Smoking cessation care provision in Australian alcohol and other drug treatment services: A cross-sectional survey of staff self-reported practices

How do patients and staff in an opioid agonist treatment service view smoking cessation medications and e-cigarettes?

INTRODUCTION

Tobacco use and related mortality is common in people receiving opioid agonist treatment (OAT). Smoking cessation medications are available and e-cigarettes are increasingly recommended for high risk populations. This study explores experience, knowledge and attitudes around smoking cessation medications (nicotine replacement therapy [NRT], bupropion and varenicline) and e-cigarettes in patients and clinicians in two public Australian OAT clinics.

METHODS

Cross-sectional surveys of patients and clinicians and a randomly sampled retrospective medical record review. Patients were recruited through an advertisement in the clinic, and clinicians through advertisement at an educational session.

RESULTS

Ninety-one patients and 10 clinicians completed the surveys. Most patients had at least one quit attempt and 43% were currently trying to quit. There were high levels of exposure to NRT, lower levels with varenicline and very limited exposure to bupropion. Patients considered e-cigarettes most helpful, but were more likely to consider using NRT. Few patients reported smoking cessation interventions from their clinicians. Most clinicians identified high tobacco use prevalence, considered this problematic, but reported low rates of smoking cessation intervention. NRT was the preferred medication. E-cigarettes were not considered helpful. Sixty-six percent of the 140 records reviewed documented patients as smokers. Tobacco cessation medication was rarely discussed or provided.

DISCUSSION AND CONCLUSIONS

Patients report high rates of tobacco cessation planning, but low rates of intervention. Experience of varenicline and bupropion is limited. E-cigarettes were preferred over varenicline and bupropion. Improving patient's and clinician's knowledge of tobacco cessation medications could improve smoking cessation interventions and uptake of approved medications.

QuitNic: A Pilot Randomized Controlled Trial Comparing Nicotine Vaping Products With Nicotine Replacement Therapy for Smoking Cessation Following Residential Detoxification

Introduction

The QuitNic pilot trial aimed to test the feasibility of providing a nicotine vaping product (NVP) compared with combination nicotine replacement therapy (NRT) to smokers upon discharge from a smoke-free residential substance use disorder (SUD) treatment service.

Methods

QuitNic was a pragmatic two-arm randomized controlled trial. At discharge from residential withdrawal, 100 clients received telephone Quitline behavioral support and either 12-week supply of NRT or an NVP. Treatment adherence and acceptability, self-reported abstinence, cigarettes smoked per day (CPD), frequency of cravings, and severity of withdrawal symptoms were assessed at 6 and 12 weeks. Results are reported for complete cases and for abstinence outcomes, penalized imputation results are reported where missing is assumed smoking.

Results

Retention on was 63% at 6 weeks and 50% at 12 weeks. At 12 weeks, 68% of the NRT group reported using combination NRT while 96% of the NVP group used the device. Acceptability ratings for the products were high in both groups. At 12 weeks, 14% of the NVP group and 18% of the NRT group reported not smoking at all in the last 7 days. Mean CPD among continued smokers decreased significantly between baseline to 12 weeks in both groups; from 19.91 to 4.72 for the NVP group (p < .001) and from 20.88 to 5.52 in the NRT group (p < .001). Cravings and withdrawal symptoms significantly decreased for both groups.

Conclusions

Clients completing residential withdrawal readily engaged with smoking cessation post-treatment when given the opportunity. Further research is required to identify the most effective treatments postwithdrawal for this population at elevated risk of tobacco-related harm.

Trial registration number

ACTRN12617000849392

Implications

This pilot study showed that smoking cessation support involving options for nicotine replacement and Quitline-delivered cognitive behavioral counseling is attractive to people after they have been discharged from SUD treatment. Both nicotine vaping products and nicotine replacement therapies were highly acceptable and used by participants who reported reductions in cravings for cigarettes and perceptions of withdrawal symptoms and reductions in number of cigarettes smoked. Some participants self-reported abstinence from cigarettes—around one in five reported having quit smoking cigarettes at 12 weeks postdischarge. The results have significant public health implications for providing quit support following discharge from SUD treatment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Improved rates of treatment success following alcohol and other drug treatment among clients who quit or reduce their tobacco smoking

INTRODUCTION AND AIMS

Alcohol and other drug (AOD) treatment seekers who smoke tobacco are more likely to die of tobacco-related causes than those attributable to their primary drug of concern (PDOC), yet smoking cessation is frequently overlooked in the context of AOD treatment settings. We explored rates of AOD treatment success among participants who quit or continued smoking 12 months after initiating AOD treatment.

DESIGN AND METHODS

Secondary analysis of data from a prospective multisite naturalistic outcome study of 559 smokers recruited from 21 publicly funded specialist AOD services as part of the Patient Pathways National Project.

RESULTS

Only 7.1% of participants successfully quit smoking at 12-month follow-up; however, doing so was associated with a 30% increase in treatment success (i.e. reliable reductions in use of their PDOC) (χ² = 8.74, P = 0.003) and a 21% reduction in the severity of PDOC dependence (χ² = 4.559, P = 0.033). Furthermore, those who did not nominate tobacco as a drug of concern reported demographic characteristics indicative of greater social disadvantage.

DISCUSSION AND CONCLUSIONS

Despite low overall rates of smoking cessation, our findings suggest clients who do successfully quit have a greater likelihood of achieving reductions in PDOC use and dependence severity. These results reinforce efforts to promote more comprehensive, routine provision of smoking cessation care (i.e. counselling and nicotine replacement therapy). AOD treatment presents a crucial opportunity to deliver smoking cessation care to all clients who smoke, particularly those who are unconcerned about their use, as this group may stand to benefit most.

Systematic Review of Factors Influencing Smoking Following Release From Smoke-Free Prisons

INTRODUCTION

Given the current proliferation of prison smoke-free policies internationally, and the multiple benefits of continued smoking abstinence for correctional populations, improved understanding of factors influencing postrelease smoking abstinence is required to inform support strategies aimed at individuals exiting smoke-free prisons.

METHODS

We systematically searched health, social science, and criminal justice databases for studies relating to smoking behaviors among people released from smoke-free prisons. Studies were included if: they were published between January 1, 2000 and July 26, 2017; they were published in English; the population was people who were incarcerated or formerly incarcerated in prisons with total smoke-free policies; and the reported outcomes included measures of: (1) prerelease intention to smoke or remain abstinent from smoking following release, (2) smoking relapse or abstinence following release, or (3) quit attempts following postrelease smoking relapse. Both authors independently screened returned citations to assess eligibility and reviewed studies for methodological quality using the Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies.

RESULTS

Fifteen of 121 publications were included. The evidence base in this area is small, almost exclusively US-based, and is mostly methodologically weak. Interventions delivered both pre and postrelease, that strengthen intention to quit, integrate with other substance-use treatment, and facilitate social support for quitting may help maintain postrelease smoking abstinence.

CONCLUSIONS

There is an urgent need for high-quality research to inform interventions to reduce high smoking relapse rates upon release from smoke-free prisons, to extend the multiple benefits of continued smoking abstinence into the community.

IMPLICATIONS

Interventions designed to help people remain abstinent from tobacco following release from smoke-free prisons are an important opportunity to improve the health, finances, and well-being of this vulnerable population.

The provision of preventive care for modifiable health risk behaviours by clinicians within substance use treatment settings: A systematic review

People who use substances have a high prevalence of other modifiable health risk behaviours such as tobacco smoking which contribute to an increased mortality and morbidity. Preventive care can reduce the prevalence of such behaviours and is recommended by clinical practice guidelines. This review describes the prevalence of preventive care delivery by substance use treatment healthcare providers and examines differences by treatment setting. Five databases were searched for studies published between 2005 and 2017. Eligible studies reported levels of preventive care (assessment, brief advice and/or referral/follow-up) in substance use treatment services for tobacco smoking, nutrition or physical activity. Two reviewers independently conducted article screening, data extraction and methodological quality assessment. Sixteen studies were included and all except one investigated care provision for tobacco smoking only. Four studies reported care levels as a proportion and 12 studies reported care as a score-based mean. Client-reported receipt of smoking cessation care ranged from: 79-90% for assessment; 15-79% for brief advice; 0-30% for referral/follow-up. Meta-regression analyses of 12 studies found clinician-reported preventative care for tobacco smoking was more frequently reported in studies assessing care occurring across multiple substance use treatment settings, compared to studies reporting provision in inpatient only. This review indicated that, compared to smoking cessation care, little is known about the level of preventive care for nutrition or physical activity. Overall, the delivery of smoking cessation care reported was sub-optimal. High levels of assessment relative to brief advice and low levels of referral to ongoing assistance were indicated.

Smoking to fit a stigmatised identity? A qualitative study of marginalised young people in Australia

In countries with comprehensive tobacco control, smoking is increasingly denormalised, with smokers subject to social stigmatisation. Qualitative research and commentary about denormalisation and stigma has largely focused on the impact on current or former smokers. Little attention has been given to the interaction between existing stigma among socially marginalised and disadvantaged young people and its role in smoking uptake, maintenance and resistance to quitting, or remaining a non-smoker. This article draws on a qualitative (grounded theory) study of young people aged 16-25 years who attended social services for at-risk youth in an inner city area in Australia, to explore the intersection between stigmatised identity and smoking in a context of increasing smoking denormalisation. Drawing on theoretical conceptualisations of stigma, we outline processes by which participants accept and apply social labels, internalise or distance themselves from stigmatised identities, and the influence of labelling on smoking trajectories, to demonstrate how the persistent dilemma of stigma shapes and reinforces smoking behaviour. The study highlights the need for tobacco control initiatives to align and integrate with broader initiatives to address structural inequality and social disadvantage.