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Guydish J, McCuistian C, Hosakote S, Le T, Masson CL, Campbell BK, Delucchi K. A cluster-randomized trial of a brief multi-component intervention to improve tobacco outcomes in substance use treatment. Subst Abuse Treat Prev Policy 2023; 18:34. [PMID: 37328775 PMCID: PMC10276468 DOI: 10.1186/s13011-023-00539-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/07/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Smoking prevalence is high among people in substance use disorder (SUD) treatment, and program interventions to address smoking are often complex and lengthy. This cluster-randomized trial tested whether a brief multi-component intervention impacted tobacco outcomes among staff and clients. METHODS Seven SUD treatment programs were randomly assigned to the multi-component intervention or to waitlist control. The 6-month intervention included a leadership motivation assessment, program incentives, 4 staff training sessions and a leadership learning community session. Survey data were collected from staff and clients at pre- and post-intervention. Outcomes were first compared across condition (intervention vs waitlist control), and then examined pre- to post-intervention with condition collapsed. RESULTS Staff in the intervention (n = 48) and control conditions (n = 26) did not differ at post-intervention on smoking prevalence, self-efficacy to help clients quit, or practices used to help clients quit smoking. Intervention clients (n = 113) did not differ from controls (n = 61) in smoking prevalence or receipt of tobacco services. Pre-post comparisons collapsed across condition showed a decrease in client and staff smoking prevalence, which could not be attributed to the intervention, and a decrease in client receipt of cessation medication. CONCLUSION The brief multi-component intervention did not support changes in smoking prevalence or in tobacco-related services received by clients. Other intervention features are needed to reduce smoking among SUD clients. TRIAL REGISTRATION Randomization occurred at the program level and outcomes measured are program-level measures. Accordingly, the trial is not registered.
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Affiliation(s)
- Joseph Guydish
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 490 Illinois St., Floor 7, San Francisco, CA 94158 USA
| | - Caravella McCuistian
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 490 Illinois St., Floor 7, San Francisco, CA 94158 USA
| | - Sindhushree Hosakote
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 490 Illinois St., Floor 7, San Francisco, CA 94158 USA
| | - Thao Le
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 490 Illinois St., Floor 7, San Francisco, CA 94158 USA
| | - Carmen L. Masson
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, USA
| | - Barbara K. Campbell
- Division of General Internal Medicine & Geriatrics, Oregon Health and Sciences University, Portland, USA
| | - Kevin Delucchi
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, USA
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Guydish J, Le T, Hosakote S, Straus E, Wong J, Martínez C, Delucchi K. Tobacco use among substance use disorder (SUD) treatment staff is associated with tobacco-related services received by clients. J Subst Abuse Treat 2022; 132:108496. [PMID: 34111773 DOI: 10.1016/j.jsat.2021.108496] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 05/10/2021] [Accepted: 05/25/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Joseph Guydish
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118, United States of America.
| | - Thao Le
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118, United States of America.
| | - Sindhushree Hosakote
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118, United States of America.
| | - Elana Straus
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118, United States of America.
| | - Jessie Wong
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118, United States of America
| | - Cristina Martínez
- Tobacco Control Unit, Cancer Control and Prevention Programme, Institut Català d'Oncologia-ICO, Av. Granvia de L'Hospitalet 199-203, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Kevin Delucchi
- Department of Psychiatry, University of California San Francisco, 401 Parnassus Ave., San Francisco, CA 94143, United States of America.
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Guydish JR, Straus ER, Le T, Gubner N, Delucchi KL. Menthol cigarette use in substance use disorder treatment before and after implementation of a county-wide flavoured tobacco ban. Tob Control 2021; 30:616-622. [PMID: 33177211 PMCID: PMC8110613 DOI: 10.1136/tobaccocontrol-2020-056000] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/08/2020] [Accepted: 09/23/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION This study examined the impact of a San Francisco City and County ban on all flavoured tobacco products, including menthol cigarettes, among clients in residential substance use disorder (SUD) treatment. METHODS We conducted cross-sectional surveys of clients at two residential SUD programmes before the County began enforcing the ban (n=160) and twice after enforcement began (n=102, n=120). The samples were compared on demographic characteristics, smoking status, smoking behaviours and the proportion reporting menthol as their usual cigarette. Menthol smokers were asked whether they smoked only menthol cigarettes, mostly menthol, both menthol and non-menthol or mostly non-menthol. Post-ban samples were asked about awareness of the ban and access to menthol cigarettes. RESULTS In multivariate analyses, we found no evidence that the ban was associated with decreased number of cigarettes per day or increased readiness to quit among current smokers. However, odds were lower post-ban for reporting menthol as the usual cigarette (OR=0.80, 95% CI 0.72 to 0.90), and for smoking only menthol cigarettes (OR=0.19, 95% CI 0.18 to 0.19). Perhaps most importantly, and with the ability to influence all other findings, 50% of self-identified menthol smokers reported purchasing menthol cigarettes in San Francisco nearly 1 year after the ban was implemented. CONCLUSION In subgroups where smoking has remained elevated, like those receiving SUD treatment, local menthol bans may have only modest impacts on smoking behaviour. Broader regional, state or national bans, that effectively restrict access to menthol products, may be needed to show stronger effects on smoking behaviour.
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Affiliation(s)
- Joseph R Guydish
- Phillip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Elana R Straus
- Phillip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Thao Le
- Phillip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Noah Gubner
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Kevin L Delucchi
- Department of Psychiatry, University of California San Francisco, San Francisco, California, USA
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Guydish J, Wahleithner J, Williams D, Yip D. Tobacco-free grounds implementation in California residential substance use disorder (SUD) treatment programs. J Addict Dis 2020; 38:55-63. [PMID: 32186480 DOI: 10.1080/10550887.2020.1713687] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Smoke-free laws and policies have contributed significantly to the decline in smoking in the U.S, but are not often applied in high-prevalence smoking populations where they are most needed. Smoking among clients in publicly funded substance use disorder (SUD) treatment is 3-4 times higher than the general population, and little is known about tobacco policies programs have adopted. To identify the prevalence of tobacco-free grounds and other smoking policies in California's publicly funded, adult, residential SUD programs. Using a California DHCS contact list of 1,921 publicly funded, non-medical, SUD programs, 362 were eligible to participate in a brief semi-structured phone survey concerning indoor and outdoor smoking for staff and clients and other tobacco policies. Of 259 programs that completed the survey, 28 (10.8%) reported tobacco-free grounds. 91 (35.1%) expressed interest in implementing tobacco-free policies and 23 have plans to do so. Nearly all programs (n = 253, 97.7%) had some policy restricting e-cigarette use, and 110 (43.5%) of these reported a complete ban on e-cigarette use. 124 (47.9%) had policies prohibiting staff and clients smoking together. Most California residential SUD programs allow outdoor smoking for staff and clients and few have adopted tobacco-free grounds policies. Given the reported interest in adopting tobacco-free policies, the high density of smokers in the SUD population, and the association of tobacco-free policies with lower client and staff smoking rates, state licensing and regulatory agencies, as well as county health departments, should work with SUD programs to adopt tobacco-free policies.
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Affiliation(s)
- Joseph Guydish
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA
| | - Jennifer Wahleithner
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA
| | - Denise Williams
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA
| | - Deborah Yip
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA
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Ballbè M, Martínez C, Feliu A, Torres N, Nieva G, Pinet C, Raich A, Mondon S, Barrio P, Hernández-Ribas R, Vicens J, Costa S, Vilaplana J, Alaustre L, Vilalta E, Blanch R, Subirà S, Bruguera E, Suelves JM, Guydish J, Fernández E. Effectiveness of a telephone-based intervention for smoking cessation in patients with severe mental disorders: study protocol for a randomized controlled trial. Trials 2019; 20:38. [PMID: 30635072 PMCID: PMC6329054 DOI: 10.1186/s13063-018-3106-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 12/05/2018] [Indexed: 01/01/2023] Open
Abstract
Background Up to 75% of inpatients with mental disorders smoke, and their life expectancy is decreased by up to 25 years compared to the general population. Hospitalized patients without monitoring after discharge quickly return to prehospitalization levels of tobacco use. The aim of the 061 QuitMental study is to assess the effectiveness of a multicomponent and motivational telephone-based intervention to stop smoking through a quitline addressed to smokers discharged from mental health hospital wards. Methods A pragmatic randomized controlled trial, single blinded, will include 2:1 allocation to the intervention group (IG) and the control group (CG). The IG will receive telephone assistance to quit smoking (including psychological and psychoeducational support, and pharmacological treatment advice if required) proactively for 12 months, and the CG will receive only brief advice after discharge. The sample size, calculated with an expected difference of 15 points on smoking abstinence between groups (IG, 20% and CG, 5%), α = 0.05, β = 0.10, and 20% loss, will be 334 participants (IG) and 176 participants (CG). Participants are adult smokers discharged from psychiatric units of five acute hospitals. Measurements include dependent variables (self-reported 7-day point prevalence smoking abstinence (carbon monoxide verified), duration of abstinence, number of quit attempts, motivation, and self-efficacy to quit) and independent variables (age, sex, and psychiatric diagnoses). In data analysis, IG and CG data will be compared at 48 h and 1, 6, and 12 months post discharge. Multivariate logistic regression (odds ratio; 95% confidence interval) of dependent variables adjusted for potential confounding variables will be performed. The number needed to treat to achieve one abstinence outcome will be calculated. We will compare the abstinence rate of enrolled patients between groups. Discussion This trial evaluates an innovative format of a quitline for smokers with severe mental disorders regardless of their motivation to quit. If effective, the pragmatic nature of the study will permit transfer to routine clinical practice in the National Health System. Trial registration ClinicalTrials.gov, NCT03230955. Registered on 24 July 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-3106-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Montse Ballbè
- Tobacco Control Unit, Cancer Control and Prevention Program, Institut Català d'Oncologia-ICO, Av. Granvia de L'Hospitalet 199-203, L'Hospitalet de Llobregat, 08908, Barcelona, Spain.,Cancer Control and Prevention Group, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, Av. Granvia de L'Hospitalet 199-203, L'Hospitalet de Llobregat, 08908, Barcelona, Spain.,Addictions Unit, Institute of Neurosciences, Hospital Clínic de Barcelona, C. Villarroel 170, 08036, Barcelona, Spain
| | - Cristina Martínez
- Tobacco Control Unit, Cancer Control and Prevention Program, Institut Català d'Oncologia-ICO, Av. Granvia de L'Hospitalet 199-203, L'Hospitalet de Llobregat, 08908, Barcelona, Spain. .,Cancer Control and Prevention Group, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, Av. Granvia de L'Hospitalet 199-203, L'Hospitalet de Llobregat, 08908, Barcelona, Spain. .,Medicine and Health Sciences School, Universitat Internacional de Catalunya, C. Josep Trueta s/n, 08915 Sant Cugat del Valles, Barcelona, Spain. .,Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, C. Feixa Llarga s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain.
| | - Ariadna Feliu
- Tobacco Control Unit, Cancer Control and Prevention Program, Institut Català d'Oncologia-ICO, Av. Granvia de L'Hospitalet 199-203, L'Hospitalet de Llobregat, 08908, Barcelona, Spain.,Cancer Control and Prevention Group, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, Av. Granvia de L'Hospitalet 199-203, L'Hospitalet de Llobregat, 08908, Barcelona, Spain.,Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, C. Feixa Llarga s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain
| | - Núria Torres
- 061 CatSalut Respon, Sistema d'Emergències Mèdiques, C. Pablo Iglesias 115, L'Hospitalet de Llobregat, 08908, Barcelona, Spain
| | - Gemma Nieva
- Smoking Cessation Unit, Addictive Behaviors Unit, Psychiatry Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research, CIBERSAM, Universitat Autònoma de Barcelona, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Cristina Pinet
- Addictive Behaviors Unit, Psychiatry Department, Hospital de la Santa Creu i Sant Pau, C. San Antoni Ma Claret 167, 08025, Barcelona, Spain
| | - Antònia Raich
- Mental Health Department, Althaia Xarxa Assistencial Universitària, C. Dr. Llatjós s/n, Manresa, 08243, Barcelona, Spain
| | - Sílvia Mondon
- Addictions Unit, Institute of Neurosciences, Hospital Clínic de Barcelona, C. Villarroel 170, 08036, Barcelona, Spain
| | - Pablo Barrio
- Addictions Unit, Institute of Neurosciences, Hospital Clínic de Barcelona, C. Villarroel 170, 08036, Barcelona, Spain
| | - Rosa Hernández-Ribas
- Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, C. Feixa Llarga s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain.,Alcohol Program, Psychiatry Department, Hospital Universitari de Bellvitge, Institut Català d'Oncologia, IDIBELL, CIBERSAM, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Jordi Vicens
- Psychiatry Department, Hestia Duran i Reynals, Av. Granvia de L'Hospitalet 199-203, L'Hospitalet de Llobregat, 08908, Barcelona, Spain
| | - Sílvia Costa
- Addictive Behaviors Unit, Psychiatry Department, Hospital de la Santa Creu i Sant Pau, C. San Antoni Ma Claret 167, 08025, Barcelona, Spain.,Institut d'Investigació Biomèdica Sant Pau, C. San Antoni Mª Claret 167, 08025, Barcelona, Spain
| | - Jordi Vilaplana
- Lleida Institute for Biomedical Research Dr. Pifarré Foundation, IRBLleida, Universitat de Lleida, Av. Alcalde Rovira Roure, 80, 25198, Lleida, Spain
| | - Laura Alaustre
- 061 CatSalut Respon, Sistema d'Emergències Mèdiques, C. Pablo Iglesias 115, L'Hospitalet de Llobregat, 08908, Barcelona, Spain
| | - Eva Vilalta
- 061 CatSalut Respon, Sistema d'Emergències Mèdiques, C. Pablo Iglesias 115, L'Hospitalet de Llobregat, 08908, Barcelona, Spain
| | - Roser Blanch
- 061 CatSalut Respon, Sistema d'Emergències Mèdiques, C. Pablo Iglesias 115, L'Hospitalet de Llobregat, 08908, Barcelona, Spain
| | - Susana Subirà
- Psychiatry Department, Hestia Duran i Reynals, Av. Granvia de L'Hospitalet 199-203, L'Hospitalet de Llobregat, 08908, Barcelona, Spain
| | - Eugeni Bruguera
- Smoking Cessation Unit, Addictive Behaviors Unit, Psychiatry Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research, CIBERSAM, Universitat Autònoma de Barcelona, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Josep Maria Suelves
- Public Health Agency of Catalonia, Health Department, Government of Catalonia, C. Roc Boronat 81-95, 08005, Barcelona, Spain
| | - Joseph Guydish
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA, 94118, USA
| | - Esteve Fernández
- Tobacco Control Unit, Cancer Control and Prevention Program, Institut Català d'Oncologia-ICO, Av. Granvia de L'Hospitalet 199-203, L'Hospitalet de Llobregat, 08908, Barcelona, Spain.,Cancer Control and Prevention Group, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, Av. Granvia de L'Hospitalet 199-203, L'Hospitalet de Llobregat, 08908, Barcelona, Spain.,Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, C. Feixa Llarga s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain
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Kelly PJ, Townsend CJ, Osborne BA, Baker AL, Deane FP, Keane C, Ingram I, Lunn J. Predicting Intention to Use Nicotine Replacement Therapy in People Attending Residential Treatment for Substance Dependence. J Dual Diagn 2018; 14:120-129. [PMID: 29488836 DOI: 10.1080/15504263.2018.1442951] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Nicotine replacement therapy (NRT) is recommended as a frontline smoking cessation tool for people attending mental health and substance dependence treatment services. Previous research suggests that NRT is underutilized in these settings. To improve the use of NRT among people attending residential treatment for substance use disorders, it is important that the factors influencing smokers' decisions to use NRT are understood. The study aimed to examine (1) smoking cessation strategies used by participants in previous quit attempts, (2) participants' attitudes toward NRT (i.e., safety concerns and perceived efficacy), and (3) the predictors of participants' intention to use NRT to support future quit attempts. METHODS Participants completed a cross-sectional survey that examined their smoking behaviors, previous experiences using smoking cessation strategies, attitudes and beliefs regarding NRT, and intention to use NRT as part of future quit attempts (N = 218). All participants were attending residential treatment for substance use disorders provided by We Help Ourselves, a large provider of specialist alcohol and other drug treatment in Australia. RESULTS The majority of respondents (98%) reported that they had smoked regularly in their lifetime, and 89% were current smokers. Forty-five percent of the current smokers reported that they had previously used NRT to support a quit attempt, with 54% reporting that they intended to use NRT to support a future quit attempt. Intentions to use NRT were not related to the participants' mental health status or the participants' perceptions regarding the safety or potential drawbacks associated with using NRT. However, participants were more likely to report that they would use NRT to support future quit attempts if they were female, had previously used NRT, and perceived NRT to be effective. CONCLUSIONS Improving the use of evidence-based smoking cessation strategies within substance use treatment continues to be a priority. To enhance the use of NRT among consumers attending mental health and addiction treatment services, NRT should be universally offered. Future research should consider strategies that help to improve participants' positive perceptions regarding the efficacy of NRT.
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Affiliation(s)
- Peter J Kelly
- a Illawarra Institute for Mental Health, School of Psychology, University of Wollongong , Wollongong , New South Wales , Australia
| | - Camilla J Townsend
- a Illawarra Institute for Mental Health, School of Psychology, University of Wollongong , Wollongong , New South Wales , Australia
| | - Briony A Osborne
- a Illawarra Institute for Mental Health, School of Psychology, University of Wollongong , Wollongong , New South Wales , Australia
| | - Amanda L Baker
- b School of Medicine and Public Health, Faculty of Health, University of Newcastle , Newcastle , New South Wales , Australia
| | - Frank P Deane
- a Illawarra Institute for Mental Health, School of Psychology, University of Wollongong , Wollongong , New South Wales , Australia
| | - Carol Keane
- a Illawarra Institute for Mental Health, School of Psychology, University of Wollongong , Wollongong , New South Wales , Australia
| | - Isabella Ingram
- a Illawarra Institute for Mental Health, School of Psychology, University of Wollongong , Wollongong , New South Wales , Australia
| | - Joanne Lunn
- c We Help Ourselves, Rozelle , Sydney , New South Wales , Australia
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Gass JC, Morris DH, Winters J, VanderVeen JW, Chermack S. Characteristics and clinical treatment of tobacco smokers enrolled in a VA substance use disorders clinic. J Subst Abuse Treat 2018; 84:1-8. [PMID: 29195588 DOI: 10.1016/j.jsat.2017.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 11/29/2022]
Abstract
Individuals with a substance use disorder (SUD) diagnosis are more than twice as likely to smoke cigarettes as the general population. Emerging research has suggested that treating a substance use disorder simultaneously with tobacco use leads to a higher rate of treatment success for both substances. Despite this, substance use treatment protocols tend not to focus on tobacco use; in fact, traditional substance use treatments often discourage patients from attempting to quit smoking. One rationale is that patients may not be motivated to quit smoking. In the current study, data from veterans enrolled in outpatient treatment for a SUD were examined to assess for general characteristics of smokers as compared to non-smokers as well as to examine motivation to quit smoking. Baseline (i.e., pre-treatment) data from 277 Veterans were used. Charts of smokers in the SUD clinic (SUDC) were reviewed to assess how smoking is handled by SUDC providers, and if smokers attempt cessation. Of 277, 163 (59%) SUDC patients reported that they currently smoke cigarettes (M=16.3 cigarettes per day, SD=11.1). Smokers in the clinic reported greater general impairment than nonsmokers on the Short Index of Problems, F(1248)=8.9, p=0.003, as well as greater specific impairment: Physical Problems, F(1258)=13.5, p=0.000; Interpersonal Problems, F(1262)=5.6, p=0.019; Intrapersonal Problems, F(1260)=6.5, p=0.011, and Social Responsibility, F(1262)=14.7, p=0.000. Smokers in the sample were marginally more anxious than their non-smoking counterparts as measured by the GAD-7, F(1254)=4.6, p=0.053, though they were not significantly more depressed (p=0.19). On a 1-10 scale, smokers reported moderate levels of importance (M=5.4, SD=3.1), readiness (M=5.6, SD=3.2), and confidence (M=5.0, SD=3.0) regarding quitting smoking. Review of smokers' medical records reveal that while SUDC providers assess tobacco use at intake (90%) and offer treatment (86.5%), a substantially small portion of smokers attempt cessation (41.1%) while enrolled in SUDC. Moreover, no patients were enrolled in smoking-specific behavioral interventions while in SUDC, though 78 patients did obtain nicotine replacement or another smoking cessation medication (41% were prescribed by a SUDC provider). Contrary to the belief that treatment-seeking substance users are not motivated to quit smoking, these preliminary analyses demonstrate that Veterans were at least contemplating quitting smoking while they were enrolled in substance use treatment. Further, there is evidence that cigarette smokers have greater impairment caused by substance use, suggesting that this subgroup is of particular high need. Specific treatment recommendations are discussed, including how behavioral health providers in SUD clinics may be better able to capitalize on patients' moderate motivation to quit at intake.
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Affiliation(s)
- Julie C Gass
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States.
| | - David H Morris
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan, Ann Arbor, MI 48109, United States
| | - Jamie Winters
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan, Ann Arbor, MI 48109, United States
| | - Joseph W VanderVeen
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan, Ann Arbor, MI 48109, United States
| | - Stephen Chermack
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan, Ann Arbor, MI 48109, United States
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Han BH, Sherman SE, Link AR, Wang B, McNeely J. Comparison of the Substance Use Brief Screen (SUBS) to the AUDIT-C and ASSIST for detecting unhealthy alcohol and drug use in a population of hospitalized smokers. J Subst Abuse Treat 2017; 79:67-74. [PMID: 28673530 PMCID: PMC5966314 DOI: 10.1016/j.jsat.2017.05.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 05/29/2017] [Accepted: 05/30/2017] [Indexed: 11/25/2022]
Abstract
Hospitalized patients have high rates of unhealthy substance use, which has important impacts on health both during and after hospitalization, but is infrequently identified in the absence of screening. The Substance Use Brief Screen (SUBS) was developed as a brief, self-administered instrument to identify use of tobacco, alcohol, illicit drugs, and non-medical use of prescription drugs, and was previously validated in primary care patients. This study assessed the diagnostic accuracy of the SUBS in comparison to longer screening instruments to identify unhealthy and high-risk alcohol and drug use in hospitalized current smokers. Participants were 439 patients, aged 18 and older, who were admitted to either two urban safety-net hospitals in New York City and enrolled in a smoking cessation trial. We measured the performance of the SUBS for identifying illicit drug and non-medical use of prescription drugs in comparison to a modified Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and its performance for identifying excessive alcohol use in comparison to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). At the standard cutoff (response other than 'never' indicates a positive screen), the SUBS had a sensitivity of 98% (95% CI 95-100%) and specificity of 61% (95% CI 55-67%) for unhealthy alcohol use, a sensitivity of 85% (95% CI 80-90%) and specificity of 75% (95% CI 78-87%) for illicit drug use, and a sensitivity of 73% (95% CI 61-83%) and specificity of 83% (95% CI 78-87%) for prescription drug non-medical use. For identifying high-risk use, a higher cutoff (response of '3 or more days' of use indicates a positive screen), the SUBS retained high sensitivity (77-90%), and specificity was 62-88%. The SUBS can be considered as an alternative to longer screening instruments, which may fit more easily into busy inpatient settings. Further study is needed to evaluate its validity using gold standard measures in hospitalized populations.
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Affiliation(s)
- Benjamin H Han
- New York University School of Medicine, Department of Medicine, United States; Center for Drug Use and HIV Research, New York University College of Nursing, United States; New York University School of Medicine, Department of Population Health, United States.
| | - Scott E Sherman
- New York University School of Medicine, Department of Medicine, United States; Center for Drug Use and HIV Research, New York University College of Nursing, United States; New York University School of Medicine, Department of Population Health, United States
| | - Alissa R Link
- New York University School of Medicine, Department of Population Health, United States
| | - Binhuan Wang
- New York University School of Medicine, Department of Population Health, United States
| | - Jennifer McNeely
- New York University School of Medicine, Department of Medicine, United States; Center for Drug Use and HIV Research, New York University College of Nursing, United States; New York University School of Medicine, Department of Population Health, United States
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9
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Apollonio D, Philipps R, Bero L. Interventions for tobacco use cessation in people in treatment for or recovery from substance use disorders. Cochrane Database Syst Rev 2016; 11:CD010274. [PMID: 27878808 PMCID: PMC6464324 DOI: 10.1002/14651858.cd010274.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Smoking rates in people with alcohol and other drug dependencies are two to four times those of the general population. Concurrent treatment of tobacco dependence has been limited due to concern that these interventions are not successful in this population or that recovery from other addictions could be compromised if tobacco cessation was combined with other drug dependency treatment. OBJECTIVES To evaluate whether interventions for tobacco cessation are associated with tobacco abstinence for people in concurrent treatment for or in recovery from alcohol and other drug dependence. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and clinicaltrials.gov databases, with the most recent search completed in August 2016. A grey literature search of conference abstracts from the Society on Nicotine Research and Treatment and the ProQuest database of digital dissertations yielded one additional study, which was excluded. SELECTION CRITERIA We included randomised controlled trials assessing tobacco cessation interventions among people in concurrent treatment for alcohol or other drug dependence or in outpatient recovery programmes. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study risk of bias and extracted data. We resolved disagreements by consensus. The primary outcome was abstinence from tobacco use at the longest period of follow-up, and the secondary outcome was abstinence from alcohol or other drugs, or both. We reported the strictest definition of abstinence. We summarised effects as risk ratios and 95% confidence intervals (CI). Two clustered studies did not provide intraclass correlation coefficients, and were excluded from the sensitivity analysis. We used the I2 statistic to assess heterogeneity. MAIN RESULTS Thirty-five randomised controlled trials, one ongoing, involving 5796 participants met the criteria for inclusion in this review. Included studies assessed the efficacy of tobacco cessation interventions, including counselling, and pharmacotherapy consisting of nicotine replacement therapy (NRT) or non-NRT, or the two combined, in both inpatient and outpatient settings for participants in treatment and in recovery. Most studies did not report information to assess the risk of allocation, selection, and attrition bias, and were classified as unclear.Analyses considered the nature of the intervention, whether participants were in treatment or recovery and the type of dependency. Of the 34 studies included in the meta-analysis, 11 assessed counselling, 11 assessed pharmacotherapy, and 12 assessed counselling in combination with pharmacotherapy, compared to usual care or no intervention. Tobacco cessation interventions were significantly associated with tobacco abstinence for two types of interventions. Pharmacotherapy appeared to increase tobacco abstinence (RR 1.60, 95% CI 1.22 to 2.12, 11 studies, 1808 participants, low quality evidence), as did combined counselling and pharmacotherapy (RR 1.74, 95% CI 1.39 to 2.18, 12 studies, 2229 participants, low quality evidence) at the period of longest follow-up, which ranged from six weeks to 18 months. There was moderate evidence of heterogeneity (I2 = 56% with pharmacotherapy and 43% with counselling plus pharmacotherapy). Counselling interventions did not significantly increase tobacco abstinence (RR 1.33, 95% CI 0.90 to 1.95).Interventions were significantly associated with tobacco abstinence for both people in treatment (RR 1.99, 95% CI 1.59 to 2.50) and people in recovery (RR 1.33, 95% CI 1.06 to 1.67), and for people with alcohol dependence (RR 1.47, 95% CI 1.20 to 1.81) and people with other drug dependencies (RR 1.85, 95% CI 1.43 to 2.40).Offering tobacco cessation therapy to people in treatment or recovery for other drug dependence was not associated with a difference in abstinence rates from alcohol and other drugs (RR 0.97, 95% CI 0.91 to 1.03, 11 studies, 2231 participants, moderate evidence of heterogeneity (I2 = 66%)).Data on adverse effect of the interventions were limited. AUTHORS' CONCLUSIONS The studies included in this review suggest that providing tobacco cessation interventions targeted to smokers in treatment and recovery for alcohol and other drug dependencies increases tobacco abstinence. There was no evidence that providing interventions for tobacco cessation affected abstinence from alcohol and other drugs. The association between tobacco cessation interventions and tobacco abstinence was consistent for both pharmacotherapy and combined counselling and pharmacotherapy, for participants both in treatment and in recovery, and for people with alcohol dependency or other drug dependency. The evidence for the interventions was low quality due primarily to incomplete reporting of the risks of bias and clinical heterogeneity in the nature of treatment. Certain results were sensitive to the length of follow-up or the type of pharmacotherapy, suggesting that further research is warranted regarding whether tobacco cessation interventions are associated with tobacco abstinence for people in recovery, and the outcomes associated with NRT versus non-NRT or combined pharmacotherapy. Overall, the results suggest that tobacco cessation interventions incorporating pharmacotherapy should be incorporated into clinical practice to reduce tobacco addiction among people in treatment for or recovery from alcohol and other drug dependence.
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Affiliation(s)
- Dorie Apollonio
- University of California San FranciscoClinical Pharmacy3333 California StreetSuite 420San FranciscoCAUSA94143‐0613
| | | | - Lisa Bero
- Charles Perkins Centre and Faculty of Pharmacy, University of Sydney6th Floor (6W76)The University of SydneySydneyNew South Wales 2006Australia
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Guydish J, Tajima B, Pramod S, Le T, Gubner NR, Campbell B, Roman P. Use of multiple tobacco products in a national sample of persons enrolled in addiction treatment. Drug Alcohol Depend 2016; 166:93-9. [PMID: 27449271 PMCID: PMC4983463 DOI: 10.1016/j.drugalcdep.2016.06.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 06/27/2016] [Accepted: 06/28/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To explore use of tobacco products in relationship to marketing exposure among persons in addiction treatment. METHOD A random sample of treatment programs was drawn from the National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN). Participants in each program completed surveys concerning use of tobacco products (N=1113). Exposure to tobacco marketing and counter-marketing, advertising receptivity, and perceived health risks of smoking were tested for their association with use of multiple tobacco products. RESULTS Prevalence of combustible cigarette use was 77.9%. Weekly or greater use of other products was: e-cigarettes (17.7%), little filtered cigars (8.6%), smokeless tobacco (5.2%), and standard cigars (4.6%) with 24.4% using multiple tobacco products. Compared to single product users, multiple product users smoked more cigarettes per day (OR=1.03, 95% CI 1.01-1.05, p<0.001), were more likely to have tried to quit (OR=1.41, 95% CI 1.02-1.96, p=0.041), reported greater daily exposure to advertising for products other than combustible cigarettes (OR=1.93, CI 1.35-2.75, p<0.001), and greater daily exposure to tobacco counter-marketing (OR=1.70, 95% CI: 1.09-2.63, p=0.019). CONCLUSION Heavier smokers and those trying to quit may be more likely to use e-cigarettes, little filtered cigars, or smokeless tobacco and have greater susceptibility to their advertising. This highlights the importance of regulating advertising related to smoking cessation as their effectiveness for this purpose has not been demonstrated.
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Affiliation(s)
- Joseph Guydish
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118, United States.
| | - Barbara Tajima
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118
| | - Sowmya Pramod
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118
| | - Thao Le
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118
| | - Noah R. Gubner
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118
| | - Barbara Campbell
- Department of Public Health and Preventive Medicine, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098
| | - Paul Roman
- Center for Research on Behavioral Health and Human Service Delivery, Owens Institute for Behavioral Research, 106 Barrow Hall, University of Georgia, Athens, GA 30602
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Guydish J, Yu J, Le T, Pagano A, Delucchi K. Predictors of Tobacco Use Among New York State Addiction Treatment Patients. Am J Public Health 2015; 105:e57-e64. [PMID: 25393179 DOI: 10.2105/ajph.2014.302096] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Joseph Guydish
- Joseph Guydish and Thao Le are with the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. Jiang Yu is with the School of Social Welfare, University at Albany, State University of New York. Anna Pagano and Kevin Delucchi are with the Department of Psychiatry, University of California, San Francisco
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12
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Martínez C, Guydish J, Le T, Tajima B, Passalacqua E. Predictors of quit attempts among smokers enrolled in substance abuse treatment. Addict Behav 2015; 40:1-6. [PMID: 25218064 DOI: 10.1016/j.addbeh.2014.08.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 03/31/2014] [Accepted: 08/20/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION This study investigates factors predicting past year quit attempts among smokers enrolled in substance abuse treatment in New York State. METHODS Data were drawn from two prior cross-sectional surveys conducted among clients treated in 10 randomly selected substance abuse treatment programs. Among 820 clients recruited, 542 self-identified as current smokers, and 485 provided information about their quit attempts. The main outcome was reporting a quit smoking attempt in the past year, dichotomized as quit attempters or non-quit attempters. Univariate and multivariate logistic regression analyses were performed to explore predictors of attempting to quit. RESULTS Half of substance abuse clients in treatment programs reported a past year quit attempt. Quit attempters were more likely to be in a preparation and contemplation stage of change (preparation: OR=2.68, 95% CI: 1.51-4.77; contemplation: OR=2.96 95% CI: 1.61-5.42), reported more positive attitudes toward quitting (OR=1.49; 95% CI: 1.11-1.99) and received more cessation services than non-quit attempters (OR=1.21; 95% CI: 1.11-1.99). CONCLUSIONS Addressing patient attitudes about quitting smoking, having clinicians address smoking in the course of addiction treatment, and offering interventions to increase readiness to quit may contribute to increased quit attempts in smokers enrolled in addiction treatment programs.
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Affiliation(s)
- Cristina Martínez
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA; Cancer Prevention and Control Group, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, Barcelona, Spain; Medicine and Health Sciences School, Universitat Internacional de Catalunya, Barcelona, Spain.
| | - Joseph Guydish
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - Thao Le
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - Barbara Tajima
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - Emma Passalacqua
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
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Golenkov AV, Kozlov VA, Sapozhnikov SP, Trofimova IN, Mikhaylov IV. A clinical and psychological study of tobacco dependence in patients with alcoholism. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:40-45. [DOI: 10.17116/jnevro20151154240-45] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Alzyoud S, Kheirallah KA, Weglicki LS, Ward KD, Al-Khawaldeh A, Shotar A. Tobacco smoking status and perception of health among a sample of Jordanian students. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2014; 11:7022-35. [PMID: 25019264 PMCID: PMC4113858 DOI: 10.3390/ijerph110707022] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 06/05/2014] [Accepted: 06/27/2014] [Indexed: 11/23/2022]
Abstract
Limited data are available from Jordan examining patterns of tobacco use among adolescents, or how use is related to health perceptions. This study aims to estimate the prevalence of tobacco use and to assess the relationship between use and health-related perceptions. A cross-sectional survey was conducted among a sample of 11–18 year old school students from a major governorate in Jordan. Using a multistage random sampling 1050 students were selected. Students were categorized as non-smokers, cigarette-only smokers, waterpipe-only smokers, or dual smokers. Rates of waterpipe-only and cigarette-only smoking were 7% and 3%, respectively, and were similar for boys and girls. In contrast, the rate of dual use was much higher than for single product use and was double in girls compared to boys (34% vs. 17%). Dual-smokers were significantly more likely to think that it is safe to smoke as long as the person intends to quit within two years compared to non-smokers, and had lower self-rated health status than other groups. This is the first study among Arab adolescents to document high rates of dual tobacco use, especially pronounced among girls. The study findings have significant implications for designing tobacco smoking prevention programs for school health settings.
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Affiliation(s)
- Sukaina Alzyoud
- Department of Community and Mental Health, Faculty of Nursing, Hashemite University, P.O. Box 150459, Zarqa 13115, Jordan.
| | - Khalid A Kheirallah
- Department of Public Health, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan.
| | - Linda S Weglicki
- College of Nursing, Wayne State University, Detroit, MI 48202, USA.
| | - Kenneth D Ward
- Division of Social and Behavioral Sciences, School of Public Health, University of Memphis, Memphis, TN 38152, USA.
| | - Abdallah Al-Khawaldeh
- Department of Community and Mental Health, Faculty of Nursing, Hashemite University, P.O. Box 150459, Zarqa 13115, Jordan
| | - Ali Shotar
- Department of Legal Medicine, Toxicology and Forensic science, School of Medicine, Jordan University of Science and Technology (JUST), P.O. Box 3030, Irbid 22110, Jordan.
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Apollonio D, Philipps R, Bero L. Interventions for tobacco use cessation in people in treatment for or recovery from substance abuse. Cochrane Database Syst Rev 2012; 12:1-10. [PMID: 23833567 PMCID: PMC3698983 DOI: 10.1002/14651858.cd010274] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This is the protocol for a review and there is no abstract. The objectives are as follows: To evaluate the effectiveness of tobacco cessation therapy offered concurrently with treatment for drug and alcohol addiction.
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Affiliation(s)
- Dorie Apollonio
- Clinical Pharmacy, University of California San Francisco, San Francisco, CA, USA
| | - Rose Philipps
- Clinical Pharmacy, University of California San Francisco, San Francisco, CA, USA
| | - Lisa Bero
- Department of Clinical Pharmacy and Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
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