Drug abuse staff and clients smoking together: A shared addiction

Reducing tobacco and nicotine use among women in treatment for substance use disorder: evaluation of the knit to quit program

INTRODUCTION

Tobacco and nicotine use are prevalent in residential substance use disorder (SUD) treatment programs that serve pregnant and parenting women. This study evaluated a group intervention that integrates knitting instruction, psychoeducation, and social support to improve readiness to quit and reduce tobacco and nicotine use among this population.

METHODS

Clients and staff in four residential SUD treatment programs were assigned to a six-week group intervention or a wait-list control group. Intervention implementation and preliminary effectiveness were assessed using surveys, interviews, and observational measures.

RESULTS

From pre- to post-test, knowledge related to tobacco and nicotine use increased and number of cigarettes smoked per day and nicotine dependence decreased, on average. Additionally, the intervention group reported lower levels of nicotine dependence relative to the control group. Participants described knitting as an enjoyable replacement for smoking and a strategy to regulate stress and emotions.

CONCLUSIONS

Smoking cessation interventions that include knitting are promising and warrant further testing.

Assessing client and staff beliefs and attitudes to inform tobacco-free campus policy implementation at substance use disorder treatment centers

INTRODUCTION

US patients with behavioral health conditions have smoking rates two to three times higher than the general population. Tobacco-free environments at substance use disorder (SUD) facilities can positively impact patient's outcomes as well as the health of staff, but client perceptions to the contrary can slow adoption. This study assessed client and staff beliefs, attitudes, and knowledge regarding the implementation of a tobacco-free campus policy at McLeod Addictive Disease Center, a full-service SUD treatment facility based in Charlotte, North Carolina.

METHODS

During the height of the 2020 COVID-19 pandemic, the research team conducted a mixed-methods study at the McLeod Center lasting from May to November 2020. Using convenience sampling, the team conducted two staff surveys that were administered online (n=134; n=28) and virtual interviews of clients (n=38) to assess beliefs, attitudes and knowledge of tobacco use and the tobacco-free campus planned for 2021.

RESULTS

Many staff identified as current or former smokers (n=57); some expressed the belief that the policy will positively impact clients' SUD recovery (n=12). Encouragingly, clients expressed positive feelings associated with the policy (n=16) and reported interest in receiving tobacco cessation treatment (n=25).

CONCLUSIONS

Staff are interested in helping clients quit tobacco use. Most of the interviewed clients, however, believed that utilizing tobacco products while receiving treatment for their dependence on another substance, would improve their success. The McLeod Center was one of the first community-based SUD treatment facilities in North Carolina to transition to a 100% tobacco-free campus in 2021. This research and results serve as a blueprint for other facilities making similar policy changes.

Reducing tobacco use in substance use treatment: The California tobacco free initiative

BACKGROUND

People in substance use disorder (SUD) treatment have a smoking prevalence that is five times higher than the national average. California funded the Tobacco Free for Recovery Initiative, designed to support programs in implementing tobacco-free grounds and increasing smoking cessation services. In the first cohort of the initiative (2018-2020) client smoking prevalence decreased from 54.2% to 26.6%. The current study examined whether similar findings would be replicated with a later cohort of programs (2020-2022).

METHOD

Cross-sectional survey data were collected from clients in 11 residential SUD treatment programs at baseline (n = 185) and at post intervention (n = 227). Multivariate logistic regression assessed change over time in smoking prevalence, tobacco use behaviors, and receipt of cessation services across the two timepoints.

RESULTS

Client smoking prevalence decreased from 60.3 % to 40.5 % (Adjusted Odds Ratio [AOR] = 0.46, 95 % CI = 0.27, 0.78; p = 0.004). Current smokers and those who quit while in treatment reported an increase in nicotine replacement therapy (NRT)/pharmacotherapy from baseline to post intervention (31.9 % vs 45.6 %; AOR = 2.22, 95 % CI = 1.08, 4.58; p = 0.031).

CONCLUSIONS

Like the first cohort, the Tobacco Free for Recovery initiative was associated with decreased client smoking prevalence and an increase in NRT/pharmacotherapy. These findings strengthen the evidence that similar initiatives may be effective in reducing smoking prevalence among people in SUD treatment.

The Bucket Approach: Developing and Implementing an On-line Training Program in Tobacco Dependence Interventions Tailored for Behavioral Health Clinicians

People coping with a mental illness and/or addictive disorders have a very high prevalence of smoking cigarettes. The Bucket Approach, a free online training, tailors evidence-based tobacco dependence interventions for behavioral health clinicians to increase the likelihood that they will also address the tobacco use of their patients. From October 2019 through August 2021, 999 people enrolled in and 447 people completed the training. Individuals who completed the training evaluated it highly with an overall mean score of 8.4 (scale = 1 for very poor to 10 for very good). 3- and 6-month follow-up surveys documented continued impact. The training resulted in substantial changes in beliefs about treating tobacco dependence. For example, before training, 18.3% of trainees strongly agreed with the statement, "The skills currently possessed by behavioral health clinicians can be easily applied to the treatment of tobacco dependence." This increased to 40.7% at the end of training.

Reducing tobacco use in substance use treatment: An intervention to promote tobacco-free grounds

BACKGROUND

People in substance use disorder (SUD) treatment experience disproportionate rates of tobacco use. California has prioritized smoking cessation among these individuals through the Tobacco-Free for Recovery Initiative, which includes an intervention aimed at supporting programs in implementing tobacco-free grounds. The current study examined changes in client smoking prevalence, tobacco use behaviors, and receipt of cessation services among the first seven programs participating in the initiative.

METHODS

Residential treatment program clients completed cross-sectional surveys at the start of the intervention (baseline: n = 249), at an interim timepoint post-baseline (interim: n = 275), and at the end of the intervention 15 months later (post-intervention: n = 219). All participants reported smoking status. Current smokers reported tobacco use behaviors, and both current smokers and those who quit in treatment reported receipt of cessation services. Univariate analyses explored differences across the three timepoints and multivariate logistic regression assessed change from baseline to interim and baseline to post-intervention.

RESULTS

Client smoking prevalence decreased from 54.2% at pre- to 26.6% at post-intervention (Adjusted Odds Ratio [AOR] = 0.25, 95% CI = 0.13, 0.45). Current smokers and those who quit while in treatment reported an increase in NRT/pharmacotherapy (11.9% vs. 25.2%; AOR = 3.02, CI = 1.24, 7.35). When comparing baseline to the interim timepoint (a timepoint before the COVID-19 pandemic), data analyses also demonstrated a significant decrease in smoking prevalence (54.2% vs. 41.8%; AOR = 0.62, CI = 0.42, 0.92) and increase in NRT/pharmacotherapy (11.9% vs. 24.5%; AOR = 3.68, CI = 1.11, 12.19).

CONCLUSION

An intervention to promote tobacco-free grounds implemented in residential SUD treatment programs was associated with a significant reduction in client smoking and an increase in NRT/pharmacotherapy. These associations were observed both before the COVID-19 pandemic and in the early stages of the pandemic, suggesting that they may be due to the intervention rather than to the pandemic.

Pre-implementation Assessment of Tobacco Cessation Interventions in Substance Use Disorder Residential Programs in California

BACKGROUND

Across the United States, substance use disorder (SUD) treatment programs vary in terms of tobacco-related policies and cessation services offered. Implementation of tobacco-related policies within this setting can face several barriers. Little is known about how program leadership anticipate such barriers at the pre-implementation phase. This study used the Consolidated Framework for Implementation Research (CFIR) during the pre-implementation stage to identify factors that may influence the implementation stage of tobacco-related cessation policies and services in residential SUD programs.

METHODS

We conducted semi-structured qualitative interviews with sixteen residential treatment program directors in California. The analysis was guided by a deductive approach using CFIR domains and constructs to develop codes and identify themes. ATLAS.ti software was used to facilitate thematic analysis of interview transcripts.

FINDINGS

Themes that arose as anticipated facilitators for implementation included the relative advantage of the intervention vs. current practice, external policies/incentives to support tobacco-related policy, program directors' strong commitment and high self-efficacy to incorporate cessation into SUD treatment, and recognizing the importance of planning and engaging opinion leaders. Potential barriers included the SUD recovery culture, low stakeholder engagement, organizational culture, lack of workforce expertise, and lack of reimbursement for smoking cessation services.

CONCLUSION

To support successful implementation of tobacco-related organizational change interventions, staff and clients of residential SUD programs require extensive education about the effectiveness of evidence-based medications and behavioral therapies for treating tobacco dependence. Publicly funded SUD treatment programs should receive support to address tobacco dependence among their clients through expanded reimbursement for tobacco cessation services.

Tobacco use among substance use disorder (SUD) treatment staff is associated with tobacco-related services received by clients

BACKGROUND

Despite disproportionately high rates of smoking among people in residential substance use disorder (SUD) treatment, few receive tobacco cessation services. Little is known about how smoking among treatment staff may impact this disparity. We explored the relationship between staff tobacco use and client tobacco use. Additionally, we examined the relationship between staff tobacco use and tobacco-related services reported by staff and clients.

METHODS

Staff (n = 363) and clients (n = 639) in 24 California publicly-funded residential SUD treatment programs were surveyed in 2019-20. Staff self-reported current tobacco use, as well as their beliefs, self-efficacy, and practices regarding smoking cessation. Clients reported their tobacco use and they services received while in treatment. Regression analyses examined the adjusted and unadjusted associations between staff and client tobacco use and other outcomes.

RESULTS

Use of any tobacco product by staff ranged from 0% to 100% by program, with an average of 32% across programs. Adjusted analyses found that higher rates of staff tobacco use were associated with higher rates of client tobacco use, and with fewer clients receiving tobacco-related counseling. In programs that had higher rates of staff tobacco use, staff were less likely to believe that clients should quit smoking in treatment and had lower self-efficacy to address smoking.

CONCLUSION

Higher rates of tobacco use among staff are associated with higher rates of client tobacco use and fewer clients receiving cessation counseling. Efforts to reduce tobacco use among SUD clients should be supported by efforts to reduce tobacco use among staff. SUD treatment programs, and agencies that fund and regulate those programs, should aim to reduce the use of tobacco products among staff.

Reciprocal influences of tobacco use on illicit opioid and alcohol use during the first six-months of specialist addiction treatment

BACKGROUND

This is the first national study of lagged reciprocal associations between tobacco smoking frequency and change in illicit opioid or alcohol use frequency within six-months of treatment.

METHODS

All adults admitted to publicly-funded specialist addiction treatment in England in 2018/19 and enrolled for at least six months for either opioid use disorder (OUD; n = 22,046; 82.4 % of those eligible) or alcohol use disorder (AUD; n = 15,251; 78.8 % of those eligible). Two cross-lagged panel models estimated, separately for OUD and AUD patients, the relationships between smoking at admission and change in main drug over six months, and between main drug use at admission and change in smoking over six months.

RESULTS

Within the OUD cohort, illicit opioid use frequency reduced from 17.7 days to 8.0 days and smoking tobacco remained at 18.8 days. After controlling for available covariates, higher smoking frequency at admission was associated with a relative increase in illicit opioid use at six-months (0.02 days [95 % CI 0.00-0.03]). Within the AUD cohort, alcohol use frequency reduced from 21.2 days to 14.4 days while smoking tobacco reduced from 12.6 days to 11.5 days. Higher smoking frequency at admission was associated with a relative increase in alcohol use at six-months (0.03 days [95 % CI 0.02-0.04]) and higher alcohol use frequency at admission was associated with a relative increase in smoking at six-months (0.04 [95 % CI 0.02-0.06]), controlling for available covariates.

CONCLUSIONS

Higher smoking frequency at admission is associated with higher illicit opioid and alcohol use frequency after six-months of specialist addiction treatment.

Nicotine and Opioids: a Call for Co-treatment as the Standard of Care

The U.S. is in the midst of an opioid epidemic. At the same time, tobacco use remains the leading cause of preventable death and disability. While the shared biological underpinnings of nicotine and opioid addiction are well established, clinical implications for co-treatment of these two substance use disorders has not been emphasized in the literature, nor have researchers, clinicians, and policy makers adequately outlined pathways for incorporating co-treatment into existing clinical workflows. The current brief review characterizes the metabolic and neural mechanisms which mediate co-use of nicotine and opioids, and then outlines clinical and policy implications for concurrently addressing these two deadly epidemics. Screening, assessment, medication-assisted treatment (MAT), and tobacco-free policy are discussed. The evidence suggests that clinical care and policies that facilitate co-treatment are an expedient means of delivering healthcare to individuals that result in better health for the population while also meeting patients' substance abuse disorder recovery goals.

Tobacco use and tobacco services in California substance use treatment programs

BACKGROUND

California has one of the lowest smoking rates in the U.S. However, the California substance use disorder (SUD) treatment system collects no information on tobacco use. We explored smoking prevalence among persons enrolled in 20 residential SUD treatment programs, and whether persons who wanted help with quitting smoking received such help.

METHODS

Treatment program clients (N = 562) were surveyed about their smoking behavior and about tobacco-related services they received. Self-report smoking status was verified via expired carbon monoxide (CO) measurement. Multivariate analyses assessed whether clients who wanted help with quitting smoking received tobacco-related services (ask, advise, referral, counseling, pharmacotherapy) RESULTS: Using client self-report and expired CO, smoking prevalence in this sample was estimated at 68.9 %. Among smokers, mean cigarettes per day (CPD) was 9.7 (SD = 7.6), 58.8 % had made a quit attempt in the past year, 32.7 % were considering quitting smoking in the next 30 days, and 37.9 % wanted help with quitting. Clients who wanted help with quitting, compared to those not wanting help, were more likely to receive advice on how to quit, and tobacco-related counseling, referral, and pharmacotherapy.

CONCLUSION

In this study, wanting help with quitting was associated with receiving tobacco related services. Nonetheless, fewer than half of the smokers in SUD treatment wanted help with quitting, and many who wanted help did not receive it. Given the high prevalence of smoking, and associated consequences for both general health and SUD recovery, SUD treatment systems should ensure tobacco-related assessment and intervention for all smokers.

Considering Systemic Barriers to Treating Tobacco Use in Clinical Settings in the United States

The Comorbidity Workgroup of the Tobacco Treatment Research Network, within the Society for Research on Nicotine and Tobacco, previously highlighted the need to provide tobacco treatment to patients diagnosed with comorbid physical and mental health conditions. Yet, systemic barriers in the United States health care system prevent many patients who present for medical treatment from getting the evidence-based tobacco treatment that they need. The identified barriers include insufficient training in the epidemiologic impact of tobacco use, related disorders, and pharmacological and behavioral treatment approaches; misunderstanding among clinicians about the effectiveness of tobacco treatment; lack of therapeutic support from clinical staff; insufficient use of health information technology to improve tobacco use identification and treatment; and limited time and reimbursement for clinicians to provide treatment. We highlight three vignettes demonstrating the complexities of practical barriers at the health care system level. We consider each of the barriers in turn and discuss evidence-based strategies that could be implemented in the clinical care of patients with comorbid conditions. In addition, in the absence of compelling data to guide implementation approaches, we offer suggestions for potential strategies and avenues for future research. Implications: Three vignettes highlighted in this article illustrate some systemic barriers to providing tobacco treatment for patients being treated for comorbid conditions. We explore the barriers to tobacco treatment and offer suggestions for changes in training, health care systems, clinical workflow, and payment systems that could enhance the reach and the quality of tobacco treatment within the US health care system.

Achieving Smoking Cessation Among Persons with Opioid Use Disorder

While prevalence of tobacco use in the US general population is declining, prevalence among those with opioid use disorder (OUD) remains high and results in excessive tobacco-related disease and premature mortality. Among smokers with OUD, tobacco cessation rates are negligible without treatment. However, both low-intensity behavioral interventions and more intensive motivational interventions yield negligible cessation rates. While contingency management has potent short-term cessation effects, effects are not maintained at post-intervention follow-up. Evidence-based smoking cessation pharmacotherapies, such as nicotine replacement therapy, bupropion, and varenicline, result in very modest cessation rates among smokers with OUD. Intensification of pharmacotherapy, such as high-dose and combination nicotine replacement therapy or extended medication treatment, has failed to improve cessation outcomes compared with standard treatment regimens. Targeting the unique challenges faced by smokers with OUD, including nicotine-opioid interactions and poor medication adherence, has potential to improve cessation outcomes, but further research is needed to optimize intervention efficacy among smokers with OUD.

Tobacco-free grounds implementation in California residential substance use disorder (SUD) treatment programs

Smoke-free laws and policies have contributed significantly to the decline in smoking in the U.S, but are not often applied in high-prevalence smoking populations where they are most needed. Smoking among clients in publicly funded substance use disorder (SUD) treatment is 3-4 times higher than the general population, and little is known about tobacco policies programs have adopted. To identify the prevalence of tobacco-free grounds and other smoking policies in California's publicly funded, adult, residential SUD programs. Using a California DHCS contact list of 1,921 publicly funded, non-medical, SUD programs, 362 were eligible to participate in a brief semi-structured phone survey concerning indoor and outdoor smoking for staff and clients and other tobacco policies. Of 259 programs that completed the survey, 28 (10.8%) reported tobacco-free grounds. 91 (35.1%) expressed interest in implementing tobacco-free policies and 23 have plans to do so. Nearly all programs (n = 253, 97.7%) had some policy restricting e-cigarette use, and 110 (43.5%) of these reported a complete ban on e-cigarette use. 124 (47.9%) had policies prohibiting staff and clients smoking together. Most California residential SUD programs allow outdoor smoking for staff and clients and few have adopted tobacco-free grounds policies. Given the reported interest in adopting tobacco-free policies, the high density of smokers in the SUD population, and the association of tobacco-free policies with lower client and staff smoking rates, state licensing and regulatory agencies, as well as county health departments, should work with SUD programs to adopt tobacco-free policies.

Smoking related outcomes before and after implementation of tobacco-free grounds in residential substance use disorder treatment programs

BACKGROUND

This study examined the impact of a tobacco-free grounds (TFG) policy and the California $2.00/pack tobacco tax increase on tobacco use among individuals in residential substance use disorder (SUD) treatment.

METHODS

We conducted three cross-sectional surveys of clients enrolled in three residential SUD treatment programs. Wave 1 (Pre-TFG) included 190 clients, wave 2 (post-TFG and pre-tax increase) included 200 clients, and wave 3 (post-tax increase) included 201 clients. Demographic and tobacco-use characteristics were first compared between waves using bivariate comparisons. Regression models were used to compare each outcome with survey wave as the predictor, while adjusting for demographic characteristics and nesting of participants within programs.

RESULTS

Odds of clients being current smokers was lower (AOR = 0.43, 95%CI = 0.30,0.60) after implementation of TFG compared to baseline. Adjusted mean ratio (AMR) for cigarettes per day was lower post-TFG compared to baseline (AMR = 0.70, CI = 0.59, 0.83). There were no differences, across waves, in tobacco-related knowledge, attitudes, or services received by program clients, or use of nicotine replacement therapy. Increased cigarette taxation was not associated with reductions in client smoking.

CONCLUSION

Implementation of a TFG policy was associated with a lower prevalence of client smoking among individuals in residential SUD treatment. Increased state cigarette excise taxes were not associated with a further reduction in client smoking in the presence of TFG policies, though this may have been confounded by relaxing of the TFG policy. SUD treatment programs should promote TFG policies and increase tobacco cessation services for clients.

Smoking-related outcomes and associations with tobacco-free policy in addiction treatment, 2015-2016

OBJECTIVE

This study assessed changes in smoking-related outcomes in two cross-sectional samples of clients enrolled in addiction treatment and whether tobacco-free grounds policies were associated with smoking-related outcomes.

METHOD

Clients in 25 programs were surveyed in 2015 (N=1176) and 2016 (N=1055). The samples were compared on smoking prevalence, cigarettes per day (CPD), thinking of quitting, past year quit attempts, staff and clients smoking together, attitudes towards quitting, and tobacco-related services. Second, programs with (n=6) and without (n=17) tobacco-free grounds at both time points were compared on smoking-related outcomes. Last, we examined changes in these measures for two programs that adopted tobacco-free grounds between 2015 and 2016.

RESULTS

There was one difference across years, such that the mean score for the tobacco Program Service scale increased from 2.37 to 2.48 (p=0.043, effect size=0.02). In programs with tobacco-free grounds policies, compared to those without, both CPD and the rate of staff and clients smoking together were significantly lower. In the two programs where tobacco-free grounds were implemented during study years, client smoking prevalence decreased (92.5% v. 67.6%, p=0.005), the rate of staff and clients smoking together decreased (35.6% v. 4.2%, p=0.031), mean CPD decreased (10.62v. 8.24, p<0.001) and mean tobacco services received by clients increased (2.08v. 3.05, p<0.001).

CONCLUSION

Addiction treatment programs, and agencies responsible for licensing, regulating and funding these programs, should implement tobacco-free grounds policies.