Stopping smoking during first year of substance use treatment predicted 9-year alcohol and drug treatment outcomes

Smoking Policies of Outpatient and Residential Substance Use Disorder Treatment Facilities in the United States

Tobacco use is associated with morbidity and mortality. Many individuals who present to treatment facilities with substance use disorders (SUDs) other than tobacco use disorder also smoke cigarettes or have a concomitant tobacco use disorder. Despite high rates of smoking among those with an SUD, and numerous demonstrated benefits of comprehensive SUD treatment for tobacco use in addition to co-occurring SUDs, not all facilities address the treatment of comorbid tobacco use disorder. In addition, facilities vary widely in terms of tobacco use policies on campus. This study examined SUD facility smoking policies in a national sample of N = 16,623 SUD treatment providers in the United States in 2021. Most facilities with outpatient treatment (52.1%) and facilities with residential treatment (67.8%) had a smoking policy that permitted smoking in designated outdoor area(s). A multinomial logistic regression model found that among facilities with outpatient treatment (n = 13,778), those located in a state with laws requiring tobacco free grounds at SUD facilities, those with tobacco screening/education/counseling services, and those with nicotine pharmacotherapy were less likely to have an unrestrictive tobacco smoking policy. Among facilities with residential treatment (n = 3449), those with tobacco screening/education/counseling services were less likely to have an unrestrictive tobacco smoking policy. There is variability in smoking policies and tobacco use treatment options in SUD treatment facilities across the United States. Since tobacco use is associated with negative biomedical outcomes, more should be done to ensure that SUD treatment also focuses on reducing the harms of tobacco use.

Resting-state electroencephalography theta predicts neurofeedback treatment 4-month follow-up response in nicotine addiction

Background

The high rate of long-term relapse is a major cause of smoking cessation failure. Recently, neurofeedback training has been widely used in the treatment of nicotine addiction; however, approximately 30% of subjects fail to benefit from this intervention. Our previous randomised clinical trial (RCT) examined cognition-guided neurofeedback and demonstrated a significant decrease in daily cigarette consumption at the 4-month follow-up. However, significant individual differences were observed in the 4-month follow-up effects of decreased cigarette consumption. Therefore, it is critical to identify who will benefit from pre-neurofeedback.

Aims

We examined whether the resting-state electroencephalography (EEG) characteristics from pre-neurofeedback predicted the 4-month follow-up effects and explored the possible mechanisms.

Methods

This was a double-blind RCT. A total of 60 participants with nicotine dependence were randomly assigned to either the real-feedback or yoked-feedback group. They underwent 6 min closed-eye resting EEG recordings both before and after two neurofeedback sessions. A follow-up assessment was conducted after 4 months.

Results

The frontal resting-state theta power spectral density (PSD) was significantly altered in the real-feedback group after two neurofeedback visits. Higher theta PSD in the real-feedback group before neurofeedback was the only predictor of decreased cigarette consumption at the 4-month follow-up. Further reliability analysis revealed a significant positive correlation between theta PSD pre-neurofeedback and post-neurofeedback. A leave-one-out cross-validated linear regression of the theta PSD pre-neurofeedback demonstrated a significant correlation between the predicted and observed reductions in cigarette consumption at the 4-month follow-up. Finally, source analysis revealed that the brain mechanisms of the theta PSD predictor were located in the orbital frontal cortex.

Conclusions

Our study demonstrated changes in the resting-state theta PSD following neurofeedback training. Moreover, the resting-state theta PSD may serve as a prognostic marker of neurofeedback effects. A higher resting-state theta PSD predicts a better long-term response to neurofeedback treatment, which may facilitate the selection of individualised interventions.

Trial registration number

ChiCTR-IPR-17011710.

Comparing client and staff reports on tobacco-related knowledge, attitudes, beliefs and services provided in substance use treatment

INTRODUCTION

Smoking is highly prevalent in substance use disorder (SUD) programs, but few studies have explored the tobacco-related attitudes of staff and clients in the same program. The aim of this study was to compare staff and client reports on 10 tobacco-related items and associate them with tobacco measures implemented in the programs.

METHODS

A cross-sectional survey was conducted in 18 residential SUD programs from 2019 to 2020. Overall, 534 clients and 183 clinical staff self-reported their tobacco use, knowledge, attitudes, beliefs, and practices/services regarding smoking cessation. Ten comparable items were asked of both clients and staff. Differences in their responses were tested using bivariate analyses. We examine the association between selected tobacco-related items on making a quit attempt and planning to quit in the next 30 days.

RESULTS

In all, 63.7% of clients were current cigarette users versus 22.9% of staff. About half of clinicians (49.4%) said they had the skills to help patients quit smoking, while only 34.0% of clients thought their clinicians had these skills (p=0.003). About 28.4% of staff reported encouraging their patients to use nicotine replacement treatment (NRT), and 23.4% of patients said they had been encouraged to use these products. Client reports of planning a quit attempt were positively correlated with whether both staff and clients reported that the use of NRT was encouraged (clients: r=0.645 p=0.004; staff: r=0.524 p=0.025).

CONCLUSIONS

A low level of tobacco-related services was provided by staff and received by clients. In programs where smokers were encouraged to use NRT, a higher percentage of smokers planned a quit attempt. Tobacco-related training among staff, and communication about tobacco use with clients, should be improved to make tobacco services more visible and accessible in SUD treatment.

Patient experiences with tobacco use during substance use disorder treatment and early recovery: a mixed method analysis of phone interview responses

Tobacco use and related mortality remain disproportionately high among individuals with substance use disorders (SUDs). Though engagement in tobacco cessation interventions is associated with improved long-term recovery, many individuals in SUD treatment do not participate. The goal of the present study was to better understand patient views regarding tobacco use/cessation during residential SUD treatment, in order to decrease barriers for this vulnerable population. This study utilized a cross-sectional design and mixed methods analysis. Following discharge from residential SUD treatment, individuals who reported any use of tobacco were invited to participate in a brief phone interview. Forty-one of the 60 who were reached (68%) agreed to participate. Responses were quantified for analysis when appropriate, and descriptive statistics were calculated for quantitative data. Thematic analysis was used to analyze qualitative responses. Most respondents (83%) reported that tobacco cessation was an important goal and were open to tobacco cessation treatment. The vast majority (85%) did not think tobacco use interfered with their recovery from other SUDs. Respondents noted the socially-reinforcing nature of tobacco use in treatment, and indicated a desire for increased access to cessation services. Results suggest increased patient education and changes to treatment center tobacco policies may assist individuals recovering from SUD with tobacco cessation.

Smoking among inpatients in treatment for substance use disorders: prevalence and effect on mental health and quality of life

BACKGROUND

Smoking is still prevalent among people with substance use disorders. The objective of this study was to investigate the prevalence of smoking among patients in treatment for substance use disorders and to analyze the effect of smoking both at baseline and follow-up on drop-out, mental health and quality of life.

METHODS

One hundred and twenty-eight inpatients (26% female), mainly with alcohol use disorder, staying at three different rehabilitation clinics in Eastern Norway, were interviewed at admission, and at 6 weeks and 6 months follow-up. The interview contained mental health-related problems, trauma, questions on alcohol and other substances and quality of life. Non-parametric tests were used to test group differences and unadjusted and adjusted linear regression to test the associations between smoking and the main outcome variables, while logistic regression was used to test the association between smoking and drop-out.

RESULTS

At admission, 75% were daily smokers. Compared to non-smokers at baseline, the smokers had higher drop-out rates (37% vs. 13%), more mental distress, and lower quality of life from baseline up to 6 months follow-up. Those quitting smoking while admitted improved in mental distress and quality of life at the same rate as non-smokers. Alcohol-related factors did not differ between smokers and non-smokers.

CONCLUSIONS

Smoking was associated with mental distress, quality of life and treatment drop-out among patients in primary alcohol use disorder treatment. The results indicate that smoking cessation should be recommended as an integral part of alcohol use treatment both before and during inpatient treatment to reduce drop-out.

An Experimental Test of the Relationship between Electronic Nicotine Delivery System Use and Alcohol Consumption

BACKGROUND

Increasing research shows that the use of electronic nicotine delivery systems (ENDS) is associated with a higher rate and quantity of alcohol consumption.

METHODS

The present study used a 2-session, within-subjects design to experimentally examine the relationship between ENDS use and laboratory ad libitum alcohol consumption. A total of N = 31 (mean age = 28.71, SD = 11.17; 45.2% women; 54.8% White/Caucasian) healthy adults from the community who use ENDS and endorsed liking beer completed the study, which included a beer consumption taste-test task that assessed the volume of beer consumed by the participants across 2 counterbalanced sessions: 1 in which concurrent ENDS use was allowed and 1 in which it was not. All analyses controlled for age, race, and gender.

RESULTS

The effect of ENDS condition on the volume of beer consumed was not statistically significant, F(1, 30) = 0.03, p = 0.86). Results of linear mixed modeling showed that ENDS puffs were significantly related to alcohol sips (estimate = 0.23, SE = 0.07, p = 0.002) across the ad libitum session.

CONCLUSIONS

Overall, ENDS use did not increase alcohol consumption; however, the data suggest that ENDS puffs might act as a prime for beer sips or that these 2 behaviors are linked through habit. Future studies should more fully measure and compare global and event-level data on ENDS and alcohol use as they might show disparate patterns of relationships.

Tobacco Smoking Rates in a National Cohort of People with Substance Use Disorder Receiving Treatment

BACKGROUND AND AIM

The prevalence of tobacco smoking among individuals receiving treatment for substance use disorder (SUD) remains high. Respiratory disease and other harms are of prime concern to health policy-makers, given the contributory role played by tobacco smoking in the excess rates of premature mortality seen in individuals with SUD. The aim was to use SUD treatment data to investigate tobacco smoking prevalence among subgroups of adults over the course of treatment.

METHODS

We used the English National Drug Treatment Monitoring System (NDTMS) to examine number of days tobacco had been smoked in the previous month in adults receiving SUD treatment (N = 106,472, median length of treatment 157 days).

RESULTS

At baseline (treatment start), 48.7% reported smoking tobacco; the highest rate was observed in opiate users (61%). Overall, the level of smoking at the latest assessment was 48.5%. Reductions (of between 5 and 7%) were observed among those who finished treatment but only within the final stages of treatment. A 5% increase in smoking was observed in those still in treatment within the study timeframe.

CONCLUSIONS

This study identifies the potential for a greater emphasis on reducing tobacco consumption within SUD treatment, for example, by offering all smokers within SUD treatment smoking cessation support as part of their SUD treatment programme.

Remission From Unhealthy Drinking Among Patients With an Alcohol Use Disorder: A Longitudinal Study Using Systematic, Primary Care-Based Alcohol Screening Data

OBJECTIVE

Using electronic health record (EHR) data from a systematic, primary care-based alcohol screening, brief intervention, and referral to treatment (SBIRT) initiative within a health system, we examined correlates of remission from unhealthy drinking among patients with an alcohol use disorder (AUD).

METHOD

We conducted a longitudinal study of 4,078 adults with AUD who screened positive for unhealthy drinking between October 1, 2015, and September 30, 2016. We extracted EHR data up to 3 years after screening until October 1, 2018. We used survival analysis to examine associations between remission (i.e., reporting abstinence or low-risk drinking at a subsequent screening) and patient characteristics, comorbidities, and treatment utilization.

RESULTS

The median time to remission from unhealthy drinking was 1.7 years. Factors significantly associated with greater odds of remitting from unhealthy drinking during follow-up were female gender; older age (50-64 years); Black or Latino/Hispanic race/ethnicity; having more medical comorbidities; not having a comorbid drug use disorder; lower alcohol consumption levels; and receiving addiction medicine treatment before the index screening. In the first follow-up year, individuals with mental health comorbidities were more likely to remit, but those in psychiatric treatment were less likely. Receiving addiction treatment during follow-up was not associated with remission.

CONCLUSIONS

Ethnic minorities and individuals with mental illness were more likely to remit, which is encouraging given the health disparities observed among these clinically important subgroups and warrants further research. Our findings may inform research on AUD recovery and clinical practice, as remission from unhealthy drinking is a crucial component of the early stages of recovery.

Remission From Unhealthy Drinking Among Patients With an Alcohol Use Disorder: A Longitudinal Study Using Systematic, Primary Care-Based Alcohol Screening Data

OBJECTIVE

Using electronic health record (EHR) data from a systematic, primary care-based alcohol screening, brief intervention, and referral to treatment (SBIRT) initiative within a health system, we examined correlates of remission from unhealthy drinking among patients with an alcohol use disorder (AUD).

METHOD

We conducted a longitudinal study of 4,078 adults with AUD who screened positive for unhealthy drinking between October 1, 2015, and September 30, 2016. We extracted EHR data up to 3 years after screening until October 1, 2018. We used survival analysis to examine associations between remission (i.e., reporting abstinence or low-risk drinking at a subsequent screening) and patient characteristics, comorbidities, and treatment utilization.

RESULTS

The median time to remission from unhealthy drinking was 1.7 years. Factors significantly associated with greater odds of remitting from unhealthy drinking during follow-up were female gender; older age (50-64 years); Black or Latino/Hispanic race/ethnicity; having more medical comorbidities; not having a comorbid drug use disorder; lower alcohol consumption levels; and receiving addiction medicine treatment before the index screening. In the first follow-up year, individuals with mental health comorbidities were more likely to remit, but those in psychiatric treatment were less likely. Receiving addiction treatment during follow-up was not associated with remission.

CONCLUSIONS

Ethnic minorities and individuals with mental illness were more likely to remit, which is encouraging given the health disparities observed among these clinically important subgroups and warrants further research. Our findings may inform research on AUD recovery and clinical practice, as remission from unhealthy drinking is a crucial component of the early stages of recovery.

Effects of ethanol, naltrexone, nicotine and varenicline in an ethanol and nicotine co-use model in Sprague-Dawley rats

BACKGROUND

As alcohol and nicotine use disorders are entwined, it may be possible to develop a single medication to treat both. We previously developed a model for ethanol (EtOH) and nicotine co-use in female selectively bred alcohol-preferring (P) rats. To model co-use in a genetically diverse population, we adapted the model to outbred Sprague-Dawley rats of both sexes and assessed the effect of drug pretreatments.

METHODS

In phase 1, rats were trained in a 2-bottle choice between water and a sweetened or unsweetened EtOH solution in operant chambers. In phase 2, rats were trained in nicotine self-administration under an increasing fixed ratio (FR) schedule with 2 bottles containing water or saccharin-sweetened EtOH also available. In phase 3, rats were pretreated with EtOH (0.5, 1.5 g/kg), naltrexone (0.3 mg/kg), nicotine (0.2, 0.6 mg/kg), varenicline (3.0 mg/kg) or vehicle before the session.

RESULTS

Sweetening the EtOH solution was required to obtain pharmacologically relevant levels of consumption in Phase 1, with males showing increased sweetened EtOH preference compared to females. In Phase 2, increasing the FR requirement for nicotine decreased nicotine infusions, but increased EtOH consumption. In Phase 3, EtOH, naltrexone, and nicotine failed to alter EtOH consumption; however, varenicline decreased both EtOH and nicotine intake.

CONCLUSIONS

The co-use model was successfully adapted to Sprague-Dawley rats by adding saccharin to the EtOH solution. In contrast to previous results in P rats, varenicline reduced both EtOH and nicotine intake, indicating it may be a useful monotherapy for co-use in a genetically diverse population.

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.

The Incentives to Quit tobacco in Pregnancy (IQuiP) protocol: piloting a financial incentive-based smoking treatment for women attending substance use in pregnancy antenatal services

INTRODUCTION

While tobacco smoking prevalence is falling in many western societies, it remains elevated among high-priority cohorts. Rates up to 95% have been reported in women whose pregnancy is complicated by other substance use. In this group, the potential for poor pregnancy outcomes and adverse physical and neurobiological fetal development are elevated by tobacco smoking. Unfortunately, few targeted and effective tobacco dependence treatments exist to assist cessation in this population. The study will trial an evidence-based, multicomponent tobacco smoking treatment tailored to pregnant women who use other substances. The intervention comprises financial incentives for biochemically verified abstinence, psychotherapy delivered by drug and alcohol counsellors, and nicotine replacement therapy. It will be piloted at three government-based, primary healthcare facilities in New South Wales (NSW) and Victoria, Australia. The study will assess the feasibility and acceptability of the treatment when integrated into routine antenatal care offered by substance use in pregnancy antenatal services.

METHODS AND ANALYSIS

The study will use a single-arm design with pre-post comparisons. One hundred clients will be recruited from antenatal clinics with a substance use in pregnancy service. Women must be <33 weeks' gestation, ≥16 years old and a current tobacco smoker. The primary outcomes are feasibility, assessed by recruitment and retention and the acceptability of addressing smoking among this population. Secondary outcomes include changes in smoking behaviours, the comparison of adverse maternal outcomes and neonatal characteristics to those of a historical control group, and a cost-consequence analysis of the intervention implementation.

ETHICS AND DISSEMINATION

Protocol approval was granted by Hunter New England Human Research Ethics Committee (Reference 17/04/12/4.05), with additional ethical approval sought from the Aboriginal Health and Medical Research Council of NSW (Reference 1249/17). Findings will be disseminated via academic conferences, peer-reviewed publications and social media.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trial Registry (Ref: ACTRN12618000576224).

Association of Medicaid Expansion and Health Insurance with Receipt of Smoking Cessation Services and Smoking Behaviors in Substance Use Disorder Treatment

This study examined whether living in a Medicaid-expanded state or having health insurance was associated with receipt of smoking cessation services or smoking behaviors among substance use disorder (SUD) treatment clients. In 2015 and 2016, 1702 SUD clients in 14 states were surveyed for health insurance status, smoking cessation services received in their treatment program, and smoking behaviors. Services and behaviors were then compared by state Medicaid expansion and health insurance status independently. Clients in Medicaid-expanded states were more likely to be insured (89.9% vs. 54.4%, p < 0.001) and to have quit smoking during treatment (AOR = 3.77, 95% CI = 2.47, 5.76). Insured clients had higher odds of being screened for smoking status in their treatment program and making quit attempts in the past year. Medicaid expansion supports greater health insurance coverage of individuals in SUD treatment and may enhance smoking cessation.

Healthy Recovery: A Pilot Study of a Smoking and Other Health Behavior Change Intervention for People Attending Residential Alcohol and Other Substance Dependence Treatment

Objective: It is common for people attending alcohol and other substance dependence treatment to present with multiple unhealthy lifestyle behaviors such as high rates of smoking, physical inactivity, and poor diet. Healthy lifestyle interventions are increasing in importance in the general population, but have been underexamined within alcohol and other substance use populations. The purpose of the current study was to pilot "Healthy Recovery," a group program that primarily aimed to help people attending alcohol or other substance dependence treatment to reduce or quit smoking. The program also encourages participants to increase physical activity and to eat more servings of fruit and vegetables. Methods: The current study was conducted as a non-randomized controlled pilot trial. All participants were attending residential substance dependence treatment provided by the Australian Salvation Army. In addition to treatment as usual, participants in the treatment condition completed Healthy Recovery (n = 50) and participants in the control group completed an online depression program (n = 27). The study examined the health outcomes of participants (i.e., smoking, physical activity, fruit and vegetable intake, and symptom distress) and the feasibility of running the group sessions within the residential facilities. Results: Within-treatment effects demonstrated medium to large positive effects for reductions in smoking and increases in physical activity, servings of fruit, and servings of vegetables for people completing Healthy Recovery. When compared to the control condition, there were medium effects in favor of the Healthy Recovery condition for reductions in smoking and increases in physical activity. There was a small effect for servings of fruit and no effect for servings of vegetables. Conclusions: Results from this study demonstrated that people attending residential substance dependence treatment are willing and capable of engaging in multiple health behavior change interventions.

Performance of the WHOQOL-BREF among Norwegian substance use disorder patients

BACKGROUND

Quality of life (QoL) is an established outcome measure of substance use disorder treatment. The WHOQOL-BREF is the gold standard tool, but its appropriateness for particularly vulnerable patient populations must be further explored. This article examines the scaling qualities of the WHOQOL-BREF in a Norwegian substance use disorder population, and explores relationships with social and health variables.

METHODS

107 participants in a larger national treatment study provided data during structured interviews. Item responses, responsiveness, and domain scaling qualities are reported. General linear models identified correlates of impaired QoL.

RESULTS

Three out of four domains exhibited acceptable scaling qualities, while the social relationships domain had low internal validity. 59% of the variance in physical health QoL was explained in our model by the negative main or interaction effects of depression, unemployment, social isolation, smoking, residential treatment, and weight dissatisfaction. 52% of the variance in psychological health QoL was explained by depression and being single. Depression also had significant main effects in social relationships QoL (R2 = .27) and environment QoL (R2 = .39), and social isolation and exercise had further interaction effects in environment QoL.

CONCLUSIONS

After one year in treatment, the impact of low social contact in reducing QoL, rather than specific substance use patterns, was striking. The social relationships domain is the shortest in the WHOQOL-BREF, yet social variables were important in other areas of QoL. Social support could benefit from more attention in treatment, as a lack of social support seems to be a strong risk factor for poor QoL in various domains. The WHOQOL-BREF exhibits otherwise satisfactory measurement characteristics and is an appropriate tool among this population.

Changes in Food Insecurity and Smoking Status over Time: Analysis of the 2003 and 2015 Panel Study of Income Dynamics

PURPOSE

To examine whether food insecurity longitudinally affects smoking status.

DESIGN

Population-based prospective study.

SETTING

Data from the 2003 and 2015 Panel Study of Income Dynamics (PSID).

PARTICIPANTS

Four thousand five hundred sixty-three adults who were smokers and nonsmokers, participating in the 2003 (current study baseline) and 2015 (current study follow-up) waves of PSID.

MEASURES

Based on self-reported smoking status at baseline and follow-up, respondents were categorized as continued smoking, stopped smoking, started smoking, and continued nonsmoking. Similarly, respondents were categorized as stayed food secure, stayed food insecure, became food insecure, and became food secure based on responses to the Food Security Survey at baseline and follow-up.

ANALYSIS

Two logistic regression analyses to examine (1) among smokers at baseline the odds of stopping versus continuing smoking by follow-up and (2) among nonsmokers at baseline the odds of starting versus continuing nonsmoking by follow-up. In both models, change in food insecurity status was the primary independent variable, controlling for demographics including poverty.

RESULTS

Among smokers at baseline, becoming food insecure (vs staying food secure) was independently associated with lower likelihood of stopping smoking by follow-up (odds ratio [OR] = 0.66). Among nonsmokers at baseline, becoming food insecure (vs staying food secure) was independently associated with higher likelihood of starting smoking by follow-up (OR = 3.77).

CONCLUSIONS

Food insecurity is a risk factor for smoking, which has significant implications for developing interventions to reduce smoking prevalence, especially among low-income groups.

Prevalence, patterns, and correlates of multiple substance use disorders among adult primary care patients

BACKGROUND

Addressing multiple substance use disorders (SUDs) in primary care-based screening and intervention may improve SUD treatment access, engagement, and outcomes. To inform such efforts, research is needed on the prevalence and patterns of multiple SUDs among primary care patients.

METHODS

Data were analyzed from a sample of 2000 adult (aged ≥ 18) primary care patients recruited for a multisite National Drug Abuse Treatment Clinical Trials Network (CTN) study (CTN-0059). Past-year DSM-5 SUDs (tobacco, alcohol, and drug) were assessed by the modified Composite International Diagnostic Interview. Prevalence and correlates of multiple versus single SUDs were examined. Latent class analysis (LCA) was used to explore patterns of multiple SUDs.

RESULTS

Multiple SUDs were found among the majority of participants with SUD for alcohol, cannabis, prescription opioids, cocaine, and heroin. Participants who were male, ages 26-34, less educated, and unemployed had increased odds of multiple SUDs compared to one SUD. Having multiple SUDs was associated with greater severity of tobacco or alcohol use disorder. LCA of the sample identified three classes: class 1 (83.7%) exhibited low prevalence of all SUDs; class 2 (12.0%) had high-moderate prevalence of SUDs for tobacco, alcohol, and cannabis; class 3 (4.3%) showed high prevalence of SUD for tobacco, opioids, and cocaine. LCA-defined classes were distinguished by sex, age, race, education, and employment status.

CONCLUSIONS

Findings suggest that primary care physicians should be aware of multiple SUDs when planning treatment, especially among adults who are male, younger, less educated, or unemployed. Interventions that target multiple SUDs warrant future investigation.

Cigarette use is increasing among people with illicit substance use disorders in the United States, 2002-14: emerging disparities in vulnerable populations

BACKGROUND AND AIMS

While cigarette smoking has declined over time, it is not known whether this decline has occurred similarly among individuals with substance use disorders (SUDs) in the United States (US). The current study estimated trends in smoking from 2002 to 2014 among US individuals with and without SUDs.

DESIGN

Linear time trends of current smoking prevalence were assessed using logistic regression models.

SETTING

United States; data were drawn from the 2002 to 2014 National Household Survey on Drug Use (NSDUH), an annual US cross-sectional study.

PARTICIPANTS

A representative, population-based sample of US individuals age 12 yeas and older (total analytical population: n = 723 283).

MEASUREMENTS

Past-month current smoking was defined as having smoked at least 100 lifetime cigarettes and reporting smoking part or all of at least one cigarette during the past 30 days. Respondents were classified as having any SUD if they met criteria for abuse or dependence for one or more of the following illicit drugs: cannabis, hallucinogens, inhalants, tranquilizers, cocaine, heroin, pain relievers, simulants and sedatives. A second SUD variable included all drugs listed above excluding cannabis use disorder (CUD). An additional variable included respondents who met criteria for cannabis abuse or dependence.

FINDINGS

Among those with any SUD, the prevalence of smoking did not change from 2002 to 2014 (P = 0.08). However, when CUDs were separated from other SUDs, a significant increase in prevalence of smoking was observed among those with SUDs excluding CUDs (P < 0.001), while smoking decreased among those with CUDs (P < 0.001). Smoking declined among those without SUDs (P < 0.001). In 2014, smoking remained significantly more common among those with any SUD (55.48%), SUDs excluding CUDs (63.34%) and CUDs (51.34%) compared with those without these respective disorders (18.16, 18.55 and 18.64%; P < 0.001).

CONCLUSIONS

The prevalence of cigarette smoking in the United States increased from 2002 to 2014 among people with substance use disorders (SUDs) excluding cannabis use disorders (CUDs) and declined among those with CUDs and without SUDs. In 2014, the prevalence of smoking was multifold higher among those with SUDs, including CUDs, compared with those without SUDs.

Cigarette Smoking Is Associated With Increased Risk of Substance Use Disorder Relapse: A Nationally Representative, Prospective Longitudinal Investigation

OBJECTIVE

Little is known about the relationship between cigarette smoking and long-term outcomes for substance use disorder (SUD). The current study examined the association between smoking and SUD relapse among adults with remitted SUDs.

METHODS

Analyses were conducted on respondents who completed Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions and met DSM-IV criteria for substance abuse and dependence prior to but not during the year before the Wave 1 interview (n = 5,515). Relationships between smoking status (Wave 2 smoking vs nonsmoking among Wave 1 smokers; Wave 2 smoking vs nonsmoking among Wave 1 nonsmokers) and Wave 2 substance use and SUD relapse were examined using logistic regression analyses. Analyses were adjusted for demographics, psychiatric and alcohol use disorders, nicotine dependence, and SUD severity.

RESULTS

In the fully adjusted models, continued smoking at Wave 2 among Wave 1 smokers was associated with significantly greater odds of substance use (OR = 1.56, 95% CI, 1.10-2.20) and SUD relapse (OR = 2.02, 95% CI, 1.65-2.47) compared to Wave 2 nonsmoking. In the fully adjusted model, smoking at Wave 2 among Wave 1 nonsmokers was associated with significantly greater odds of SUD relapse compared to Wave 2 nonsmoking (OR = 4.86, 95% CI, 3.11-7.58).

CONCLUSIONS

Continued smoking among smokers and smoking initiation among nonsmokers were associated with greater odds of SUD relapse. More research is needed to examine the timing of SUD relapse in relation to smoking behaviors. Incorporating smoking cessation and prevention efforts into substance abuse treatment may improve long-term substance use outcomes for adult smokers with SUDs.

Impact of quitting smoking and smoking cessation treatment on substance use outcomes: An updated and narrative review

BACKGROUND

Historically, smoking cessation was thought to negatively impact substance use outcomes among smokers who use other substances. We sought to synthesize recent reports on this association.

METHODS

Google Scholar, PubMed, and Cinahl were searched for studies published from 2006 to March 29, 2016 that reported impact of smoking cessation treatment or quitting smoking on substance use or substance use disorder treatment outcomes in the general population and among those in substance abuse treatment. Studies were grouped by reported impact as follows: "positive" (i.e. improved), "null" (i.e. no change), or "negative" (i.e. worsened).

RESULTS

Twenty-four studies were included. Eighteen reported the impact of quitting smoking and six reported the impact of smoking cessation treatment intervention, independent of quitting, on substance use outcomes. Eleven studies (46%) reported solely positive impact; four (17%) reported solely null impact; eight (33%) reported mixed positive and null impact by analysis (combined and subgroup, n=1); substance (n=4); length of follow-up (n=2); and comparison group (n=1). One study (4%) reported mixed negative and null impact by ethnic group. No studies reported increased substance use.

CONCLUSION

Smoking cessation does not appear to have a negative effect, and often has a positive effect on substance use outcomes. Smoking cessation advice should be offered, without hesitation, to smokers who report substance use and those in treatment for substance use disorder.

A Randomized Trial Evaluating Whether Topiramate Aids Smoking Cessation and Prevents Alcohol Relapse in Recovering Alcohol-Dependent Men

BACKGROUND

Alcohol and nicotine dependence frequently co-occur, and quitting smoking might enhance long-term alcohol abstinence. Topiramate appears to help non-alcohol-dependent individuals quit smoking, and our pilot work suggested efficacy only in men. It also prevents relapse to alcohol in recently detoxified alcoholics. We evaluated topiramate in abstinent alcohol-dependent men to assess whether this medication (i) promotes smoking cessation and (ii) prevents alcohol and other drug relapse in the context of smoking cessation treatment.

METHODS

One hundred and twenty-nine alcohol-abstinent (mean ~6 months) alcohol-dependent male smokers (80% with other substance use disorders) participated in this 12-week randomized, double blind, parallel group comparison of topiramate (up to 200 mg/d) and placebo with a 24-week nontreatment follow-up period. The study was carried out sequentially at 2 academic centers in the Midwest and Southern California between March 23, 2009 and November 20, 2014. All participants received manual-guided smoking cessation counseling combined with medication-focused compliance enhancement therapy. Randomization was block designed by the research pharmacist in a 1:1 ratio. Participants, investigators, and research personnel were masked to treatment assignment. The primary smoking end point was biochemically confirmed 4-week continuous abstinence from smoking during weeks 9 to 12, while the secondary end point was relapse to any drinking or drug use during the entire 36-week evaluation period. Logistic regression was used to determine the effects of topiramate on quitting smoking and alcohol relapse, controlling for relevant covariates. The trial is registered at ClinicalTrials.gov (number NCT00802412) and is now closed.

RESULTS

Only a small proportion (7.9%) of topiramate-treated participants were able to quit smoking, and this cessation rate was similar to placebo (10.6%; odds ratio = 1.60; 95% confidence interval 0.4, 6.5; p = 0.51). Roughly 30% of the sample had a documented relapse to drinking or drug use during the study, and these rates were similar in the topiramate (20/63; 31.8%) and placebo groups (18/66; 27.3%; p = 0.58). Results of a longitudinal logistic regression model examining time to any alcohol relapse revealed no medication effect.

CONCLUSIONS

Topiramate at a daily dosage of up to 200 mg per day, combined with smoking cessation and medication adherence counseling, had no effects on smoking cessation or the prevention of alcohol or drug relapse in male smokers who were in early or sustained full remission from alcohol and motivated to make a quit attempt. Alternative approaches for treating this high-risk, dually dependent population are needed.

Commitment and capacity for providing evidence-based tobacco treatment in US drug treatment facilities

BACKGROUND

Although people with mental illness, including substance use disorders, consume 44% of cigarettes in the United States, few facilities provide tobacco treatment. This study assesses staff- and facility-level drivers of tobacco treatment in substance use treatment.

METHODS

Surveys were administered to 405 clinic directors selected from a comprehensive inventory of 3800 US outpatient facilities. The main outcome was the validated 7-item Index of Tobacco Treatment Quality. Other measures included the validated Tobacco Treatment Commitment Scale and indicators of facility resources for providing tobacco treatment.

RESULTS

Stepwise model selection was used to determine the relationship between capacity/resources and treatment quality. The final model retained 7 items and had good fit (adjusted R² = 0.43). Four capacities significantly predicted treatment quality. Structural equation modeling (SEM) was used to test the impact of staff commitment on treatment quality; the model had good fit and the relationship was significant (comparative fit index [CFI] = 0.951, root mean square error of approximation [RMSEA] = 0.054). Adding the 7 capacity/resources maintained similar model fit (CFI = 0.922, RMSEA = 0.053). Staff commitment was slightly strengthened in this model, with a rise in parameter estimate from 0.449 to 0.560. All resource/capacity items were also significant predictors of treatment quality; the strongest was receiving training in how to provide tobacco treatment (0.360), followed by dedicated staff time (0.279) and having a policy that requires staff to offer treatment (0.272).

CONCLUSIONS

Staff commitment to providing tobacco treatment was the strongest predictor of tobacco treatment quality, followed by resources for providing treatment. Interventions to change staff attitudes and improve resources for tobacco treatment have the strongest potential for improving quality of care.

Quitting smoking during substance use disorders treatment: Patient and treatment-related variables

Although individuals in substance use disorders (SUD) treatment continue to smoke at high rates, regulatory, policy and programming changes promoting tobacco cessation are being implemented and some patients quit successfully. We examined associations of smoking patterns, tobacco advertising receptivity, anti-tobacco message awareness, health risk perception, attitudes towards addressing smoking and availability of smoking cessation services with quitting smoking during SUD treatment. Surveys were completed by 1127 patients in 24 programs chosen randomly, stratified by program type (residential, methadone maintenance, outpatient), from among publicly funded, adult treatment programs within the National Drug Abuse Treatment Clinical Trials Network. Among respondents who had been in SUD treatment for at least one month, there were 631 current smokers and 52 former smokers who reported quitting smoking during treatment for at least one month prior to survey completion; these respondents comprised our sample (N=683). Results showed that participants who reported health concerns as a reason for quitting were 1.27 times more likely to have quit during treatment (p=0.015) than those reporting health concerns affected quitting a little or not at all. Additionally, participants who reported that smoking cessation was part of their personal treatment plan during SUD treatment were 1.08 times more likely to have quit during treatment (p<0.001). Participants in methadone treatment were 49% less likely to report successfully quitting during treatment than those in outpatient treatment (95%CI: 0. 35-0.75, p<0.001). Leveraging health concerns about smoking and including smoking cessation in an individualized treatment plan may help increase smoking cessation during SUD treatment.

A review of epidemiologic research on smoking behavior among persons with alcohol and illicit substance use disorders

Persons with alcohol use disorders (AUDs) and substance use disorders (SUDs) appear to be heavily affected by cigarette smoking. In order to address the consequences of smoking in this population, an understanding of the current state of knowledge is needed. Epidemiologic research provides the opportunity to obtain detailed information on smoking behaviors in large community samples. The aim of this paper was to synthesize the epidemiologic evidence on smoking among persons with AUDs/SUDs and suggest directions for future research. Literature searches of Medline and PubMed were used to identify articles and additional articles were elicited from publication reference lists. To be included in the review, papers had to be published in English, analyze epidemiologic data, and examine an aspect of smoking behavior in persons with AUDs/SUDs. Twenty-nine studies met inclusion criteria and were included in the review. In summary, epidemiologic evidence to date suggests greater lifetime and current smoking, nicotine dependence, and non-cigarette tobacco use; lower quitting; and differences in quit attempts and withdrawal symptoms for persons with AUDs/SUDs compared to other people. Most studies examined nationally representative data and were conducted on persons in the United States and Australia. Few publications examined outcomes by demographics (e.g., gender, age) but these studies suggested that specific patterns differ by demographic subgroups. More research is needed on persons with AUDs/SUDs in order to develop the most effective public health and clinical interventions to reduce smoking behaviors, improve cessation outcomes, and reduce the harmful consequences of smoking for those with AUDs/SUDs.

Barriers and Facilitators to Tobacco Cessation in a Nationwide Sample of Addiction Treatment Programs

INTRODUCTION

Smoking rates among addiction treatment clients are 3-4 times higher than those of the general population. Recent studies indicate that ceasing tobacco use during treatment may improve recovery outcomes. Across the United States, publicly funded addiction treatment programs vary widely in terms of their tobacco policies and tobacco cessation services offered to clients.

METHODS

The study reported here is the qualitative component of a larger study. Twenty-four programs were recruited from a random sample of publicly funded programs participating in the NIDA Clinical Trials Network. Semi-structured interviews were administered by phone to program directors. ATLAS.ti software was used to facilitate thematic analysis of interview transcripts.

FINDINGS

While all directors expressed interest in helping clients to quit smoking, they cited numerous barriers to implementing tobacco policies and services. These included smoking culture, client resistance, lack of resources, staff smoking, and environmental barriers. Directors also cited several factors that they believed would support tobacco cessation. These included financial support, enhanced leadership, and state mandates against smoking in addiction treatment programs.

CONCLUSION

Addiction treatment programs are beginning to place more emphasis on tobacco cessation during treatment. However, furthering this goal requires substantial infrastructural and cultural change. These qualitative study findings may help to inform Single State Agencies (SSAs) to support publicly funded addiction treatment programs in their tobacco cessation efforts. In order to maximize effectiveness, state-level policies regarding tobacco cessation during treatment should be informed by ongoing dialogue between service providers and SSAs.

A Systematic Review of Smoking Cessation Interventions for Adults in Substance Abuse Treatment or Recovery

INTRODUCTION

The aim was to evaluate the effectiveness of smoking cessation interventions for patients with substance use disorders. The secondary aim was to evaluate impact on substance use treatment outcomes.

METHODS

Randomized controlled trials involving adult smokers, recently or currently receiving inpatient or outpatient treatment for substance use disorders were reviewed. Databases, grey literature, reference lists, and journals were searched for relevant studies between 1990 and August 2014. Two authors extracted data and assessed quality. The primary outcome was biochemically verified continuous abstinence from smoking at 6 or 12 months, secondary outcomes were biochemically verified 7-day point prevalence smoking abstinence (PPA) at 6 or 12 months and substance use outcomes. Heterogeneity between studies precluded pooled analyses of the data.

RESULTS

Seventeen of 847 publications were included. Five studies reported significant effects on smoking cessation: (1) nicotine patches improved continuous abstinence at 6 months; (2) nicotine gum improved continuous abstinence at 12 months; (3) counseling, contingency management and relapse prevention improved continuous abstinence at 6 and 12 months; (4) cognitive behavioral therapy, plus nicotine replacement therapy (NRT), improved PPA at 6 months; and (5) a combination of bupropion, NRT, counseling and contingency management improved PPA at 6 months. Two studies showed some evidence of improved substance use outcomes with the remaining eight studies measuring substance use outcomes showing no difference.

CONCLUSIONS

NRT, behavioral support, and combination approaches appear to increase smoking abstinence in those treated for substance use disorders. Higher quality studies are required to strengthen the evidence base.

Evaluating Nicotine Craving, Withdrawal, and Substance Use as Mediators of Smoking Cessation in Cocaine- and Methamphetamine-Dependent Patients

INTRODUCTION

Smoking is highly prevalent in substance dependence, but smoking-cessation treatment (SCT) is more challenging in this population. To increase the success of smoking cessation services, it is important to understand potential therapeutic targets like nicotine craving that have meaningful but highly variable relationships with smoking outcomes. This study characterized the presence, magnitude, and specificity of nicotine craving as a mediator of the relationship between SCT and smoking abstinence in the context of stimulant-dependence treatment.

METHODS

This study was a secondary analysis of a randomized, 10-week trial conducted at 12 outpatient SUD treatment programs. Adults with cocaine and/or methamphetamine dependence (N = 538) were randomized to SUD treatment as usual (TAU) or TAU+SCT. Participants reported nicotine craving, nicotine withdrawal symptoms, and substance use in the week following a uniform quit attempt of the TAU+SCT group, and self-reported smoking 7-day point prevalence abstinence (verified by carbon monoxide) at end-of-treatment.

RESULTS

Bootstrapped regression models indicated that, as expected, nicotine craving following a quit attempt mediated the relationship between SCT and end-of-treatment smoking point prevalence abstinence (mediation effect = 0.09, 95% CI = 0.04% to 0.14%, P < .05, 14% of total effect). Nicotine withdrawal symptoms and substance use were not significant mediators (Ps > .05, <1% of total effect). This pattern held for separate examinations of cocaine and methamphetamine dependence.

CONCLUSIONS

Nicotine craving accounts for a small but meaningful portion of the relationship between smoking-cessation treatment and smoking abstinence during SUD treatment. Nicotine craving following a quit attempt may be a useful therapeutic target for increasing the effectiveness of smoking-cessation treatment in substance dependence.

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.

A Pilot Study of a Readiness Group to Increase Initiation of Smoking Cessation Services among Women in Residential Addiction Treatment

This study implemented a smoking cessation readiness group (RG) in two women-focused residential substance abuse treatment programs, with the aim of engaging women in smoking cessation services. The primary outcome was defined as attending at least one cessation group after the RG ended. The RG combined features of the Expert Systems (ES) approach with a practice quit attempt. ES is an interactive system which tailors intervention to the smokers' stage of change, while the practice quit attempt rehearses the process of quitting smoking. As a secondary aim we tested whether incentives, used to promote participation and engagement in the RG, would increase initiation of smoking cessation services. Participants (N=75) were women smokers enrolled in two residential programs, and intention to quit smoking was not required for participation. Twelve participant cohorts were randomly assigned to receive the RG with or without incentives. Following the RG intervention, 38.7% of participants (n=29) attended at least one smoking cessation session. Both the number of RG sessions attended and a successful practice quit attempt predicted the later use of cessation services, while incentives did not. From pre- to post-RG, participants reported decreased cigarettes per day (CPD: 11.8 vs. 7.6, p<.0001) and decreased nicotine dependence as measured by the Heaviness Smoking Index (HSI: 2.3 vs. 1.8, p<.001). The 3-session group-format RG intervention was associated with initiation of smoking cessation services and with changes in smoking behavior.

Exploring Issues of Comorbid Conditions in People Who Smoke

Smoking affects comorbid disease outcomes, and patients with comorbid conditions may have unique characteristics that are important to consider when treating tobacco use. However, addressing tobacco in patients being treated for comorbid conditions is not a consistent practice. Recognizing the need for a "call-to-action" to address tobacco use in people with comorbid conditions, the Tobacco Treatment Network within the Society for Research on Nicotine and Tobacco (SRNT) convened a Comorbidities Workgroup to explore the relationship between smoking and comorbid disease to identify common themes including: the harms associated with continued tobacco use, the frequency of comorbid disease and tobacco use, the potential effect of comorbid disease on the ability to quit tobacco use, the association between tobacco use and suboptimal disease-specific treatment response, and evidence regarding potential approaches to improve addressing tobacco use in patients with comorbid disease. Five candidate conditions (psychiatric, cancer, cardiovascular, pulmonary, and human immunodeficiency virus infected patients) were explored. Across comorbid conditions, smoking adversely affects treatment efficacy and promotes other adverse health conditions. People with comorbid conditions who smoke are motivated to quit and respond to evidence-based smoking cessation treatments. However, tobacco cessation is not regularly incorporated into the clinical care of many individuals with comorbidities. Optimal strategies for addressing tobacco use within each comorbid disease are also not well defined. Further work is needed to disseminate evidence-based care into clinical practice for smokers with comorbid disease and addiction research should consider comorbid conditions as an important construct to explore.

IMPLICATIONS

This article explores how physical and psychiatric conditions may interact in the treatment of tobacco dependence, and discusses the need for smoking cessation as a critical component of comorbid condition management. Five common comorbid domains-psychiatric, cancer, pulmonary, cardiovascular, and human immunodeficiency virus (HIV)-are highlighted to illustrate how these different conditions might interact with smoking with respect to prevalence and harm, motivation to quit, and cessation treatment utilization and success.

Medicaid, Private Insurance, and the Availability of Smoking Cessation Interventions in Substance Use Disorder Treatment

OBJECTIVE

Integration of smoking cessation services in substance use disorder treatment would benefit many patients. Although prior studies have identified organizational characteristics associated with delivery of these services, less is known regarding associations between financial factors and the availability of smoking cessation services. This study examined whether reliance on Medicaid and private insurance revenues is associated with the availability of a formal counseling-based smoking cessation program and medications (sustained-release bupropion, varenicline, and nicotine replacement) within U.S. specialty treatment organizations.

METHODS

Administrators of a national sample of 372 treatment organizations participated in face-to-face structured interviews from October 2011 to December 2013. Participants provided data regarding smoking cessation services, revenue sources, and other organizational characteristics. Multiple imputation was used to address missing data, and models were estimated by using logistic regression with adjustment for clustering of organizations within states.

RESULTS

Greater reliance on Medicaid revenues was positively associated with the odds of offering counseling-based smoking cessation programs, sustained-release bupropion, varenicline, and nicotine replacement. For example, a 10-percentage point increase in Medicaid revenues was associated with a 12% increase in the odds of offering a smoking cessation program. Reliance on private insurance revenues was positively associated with the odds of offering the three medications.

CONCLUSIONS

The findings point to future potential increases in the availability of smoking cessation services in the context of expanding insurance coverage under health care reform. Longitudinal research will be needed to examine whether this impact is realized.

Cigarette Smoking During Substance Use Disorder Treatment: Secondary Outcomes from a National Drug Abuse Treatment Clinical Trials Network study

INTRODUCTION

The majority of patients enrolled in treatment for substance use disorders (SUDs) also use tobacco. Many will continue to use tobacco even during abstinence from other drugs and alcohol, often leading to smoking-related illnesses. Despite this, little research has been conducted to assess the influence of being a smoker on SUD treatment outcomes and changes in smoking during a treatment episode.

METHODS

In this secondary analysis, cigarette smoking was evaluated in participants completing outpatient SUD treatment as part of a multi-site study conducted by the National Drug Abuse Treatment Clinical Trials Network. Analyses included the assessment of changes in smoking and nicotine dependence via the Fagerström Test for Nicotine Dependence during the 12-week study among all smokers (aim #1), specifically among those in the experimental treatment group (aim #2), and the moderating effect of being a smoker on treatment outcomes (aim #3).

RESULTS

Participants generally did not reduce or quit smoking throughout the course of the study. Among a sub-set of participants with higher baseline nicotine dependence scores randomized to the control arm, scores at the end of treatment were lower compared to the experimental arm, though measures of smoking quantity did not appear to decrease. Further, being a smoker was associated with poorer treatment outcomes compared to non-smokers enrolled in the trial.

CONCLUSIONS

This study provides evidence that patients enrolled in community-based SUD treatment continue to smoke, even when abstaining from drugs and alcohol. These results add to the growing literature encouraging the implementation of targeted, evidence-based interventions to promote abstinence from tobacco among SUD treatment patients.

Effects of nicotine on ethanol-induced locomotor sensitization: A model of neuroadaptation

Co-morbid use of nicotine-containing tobacco products and alcohol (ethanol) is prevalent in young adults initiating use and in alcohol dependent adults, suggesting that these drugs in combination may increase risk to develop dependence on one or both drugs. Neuroadaptations caused by repeated drug exposure are related to the development of drug dependence and vulnerability to relapse. Locomotor sensitization has been used as a behavioral measure used to detect changes in neural drug sensitivity that are thought to contribute to drug dependence and relapse. Locomotor sensitization was measured in the current studies to examine potential differences in the effects of nicotine and ethanol given alone and in combination. Baseline activity levels of DBA/2J mice were assessed on 2 days, then mice were treated for 10 days with saline, nicotine (1 or 2mg/kg of nicotine tartrate), ethanol (1 or 2g/kg), or nicotine plus ethanol and locomotor activity was assessed every third day. On the following day, all mice were challenged with ethanol to measure the expression of sensitization. Mice treated with both nicotine and ethanol exhibited greater stimulation than predicted from the combined independent effects of these drugs, consistent with our previously published results. The combined effects of nicotine and ethanol on locomotor sensitization were dependent on the dose of ethanol and whether testing was performed after the drugs were given together, or after challenge with ethanol alone. These results suggest that nicotine and ethanol in combination can have neuroadaptive effects that differ from the independent effects of these drugs.

Concurrent alcohol and tobacco treatment: Effect on daily process measures of alcohol relapse risk

OBJECTIVE

The aim of this study was to compare the effects of alcohol treatment along with concurrent smoking treatment or delayed smoking treatment on process measures related to alcohol relapse risk.

METHOD

Alcohol dependent smokers (N = 151) who were enrolled in an intensive outpatient alcohol treatment program and were interested in smoking cessation were randomized to a concurrent smoking cessation (CSC) intervention or to a waiting list for delayed smoking cessation (DSC) intervention scheduled to begin 3 months later. Daily assessments of relapse process measures were obtained using an Interactive Voice Response (IVR) system for 12 weeks after the onset of smoking treatment in the CSC condition, and before beginning smoking treatment in the DSC condition. Smoking outcomes were assessed at 2 and 13 weeks after starting treatment.

RESULTS

Seven-day carbon monoxide (CO) verified smoking abstinence in the CSC condition was 50.5% at 2 weeks and 19.0% at 13 weeks compared with 2.2% abstinence at 2 weeks and 0% abstinence at 13 weeks for those in the DSC condition. Drinking outcomes were not significantly different for CSC versus DSC treatment conditions. On daily IVR assessments, CSC participants had significantly lower positive alcohol outcome expectancies relative to DSC participants. Multilevel modeling (MLM) analyses of within-person effects across the 12 weeks of daily monitoring showed that daily smoking abstinence was significantly associated with same day reports of lower alcohol consumption, lower urge to drink, lower negative affect, lower positive alcohol outcome expectancies, greater alcohol abstinence self-efficacy, greater alcohol abstinence readiness to change, and greater perceived self-control demands.

CONCLUSIONS

Analyses of process measures provide support for recommending smoking intervention concurrent with intensive outpatient alcohol treatment. (PsycINFO Database Record

Predictors of Tobacco Use Among New York State Addiction Treatment Patients

Objectives. We used admissions data from the New York State addiction treatment system to assess patient self-reported tobacco use and factors associated with tobacco use. Methods. We compared prevalence of tobacco use in the state addiction treatment system with that of a national sample of people receiving addiction treatment and with that of the New York general population in 2005 to 2008. A random effects logistic model assessed relationships between patient- and program-level variables and tobacco use. Results. Prevalence of tobacco use in the New York treatment system was similar to that in national addiction treatment data and was 3 to 4 times higher than that in the general population. Co-occurring mental illness, opiate use, methadone treatment, and being a child of a substance-abusing parent were associated with higher rates of tobacco use. Conclusions. We call on federal leadership to build capacity to address tobacco use in addiction treatment, and we call on state leadership to implement tobacco-free grounds policies in addiction treatment systems.

Marijuana use and achievement of abstinence from alcohol and other drugs among people with substance dependence: a prospective cohort study

BACKGROUND

Many with alcohol and other drug dependence have concurrent marijuana use, yet it is not clear how to address it during addiction treatment. This is partially due to the lack of clarity about whether marijuana use impacts one's ability to achieve abstinence from the target of addiction treatment. We examined the association between marijuana use and abstinence from other substances among individuals with substance dependence.

METHODS

A secondary analysis of the Addiction Health Evaluation And Disease management study, a randomized trial testing the effectiveness of chronic disease management. Individuals met criteria for drug or alcohol dependence and reported recent drug (i.e. opioid or stimulant) or heavy alcohol use. Recruitment occurred largely at an inpatient detoxification unit, and all participants were referred to primary medical care. The association between marijuana use and later abstinence from drug and heavy alcohol use was assessed using longitudinal multivariable models.

RESULTS

Of 563 study participants, 98% completed at least one follow-up assessment and 535 (95%) had at least one pair of consecutive assessments and were included. In adjusted analyses, marijuana use was associated with a 27% reduction in the odds of abstinence from drug and heavy alcohol use (adjusted odds ratio 0.73 [95% CI, 0.56-0.97], P=0.03).

CONCLUSIONS

Marijuana use among individuals with alcohol or other drug dependence is associated with a lower odds of achieving abstinence from drug and heavy alcohol use. These findings add evidence that suggests concomitant marijuana use among patients with addiction to other drugs merits attention from clinicians.

Smoking and its treatment in addiction services: clients' and staff behaviour and attitudes

BACKGROUND

High smoking prevalence has been observed among those misusing other substances. This study aimed to establish smoking behaviours and attitudes towards nicotine dependence treatment among clients and staff in substance abuse treatment settings.

METHODS

Cross-sectional questionnaire survey of staff and clients in a convenience sample of seven community and residential addiction services in, or with links to, Europe's largest provider of mental health care, the South London and Maudsley NHS Foundation Trust. Survey items assessed smoking behaviour, motivation to quit, receipt of and attitudes towards nicotine dependence treatment.

RESULTS

Eighty five percent (n = 163) and 97% (n = 145) response rates of clients and staff were achieved. A high smoking prevalence was observed in clients (88%) and staff (45%); of current smokers, nearly all clients were daily smokers, while 42% of staff were occasional smokers. Despite 79% of clients who smoked expressing a desire to quit and 46% interested in receiving advice, only 15% had been offered support to stop smoking during their current treatment episode with 56% reported never having been offered support. Staff rated smoking treatment significantly less important than treatment of other substances (p < 0.001), and only 29% of staff thought it should be addressed early in a client's primary addiction treatment, compared with 48% of clients.

CONCLUSIONS

A large unmet clinical need is evident with a widespread failure to deliver smoking cessation interventions to an extraordinarily high prevalence population of smokers in addiction services. This is despite the majority of smokers reporting motivation to quit. Staff smoking and attitudes may be a contributory factor in these findings.

A Case Series of a Behavioral Activation−Enhanced Smoking Cessation Program for Inpatient Substance Users With Elevated Depressive Symptoms

Smoking is the leading preventable cause of death and disease in the world and represents a critical public health problem. Smokers with substance use disorders and depressive symptoms have particular difficulties quitting smoking and represent an underserved population. The current study utilized a novel behavioral activation (BA)−enhanced smoking cessation treatment with three clients in residential substance use treatment who had elevated depressive symptoms. We present detailed descriptions of the treatment they received and the challenges they faced. Our clients, who received five individual BA-enhanced smoking cessation sessions and two follow-up booster sessions, benefited significantly from the BA treatment. Over an 8-week follow-up period, they did not relapse to smoking and experienced significant decreases in depressive symptoms. This suggests BA may be a beneficial treatment strategy for this particularly challenging population.

Staff commitment to providing tobacco dependence in drug treatment: Reliability, validity, and results of a national survey

Although most people in treatment for illicit drug use smoke cigarettes, few facilities offer any form of treatment for tobacco dependence. One reason for this may be that drug treatment staff have varying levels of commitment to treat tobacco. We developed and validated a 14-item Tobacco Treatment Commitment Scale (TTCS), using 405 participants in leadership positions in drug treatment facilities. We first conducted a confirmatory factor analysis to evaluate 4 a priori domains suggested by our original set of 38 items-this did not produce a good fit (comparative fit index [CFI] = 0.782, root mean square error of approximation [RMSEA] = 0.067). We then conducted a series of exploratory factor analyses to produce a more precise and reliable scale. The final confirmatory factor analysis indicated a 3-factor solution, produced a good fit (CFI = 0.950, RMSEA = 0.058), and had substantial unified reliability of 0.975. The final TTCS contained 14 items in 3 domains: "Tobacco is less harmful than other drugs," "It's not our job to treat tobacco," and "Tobacco treatment will harm clients." These constructs account for most of the variance in the survey items and emerged as major sentiments driving staff commitment to providing tobacco services. The TTCS can be used to understand the role of staff attitudes in the adoption of tobacco services in this important treatment setting.

Bupropion-SR for smoking reduction and cessation in alcohol-dependent outpatients: a naturalistic, open-label study

BACKGROUND

We sought to determine whether sustained-release bupropion (bupropion-SR) reduces smoking and promotes smoking cessation among alcohol-dependent (AD) smokers while they are in early recovery from alcohol.

METHODS

We conducted an open-label, naturalistic study among AD smokers enrolled in an outpatient treatment program. The treatment group (n=58) was offered bupropion-SR and brief smoking cessation counseling. A control group (n=57) was matched to the treatment group by age, sex, ethnicity, cigarette use, and years of alcohol dependence. The controls received no smoking cessation intervention. We collected tobacco and alcohol abstinence data for 6 months after enrollment.

RESULTS

Participants in the treatment group were more likely to abstain from smoking than controls, at any of the followup time points. The treatment group smoked less cigarettes per day (CPD) at baseline, 30 days and 180 days post-baseline, compared to controls. These findings persisted after adjusting for possible covariates.

CONCLUSION

Bupropion-SR may be helpful to quit or reduce smoking for recently abstinent AD individuals.

Smoking cessation treatment among office-based buprenorphine treatment patients

Opioid-dependent patients smoke at high rates, and office-based buprenorphine treatment provides an opportunity to offer cessation treatment. We examined tobacco use and smoking cessation treatment patterns among office-based buprenorphine treatment patients. We reviewed records of 319 patients treated with buprenorphine from 2005 to 2010. We examined smoking status, cessation medication prescriptions, and factors associated with receipt of cessation prescriptions. Mean age was 43.9 years; most were men (74.2%) and Hispanic (70.9%). At buprenorphine initiation, 21.9% had no documentation of smoking status, while 67.4% were current, 10% former, and 0.9% never smokers. Of current smokers, 16.8% received smoking cessation prescriptions. Patients retained (vs. not retained) in buprenorphine treatment were more likely to receive smoking cessation medications (26.3% vs. 11.2%, p<0.005). We observed a high tobacco use prevalence among buprenorphine patients, and limited provision of cessation treatment. This is a missed opportunity to impact the high tobacco use burden in opioid-dependent persons.

Motivational interviewing versus brief advice for cigarette smokers in residential alcohol treatment

Residential treatment for substance use disorders (SUD) provides opportunity for smoking intervention. A randomized controlled trial compared: (1) motivational interviewing (MI) to brief advice (BA), (2) in one session or with two booster sessions, for 165 alcoholics in SUD treatment. All received nicotine replacement (NRT). MI and BA produced equivalent confirmed abstinence, averaging 10% at 1 month, and 2% at 3, 6 and 12 months. However, patients with more drug use pretreatment (>22 days in 6 months) given BA had more abstinence at 12 months (7%) than patients in MI or with less drug use (all 0%). Boosters produced 16-31% fewer cigarettes per day after BA than MI. Substance use was unaffected by treatment condition or smoking cessation. Motivation to quit was higher after BA than MI. Thus, BA plus NRT may be a cost-effective way to reduce smoking for alcoholics with comorbid substance use who are not seeking smoking cessation.

Expectancies for smoking cessation among drug-involved smokers: implications for clinical practice

Drug-involved smokers may be less motivated to quit smoking because they expect smoking cessation to occasion adverse outcomes (e.g., exacerbation of drug use). Non-treatment-seeking adult smokers from the community (N=507) reported drug involvement, expectancies for smoking abstinence via the Smoking Abstinence Questionnaire (SAQ), and motivation to quit smoking (desire to quit and abstinence goal). Mediation analyses evaluated the indirect effects of binge drinking, marijuana, cocaine, other stimulant, opiate, and barbiturate/other sedative involvement on motivation to quit smoking through the SAQ Adverse Outcomes scale. Adverse outcomes expectancies accounted for a reduced desire to quit smoking and a lower likelihood of endorsing a goal of complete smoking abstinence among those involved with binge drinking, marijuana, cocaine, other stimulants, opiates, and barbiturates/other sedatives. Drug-involved smokers' greater expectancies for adverse outcomes upon quitting smoking may deter smoking quit attempts. Interventions are encouraged to counteract the notion that smoking cessation jeopardizes sobriety.

Cognitive behavioral therapy and the nicotine transdermal patch for dual nicotine and cannabis dependence: a pilot study

BACKGROUND AND OBJECTIVES

We assessed the feasibility of a new cognitive behavioral therapy (CBT) manual, plus transdermal patch nicotine replacement therapy (NRT), to treat co-occurring nicotine and cannabis dependence.

METHOD

Seven of 12 (58.3%) adults with DSM-IV diagnoses of both nicotine and cannabis dependence completed 10 weeks of individual CBT and NRT.

RESULTS

Participants smoked 12.6 ± 4.9 tobacco cigarettes per day at baseline, which was reduced to 2.1 ± 4.2 at the end of treatment (F[5]  = 23.5, p < .0001). The reduction in cannabis use from 10.0 ± 5.3 inhalations per day at baseline to 8.0 ± 5.3 inhalations per day at 10 weeks was not significant (F[5]  = 1.12, p = .37). There was a significant decrease from the mean baseline Fagerstrom Test for Nicotine Dependence scores at weeks 4, 6, 8, and 10 of treatment (F[4]  = 19.8, p < .001) and mean Client Satisfaction Questionnaire scores were uniformly high (30.6 ± 1.9).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

A CBT plus NRT treatment program significantly reduced tobacco smoking but did not significantly reduce cannabis use in individuals with co-occurring nicotine and cannabis dependence. There was no compensatory increase in cannabis use following the reduction in tobacco smoking, suggesting that clinicians can safely pursue simultaneous treatment of co-occurring nicotine and cannabis dependence. The intervention was well-liked by the 7 of the 12 enrollees who completed the study.

Five-year healthcare utilization and costs among lower-risk drinkers following alcohol treatment

BACKGROUND

Lower-risk drinking is increasingly being examined as a treatment outcome for some patients following addiction treatment. However, few studies have examined the relationship between drinking status (lower-risk drinking in particular) and healthcare utilization and cost, which has important policy implications.

METHODS

Participants were adults with alcohol dependence and/or abuse diagnoses who received outpatient alcohol and other drug treatment in a private, nonprofit integrated healthcare delivery system and had a follow-up interview 6 months after treatment entry (N = 995). Associations between past 30-day drinking status at 6 months (abstinence, lower-risk drinking defined as nonabstinence and no days of 5+ drinking, and heavy drinking defined as 1 or more days of 5+ drinking) and repeated measures of at least 1 emergency department (ED), inpatient or primary care visit, and their costs over 5 years were examined using mixed-effects models. We modeled an interaction between time and drinking status to examine trends in utilization and costs over time by drinking group.

RESULTS

Heavy drinkers and lower-risk drinkers were not significantly different from the abstainers in their cost or utilization at time 0 (i.e., 6 months postintake). Heavy drinkers had increasing odds of inpatient (p < 0.01) and ED (p < 0.05) utilization over 5 years compared with abstainers. Lower-risk drinkers and abstainers did not significantly differ in their service use in any category over time. No differences were found in changes in primary care use among the 3 groups over time. The cost analyses paralleled the utilization results. Heavy drinkers had increasing ED (p < 0.05) and inpatient (p < 0.001) costs compared with the abstainers; primary care costs did not significantly differ. Lower-risk drinkers did not have significantly different medical costs compared with those who were abstinent over 5 years. However, post hoc analyses found lower-risk drinkers and heavy drinkers to not significantly differ in their ED use or costs over time.

CONCLUSIONS

Performance measures for treatment settings that consider treatment outcomes may need to take into account both abstinence and reduction to nonheavy drinking. Future research should examine whether results are replicated in harm reduction treatment, or whether such outcomes are found only in abstinence-based treatment.

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 index of tobacco treatment quality: development of a tool to assess evidence-based treatment in a national sample of drug treatment facilities

Background

Quitting smoking improves health and drug use outcomes among people in treatment for substance abuse. The twofold purpose of this study is to describe tobacco treatment provision across a representative sample of U.S. facilities and to use these data to develop the brief Index of Tobacco Treatment Quality (ITTQ).

Methods

We constructed survey items based on current tobacco treatment guidelines, existing surveys, expert input, and qualitative research. We administered the survey to a stratified sample of 405 facility administrators selected from all 3,800 U.S. adult outpatient facilities listed in the SAMHSA Inventory of Substance Abuse Treatment Services. We constructed the ITTQ with a subset of 7 items that have the strongest clinical evidence for smoking cessation.

Results

Most facilities (87.7%) reported that a majority of their clients were asked if they smoke cigarettes. Nearly half of facilities (48.6%) reported that a majority of their smoking clients were advised to quit. Fewer (23.3%) reported that a majority of their smoking clients received tobacco treatment counseling and even fewer facilities (18.3%) reported a majority of their smoking clients were advised to use quit smoking medications. The median facility ITTQ score was 2.57 (on a scale of 1–5) and the ITTQ displayed good internal consistency (Cronbach’s alpha = .844). Moreover, the ITTQ had substantial test-retest reliability (.856), and ordinal confirmatory factor analysis found that our one-factor model for ITTQ fit the data very well with a CFI of 0.997 and an RMSEA of 0.042.

Conclusions

The ITTQ is a brief and reliable tool for measuring tobacco treatment quality in substance abuse treatment facilities. Given the clear-cut room for improvement in tobacco treatment, the ITTQ could be an important tool for quality improvement by identifying service levels, facilitating goal setting, and measuring change.

Psychiatric diagnoses among quitters versus continuing smokers 3 years after their quit day

BACKGROUND

People with psychiatric disorders are more likely to smoke and smoke more heavily than the general population, and they suffer disproportionally from smoking-related illnesses. However, little is known about how quitting versus continuing to smoke affects mental health and the likelihood of developing a psychiatric diagnosis. This study used data from a large prospective clinical trial to examine the relations of smoking cessation success with psychiatric diagnoses 1 and 3 years after the target quit day.

METHODS

This study enrolled 1504 smokers (83.9% white; 58.2% female) in a cessation trial that involved the completion of the Composite International Diagnostic Interview to assess psychiatric diagnoses and biochemical confirmation of point-prevalence abstinence at Baseline and Years 1 and 3.

RESULTS

Regression analyses showed that, after controlling for pre-quit (past-year) diagnoses, participants who were smoking at the Year 3 follow-up were more likely to have developed and maintained a substance use or major depressive disorder by that time than were individuals who were abstinent at Year 3.

CONCLUSIONS

Quitting smoking does not appear to negatively influence mental health in the long-term and may be protective with respect to depression and substance use diagnoses; this should encourage smokers to make quit attempts and encourage clinicians to provide cessation treatment.

Posttreatment low-risk drinking as a predictor of future drinking and problem outcomes among individuals with alcohol use disorders

BACKGROUND

Treatment for alcohol disorders has traditionally been abstinence-oriented, but evaluating the merits of a low-risk drinking outcome as part of a primary treatment endpoint is a timely issue given new pertinent regulatory guidelines. This study explores a posttreatment low-risk drinking outcome as a predictor of future drinking and problem severity outcomes among individuals with alcohol use disorders in a large private, not for profit, integrated care health plan.

METHODS

Study participants include adults with alcohol use disorders at 6 months (N = 995) from 2 large randomized studies. Logistic regression models were used to explore the relationship between past 30-day drinker status at 6 months posttreatment (abstinent [66%], low-risk drinking [14%] defined as nonabstinence and no days of 5+ drinking, and heavy drinking [20%] defined as 1 or more days of 5+ drinking) and 12-month outcomes, including drinking status and Addiction Severity Index measures of medical, psychiatric, family/social, and employment severity, controlling for baseline covariates.

RESULTS

Compared to heavy drinkers, abstinent individuals and low-risk drinkers at 6 months were more likely to be abstinent or low-risk drinkers at 12 months (adj. ORs = 16.7 and 3.4, respectively; p < 0.0001); though, the benefit of abstinence was much greater than that of low-risk drinking. Compared to heavy drinkers, abstinent and low-risk drinkers were similarly associated with lower 12-month psychiatric severity (adj. ORs = 1.8 and 2.2, respectively, p < 0.01) and family/social problem severity (adj. OR = 2.2; p < 0.01). While abstinent individuals had lower 12-month employment severity than heavy drinkers (adj. OR = 1.9; p < 0.01), low-risk drinkers did not differ from heavy drinkers. The drinking groups did not differ on 12-month medical problem severity.

CONCLUSIONS

Compared to heavy drinkers, low-risk drinkers did as well as abstinent individuals for many of the outcomes important to health and addiction policy. Thus, an endpoint that allows low-risk drinking may be tenable for individuals undergoing alcohol specialty treatment.