker at treatment entry is a predictor for alcohol abstinence 7 years later. The rate of non-smokers among the abstinent patients increased by 32%. Potential explanations for our findings lie in carry-over effects. Skills and insights gained in treatment of alcohol dependence could be instrumental in coping with smoking behavior as well. Non-smokers may have more functional coping abilities from the beginning. We conclude that it is warranted and recommendable to explore the willingness of alcohol-dependent patients to quit smoking and to offer them treatment options addressing this point.

Attitudes toward the integration of smoking cessation treatment into drug abuse clinics

This article examines the variables associated with the presence of smoking cessation interventions in drug abuse treatment units, as well as staff attitudes toward the integration of smoking cessation services as a component of care. Surveys were administered to 106 organizations, 348 treatment clinics, and 3,786 employees in agencies that participated in the National Drug Abuse Treatment Clinical Trials Network. Organizational factors, attributes of the treatment setting, and staff attitudes toward smoking cessation treatment were assessed. Use of smoking cessation interventions was associated with the number of additional services offered at clinics, residential detoxification services, and attitudes of the staff toward smoking cessation treatment. Staff attitudes toward integrating smoking cessation services in drug treatment were influenced by the number of pregnant women admitted, the number of ancillary services provided, the attitudes of staff toward evidence-based practices, and whether smoking cessation treatment was offered as a component of care.

Addressing Smoking Cessation in Methadone Programs

Little is known about how well methadone programs address smoking cessation. We describe the frequency of smoking cessation counseling, and factors affecting its provision in methadone programs. We conducted a cross-sectional survey of methadone patients and their counselors. Of 575 patients, 76% were eligible smokers. Although only 48% of patients reported receiving smoking cessation counseling within the previous six months, 97% of counselors reported providing it (p < 0.0001). Time with one counselor was significantly associated with patient report of receiving smoking cessation counseling (OR 1.19 [95% CI 1.04-1.36]). Although addiction counseling is required in methadone programs, nicotine addiction is addressed less than half the time. Methadone programs should prioritize the provision of effective smoking cessation and facilitate continuity of patient-counselor relationships.

Benefits of and Barriers to Providing Smoking Treatment in Methadone Clinics: Findings from a National Study

Although smoking increases morbidity and mortality among patients in addictions clinics, few clinics provide routine smoking treatment. To understand staff attitudes toward treatment, we surveyed leaders of outpatient methadone treatment clinics nationwide. Our response rate was 59% (408/697). Most clinic leaders thought they should provide smoking treatment (76%) or refer patients for care (91%); however, fewer than half of these had provided treatment in the month prior to the survey. Leaders said smoking treatment would benefit their clinics, patients and communities, but said barriers-primarily insufficient staff training-prevented routine care. Addressing these barriers could increase smoking treatment in addictions clinics and save lives.

Twenty-four week maintenance treatment of cigarette smoking with nicotine gum, clonidine and naltrexone

This research study investigated the effect of nicotine gum, clonidine, and naltrexone, in the maintenance treatment of cigarette smoking. In a double blind study, 171 nicotine-dependent male subjects who met DSM-IV criteria for nicotine dependence and smoking 10 cigarettes or more per day, were allocated randomly to three equal groups of 57. Subjects received nicotine gum, clonidine, or naltrexone over a 24-week treatment period. The nicotine gum dose was 2 mg every 1 to 2 h for the first 6 weeks, 2 mg every 2 to 4 h for the next 3 weeks, and 2 mg every 4 to 8 h for the remaining 15 weeks. The clonidine dose was 0.4 mg and the naltrexone dose was 50 mg per day. Continuous abstinence rates were recorded weekly for 24 weeks from the quit date. The abstinence rates by treatment groups were 36.8% for the nicotine gum group, 19.3% for the clonidine group, and 5.3% for the naltrexone group,and all between groups differences were significant. These results support the efficacy and safety of nicotine gum and clonidine for smoking relapse prevention among Iranian nicotine-dependent patients, but call in question the utility of naltrexone treatment for smoking relapse prevention.

Smoking intervention within alcohol and other drug treatment services: a selective review with suggestions for practical management

This selective review was undertaken in order to highlight the need for alcohol and other drug treatment services to provide intervention for tobacco smoking to their clients. The reasons for the failure of treatment services to date to deal with nicotine addiction within their programmes are discussed and positive suggestions for change are proferred. In addition to the transformation of institutional culture which will be required, managers and staff of alcohol and other drug agencies need to know how best to implement smoking intervention within the treatment setting. The paper concludes with some practical suggestions for the management of intervention for tobacco smoking within treatment settings. These suggestions include: making decisions and formulating policies and procedures with regard to how tobacco smoking will be addressed; considering the particular physical, psychological and social/environmental factors that apply to substance abuse clients; building intervention around a simple structure such as the '5 A's'; encouraging and facilitating the use of nicotine replacement therapies; and allowing flexibility to tailor intervention to the individual. A great deal of further research is required to inform us as to how to intervene most effectively for tobacco smoking among this population group.

Prevalence of cigarette smoking in Iran

The current research assessed the prevalence of cigarette smoking in Shiraz, Iran by randomly selecting 1,335 subjects (782 men and 553 women) from the city for a face-to-face interview and completion of a questionnaire. Of the participants, 205 (26%) of the men and 20 (3.6%) of the women reported being current smokers. The mean ages of smokers and nonsmokers were 41.8 and 37.0 yr., respectively (range between 16 and 90 years for smokers and nonsmokers). The mean age of starting to smoke cigarettes was 21.3 yr. (range of 10 to 60). The most common reasons for current cigarette smoking were Need to avoid withdrawal symptoms, Release of tension, and Pleasurable purposes. Foreign filter-tipped cigarettes were the most common type consumed. The mean number of cigarettes per day was 13.4 (SD = 10.3). Reports for onset of cigarette smoking included Modeling, Release of tension, and Pleasurable purposes. Cigarette smoking was reported by more males than females. The most common reason for onset of cigarette smoking was different from that for current smoking. Frequencies of smokers within age groups were varied.

A controlled smoking cessation trial for substance-dependent inpatients

Smoking treatment for newly recovering drug and alcohol-dependent smokers in a residential rehabilitation program was examined. The randomly assigned conditions (n = 50 each) were multicomponent smoking treatment (MST), MST plus generalization training of smoking cessation to drug and alcohol cessation (MST+G), or usual care (UC). Fifty participants who declined smoking treatment (treatment refusers) also were studied. Both treatment conditions achieved continuous smoking abstinence rates (MST: 12%, MST+G: 10%, at 12-month follow-up) that were significantly higher than in the UC condition (0%). The MST condition had a continuous drug and alcohol abstinence rate that was significantly higher than that of the MST+G condition (40% vs. 20% at 12-month follow-up) although neither differed significantly from that of the UC condition (33%). These results support the feasibility of smoking treatment for this population and provide information regarding appropriate treatment components.

Changes in cigarette smoking among alcohol and drug misusers during inpatient detoxification

Smoking prevalence and changes during inpatient detoxification were examined among 135 admissions to an inpatient alcohol and drug detoxification unit, of whom 83 (61.5%) were re-interviewed one week later. Ninety-two per cent of the initial sample were currently smokers; 87% of alcohol misusers, 97% of drug misusers and 100% of drug/alcohol misusers. Smokers consumed a daily mean of 27 cigarettes before admission. Those classified as heavy smokers (smoking 40 or more cigarettes prior to admission) decreased their smoking levels by an average of 10.5 cigarettes during detoxification. Light smokers (1-19 cigarettes per day) increased by a daily average of 8.6 cigarettes and intermediate smokers (20-39 cigarettes) by 4.9 cigarettes. The findings suggest a dose-dependent relationship between cigarette smoking and inpatient detoxification that requires further study. Over three-quarters of the sample expressed a desire to change their smoking behaviour, many of whom felt they would like help to tackle this change. Given the high smoking prevalence and reported interest in smoking cessation/reduction, there is an opportunity to address the smoking behaviour of drug and alcohol misusers entering inpatient care, whether during or after their detoxification.

Smoking cessation in drug treatment programs

Substance abusers are more likely to smoke cigarettes than the general population. Yet, in most drug treatment programs smoking cessation receives little attention. The purposes of this study were to: (1) examine substance abuse counselors' attitudes toward and practices related to nicotine addiction and smoking cessation treatment; and (2) describe barriers to smoking cessation treatment and smoking policies in substance abuse treatment facilities. A total of 254 substance abuse counselors in Kentucky completed mailed questionnaires (53% response rate). Almost one-fourth were current smokers. Smoking and nonsmoking counselors differed in their attitudes toward nicotine addiction, barriers to treatment, and satisfaction with smoking cessation training. Few counselors routinely followed the clinical preventive guidelines with nicotine-dependent clients. However, they were receptive to providing smoking cessation treatment. Over half of the drug treatment programs banned indoor smoking, but permitted smoking on facility grounds. Implications for policy change by national addiction certification and licensing organizations and state accreditation authorities are discussed.

Tobacco cessation with patients recovering from alcohol and other substance abuse

This article focuses on the problem of tobacco cessation in the patient recovering from alcohol or other substance abuse. The authors review the epidemiology of the problem, specific health risks to this population from continued tobacco use, and recent research findings that address previous treatment concerns. Recommendations for counseling by physicians are made. These include an algorithm for determining the patient's stage of readiness for making a quit attempt, specific counseling tasks based on the patients stage, and motivational counseling strategies aimed at increasing the patients motivation to quit.

Adding a choice-based program for tobacco smoking to an abstinence-based addiction treatment program

A smoking program that provides awareness education about smoking to all chemical dependency (CD) clients and staff, while allowing treatment for smoking to be optional, was developed at an abstinence-based addiction treatment center. This study measured the effects of introducing this mixed model for treatment of smoking and other substances on clients and staff. Attitude and program utilization data were collected, and CD clients were followed-up. The value of offering a smoking program during CD treatment and of framing it within a choice-based philosophy was strongly endorsed by staff and CD clients. Smoking program CD clients did not report major problems with other clients continuing to smoke. Most (55.6%) of the staff who smoked (n = 18) entered the smoking program during the first year of implementation; 38.0% of CD clients who smoked (n = 424) actively joined the smoking program; and of CD clients who chose cessation, 17.5% were abstinent at follow-up.

Smoking intervention with adolescent substance abusers. Initial recommendations

Recent increases in adolescent cigarette smoking have provided an impetus for developing effective youth smoking-cessation interventions. Adolescents treated for substance abuse are a particularly important target for tobacco use intervention given the high prevalence and persistence of smoking among this subgroup of youth. The few studies to date of adolescent smoking cessation have demonstrated little success in effecting change in tobacco use. In the absence of empirical evidence, recommendations for tobacco intervention with substance-abusing adolescents are proposed based on information from several sources: studies of adolescent smoking cessation, adolescent developmental considerations, issues specific to substance abusers, motivational concerns, and adult smoking-cessation techniques. An outline is provided of components to consider for inclusion in a substance-abusing adolescent smoking intervention. It is suggested that tobacco-focused interventions be incorporated as a routine part of treatment for adolescent substance abuse.

Effect of counselor and client education in nicotine addiction on smoking in substance abusers

Smoking cessation has received little attention in substance abuse programs. The present study analyzed the effect that counselor and client education in nicotine addiction had on clients' treatment readiness for a smoking cessation program. Thirty-eight smoking clients and two counselors from a short-term residential alcohol treatment facility participated in this study. Counselors served in both the treatment and control conditions in this 2x2 mixed factorial design by first participating in the control condition (general substance abuse education) and then in the treatment condition (smoking education). Counselors proceeded to work (for 6 weeks) with clients who had participated in the control education in general substance abuse issues and with clients who participated in the treatment education series in smoking issues. Clients completed the Fagerstrom Test for Nicotine Dependence and Stages of Change Ladders pre- and posttest. Results indicated that counselor and client education was effective in significantly changing the clients' thoughts toward smoking cessation and their smoking behaviors. Implications for instituting a smoking education program involving counselors, as well as clients, are discussed.

Predictors of relapse to heavy drinking in alcohol dependent subjects following alcohol detoxification-the role of quality of life measures, ethnicity, social class, cigarette and drug use

Sixty DSM-IV alcohol dependent adults (39 males, 21 females) admitted to a voluntary sector alcohol detoxification unit in South London were studied. Socio-demographic data and information on level of alcohol dependence, quality of life, family history, cigarette smoking and the use of prescription/illicit drugs were collected. The subjects were followed-up at 12 weeks and subdivided into two groups, relapse and non-relapse. A relapse was defined as drinking 21 units or more per week for males and 14 units or more per week for females. Data were analysed for baseline and 12-week follow-up comparisons. At 12 weeks, 58 (97%) subjects (38 males, 20 females) were successfully followed-up and 36/58 (62%) had relapsed. After controlling for a Type I error there were significant differences between the relapse and non-relapse subgroups at 12-week followup on the following outcome measures; depression, life situation, withdrawal symptoms, energy, emotional reactions and social isolation. There were no significant differences at baseline between the relapse and nonrelapse subgroups for most of the socio-demographic variables, but Irish nationality and membership of lower social classes (IV and V) were associated with relapse. Major predictors of relapse at baseline after a forward stepwise logistic regression were (in order of increasing statistical significance) Irish nationality, lower social class, greater number of cigarettes smoked and disturbed sleep. The findings are discussed with reference to their consistency with existing research and potential clinical implications.

Smoking cessation for clients in chemical dependence treatment. A demonstration project

A demonstration project was conducted to examine the factors that facilitate implementation of nicotine dependence treatment in a chemical dependence (cd) program. The project included: (a) staff education; (b) staff training to conduct nicotine dependence treatment groups; (c) voluntary smoking cessation treatment for smoking staff; and (d) smoking cessation treatment for client volunteers in outpatient and residential cd programs. A 12-week, cognitive/behavioral group program with nicotine patches was conducted separately for staff and client volunteers. Forty-two of approximately 70 staff returned smoking questionnaires, 10 of whom reported current smoking. Four staff members began treatment, in addition to four staff from a second treatment agency. There were three of eight staff (37.5%) who reported ongoing abstinence at the end of the 12-week program. There were 83 cd clients (approximately 20% of smoking clients) who volunteered to participate in smoking cessation treatment. Forty clients began treatment, 3 (7.5%) of whom were abstinent from smoking at the conclusion of the 12-week program. Staff smoking, lack of clinic resources devoted to the project, and voluntary client participation, which was adjunctive to other treatment components, were impediments to implementation and success. Success was greatest in a clinical setting in which smoking cessation treatment was staff supported and integrated with cd treatment. We recommend that (a) smoking cd staff be offered nicotine dependence treatment, (b) nicotine dependence treatment become a standard, integrated component of cd treatment, and (c) initiation of smoking cessation be individualized according to clients' needs and circumstances.

Interest in smoking cessation among methadone maintained outpatients

The prevalence of cigarette smoking among opiate abusers is extremely high and tobacco related diseases are a major factor associated with morbidity and mortality for this group. Yet, many treatment providers remain reluctant to address smoking cessation with their clients due in part to the belief that substance abusers are not interested in quitting smoking. The present study examined self-reported interest in smoking cessation among methadone maintenance clients (N = 120) in four clinics in Los Angeles. Fifty-eight percent of subjects rated themselves as 'Somewhat' or 'Very Interested' in a smoking cessation program. Overall subjects appeared to accurately perceive the personal risks from tobacco smoking. In conclusion we find that clients in methadone maintenance treatment programs evidence a high level of interest in quitting smoking and may well be suited for a highly structured smoking cessation intervention.

Issues related to smoking cessation among substance abusers

Initial studies have found that stop-smoking treatments for newly recovering substance abusers have been neither harmful to sobriety nor effective in achieving smoking cessation. The development of more effective stop-smoking treatments for this population could be aided by delineating their particular smoking-related characteristics. This article describes the biopsychosocial characteristics of newly recovering substance abusers that are relevant to smoking cessation, and suggests that there are notable differences between abusers and nonabusers that may contribute to abusers' greater difficulty in quitting smoking. It also recommends changes in existing treatment protocols where applicable and identifies key areas for future research.

Training chemical dependency counselors to treat nicotine dependence

To test the effectiveness of providing chemical dependency (CD) staff with a knowledge-and-skills-building workshop on treatment of nicotine dependence, we employed a nested cross-sectional design with six outpatient CD programs in Nebraska (3 intervention, 3 control sites). Data on tobacco counseling provided by CD staff were obtained by telephone from sequential samples of smokers currently receiving alcohol treatment at each participating site. Intervention site clients with clinic visits after the staff training workshop were no more likely than intervention-site clients with clinic visits before the workshop to report having been counseled about their smoking (OR = 0.95, 95% confidence interval (CI): 0.74-1.21). However, control-site clients were significantly more likely to report having been counseled about smoking during the second half of the study (OR = 2.15, 95% CI: 1.49-3.08), even though staff training was not provided at control sites until data collection had been completed. These findings suggest that in some alcohol treatment programs simple monitoring of staff counseling practices may be sufficient to increase the frequency of attention to tobacco. In others, more intensive efforts might be needed to shift CD staff toward more consistent treatment of nicotine dependence.

Involuntary smoking cessation: a treatment option in chemical dependency programs for women and children

Recent research has indicated that a relationship exists between nicotine addiction and the abuse of other substances. This relationship, as well as the severe impact of nicotine addiction on the health of women, their children, and the developing fetus, provides the basis of a rationale for developing chemical dependency programs for women where smoking is not allowed. Involuntary smoking cessation (ISC) programs have been tried recently in mixed-gender and male-only programs, and have met with strong resistance from clients. In most published reports this resistance was strong enough to force the programs to eliminate the ISC policy. This article describes the development of an ISC program at a residential substance abuse treatment center for pregnant and postpartum women and their children. It traces the evolution of tactics to defuse resistance and enlist client support for the program. The development of techniques to measure the effectiveness of the program are also presented. Preliminary results indicate that a properly designed program can be instituted at a residential treatment center for women without excessive program disruption and with positive results.

Nicotine dependence and intentions to quit smoking in three samples of male and female recovering alcoholics and problem drinkers

We report gender-specific data on tobacco use and quitting smoking from three studies of nicotine-related issues during alcoholism treatment. Study 1 data are from 309 alcoholism treatment professionals who were current or former smokers with a personal history of alcoholism or problem drinking. Study 2 data are from 496 smokers receiving counseling for their problems with alcohol in outpatient alcoholism treatment centers. Study 3 data are from 90 smokers receiving intensive alcoholism treatment in residential or inpatient programs. Interest in smoking cessation was high in all groups. Significant gender differences were apparent among the recovering alcoholics but not among the problem drinkers. Severity of alcohol use problems also showed some association with smoking cessation behaviors.

Substance-dependent inpatients who accept smoking treatment

Delineating the characteristics of substance-dependent inpatients who are interested in receiving smoking treatment is critical to developing effective recruitment strategies and interventions for this population. Thus, this study comprehensively assessed and compared substance-dependent inpatients who accepted (n = 75) versus refused (n = 25) a stop-smoking treatment. Univariate analyses found treatment acceptors were younger, more addicted to nicotine, had more smoking-related health problems, had more positive attitudes about quitting smoking, and had more positive attitudes about the relationship between smoking cessation and drug/alcohol sobriety (e.g., believed cessation would positively impact sobriety). Logistic regression revealed that believing inpatient treatment was the best time to quit smoking was the primary factor associated with accepting treatment. Aside from their attitudes about the relationship between smoking cessation and sobriety, substance abusers who accepted smoking treatment appeared similar (e.g., in demographics, smoking behaviors) to nonabusers described in previous studies.