Recovering staff and smoking in chemical dependency programs in rural Nebraska

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.

Smoking cessation for substance misusers: A systematic review of qualitative studies on participant and provider beliefs and perceptions

INTRODUCTION

Smoking prevalence among those in substance misuse treatment remains much higher than the general population, despite evidence for effective cessation interventions that do not negatively impact substance misuse outcomes. This systematic review summarises qualitative data on barriers and facilitators to smoking cessation for people in substance misuse treatment, participants' and providers' perceptions about effects of smoking cessation on substance misuse treatment, timing of intervention delivery and aspects of interventions perceived to be effective.

METHODS

Systematic review of qualitative studies and thematic synthesis of published qualitative data.

RESULTS

10939 records and 132 full texts were screened. 22 papers reporting on 21 studies were included. Key themes identified were: strong relationships between smoking and other substance misuse; environmental influences; motivation; mental health; aspects of interventions perceived to be effective/ineffective; barriers and facilitators to intervention implementation; smoking bans/restrictions; and relationships with professionals. Many service users were motivated toward smoking cessation but were not offered support. Some felt interventions should be delivered after substance misuse treatment, whilst others felt concurrent/dual interventions would be beneficial, due to strong associations between smoking and other substances. Treatment providers felt they lacked training and resources for supporting smoking cessation, and were concerned about impact on substance misuse outcomes.

CONCLUSIONS

Many substance misusers who also smoke are motivated to quit but perceive a lack of support from professionals. Additional training and resources are required to enable professionals to provide the support needed. More research is required to develop enhanced packages of care for this deprived group of smokers.

Characterizing smoking, cessation services, and quit interest across outpatient substance abuse treatment modalities

The majority of individuals seeking treatment for substance use disorders are cigarette smokers, yet smoking cessation is rarely addressed during treatment. Conducting a detailed smoking-related characterization of substance abuse treatment patients across treatment modalities may facilitate the development of tailored treatment strategies. This study administered a battery of self-report instruments to compare tobacco use, quit attempts, smoking knowledge and attitudes, program services, and interest in quitting among smoking patients enrolled in opioid replacement therapy (ORT) versus non-opioid replacement (non-ORT). ORT compared with non-ORT participants smoked more heavily, had greater tobacco dependence, and endorsed greater exposure to smoking cessation services at their treatment programs. Favorable attitudes towards cessation during treatment were found within both groups. These data identify several potential clinical targets, most notably including confidence in abstaining and attitudes toward cessation pharmacotherapies that may be addressed by substance abuse treatment clinics.

The New York policy on smoking in addiction treatment: findings after 1 year

OBJECTIVES

We assessed changes in smoking prevalence and other measures associated with the July 2008 New York Office of Alcoholism and Substance Abuse Services tobacco policy, which required that all publicly funded addiction treatment programs implement smoke-free grounds, have "no evidence" of smoking among staff, and make tobacco dependence treatment available for all clients.

METHODS

In a random sample of 10 programs, staff and clients were surveyed before the policy and 1 year later. Measures included tobacco-related knowledge, attitudes, and practices used by counselors and received by clients.

RESULTS

Client smoking decreased from 69.4% to 62.8% (P = .044). However, response to the policy differed by program type. Outpatient programs showed no significant changes on any of the staff and client survey measures. In methadone programs, staff use of tobacco-related practices increased (P < .01), client attitudes toward tobacco treatment grew more positive (P < .05), and clients received more tobacco-related services (P < .05). Residential clients were more likely to report having quit smoking after policy implementation (odds ratio = 4.7; 95% confidence interval = 1.53, 14.19), but they reported less favorable attitudes toward tobacco treatment (P < .001) and received fewer tobacco-related services from their program (P < .001) or their counselor (P < .001).

CONCLUSIONS

If supported by additional research, the New York policy may offer a model that addiction treatment systems can use to address smoking in a population where it has been prevalent and intractable. Additional intervention or policy supports may be needed in residential programs, which face greater challenges to implementing tobacco-free grounds.

Addressing Tobacco Through Organizational Change (ATTOC) in residential addiction treatment settings

BACKGROUND

Smoking prevalence among persons in addiction treatment is 3-4 times higher than in the general population. However, treatment programs often report organizational barriers to providing tobacco-related services. This study assessed the effectiveness of a six month organizational change intervention, Addressing Tobacco Through Organizational Change (ATTOC), to improve how programs address tobacco dependence.

METHODS

The ATTOC intervention, implemented in three residential treatment programs, included consultation, staff training, policy development, leadership support and access to nicotine replacement therapy (NRT) medication. Program staff and clients were surveyed at pre- and post-intervention, and at 6 month follow-up. The staff survey measured knowledge of the hazards of smoking, attitudes about and barriers to treating smoking, counselor self-efficacy in providing such services, and practices used to address tobacco. The client survey measured knowledge, attitudes, and tobacco-related services received. NRT use was tracked.

RESULTS

From pre- to post-intervention, staff beliefs became more favorable toward treating tobacco dependence (F(1, 163)=7.15, p=0.008), NRT use increased, and tobacco-related practices increased in a non-significant trend (F(1, 123)=3.66, p=0.058). Client attitudes toward treating tobacco dependence became more favorable (F(1, 235)=10.58, p=0.0013) and clients received more tobacco-related services from their program (F(1, 235)=92.86, p<0.0001) and from their counselors (F(1, 235)=61.59, p<0.0001). Most changes remained at follow-up.

CONCLUSIONS

The ATTOC intervention can help shift the treatment system culture and increase tobacco services in addiction treatment programs.

Understanding the drug treatment community's ambivalence towards tobacco use and treatment

BACKGROUND

Most clients in drug treatment smoke cigarettes, but few facilities provide treatment for tobacco dependence. We identify subjective experiences and social processes that may influence facility adoption of tobacco treatment policies and practices.

METHODS

Cross-sectional, semi-structured interviews were conducted with staff, directors and clients of 8 drug treatment facilities in the Midwestern U.S. We assembled a purposive sample stratified by ownership, methadone provision, and treatment service provision. We conducted in-person interviews with clinic directors and 54 staff and clients and employed a mixed-method analytic approach.

RESULTS

Facility policies and philosophy related to tobacco differed from those regarding alcohol and other drugs. Participants suggested facilities may not treat tobacco dependence because it does not create legal and social problems that force clients into treatment. Tobacco dependence treatment falls outside of a core function of drug treatment, which is to help clients fix legal problems caused by their drug use. Moreover, proactively treating clients for tobacco dependence creates strong ambivalence amongst staff and directors. On the one hand, staff smoking would violate core principles of drug treatment (i.e., the importance of staff abstinence from drugs of abuse); on the other, staff who smoke feel their personal rights and jobs are threatened. This situation creates strong incentives for staff to resist adoption of tobacco dependence treatment. Unlike other studies, the fear of jeopardising clients' abstinence from other drugs did not emerge as a downside for treating tobacco dependence.

CONCLUSIONS

International and national trends will probably increase the pressure to treat tobacco dependence during drug treatment. However, the U.S. context of drug treatment, as a patchwork, under-funded industry with high employee turnover, may undermine true adoption. At present, many facility staff resolve their ambivalence by reporting they "offer" treatment, but actually providing none. To facilitate dissemination of service provision, it may be useful to identify incentives for U.S. facilities that are closely aligned with the criminal justice system, help facilities define policies and treatment roles for staff who smoke, and better define the role of facilities in preventing morbidity and mortality.

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.

Self-initiated tobacco cessation and substance use outcomes among adolescents entering substance use treatment in a managed care organization

PURPOSE

Adolescents with substance use (SU) problems have high rates of tobacco use, yet SU treatment has historically ignored treatment for tobacco use. Barriers to such efforts include the belief that tobacco cessation could compromise other SU abstinence. This study examines self-initiated tobacco cessation and 12-month alcohol and drug abstinence in adolescents entering SU treatment in a private, managed care organization.

RESULTS

Self-initiated tobacco cessation at 6 months, and at both 6 and 12 months, were related to higher odds of drug abstinence but not alcohol abstinence.

CONCLUSION

Self-initiated tobacco cessation was not related to poor SU outcomes, and may be important to maintaining drug abstinence. Implementing tobacco cessation efforts in SU treatment can be challenging, but comprised SU outcomes may not be a barrier. The positive associations for drug abstinence and lack of associations for alcohol abstinence could be due to differences in motivation, medical conditions, or to the illicit nature of drug use. Tobacco use has serious long-term health consequences, and tobacco cessation efforts in adolescent SU treatment programs need further research.

Addressing smoking in community drug abuse treatment programs: practical and policy considerations

Smoking is the leading cause of preventable death in the United States. This public health problem is of particular concern among individuals with substance use disorders in that they smoke at a greater rate than the general public. Smoking-related illness represents a major source of preventable death in persons with drug dependencies. Substance abuse treatment programs have access to persons with substance use disorders and the opportunity to intervene on their smoking; however, nicotine dependence has historically not been viewed in the same light as other drug dependencies by the treatment field. As a result, many persons in these treatment program settings do not receive opportunities to address their smoking. When substance abuse treatment organizations consider implementing smoking policies and services, many questions and choices arise. In practice, a range of approaches has been developed from simple assessment and referral for smoking cessation treatment to implementing smoke-free grounds and requiring that patients stop smoking concurrent with addressing their other drug dependencies. Smoking cessation policy decisions have the potential to directly affect the patients, the workforce, the referral network, and other major stakeholders related to these organizations. The authors consider a range of both practical and policy issues facing treatment organizations and conclude that advances in smoking policy are possible with current resources.

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.

Addressing tobacco use through organizational change: a case study of an addiction treatment organization

Compared to the general population, persons entering addiction treatment are three to four times more likely to be tobacco dependent and even addiction treatment staff members are two to three times more likely to be tobacco dependent. In these settings, tobacco use continues to be the norm; however addiction treatment programs are increasingly aware of the need to assess for and treat tobacco dependence. The problem is a cultural issue that is so ingrained that assumptions about tobacco use and dependence in addiction treatment are rarely questioned. Denial, minimization, and rationalization are common barriers to recovery from other addictions; now is the time to recognize how tobacco use and dependence must be similarly approached. This article describes the Addressing Tobacco through Organizational Change (ATTOC) model which has successfully helped many addiction treatment programs to more effectively address tobacco use. The article will review the six core strategies used to implement the ATTOC intervention, the 12-Step approach guiding the model, and describe a case study where the intervention was implemented in one clinic setting. Other treatment programs may use the experience and lessons learned from using the ATTOC organizational change model to better address tobacco use in the context of drug abuse treatment.

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.

Substance abuse counselor certification in California: how is nicotine addiction addressed?

Persons entering substance abuse treatment smoke at rates three to four times that of the general population, but programs providing substance abuse treatment rarely address comorbid nicotine addiction. With California's recent adoption of a regulation requiring alcohol and other drug (AOD) counselors to be certified, this study explored the degree to which nicotine addiction education was required or recommended to obtain certification by examining pertinent documentation and Web sites. Findings reveal two main points. First, the text of the California AOD Counselor Certification regulation and supporting documents make no mention of cigarettes, nicotine, smoking, or tobacco, and thus do not mandate or recommend they be addressed in the counselor certification process. Second, although nicotine or tobacco were not mentioned in regulatory or supporting documents, four of the 10 certifying organizations mentioned nicotine at least once in handbooks, program books, continuing education topics, or other materials available online. One certifying organization offered specialization in smoking and nicotine addiction as separate tracks within its certification training program. While systematic inclusion of smoking and nicotine addiction in counselor training offers one strategy to address smoking in substance abuse treatment settings, these topics are not addressed in regulations or supporting documents governing the certification of California AOD counselors.

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.

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.

A population-based study of cigarette smoking among illicit drug users in the United States

AIMS

People who use illicit drugs are thought to have high rates of cigarette smoking; however, few population-based studies have been reported. We describe smoking patterns among illicit drug users, assess whether cigarette smoking is more prevalent among illicit drug users than it is among non-users and explore how smoking relates to level and type of drug use.

DESIGN, SETTING, PARTICIPANTS

We used adult responses to the 1997 National Household Survey on Drug Abuse (n = 16 661). Multivariate analyses used SUDAAN to adjust standard errors for the sampling design and controlled for age, race, sex, education, depression, treatment history and alcohol.

MEASUREMENTS

Smoking rates, cessation rates and smoking levels.

FINDINGS

Seventy-one per cent of recent illicit drug users smoked cigarettes at least once in the past month. Their adjusted odds of being a smoker were much greater than for the general population (OR = 3.07, P < 0.0001). Their quit rate, although substantial, was half that of non-users (23% versus 56%, P=0.0001). Odds of being a smoker were higher for poly- versus monodrug users (OR = 2.35, P=0.0020) and rose with increased drug use (OR = 1.36, P=0.0374). Illicit drug users who perceived smoking to be risky were four times less likely to smoke (OR = 0.23, P=0.0008).

CONCLUSIONS

Although most recent illicit drug users smoke, some are able to quit. Better understanding of concurrent cigarette and illicit drug use may provide impetus for policy change and shed light on underlying mechanisms of addiction. Clinicians, policy makers and user advocates should address tobacco use in drug treatment and in harm reduction interventions.

Smoking cessation among persons in recovery

The literature on smoking cessation for those in recovery from other drug use is reviewed. Reasons for engaging in this work, arguments against treatment of smoking along with another drug, characteristics of drug users who smoke, and treatment content implications are reviewed. Outcomes of 24 studies are presented. It is concluded that the future of research and practice in this arena should include facilitating smoking cessation among those early in recovery.

A case for addressing cigarette use in methadone and other opioid treatment programs

Most persons attending drug treatment smoke cigarettes. They will eventually experience predictable, but devastatingly high, tobacco-related mortality. Recent studies indicate that many clients are ready to quit smoking and that quitting does not threaten progress made in treatment. Methadone and other opioid treatment providers are in an excellent position to address tobacco use among their clients. The present paper describes the prevalence of smoking among methadone clients, reviews promising interventions, and describes how programs can implement a systematic approach to smoking cessation that includes creating a cue system for identifying smokers, providing brief on-site intervention, and arranging follow-up or more intensive treatment.

Smoking cessation following treatment in a smoke-free Navy Alcohol Rehabilitation program

The purpose of this study was to examine changes in smoking behavior and attitudes following treatment in the smoke-free Navy Alcohol Rehabilitation program (NARC) and to evaluate changes in staff attitudes toward the smoke-free policy. Consecutive patients (N = 404; 93.8% male) admitted to the NARC between February 1, 1993 and September 30, 1993 were studied, of whom 54.7% were current smokers. Measures included patient surveys administered repeatedly at admission and discharge and at 12 months following the 4-week treatment program. The staff were also administered a survey 2 months before (N = 86) and 6 months after (N = 104) policy implementation. Results indicate that alcohol treatment in a smoke-free environment did not markedly affect the smoking status of patients; the proportion of current smokers at discharge was 54.7%. Significant reductions in cigarettes smoked per day (p < .001) were observed among patients from admission to discharge. However, no statistically significant change in readiness to consider smoking cessation scores was detected. Results indicated no significant change in patient smoking status at 12-month follow-up, although the survey response rate was low (35.1%; N = 142). Six months following implementation of the smoke-free policy, 84.6% of staff indicated that the NARC should remain smoke-free and 84.6% recommended that other alcohol and drug treatment facilities be smoke-free.

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.

Incorporating nicotine dependence into addiction treatment

An addiction treatment program devoted two years to preparing to become a smokefree treatment unit that addressed nicotine dependence as another drug dependency. Data collected from September 1990 to July 1995 on 263 admissions before becoming smokefree and 2182 admissions after making the transition revealed that going smokefree did not affect the incidence of premature discharges or aggressive behavior, and did not change the overall rate of program completion by either smokers or nonsmokers. During the first three months after going smokefree, the program completion rate dropped for both smokers and nonsmokers; by the fourth month, it had returned to previous levels. Seventeen months after going smokefree, the program completion rate was higher than it had ever been. This suggests that the drop in the program completion rate was due to the disruption caused by a significant programmatic change and not due to the unit's smokefree status, and that the increasing experience of staff in treating nicotine dependence resulted in improved patient outcomes.

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.

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.

Treating cigarette smoking in drug-abusing clients

Clients in substance abuse treatment are at high risk for smoking-related illness due to higher rates and heavier smoking than the general population. Three myths widely held by both treatment staff and substance abusers in treatment-people in treatment do not want to quit smoking, people in treatment will relapse to other drug use if they attempt to quit smoking, and people in treatment are unable to quit smoking-make it difficult to broach the matter of smoking cessation. A 16-week, cognitive-behavioral group program with nicotine patches was conducted at Oregon's largest, private, nonprofit substance abuse treatment agency. Of 490 clients, approximately 85% of whom smoke, 106 (25% of the smokers) were interested enough in quitting to attend an orientation. Approximately 40% of these were methadone maintenance clients. The others were distributed among two residential and two outpatient drug-free treatment services. Of 90 assigned, 68 began voluntary treatment, and 21 were assigned to delayed treatment. Of the 66 smokers who began, 74% succeeded in quitting smoking for at least 1 day, and 23% were abstinent for at least 4 continuous weeks. At the end of the 16-week treatment, 7 subjects (11%) were abstinent. No control subjects quit smoking on their own. The article discusses issues of institutionalizing smoking cessation services in drug treatment agencies.

Nicotine treatment at the Drug Dependency Program of the Minneapolis VA Medical Center. A researcher's perspective

Substance use disorder treatment professionals historically have been reluctant to address tobacco dependence in their patients, despite a high prevalence of smoking, unique health effects, and evidence of physical addiction to nicotine. We performed two prospective studies to examine (1) the feasibility of a smoke-free policy and nicotine treatment program in an inpatient drug and alcohol treatment program, and (2) the impact of this intervention on long-term treatment outcomes. In both studies we used self-reported data from two groups of patients; one hospitalized after the implementation of the intervention and a historical control. The first set of data indicated that patients were more interested in quitting smoking and were more likely to abstain from smoking after the policy was implemented than before. They did not feel quitting smoking would threaten abstinence, and the policy did not increase early discharges. The second study failed to show that the change in policy was associated with an adverse effect on drug and alcohol treatment outcomes. A small but significant positive effect was demonstrated for smoking cessation. These studies also showed that many patients regard smoking as different from the primary drug that brought them to treatment. Randomized clinical trials testing a variety of smoking intervention techniques are desperately needed in this population to scientifically determine effective methods to decrease smoking.

Following the pioneers. Addressing tobacco in chemical dependency treatment

Traditionally, tobacco has been ignored as an issue in the treatment of addictions to alcohol and other drugs. Beginning in 1985, and especially since the publication of the 1988 Surgeon General's Report on nicotine addiction, a handful of treatment programs have worked at coming to terms with tobacco. This article explores the reasons for addressing nicotine in the course of managing other addictions and summarizes the lessons learned from the programs which have done pioneering work in this area. The reasons for addressing nicotine are compelling, and the accumulated experiences among the pioneering programs are consistently encouraging. Regional projects to help alcohol and drug treatment programs come to terms with tobacco are an appropriate next step.

When to begin smoking cessation in substance abusers

During the past several years, there has been an increasing recognition and acceptance that the use of tobacco products often produces nicotine dependence and nicotine addiction. Despite this, the substance abuse treatment community has been slow to promote smoking cessation for patients who are in substance abuse treatment for another addiction. Dogma, although starting to change, persists that cigarette smoking pales in comparison to other addictions and should not be addressed at the time of initial treatment for another addiction. The limited research to date, which will be reviewed in this article, does not support this dogma. In addition, patients presenting for substance abuse treatment report high interest in stopping smoking, including interest in stopping when they initially present for substance abuse treatment.