Implementation of a tobacco-free regulation in substance use disorder treatment facilities

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Policy and Practice Changes Associated with a Tobacco-Free Initiative in Residential Substance Use Disorder Treatment

A California-sponsored, 18-month, tobacco-free intervention in residential substance use disorder (SUD) programs was associated with increases in tobacco-free grounds and tobacco-related client services. The current study examined whether positive results would be replicated in 11 programs participating subsequently. Program directors (N = 11) completed surveys of tobacco-related policies pre- and post-intervention. Pre- (n = 163) and post-intervention (n = 128) cross-sectional staff surveys examined tobacco-related training, beliefs, practices, smoking policy, and smoking status. Directors reported increases in tobacco-free grounds (from 3 to 8 programs), tobacco-related staff training (1 to 10 programs), tobacco cessation staff services (1 to 9 programs) and nicotine replacement therapy (NRT) provision (6 to 10 programs). At post-intervention, staff were more likely to report smoke-free workplaces (p = 0.008), positive beliefs about treating tobacco use (p = 0.017) and less likely to report current smoking (p = 0.003). Clinical staff were more likely to report tobacco-related training receipt (p = 0.001), program-level NRT provision (p = 0.009) and conducting tobacco-related client services (p < 0.0001) post-intervention. Findings of increases in tobacco-free grounds and tobacco cessation client services corroborated prior results. These and the additional finding of decreases in staff smoking strengthen evidence that initiatives supporting tobacco-free policies can be successfully implemented in SUD treatment.

A cluster-randomized trial of a brief multi-component intervention to improve tobacco outcomes in substance use treatment

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.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Implementing tobacco-free policy in residential substance use disorders treatment: Practice changes among staff

Introduction

Implementing tobacco-free policies in substance use disorders (SUD) treatment may reduce tobacco-related, health disparities. This study examined adoption of tobacco-related policy and practices in six residential programs participating in a California-sponsored, 18-month, tobacco-free policy intervention.

Methods

Directors (N=6) completed surveys of tobacco-related policies before and after the intervention. Staff completed cross-sectional surveys assessing tobacco-related training, beliefs, practices, workplace smoking policy, tobacco cessation program services, and smoking status pre- (n=135) and post-intervention (n=144).

Results

Director surveys indicated no programs had tobacco-free grounds, one provided tobacco-related staff training, and two provided nicotine replacement therapy (NRT) pre-intervention. At post-intervention, 5 programs had implemented tobacco-free grounds, 6 provided tobacco cessation training, and 3 provided NRT. Across all programs, staff were more likely to report smoke-free workplaces (AOR = 5.76, 95% CI1.14,29.18) post- versus pre-intervention. Staff positive beliefs towards addressing tobacco use were higher post-intervention (p<0.001). Odds of clinical staff reporting tobacco-related training participation (AOR = 19.63, 95% CI14.21,27.13) and program-level provision of NRT (AOR = 4.01, 95% CI 1.54, 10.43) increased post- versus pre-intervention. Clinical staff reporting they provided tobacco cessation services were also higher post-intervention (p= 0.045). There were no changes in smoking prevalence or quit intention among smoking staff.

Conclusion

A tobacco-free policy intervention in SUD treatment was associated with implementation of tobacco-free grounds, tobacco-related training among staff, more positive staff beliefs towards and delivery of tobacco cessation services to clients. The model may be improved with greater emphasis on staff policy awareness, facilitating availability of NRT, and reducing staff smoking.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

CONCLUSION

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

Organizational-Level Moderators Impacting Tobacco-Related Knowledge Change after Tobacco Education Training in Substance Use Treatment Centers

Tobacco use is disproportionately elevated among patients with substance use disorders relative to the general U.S. population. Tobacco interventions are lacking within substance use treatment centers (SUTCs) due to lack of knowledge and training. This study examined knowledge gain and the organizational factors that might moderate knowledge gains following tobacco education training provided to employees (N = 580) within 15 SUTCs that were participating in a tobacco-free workplace program. The number of total annual patient visits, unique annual patient visits, number of full-time employees, and organizational readiness for implementing change (ORIC) as assessed prior to implementation were examined as potential moderators. Results demonstrated significant knowledge gain (p < 0.001) after training overall; individually, 13 SUTCs had significant knowledge gain (p's < 0.014). SUTCs with fewer total annual patient visits and fewer full-time employees showed greater knowledge gains. The ORIC total score and all but one of its subscales (Resource Availability) moderated knowledge gain. SUTCs with greater initial Change Efficacy (p = 0.029), Valence (p = 0.027), and Commitment (p < 0.001) had greater knowledge gain than SUTCs with lower scores on these constructs; SUTCs with greater Task Knowledge (p < 0.001) regarding requirements for change exhibited less knowledge gain. Understanding the organizational-level factors impacting training effectiveness can inform efforts in organizational change and tobacco control program implementation.

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

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

Tobacco use and tobacco services in California substance use treatment programs

BACKGROUND

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

METHODS

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

CONCLUSION

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

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

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

Integrating smoking cessation care in alcohol and other drug treatment settings using an organizational change intervention: a systematic review

BACKGROUND AND AIMS

Organizational change interventions involve systems and cultural change within health-care services to make smoking cessation care delivery part of usual treatment. Six strategies for organizational change have been proposed. This study examined the evidence for organizational change interventions in the alcohol and other drug (AOD) setting on: (a) smoking cessation care; and (b) smoking cessation and cessation-related outcomes.

METHODS

A systematic review with narrative synthesis was conducted. MEDLINE, PsycINFO, CINAHL, EMBASE and Scopus were searched using keywords and MeSH terms from database inception to 1 June 2018. Interventions were assessed against the six organizational change strategies.

RESULTS

Of the 5155 papers identified, 14 publications from seven unique studies were included. Most studies employed four or fewer organizational change strategies. The majority (n = 11) were rated weak to moderate in methodological quality. Nine published papers, four unique studies, examined staff reported provision of smoking cessation care; eight reported an increase, one found no change. Three papers, two unique studies, examined client receipt of care; all found significant increases. Three papers, two unique studies, assessed staff smoking prevalence from pre- to post-intervention. Only one study reported a significant reduction in staff smoking prevalence (35.2 versus 21.8%, P = 0.005). Nine papers, six unique studies, assessed client smoking cessation and smoking-related outcomes. Seven papers reported on client smoking prevalence; two found a significant decrease and five found no change to smoking. Four papers reported on number of cigarettes per day, three found a significant decrease and one found no change. Two papers reported on smoking cessation finding a 10% and a 25% seven-day point prevalence abstinence post-discharge from the AOD service.

CONCLUSIONS

Organizational change interventions within health-care services to make smoking cessation care delivery part of usual treatment offer promise for increasing smoking cessation care and reducing smoking prevalence.

Smoking Cessation for Those Pursuing Recovery from Substance Use Disorders

This article summarizes the literature regarding the similar biopsychosocial mechanisms of tobacco use and alcohol and substance use disorders, and the evidence for and against the provision of tobacco cessation for those in treatment for alcohol and substance use disorders. The practicality of treatment, focusing on methods, timing, and breadth of intervention strategies, are also presented. Common methodologies that may be used across tobacco use and alcohol and substance use disorder to prevent lapse and relapse are discussed. Physicians can and should adhere to the policy that tobacco use is a common and dangerous comorbid condition that demands concomitant treatment.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Availability of tobacco cessation services in substance use disorder treatment programs: Impact of state tobacco control policy

OBJECTIVE

Given the high prevalence of smoking among substance use disorder (SUD) patients, the specialty SUD treatment system is an important target for adoption and implementation of tobacco cessation (TC) services. While research has addressed the impact of tobacco control on individual tobacco consumption, largely overlooked in the literature is the potential impact of state tobacco control policies on availability of services for tobacco cessation. This paper examines the association between state tobacco control policy and availability of TC services in SUD treatment programs in the United States.

METHODS

State tobacco control and state demographic data (n=51) were merged with treatment program data from the 2012 National Survey of Substance Abuse Treatment Services (n=10.413) to examine availability of TC screening, counseling and pharmacotherapy services in SUD treatment programs using multivariate logistic regression models clustered at the state-level.

RESULTS

Approximately 60% of SUD treatment programs offered TC screening services, 41% offered TC counseling services and 26% offered TC pharmacotherapy services. Results of multivariate logistic regression showed the odds of offering TC services were greater for SUD treatment programs located in states with higher cigarette excise taxes and greater spending on tobacco prevention and control.

CONCLUSIONS

Findings indicate cigarette excise taxes and recommended funding levels may be effective policy tools for increasing access to TC services in SUD treatment programs. Coupled with changes to insurance coverage for TC under the Affordable Care Act, state tobacco control policy tools may further reduce tobacco use in the United States.

Facility-level, state, and financial factors associated with changes in the provision of smoking cessation services in US substance abuse treatment facilities: Results from the National Survey of Substance Abuse Treatment Services 2006 to 2012

Cigarette smoking is common among patients in substance abuse treatment. Tobacco control programs have advocated for integrated tobacco dependence treatment into behavioral healthcare, including within substance abuse treatment facilities (SATFs) to reduce the public health burden of tobacco use. This study used data from seven waves (2006 to 2012) of the National Survey of Substance Abuse Treatment Services (n=94,145) to examine state and annual changes in the provision of smoking cessation services within US SATFs and whether changes over time could be explained by facility-level (private vs public ownership, receipt of earmarks, facility admissions, acceptance of government insurance) and state-level factors (cigarette tax per pack, smoke free policies, and percent of CDC recommended tobacco prevention spending). Results showed that the prevalence of SATFs offering smoking cessation services increased over time, from 13% to 65%. The amount of tax per cigarette pack, accepting government insurance, government (vs private) ownership, facility admissions, and CDC recommended tobacco prevention spending (per state) were the strongest correlates of the provision of smoking cessation programs in SATFs. Facilities that received earmarks were less likely to provide cessation services. Adult smoking prevalence and state-level smoke free policies were not significant correlates of the provision of smoking cessation services over time. Policies aimed at increasing the distribution of tax revenues to cessation services in SATFs may offset tobacco-related burden among those with substance abuse problems.

Prevalence of and Factors Related to Tobacco Ban Implementation in Substance Use Disorder Treatment Programs

This study examined the prevalence of and factors (psychological climate for change and staff attributes) related to indoor and outdoor tobacco bans for patients, employees, and visitors in U.S. substance use disorder treatment programs. Data were collected from a random sample of 1,026 program administrators. Almost all programs banned tobacco use indoors and around one third banned tobacco use outdoors. When there was no tobacco ban, the majority of programs restricted smoking to designated indoor and/or outdoor areas. Further, all psychological climate for change factors (perceived program support, perceived tobacco culture, and tobacco ban beliefs) but none of the staff attributes (percentage licensed/certified clinicians, percentage clinicians with master's degrees, total staff with education in health-related field) were significantly related to the implementation of comprehensive tobacco bans (both indoors and outdoors).

A mixed-method systematic review and meta-analysis of mental health professionals' attitudes toward smoking and smoking cessation among people with mental illnesses

BACKGROUND AND AIMS

People with mental illnesses and substance abuse disorders are important targets for smoking cessation interventions. Mental health professionals (MHPs) are ideally placed to deliver interventions, but their attitudes may prevent this. This systematic review therefore aimed to identify and estimate quantitatively MHPs attitudes towards smoking and main barriers for providing smoking cessation support and to explore these attitudes in-depth through qualitative synthesis.

METHODS

The online databases AMED, EMBASE, Medline, PsychINFO, HMIC and CINAHL were searched in March 2015 using terms relating to three concepts: 'attitudes', 'mental health professionals' and 'smoking cessation'. Quantitative or qualitative studies of any type were included. Proportions of MHPs' attitudes towards smoking and smoking cessation were pooled across studies using random effects meta-analysis. Qualitative findings were evaluated using thematic synthesis.

RESULTS

Thirty-eight studies including 16 369 participants were eligible for inclusion. Pooled proportions revealed that 42.2% [95% confidence interval (CI) = 35.7-48.8] of MHPs reported perceived barriers to smoking cessation interventions, 40.5% (95% CI = 30.4-51.0) negative attitudes towards smoking cessation and 45.0% (95% CI = 31.9-58.4) permissive attitudes towards smoking. The most commonly held beliefs were that patients are not interested in quitting (51.4%, 95% CI = 33.4-69.2) and that quitting smoking is too much for patients to take on (38%, 95% CI = 16.4-62.6). Qualitative findings were consistent with quantitative results, revealing a culture of smoking as 'the norm' and a perception of cigarettes as a useful tool for patients and staff.

CONCLUSIONS

A significant proportion of mental health professionals hold attitudes and misconceptions that may undermine the delivery of smoking cessation interventions; many report a lack of time, training and confidence as main barriers to addressing smoking in their patients.

Implementation of smoking cessation treatment in substance use disorder treatment settings: a review

BACKGROUND

The high prevalence of smoking among individuals receiving treatment for substance use disorder (SUD) has led to repeated calls for integrating smoking cessation treatment into these settings.

OBJECTIVES

This review summarizes key findings from the research on the implementation of smoking cessation in SUD treatment.

METHODS

PubMed searches of articles published from 2000 to 2015 yielded 48 empirical studies that focused on the delivery of smoking cessation in the US specialty SUD treatment settings in which organizations and counselors were the unit of analysis. Most studies used observational designs to gather data from organizations and counselors. Organizational studies show that few SUD treatment programs offer cessation counseling or pharmacotherapy. Organizational barriers include limited training, inadequate resources, and cultural norms that do not recognize smoking cessation as part of the organization's mission. Smoking cessation services are more likely to be available in medically oriented treatment settings, larger treatment programs, those offering a broader array of comprehensive services, and those that are more reliant on fee-for-service reimbursement (e.g., insurance, Medicaid). Surveys of counselors also show very low implementation. Counselors' personal skills and attitudes, their perceptions of managerial and coworker support for smoking cessation, and the availability of resources and reimbursement to support these services are correlated with implementation. State policies requiring treatment programs to offer tobacco treatment increase both adoption and implementation, yet these services continue to reach only modest percentages of the patients.

CONCLUSIONS

Few studies have tested specific implementation strategies. Such research is needed to determine how to accelerate the diffusion of these evidence-based practices to the SUD treatment field.

Impact of institutional smoking bans on reducing harms and secondhand smoke exposure

BACKGROUND

Smoking bans or restrictions can assist in eliminating nonsmokers' exposure to the dangers of secondhand smoke and can reduce tobacco consumption amongst smokers themselves. Evidence exists identifying the impact of tobacco control regulations and interventions implemented in general workplaces and at an individual level. However, it is important that we also review the evidence for smoking bans at a meso- or organisational level, to identify their impact on reducing the burden of exposure to tobacco smoke. Our review assesses evidence for meso- or organisational-level tobacco control bans or policies in a number of specialist settings, including public healthcare facilities, higher education and correctional facilities.

OBJECTIVES

To assess the extent to which institutional smoking bans may reduce passive smoke exposure and active smoking, and affect other health-related outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE, EMBASE, and the reference lists of identified studies. We contacted authors to identify completed or ongoing studies eligible for inclusion in this review. We also checked websites of state agencies and organisations, such as trial registries. Date of latest searches was 22nd June 2015.

SELECTION CRITERIA

We considered studies that reported the effects of tobacco bans or policies, whether complete or partial, on reducing secondhand smoke exposure, tobacco consumption, smoking prevalence and other health outcomes, in public healthcare, higher educational and correctional facilities, from 2005 onwards.The minimum standard for inclusion was having a settings-level policy or ban implemented in the study, and a minimum of six months follow-up for measures of smoking behaviour. We included quasi-experimental studies (i.e. controlled before-and-after studies), interrupted time series as defined by the Cochrane Effective Practice and Organization of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

Two or more review authors independently assessed studies for inclusion in the review. Due to variation in the measurement of outcomes we did not conduct a meta-analysis for all of the studies included in this review, but carried out a Mantel-Haenszel fixed-effect meta-analysis, pooling 11 of the included studies. We evaluated all studies using a qualitative narrative synthesis.

MAIN RESULTS

We included 17 observational studies in this review. We found no randomized controlled trials. Twelve studies are based in hospitals, three in prisons and two in universities. Three studies used a controlled before-and-after design, with another site used for comparison. The remaining 14 studies used an uncontrolled before-and-after study design. Five studies reported evidence from two participant groups, including staff and either patients or prisoners (depending on specialist setting), with the 12 remaining studies investigating only one participant group.The four studies (two in prisons, two in hospitals) providing health outcomes data reported an effect of reduced secondhand smoke exposure and reduced mortality associated with smoking-related illnesses. No studies included in the review measured cotinine levels to validate secondhand smoke exposure. Eleven studies reporting active smoking rates with 12,485 participants available for pooling, but with substantial evidence of statistical heterogeneity (I² = 72%). Heterogeneity was lower in subgroups defined by setting, and provided evidence for an effect of tobacco bans on reducing active smoking rates. An analysis exploring heterogeneity within hospital settings showed evidence of an effect on reducing active smoking rates in both staff (risk ratio (RR) 0.71, 95% confidence interval ( CI) 0.64 to 0.78) and patients (RR 0.86, 95% CI 0.76 to 0.98), but heterogeneity remained in the staff subgroup (I² = 76%). In prisons, despite evidence of reduced mortality associated with smoking-related illnesses in two studies, there was no evidence of effect on active smoking rates (1 study, RR 0.99, 95% CI 0.84 to 1.16).We judged the quality of the evidence to be low, using the GRADE approach, as the included studies are all observational.

AUTHORS' CONCLUSIONS

We found evidence of an effect of settings-based smoking policies on reducing smoking rates in hospitals and universities. In prisons, reduced mortality rates and reduced exposure to secondhand smoke were reported. However, we rated the evidence base as low quality. We therefore need more robust studies assessing the evidence for smoking bans and policies in these important specialist settings.

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.

Smoking Behaviors and Attitudes Among Clients and Staff at New York Addiction Treatment Programs Following a Smoking Ban: Findings After 5 Years

INTRODUCTION

Addiction treatment clients are more likely to die of tobacco-related diseases than of alcohol or illicit drug-related causes. We aimed to assess smoking behavior, and smoking-related attitudes and services, in New York addiction treatment programs before a statewide smoking ban in treatment facilities was implemented (2008), 1 year (2009) and 5 years after implementation (2013).

METHODS

We conducted surveys at each time point with clients (N = 329, 341, and 353, respectively) and staff (N = 202, 203, and 166, respectively) from five residential and two methadone maintenance programs in New York State. At each data collection wave, questionnaires measured smoking behavior as well as smoking-related knowledge, attitudes, and experiences with tobacco cessation services as part of addiction treatment.

RESULTS

Staff smoking prevalence decreased from 35.2% in 2008 to 21.8% in 2013 (P = .005) while client smoking prevalence over the same period was unchanged (68.1% vs. 66.0%, P = .564). Among clients who smoked, mean cigarettes per day decreased from 13.7 (SD = 8.38) to 10.2 (SD = 4.44; P < .001). There were significant time-by-treatment-type interactions for client tobacco-related attitudes and cessation services received; and for staff self-efficacy and cessation services provided. In residential programs, scores for most items decreased (became less positive) in 2009 followed by a partial rebound in 2013. Methadone program scores tended to rise (become more positive) throughout the study period.

CONCLUSIONS

Staff and clients may respond differentially to tobacco-free policies depending on type of treatment program, and this finding may help to inform the implementation of tobacco-free policies in other statewide addiction treatment systems.

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.

Predictors of quit attempts among smokers enrolled in substance abuse treatment

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.

Counselor and clinical supervisor perceptions of OASAS tobacco-free regulation implementation extensiveness, perceived accountability, and use of resources

New York State required substance use disorder (SUD) treatment programs to be 100% tobacco-free in 2008. The current study examined counselor (N = 364) and clinical supervisor (N = 98) perceptions of how extensively the tobacco-free regulation was implemented in their treatment programs, perceived accountability for implementing the regulation, and use of OASAS-provided resources to aid implementation one year after the regulation went into effect. Results showed that compared to counselors, supervisors perceive greater implementation extensiveness and report using more resources, yet they perceive lower accountability. In addition, whereas perceived accountability is significantly and positively associated with implementation extensiveness perceptions for counselors, the relationship is negative for supervisors. The association between use of resources and implementation extensiveness perceptions is significant and positive for both counselors and supervisors. We conclude that implementation experiences differ between counselors and clinical supervisors, suggesting the importance of tailoring interventions to promote tobacco-free policies in SUD treatment programs.

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.

A quasi-experimental study examining New York State's tobacco-free regulation: effects on clinical practice behaviors

BACKGROUND

On July 24, 2008, New York State (NYS) became the first state to require all state-funded or state-certified substance use disorder (SUD) treatment organizations to be 100% tobacco-free and offer tobacco cessation (TC) treatment.

METHODS

The current study used a quasi-experimental, non-equivalent control group design with a pretest and posttest to examine the effect of the NYS tobacco-free regulation on three clinical practice behaviors (use of TC-related intake procedures, use of guideline recommended counseling for TC, and pharmacotherapy availability) in a diverse sample of SUD treatment programs. Repeated cross-sectional data were collected from NYS counselors (experimental group) and non-NYS counselors (control group) approximately 4 months pre-regulation (N=282 and 659, respectively) and 10-12 months post-regulation (N=364 and 733, respectively).

RESULTS

Using mixed-effects models, results at pre-regulation indicate no group differences in the three clinical practice behaviors. However, significant post-regulation effects were found such that the experimental group reports greater use of TC-related intake procedures, guideline recommended counseling, and availability of pharmacotherapy than the control group. Additionally, the experimental but not the control group shows increases in all three clinical practice behaviors from pre-regulation to post-regulation.

CONCLUSIONS

We conclude that the NYS tobacco-free regulation had a significant and positive effect on promoting patient TC efforts among counselors.

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.

Perceived implementation of the Office of Alcoholism and Substance Abuse Services (OASAS) tobacco-free regulation in NY State and clinical practice behaviors to support tobacco cessation: a repeated cross-sectional study

This study measured substance use disorder clinicians' perceptions regarding the implementation extensiveness of the Office of Alcohol and Substance Abuse Services (OASAS) tobacco-free regulation, passed in New York State in July of 2008, at three time-points and across organizations with varying characteristics. Repeated cross-sectional data were collected from clinicians approximately 4months pre-regulation (time 0, n=362), 10-12months post-regulation (time 1, n=462), and 20-24months post-regulation (time 2, n=509). Clinician perceptions of implementation extensiveness (number of required policies in effect), use of tobacco cessation-related intake procedures, and use of guideline recommended counseling for treating tobacco dependence are significantly greater at time 1 and time 2 compared to time 0. Additionally, differences are found in perceived implementation extensiveness based on hospital-based status, profit status, and level of care offered, although the pattern of effects differed some over the three time-points under investigation.

Sustainment of smoking cessation programs in substance use disorder treatment organizations

INTRODUCTION

The majority of individuals who enter substance use disorder (SUD) treatment also use tobacco. Integrating smoking cessation services into SUD treatment may have substantial public health benefits, but few studies have examined whether organizations offering counseling-based smoking cessation programs sustain them over time.

METHODS

This study examines sustainment of smoking cessation programs using 2 waves of data collected from 150 SUD treatment organizations. Data were collected in 2006-2008 and 2009-2010 using face-to-face interviews, telephone interviews, and mailed surveys. Logistic regression models of sustainment were estimated with administrators' attitudes toward smoking cessation and organizational barriers as covariates.

RESULTS

About 60.2% of these SUD treatment organizations sustained their counseling-based smoking cessation programs at follow-up. Sustainment was significantly more likely when administrators' baseline attitudes about the impact of smoking cessation on recovery were more supportive (odds ratio, OR = 1.84; 95% confidence interval, CI = 1.13-3.01; p =.015) and when programs were accredited (OR = 3.95, 95% CI = 1.65-9.50, p =.002). Worsening over time of barriers encompassing staff interest, staff skills, and competing treatment demands were negatively associated with sustainment (OR = 0.58, 95% CI = 0.42-0.81, p =.001).

CONCLUSIONS

These findings provided empirical support for theoretical perspectives regarding the importance of leadership and staff expertise in promoting sustainment of innovations over time. Although the majority of SUD treatment organizations sustained their smoking cessation programs, the 40% rate of discontinuation is concerning and highlights the ongoing challenges faced by tobacco control efforts in substance abuse treatment.