Smoking cessation among persons in recovery

Narcotics Anonymous attendees' perceptions and experiences of substitute behaviors in the Western Cape, South Africa

BACKGROUND

Much remains unknown about the dynamics of substitute behaviors during addiction recovery among persons attending recovery support groups. Insight into the nature, motives for, and course of substitute behaviors could help to shape recovery support and harm reduction services.

METHODS

Twenty-three semi-structured in-depth interviews (n = 14 males and n = 9 females) were conducted with a convenience sample of Narcotics Anonymous attendees from a number of groups in the Western Cape, South Africa. Participants ranged in age from 22-55 years (M = 39.3, SD = 9.35).

RESULTS

Thematic analysis yielded four themes: (i) substance-to-substance substitution; (ii) substance-to-behavior substitution; (iii) substitute behaviors and harm (reduction) and (iv) support needs to manage and resolve substitute behaviors. According to the study, participants' substitute behaviors developed across recovery stages; were temporary or long-term replacements for substance use disorders and were engaged for distraction, isolation from others, calming, assuaging boredom, keeping occupied, filling a perceived experiential void, modifying mood and to self-medicate. While substitutes were utilized for harm reduction or relapse prevention, the potential for ostensibly healthy behaviors to threaten recovery and lead to relapse was also recognized.

CONCLUSIONS

Self-monitoring, ongoing vigilance, and awareness of when substitutes become genuine addictions are critical for timely, suitable interventions.

Characterising smoking and smoking cessation attempts by risk of alcohol dependence: A representative, cross-sectional study of adults in England between 2014-2021

Background

There is a strong shared association between smoking tobacco and drinking alcohol. This study aimed to compare smoking prevalence and smoking characteristics in drinkers who were versus were not at risk of alcohol dependence in England.

Methods

We used cross-sectional data from a monthly, nationally representative survey of adults in England (weighted n=144,583) collected between 2014-2021. Smoking and smoking cessation attempt characteristics were regressed on to alcohol dependence (drinkers at risk versus not at risk), adjusting for survey year.

Findings

Past-year smoking prevalence was 63·3% (95% CI=59·7-66·8) among drinkers at risk of alcohol dependence compared with 18·7% (95% CI=18·4-18·9) among those not at risk, and 19·2% (95% CI=18·8-19·7) among non-drinkers. Among past-year smokers, drinkers at risk of alcohol dependence (versus not at risk) smoked more cigarettes per day (B=3·0, 95% CI=2·3-3·8) and were more likely to smoke their first cigarette within 5 (versus >60) minutes of waking (OR=2·81, 95% CI=2·25-3·51).

Interpretation

In a representative sample of adults in England, a graded effect was observed where smoking prevalence increased with level of alcohol consumption. Past-year smokers at risk of alcohol dependence had higher levels of cigarette dependence than drinkers not at risk. Therefore, smokers at risk of alcohol dependence are a high priority group to target to reduce smoking prevalence as part of the NHS long-term plan.

Funding

Cancer Research UK and the National Institute for Health Research.

Timing of smoking cessation treatment integrated into outpatient treatment with medications for opioid use disorder: Feasibility trial

INTRODUCTION

Cigarette smoking rates among individuals with opioid use disorder (OUD) are notoriously high and may be improved by considering the timing of treatment integration for these two substances. The current study examined the feasibility of a method for assessing the timing of integrating smoking cessation pharmacotherapy within three different phases of outpatient treatment with medication for OUD (MOUD).

METHODS

Seventy-four buprenorphine-maintained smokers were enrolled in a quasi-experimental study across three MOUD treatment phases: 0-90 (Phase 1), 91-365 (Phase 2), and > 365 days of MOUD treatment (Phase 3). During a 12-week varenicline-based intervention, the study assessed outcomes daily via text messages (cigarette smoking, varenicline adherence, side effects) or monthly at in-person visits (quit motivation and carbon monoxide levels).

RESULTS

Thirty-five participants completed the study, with a lower retention rate in Phase 1 (37.5%) relative to Phases 2 (53.5%) or 3 (57.1%). A trend occurred for Phase 1 participants to report aversive side effects (e.g., abnormal dreams, gastrointestinal distress) on more study days. Among completers, adherence to text messaging and varenicline use was high and independent of MOUD treatment phase. Participants in all phases reported declines in cigarette smoking and increases in quit motivation over time; the study observed biochemically verified tobacco abstinence among only a few participants from Phases 2 or 3.

CONCLUSIONS

This feasibility study demonstrates a method to evaluate the timing of treatment integration for cigarette smoking and MOUD. Method strengths include a study schedule that coincided with the MOUD clinic schedule and use of text messaging to encourage varenicline adherence and evaluate outcomes regularly.

Smoking status and quit behaviors among health center patients with substance use disorders: A national study

BACKGROUND

Despite a high prevalence of smoking among individuals with substance use disorders, tobacco dependence in this vulnerable population is undertreated.

METHODS

We analyzed data from 5592 adult (≥18 years old) respondents to the 2014 Health Center Patient Survey, a nationally representative cross-sectional survey of individuals who receive care at U.S. Federally Qualified Health Centers. We evaluated self-reported smoking status, smoking-related quit behaviors (having quit, wanting or attempting to quit in the past year, and planning to quit in the next 6 months), and receipt of advice to quit smoking among participants with and without alcohol use disorder (AUD) and drug use disorder (DUD).

RESULTS

Current smoking was common among individuals with AUD (64.3%) and DUD (55.0%). Few patients with AUD or DUD had quit smoking (16.7% and 24.0%, respectively). Smokers with AUD had higher odds of wanting to quit smoking in the past year (adjusted odds ratio = 2.88; 95% confidence interval = 1.19, 7.05), but were not more likely to have made a past-year quit attempt. DUD was not significantly associated with smoking-related quit behaviors. Smokers with AUD or DUD, as well as those who engaged in treatment for AUD or DUD, did not differ significantly from other smokers in receipt of advice to quit smoking.

CONCLUSIONS

Smokers with AUD and DUD were unlikely to have quit smoking despite interest in quitting. Our findings suggest a need for individualized tobacco treatment approaches in patients with AUD and DUD and missed opportunities to provide tobacco cessation counseling during addiction treatment.

Characteristics and clinical treatment of tobacco smokers enrolled in a VA substance use disorders clinic

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.

Cognitive-Behavioral Treatment of Nicotine Dependence for a Female With a History of Alcohol and Respiratory Problems

This case study describes the effectiveness of cognitive-behavioral therapy for nicotine dependence among smokers with comorbid alcohol dependence and severe respiratory difficulties. Although clinical practice guidelines exist for the treatment of nicotine dependence, smokers with complicated psychological and medical histories remain resilient to recommended treatments. Successfulsmoking cessation programs for these patients require a comprehensive biopsychosocial assessment as well as a tailored treatment approach. A theoretical and empirically based rationale for cognitive-behavioral treatment is provided followed by the development of a case conceptualization, course of treatment, use of assessment data, and recommendations.

An organisational change intervention for increasing the delivery of smoking cessation support in addiction treatment centres: study protocol for a randomized controlled trial

Background

The provision of smoking cessation support in Australian drug and alcohol treatment services is sub-optimal. This study examines the cost-effectiveness of an organisational change intervention to reduce smoking amongst clients attending drug and alcohol treatment services.

Methods/design

A cluster-randomised controlled trial will be conducted with drug and alcohol treatment centres as the unit of randomisation. Biochemically verified (carbon monoxide by breath analysis) client 7-day-point prevalence of smoking cessation at 6 weeks will be the primary outcome measure. The study will be conducted in 33 drug and alcohol treatment services in four mainland states and territories of Australia: New South Wales, Australian Capital Territory, Queensland, and South Australia. Eligible services are those with ongoing client contact and that include pharmacotherapy services, withdrawal management services, residential rehabilitation, counselling services, and case management services. Eligible clients are those aged over 16 years who are attending their first of a number of expected visits, are self-reported current smokers, proficient in the English language, and do not have severe untreated mental illness as identified by the service staff. Control services will continue to provide usual care to the clients. Intervention group services will receive an organisational change intervention, including assistance in developing smoke-free policies, nomination of champions, staff training and educational client and service resources, and free nicotine replacement therapy in order to integrate smoking cessation support as part of usual client care.

Discussion

If effective, the organisational change intervention has clear potential for implementation as part of the standard care in drug and alcohol treatment centres.

Trial registration

Australian and New Zealand Clinical Trials Registry, ACTRN12615000204549. Registered on 3 March 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1401-6) contains supplementary material, which is available to authorized users.

"First Things First": What is the First Thing?

This op-ed piece comments on the down-side of an otherwise useful 12-step slogan, "First Things First," which generally refers to staying sober (not drinking or using no matter what). While important, there are environmental, microsocial, psychiatric, and neurobiological considerations that may place other needs at an equal or higher priority than sobriety per se. That is, other changes may be needed to set the stage for, or enhance efforts at sobriety, prior to or concurrent with attempting to quit one's drug of choice. Perhaps slogans should be considered in a broader context and not be taken too literally.

A Perspective on Cigarette Smoking During Alcohol and Substance Use Treatment

Individuals in treatment for substance use continue to smoke at higher rates than the general population of the United States. This editorial presents a different perspective on cigarette smoking that might reflect aspects of the subculture of individuals who, representing a heterogeneous population, smoke while recovering from substance use associated problems. We discuss factors that independently and, in combination, influence cigarette smoking during treatment and recovery from substance use. We conclude that more qualitative research is needed to understand which factors, not typically emphasized in standard tobacco cessation programming, may contribute to cigarette smoking cessation for this population.

Cigarette smoking and drug use among a nationally representative sample of HIV-positive individuals

BACKGROUND AND OBJECTIVES

Among HIV-positive populations, the prevalence of cigarette smoking remains disproportionately high and is associated with significant morbidity and mortality. Little is known about this topic among HIV-positive persons in the general population.

METHODS

Data came from the 2005 to 2011 National Survey on Drug Use and Health (NSDUH) public use data files. Unadjusted and adjusted multinomial logistic regression analyses explored the associations between socio-demographic, drug and alcohol use, and drug and/or alcohol treatment characteristics with smoking status among HIV-positive individuals (n = 349).

RESULTS

More than 40% of the sample was current smokers. In adjusted analyses, females (aRRR = .11, 95% CI = .03-.41) and participants who had never been married (aRRR = .19, 95% CI = .05-.58), were more likely to be former smokers than never smokers. Females (aRRR = .37, 95% CI = .14-.96) and individuals older than age 35 (aRRR = .37, 95% CI = .16-.89) were less likely to be current smokers than never smokers. Conversely, previously married persons (aRRR = 5.72, 95% CI = 1.40-23.31), participants reporting binge drinking (aRRR = 5.96, 95% CI = 2.27-15.64), and lifetime drug or alcohol treatment (aRRR = 5.12, 95% CI = 2.09-12.55) were more likely to be current smokers than never smokers.

CONCLUSIONS

Findings help confirm the high prevalence of smoking among HIV-positive persons suggesting the need for integrated substance use and smoking cessation treatment among HIV-positives.

SCIENTIFIC SIGNIFICANCE

The present findings have implications for the development and implementation of targeted smoking cessation programs for HIV-positive smokers.

Current cigarette smoking among HIV-positive current and former drug users: associations with individual and social characteristics

Cigarette smoking is endemic among HIV-positive populations and is related to substantial morbidity and mortality. Research has largely focused on individual-level characteristics associated with smoking, with less attention to social factors. We aimed to explore individual- and social-level characteristics associated with current cigarette smoking among people living with HIV. Data came from 358 individuals on antiretroviral therapy interviewed in a study on informal HIV caregiving, conducted in Baltimore, MD, USA. Most participants (75 %) were current smokers and 45 % reported current illegal drug use. In adjusted logistic regression analyses, current drug use (aOR 2.90, 95 % CI 1.58-5.30), 12-step program participation (aOR 1.74, 95 % CI 1.02-2.97), and having a main Supporter who is a current smoker (aOR 1.93, 95 % CI 1.12-3.33) were associated with current smoking. Findings suggest the importance of social-level factors in cigarette smoking among HIV seropositive drug users and have implications for developing targeted smoking cessation interventions for smokers living with HIV.

Cigarette exposure, dependence, and craving are related to insula thickness in young adult smokers

The age period spanning late adolescence to emergent adulthood is associated with the highest prevalence of cigarette smoking in the United States, and is also a time of continued brain development. Nonetheless, although prior research has shown group differences in brain structure associated with smoking status in adults, few studies have examined how smoking and associated behavioral states relate to brain structure in this age group. Neuroimaging and lesion studies have suggested that the insula, a cortical region that integrates heterogeneous signals about internal states and contributes to executive functions, plays an important role in cigarette smoking behavior. Using high-resolution structural magnetic resonance imaging, we therefore measured cortical thickness of the insula in 18 smokers and 24 nonsmokers between the ages of 16 and 21 years. There were no group differences in insula thickness, but cigarette exposure (pack-years) was negatively associated with thickness in right insula. Cigarette dependence and the urge to smoke were negatively related to cortical thickness in the right ventral anterior insula. Although the results do not demonstrate causation, they do suggest that there are effects of cigarette exposure on brain structure in young smokers, with a relatively short smoking history. It is possible that changes in the brain due to prolonged exposure or to the progression of dependence lead to more extensive structural changes, manifested in the reported group differences between adult smokers and nonsmokers. Structural integrity of the insula may have implications for predicting long-term cigarette smoking and problems with other substance abuse in this population.

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

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

Implementation of a Smoking Cessation Treatment Study at Substance Abuse Rehabilitation Programs: Smoking Behavior and Treatment Feasibility Across Varied Community-based Outpatient Programs

Cigarette smoking is widely prevalent among individuals in treatment for drug or alcohol dependence; however, the treatment of nicotine addiction in this population has numerous obstacles at both programmatic and patient levels. Despite these difficulties, recent studies have demonstrated moderate success in implementing smoking cessation treatment in drug rehabilitation programs. The National Drug Abuse Treatment Clinical Trials Network sponsored a smoking cessation study in 13 community-based outpatient substance abuse rehabilitation programs across the country. The study evaluated the effectiveness of smoking cessation treatment provided as an adjunct to substance abuse treatment-as-usual. This report summarizes the practical and clinical experiences encountered at each of the study sites with regard to implementing the smoking cessation treatment intervention. Smoking behavior of the treatment clientele was assessed by anonymous survey at each site. In addition, sites were systematically characterized by using program review and assessment tools completed by the respective staff and program directors at the site. Survey and recruitment data indicated that cigarette smoking is more prevalent and that smoking cessation treatment is more feasible, in methadone maintenance treatment programs. Other factors associated with smoking behavior and with the recruitment of drug- and alcohol-dependent individuals into the smoking cessation treatment study are described.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cigarette smoking and short-term addiction treatment outcome

Cigarette smoking is common among patients in cocaine and opioid dependence treatment, and may influence treatment outcome. We addressed this issue in a secondary analysis of data from an outpatient clinical trial of buprenorphine treatment for concurrent cocaine and opioid dependence (13 weeks, N=200). The association between cigarette smoking (lifetime cigarette smoking status, number of cigarettes smoked per day prior to study entry) and short-term treatment outcome (% of urine samples positive for cocaine or opioids, treatment retention) was evaluated with analysis of covariance, bivariate correlations, and multivariate linear regression. Nicotine-dependent smokers (66% of participants) had a significantly higher percentage of cocaine-positive urine samples than non-smokers (12% of participants) (76% vs. 62%), but did not differ in percentage of opioid-positive urine samples or treatment retention. Number of cigarettes smoked per day at baseline was positively associated with percentage of cocaine-positive urine samples, even after controlling for baseline sociodemographic and drug use characteristics, but was not significantly associated with percentage of opioid-positive urine samples or treatment retention. These results suggest that cigarette smoking is associated with poorer short-term outcome of outpatient treatment for cocaine dependence, but perhaps not of concurrent opioid dependence, and support the importance of offering smoking cessation treatment to cocaine-dependent patients.

Counselors' knowledge of the adoption of tobacco cessation medications in substance abuse treatment programs

This study assessed counselors' knowledge of the adoption of evidence-based tobacco cessation medications (TCMs)--varenicline, bupropion, and five nicotine replacement therapies (NRTs)--and predictors of adoption in diverse substance abuse treatment settings. We used Managing Effective Relationships in Treatment Services (MERITS I) data from 658 counselors working in 26 programs. Adoption of varenicline was reported by 16% of counselors, bupropion by 11%, and NRTs by 27%. Knowledge of the adoption of all types of TCMs was more likely to be reported by counselors who worked in treatment programs that adhered less to a 12-step orientation and restricted outdoor smoking for employees. Several additional unique predictors of varenicline and NRTs were identified. 

Cigarette smoking knowledge, attitudes, and practices of patients and staff at a perinatal substance abuse treatment center

This study compares cigarette smoking knowledge, attitudes, and practices (S-KAP) of opioid- and other substance-dependent patients and their multidisciplinary staff at an outpatient perinatal substance abuse treatment center. Consenting patients (n = 95) and staff (n = 41) concurrently completed a modified form of the S-KAP survey instrument. Ninety-five percent of patients reported currently smoking, and half endorsed wanting "to quit smoking now." This patient desire to quit smoking was significantly underrated by staff compared to the patients themselves (p = .028). Both patients and staff demonstrated suboptimal knowledge of smoking health risks, but 73% of patients reported trying to quit with past pregnancies to avoid harm to the fetus/baby. Although results show that patients could benefit from smoking cessation strategies centered on smoking's fetal/neonatal health risks, organizational interventions that focus on changing staff attitudes about patient desire to quit smoking may first need to be implemented.

Women and tobacco control policies: social-structural and psychosocial contributions to vulnerability to tobacco use and exposure

This article explores the psychosocial and social-structural vulnerability in relation to women's tobacco use, smoke exposure and responses to policy, and examines these issues in the context of women's lives and roles, describing forward looking strategies that could improve research and equity in outcomes for women. Various literatures on smoking among women and girls, and how women and sub-populations of women respond to tobacco control policies are reviewed. Specific sub-populations exhibiting more tobacco use and exposure are described, such as young pregnant and mothering women and low-income women. Emerging evidence also reveals links between smoking and experiences such as childhood sexual abuse, interpersonal violence, post-traumatic stress disorder, mental health issues and alcohol and drug dependence. Varied sub-populations of women respond in different ways to price and taxation, sales restrictions and location restrictions. However, tobacco control policies have, to date, been fashioned as broad instruments, not taking into account social context, trauma backgrounds, gendered roles such as mothering, unequal power relations affecting women in relationships and workplaces, and differences in access to resources and social support. When these issues are considered, the implications for tobacco policy development include: widening the policy purview, accounting for uneven and differential responses to policies, committing to an ethical framework, extending sex, gender and diversity based analyses, and improving research methods and approaches.

Smoking cessation during alcohol treatment: a randomized trial of combination nicotine patch plus nicotine gum

AIMS

The primary aim was to compare the efficacy of smoking cessation treatment using a combination of active nicotine patch plus active nicotine gum versus therapy consisting of active nicotine patch plus placebo gum in a sample of alcohol-dependent tobacco smokers in an early phase of out-patient alcohol treatment. A secondary aim was to determine whether or not there were any carry-over effects of combination nicotine replacement on drinking outcomes.

DESIGN

Small-scale randomized double-blind placebo-controlled clinical trial with 1-year smoking and drinking outcome assessment.

SETTING

Two out-patient substance abuse clinics provided a treatment platform of behavioral alcohol and smoking treatment delivered in 3 months of weekly sessions followed by three monthly booster sessions.

PARTICIPANTS

Participants were 96 men and women with a diagnosis of alcohol abuse or dependence and smoking 15 or more cigarettes per day.

INTERVENTION

All participants received open-label transdermal nicotine patches and were randomized to receive either 2 mg nicotine gum or placebo gum under double-blind conditions.

FINDINGS

Analysis of 1-year follow-up data revealed that patients receiving nicotine patch plus active gum had better smoking outcomes than those receiving patch plus placebo gum on measures of time to smoking relapse and prolonged abstinence at 12 months. Alcohol outcomes were not significantly different across medication conditions.

CONCLUSIONS

Results of this study were consistent with results of larger trials of smokers without alcohol problems, showing that combination therapy (nicotine patch plus gum) is more effective than monotherapy (nicotine patch) for smoking cessation.

Smoking cessation interventions in Australian drug treatment agencies: a national survey of attitudes and practices

A cross-sectional survey was mailed to all Australian drug and alcohol treatment agencies to assess their smoking cessation policies and practices and related staff attitudes. Barriers to smoking cessation interventions were also examined. Completed questionnaires were returned by 213 managers and 204 other staff representing 260 agencies (59.8% consent rate). Approximately one-quarter of agencies have smoking cessation intervention policies and one-third of clients receive adequate smoking advice. Of 12 intervention strategies, only the recording of smoking status on file occurs in a majority of cases. Concerns about the potential negative impact of smoking interventions and lack of client interest were endorsed as very important barriers by the highest percentage of respondents. 12.6% of managers and 16.5% of other staff agreed that it is occasionally useful for staff to smoke with a client. Smoking cessation receives little systematic attention from drug and alcohol agencies. Training and policy initiatives are needed urgently to address negative staff attitudes impeding progress in this area.

Medical and Mental Health Status Among Drug Dependent Patients Participating in a Smoking Cessation Treatment Study

Substance Abusers have a large number of medical and psychiatric problems, and 70-90% are smokers. The aim of this analysis was to examine the prevalence and correlates of medical and psychiatric problems in this sample of drug dependent patients who were participants in a multi-site study of smoking cessation interventions while engaged in substance abuse treatment. Descriptive analyses showed at baseline, 72.8% of participants had at least one medical problem and 64.1% had at least one psychiatric diagnosis. Medical problems correlated strongly with age, smoking severity, and pack-years; Psychiatric problems correlated with gender and ethnicity. Smoking cessation treatment was associated with a moderate reduction in the ASI Medical composite score. More research is needed on the possible effects of combined treatment of substance abuse and concurrent medical and psychiatric problems. Offering smoking cessation in conjunction with primary care may be a way to address the health needs of this population.

Development of the Smoking Knowledge, Attitudes, and Practices (S-KAP) Instrument

This report describes the development and measurement characteristics of a new measure of smoking knowledge, attitudes, and practices (S-KAP) among treatment providers. Data are based on survey responses from 336 paid staff working in one of three drug abuse treatment or HIV care settings. Exploratory factor analysis, used to examine the factor structure, pointed towards five underlying factors: a single "knowledge" factor, three "attitude" factors ('treatment barriers,' 'counselor self-factor. The Knowledge scale had a standardized Cronbach's alpha coefficient of .85. The coefficients for Barriers, Self-Efficacy, and Attitudes were .81, .72, and .74, respectively. The Practice scale had a standardized Cronbach's alpha coefficient of .91. These results indicate that the proposed scales have reasonably good psychometric characteristics and will allow researchers to quantify staff knowledge, attitudes, and practices regarding smoking cessation treatments and issues.

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

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

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

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

Alcohol history and smoking cessation in nicotine replacement therapy, bupropion sustained release and varenicline trials: a review

AIMS

We conducted a review of published reports of smoking cessation pharmacotherapy trials in order to address the following: (i) the generalizability of findings to smokers with a history of alcohol problems; (ii) the extent to which alcohol use affects smoking cessation overall and the efficacy of pharmacotherapy specifically and (iii) the effect of smoking cessation on alcohol use.

METHODS

We located published reports of nicotine replacement therapy (NRT), bupropion sustained release (SR) and varenicline clinical trials using an approach based on prior Cochrane reviews. The reports were searched for alcohol-related inclusion/exclusion criteria and for findings related to alcohol.

RESULTS

The present review included 212 published reports from 149 trials. Alcohol-related exclusion criteria appeared frequently (41.6% of trials)--45/125 NRT trials (36%), 15/22 bupropion SR trials (68.2%) and 3/3 varenicline trials--and most commonly involved exclusion of participants with either current or recent alcohol problems. Most studies failed to provide any baseline alcohol-related characteristics. Eleven trials reported on the relationship between alcohol history and likelihood of smoking cessation. In the majority of these studies, smokers with a past history of alcohol problems were not at a disadvantage, although contrary findings exist. Only two studies examined the potential influence of smoking cessation on alcohol use.

CONCLUSIONS

Smokers with alcohol problems, particularly those with current or recent problems, are underrepresented in studies of approved pharmacotherapy for smoking cessation. Future trials should assess alcohol use at baseline and during treatment and examine reciprocal influences between alcohol consumption and smoking cessation.

Intention to quit tobacco use among clients in substance use disorder treatment settings

The purpose of this study was to investigate the influence of age, gender, tobacco-related knowledge, treatment modality, and changes in smoking patterns on intention to quit tobacco use among individuals participating in substance use disorder (SUD) treatment in Ohio. Of the 791 SUD program attendees, 91.7% currently used tobacco, with cigarette smoking being the most prevalent form of use. Among tobacco users, 67% reported intention to quit tobacco use. Four of the five hypothesized predictor variables had a significant relationship with intention to quit tobacco: gender, age, treatment modality, and smoking pattern, with age and gender demonstrating the strongest relationships to intention to quit smoking.

High-dose nicotine patch therapy for smokers with a history of alcohol dependence: 36-week outcomes

This study reports findings from an investigation of the efficacy of high-dose nicotine patch (NP) therapy for heavy smokers with a history of alcohol dependence. One hundred thirty participants were randomly assigned to 42 or 21 mg of transdermal nicotine. Follow-up assessments were conducted at 4, 12, 24, and 36 weeks. Differences between dose conditions were nonsignificant, although, unexpectedly, outcomes favored participants in the 21-mg NP condition. Nicotine abstinence rates in the 21- and 42-mg NP conditions on Week 36 follow-up were 16.9% and 9.2%, respectively. Patch condition did not interact with severity of nicotine dependence. However, nicotine abstinence at follow-up was related to a longer length of alcohol abstinence. No evidence was found for better outcomes as a function of the percentage of baseline cotinine replaced by NPs. Future research should focus primarily on investigating ways to improve smoking quit rates for smokers in early alcohol recovery.

Attitudes toward the integration of smoking cessation treatment into drug abuse clinics

This article examines the variables associated with the presence of smoking cessation interventions in drug abuse treatment units, as well as staff attitudes toward the integration of smoking cessation services as a component of care. Surveys were administered to 106 organizations, 348 treatment clinics, and 3,786 employees in agencies that participated in the National Drug Abuse Treatment Clinical Trials Network. Organizational factors, attributes of the treatment setting, and staff attitudes toward smoking cessation treatment were assessed. Use of smoking cessation interventions was associated with the number of additional services offered at clinics, residential detoxification services, and attitudes of the staff toward smoking cessation treatment. Staff attitudes toward integrating smoking cessation services in drug treatment were influenced by the number of pregnant women admitted, the number of ancillary services provided, the attitudes of staff toward evidence-based practices, and whether smoking cessation treatment was offered as a component of care.

A rationale and model for addressing tobacco dependence in substance abuse treatment

Most persons in drug treatment smoke cigarettes. Until drug treatment facilities systematically treat their patients' tobacco use, millions will flow through the drug treatment system, overcome their primary drug of abuse, but die prematurely from tobacco-related illnesses. This paper reviews the literature on the health benefits of quitting smoking for drug treatment patients, whether smoking causes relapse to other drug or alcohol abuse, the treatment of tobacco dependence, and good and bad times for quitting smoking among drug treatment patients. It also presents a conceptual model and recommendations for treating tobacco in substance abuse treatment, and provides references to internet and paper-copy tools and information for treating tobacco dependence. At present, research on tobacco treatment in drug treatment is in its infancy. Although few drug treatment programs currently offer formal services, many more will likely begin to treat nicotine dependence as external forces and patient demand for these services increases. In the absence of clear guidelines and attention to quality of care, drug treatment programs may adopt smoking cessation services based on cost, convenience, or selection criteria other than efficacy. Because research in this field is relatively new, substance abuse treatment professionals should adhere to the standards of care for the general population, but be prepared to update their practices with emerging interventions that have proven to be effective for patients in drug treatment.

Co-morbidity of smoking in patients with psychiatric and substance use disorders

This article reviews cigarette smoking in patients with psychiatric disorders (PD) and substance use disorders (SUD). Rates of smoking are approximately 23% in the U.S. population but approximately two- to four-fold higher in patients with PD and SUD. Many remaining smokers have had repeated smoking cessation failures, possibly due to the presence of co-morbid PD and SUDs. There is modest, evidence-based support for effective treatment interventions for nicotine addiction in PD and SUD. Further research is needed to increase our understanding of nicotine addiction in PD and SUD and develop more effective treatment interventions.

A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery

This meta-analysis examined outcomes of smoking cessation interventions evaluated in 19 randomized controlled trials with individuals in current addictions treatment or recovery. Smoking and substance use outcomes at posttreatment and long-term follow-up (> or = 6 months) were summarized with random effects models. Intervention effects for smoking cessation were significant at posttreatment and comparable for participants in addictions treatment and recovery; however, intervention effects for smoking cessation were nonsignificant at long-term follow-up. Smoking cessation interventions provided during addictions treatment were associated with a 25% increased likelihood of long-term abstinence from alcohol and illicit drugs. Short-term smoking cessation effects look promising, but innovative strategies are needed for long-term cessation. Contrary to previous concerns, smoking cessation interventions during addictions treatment appeared to enhance rather than compromise long-term sobriety.

Twelve-Week Outcomes From an Investigation of High-Dose Nicotine Patch Therapy for Heavy Smokers With a Past History of Alcohol Dependence

This study reports findings from an investigation of the efficacy of high-dose nicotine patch (NP) therapy for heavy smokers with a past history of alcohol dependence. One hundred thirty participants were randomly assigned to 42 mg or 21 mg of transdermal nicotine for 4 weeks, followed by an 8-week dose titration. Follow-up assessments were conducted at 4 and 12 weeks. Differences between dose conditions were nonsignificant, although unexpectedly, outcomes favored participants in the 21-mg NP condition. Nicotine abstinence at follow-up was related to longer length of alcohol abstinence at time of enrollment. Future research should investigate ways to improve smoking quit rates in this population, including more frequent counseling sessions and/or other pharmacotherapies. These investigations should focus primarily on smokers in early alcohol recovery.

Alcoholic liver disease (ALD): a new domain for prevention efforts

Alcoholic liver disease (ALD) is a leading cause of death; yet relatively little has been written about it in the health behavior research literature. This paper will describe ALD, what factors predict ALD including findings from analyses of the 1998 state of California and Los Angeles County hospital discharge data, and possible means of preventing this disease. It is hoped that new interest among health behavior researchers and practitioners will be stimulated.