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

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

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

Displacement imposition scale assesses reactions of cigarette and e-cigarette users impacted by a campus-wide smoking ban

OBJECTIVE

The present study developed a measure assessing the emotional responses, "Displacement Imposition," of cigarette and e-cigarette users on a college campus with a smoking/vaping ban. It also examined the relationship between Displacement Imposition and readiness to quit smoking/vaping, and how this relationship differed between cigarette and e-cigarette users.

PARTICIPANTS

Participants (N = 297) were from a large, Midwestern university.

METHODS

Participants completed online questionnaires assessing demographics, cigarette and e-cigarette use, Displacement Imposition, and readiness to quit.

RESULTS

All six Displacement Imposition items loaded onto a single factor. A significant interaction emerged between Displacement Imposition and product use in predicting readiness to quit. At high levels of Displacement Imposition, cigarette users were less ready to quit than e-cigarette users.

CONCLUSIONS

Findings suggest restrictions imposed on cigarette and e-cigarette users were associated with reduced readiness to quit. Findings inform tobacco control policies as tobacco denormalization may increase the burden placed on tobacco users.

Tobacco use among substance use disorder (SUD) treatment staff is associated with tobacco-related services received by clients

BACKGROUND

Despite disproportionately high rates of smoking among people in residential substance use disorder (SUD) treatment, few receive tobacco cessation services. Little is known about how smoking among treatment staff may impact this disparity. We explored the relationship between staff tobacco use and client tobacco use. Additionally, we examined the relationship between staff tobacco use and tobacco-related services reported by staff and clients.

METHODS

Staff (n = 363) and clients (n = 639) in 24 California publicly-funded residential SUD treatment programs were surveyed in 2019-20. Staff self-reported current tobacco use, as well as their beliefs, self-efficacy, and practices regarding smoking cessation. Clients reported their tobacco use and they services received while in treatment. Regression analyses examined the adjusted and unadjusted associations between staff and client tobacco use and other outcomes.

RESULTS

Use of any tobacco product by staff ranged from 0% to 100% by program, with an average of 32% across programs. Adjusted analyses found that higher rates of staff tobacco use were associated with higher rates of client tobacco use, and with fewer clients receiving tobacco-related counseling. In programs that had higher rates of staff tobacco use, staff were less likely to believe that clients should quit smoking in treatment and had lower self-efficacy to address smoking.

CONCLUSION

Higher rates of tobacco use among staff are associated with higher rates of client tobacco use and fewer clients receiving cessation counseling. Efforts to reduce tobacco use among SUD clients should be supported by efforts to reduce tobacco use among staff. SUD treatment programs, and agencies that fund and regulate those programs, should aim to reduce the use of tobacco products among staff.

Exploring attitudes towards smoking behaviour and cessation among hospitalised smokers via a socio-ecological framework: A scoping review

OBJECTIVES

Cigarette smoking is a leading cause of preventable mortality and disability. Smoke-free policies in healthcare settings have been implemented as a public health measure. This scoping review aims to explore attitudes on smokers' cessation in smoke-free healthcare settings using a socio-ecological framework.

METHODS

Four databases were searched for terms: smoking cessation, patient attitudes, and smoke-free policy. Of 420 studies, 17 met full inclusion criteria.

RESULTS

The review identified four socio-ecological aspects of smoking cessation in smoke-free healthcare settings: Intrapersonal factors (health literacy, health conditions, and self-efficacy), interpersonal factors (social support, peer pressure, and social responsibility), healthcare factors (perceived mixed messages, healthcare setting, clinical, psychosocial and health promotion supports), and societal factors (restrictions on smoking in a public place and social acceptability of smoking). Smoke-free policies effectively encouraged cessation in some patients but were ineffective in those that felt a loss of autonomy. Provision of smoke breaks within smoke-free policies was considered a mixed message.

CONCLUSIONS

Holistic strategies are required to interconnect the four socio-ecological dimensions for successful smoking cessation.

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.

Evaluating the short-term impact of a tobacco-free policy in an inpatient addiction treatment setting

PURPOSE

Tobacco use is highly prevalent within addiction treatment settings, despite the potential benefits that cessation may provide to patients' psychosocial functioning and overall sobriety. Moreover, tobacco cessation is often insufficiently addressed in addiction treatment programs, although evidence suggests that tobacco control policies, such as access to evidence-based treatment or tobacco-free policies, may be effective. The objective of our study was to evaluate the impact of the implementation of these two tobacco control policies in an inpatient addiction treatment centre.

METHODS

Using a 3-group quasi-experimental design, we examined how the implementation of the Ottawa Model for Smoking Cessation (OMSC) and a subsequent campus-wide tobacco ban influenced patients' overall smoking status, frequency, amount used per day, and quit attempts during treatment, compared to usual care. Participants (N = 397) responded to a comprehensive questionnaire upon admission and discharge from an addiction treatment program. We used generalized linear mixed modelling to measure changes over time while accounting for relevant sociodemographic covariates.

RESULTS

Patients exposed to a more comprehensive tobacco control environment (i.e., the OMSC, plus complete tobacco ban) were over 80% less likely to report having used tobacco during treatment, compared to patients exposed to usual care (AOR = 0.17, 95% CI [0.05-0.63]). Receiving treatment in this setting also contributed to a 35% decrease in the average number of days patients used tobacco compared to usual care (AOR = 0.65, 95% CI [0.53-0.98]), and a 27% decrease in the average number of cigarettes used per day compared to usual care (AOR = 0.73, 95% CI [0.58-0.93]).

CONCLUSION

Comprehensive tobacco control policy interventions within inpatient addiction treatment hospitals promote tobacco cessation. Such interventions should include a combination of evidence-based treatment for patients and environmental restrictions to discourage tobacco use. The results of our study suggest that, within inpatient addiction treatment settings, use of the OMSC in combination with a campus-wide tobacco ban may be more effective than usual care or the OMSC alone.

Smoking and Tobacco-Free Policies in Women's Residential Substance Use Disorder Treatment Facilities: A Community-Engaged Approach

Introduction

The purpose of this study was to (1) describe the role of smoking in the lives of women in residential substance use disorder (SUD) treatment and (2) explore perceptions of the facilitators and barriers to tobacco-free policy among women in residential SUD treatment.

Methods

This was a community-engaged study using qualitative descriptive methods. We first recruited women in a residential SUD treatment facility to participate on a community research team. Interviews with staff (N = 10) and focus groups with clients (N = 42) were conducted using guides informed by the community research team. Interviews and focus groups were analyzed using content analysis.

Results

There were two themes related to the role of smoking in the women's lives: (1) smoking facilitates socialization and (2) smoking as a coping mechanism. There were three themes related to the benefits of tobacco-free policy: (1) improved health, (2) support for continued abstinence from a previous tobacco-free placement (eg, prison), and (3) less grounds up-keep. Barriers to tobacco-free policy included (1) lack of an alternative coping mechanism to smoking, (2) fear that a tobacco-free policy would drive clients away, and (3) anticipation of implementation challenges.

Conclusions

Many women in residential SUD treatment smoke, which they attribute to the fact that smoking is used to facilitate socialization and cope with stress. Future research is needed to develop and test messages to counter the misperception that smoking is an effective method to cope with stress. Ultimately, evidence-based tobacco-free policies are needed to reduce tobacco-related disease among women with SUDs.

Implications

To promote smoking cessation among women with substance use disorders through evidence-based tobacco policy, it is necessary to first understand the role of smoking in their lives as well as facilitators and barriers to tobacco-free policy in residential treatment facilities. Participants reported that smoking facilitated socialization and served as a coping mechanism. Tobacco-free policies have many benefits, including improved health, support for continued abstinence from a previous tobacco-free placement (eg, prison), and less grounds up-keep. Barriers include the lack of an alternative coping mechanism, fear that a tobacco-free policy would drive away clients and anticipation of implementation challenges. To reduce the burden of tobacco-related morbidity and mortality among women and their children, it is necessary to catalyze a culture change in behavioral health settings to prioritize the treatment of tobacco alongside treatment of other addictions.

Smoking related outcomes before and after implementation of tobacco-free grounds in residential substance use disorder treatment programs

BACKGROUND

This study examined the impact of a tobacco-free grounds (TFG) policy and the California $2.00/pack tobacco tax increase on tobacco use among individuals in residential substance use disorder (SUD) treatment.

METHODS

We conducted three cross-sectional surveys of clients enrolled in three residential SUD treatment programs. Wave 1 (Pre-TFG) included 190 clients, wave 2 (post-TFG and pre-tax increase) included 200 clients, and wave 3 (post-tax increase) included 201 clients. Demographic and tobacco-use characteristics were first compared between waves using bivariate comparisons. Regression models were used to compare each outcome with survey wave as the predictor, while adjusting for demographic characteristics and nesting of participants within programs.

RESULTS

Odds of clients being current smokers was lower (AOR = 0.43, 95%CI = 0.30,0.60) after implementation of TFG compared to baseline. Adjusted mean ratio (AMR) for cigarettes per day was lower post-TFG compared to baseline (AMR = 0.70, CI = 0.59, 0.83). There were no differences, across waves, in tobacco-related knowledge, attitudes, or services received by program clients, or use of nicotine replacement therapy. Increased cigarette taxation was not associated with reductions in client smoking.

CONCLUSION

Implementation of a TFG policy was associated with a lower prevalence of client smoking among individuals in residential SUD treatment. Increased state cigarette excise taxes were not associated with a further reduction in client smoking in the presence of TFG policies, though this may have been confounded by relaxing of the TFG policy. SUD treatment programs should promote TFG policies and increase tobacco cessation services for clients.

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.

Cigarette smoking and quit attempts among Latinos in substance use disorder treatment

BACKGROUND

Differences in tobacco use behaviors have been identified between Latinos and non-Latino whites in the general US population. Little is known about cigarette smoking and quitting behaviors of Latinos in treatment for substance use disorders (SUDs), who represent two major tobacco-vulnerable groups.

OBJECTIVES

To compare, in a national sample of persons enrolled in SUD treatment, demographic, drug use, and smoking and quitting prevalence and behaviors between Latinos and non-Latino whites.

METHODS

We surveyed 777 SUD treatment clients, sampled from 24 clinics selected at random from the National Institute on Drug Abuse Clinical Trials Network (Latino client n = 141; 40% female). We then conducted univariate and multivariate analyses to identify correlates of smoking behaviors by Latino/non-Latino white ethnicity.

RESULTS

Latinos' smoking prevalence resembled that of non-Latino whites (78.7% vs. 77.4%). In regression analyses, Latino smokers (n = 111) tended to smoke fewer cigarettes per day (CPD) than non-Latino white smokers (n = 492); were more often nondaily smokers and menthol smokers; more often reported a smoking quit attempt in the last year; and tended to report higher numbers of past-year quit attempts. Among Latino smokers, those with less education and those reporting opioids as their primary drug of use reported higher CPD.

CONCLUSIONS

Latinos in SUD treatment are at equally high risk of being current heavy smokers as compared to non-Latino whites in SUD treatment. At the same time, Latinos in SUD treatment exhibit ethnic-specific smoking and quitting behaviors that should be considered when designing smoking interventions for this group.

How can we help African American substance users stop smoking? client and agency perspectives

Research is needed to better understand barriers to smoking cessation and sustained abstinence among racial/ethnic minority polydrug users. We conducted community dialogue groups involving 49 clients in substance use treatment programs with predominantly ethnic minority clientele and individual dialogues/interviews with seven program providers (stakeholders). Most clients were African American, under 40 years old, women, current smokers, and high school graduates. Smoking cessation services in these programs were considered inadequate and community programs insufficiently culturally tailored and economically and geographically inaccessible. Participants discussed individual "willpower" and choice; agency tobacco-related programs and policies; the relationships between smoking, smoking cessation, and treatment goals; and steps needed to reshape agency services and policies to provide greater support for smoking cessation in this at-risk population.

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.

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.

Motivation for smoking cessation among drug-using smokers under methadone maintenance treatment in Vietnam

Background

Smoking cessation treatment service is concerned to be a critical element in methadone maintenance treatment (MMT) in order to diminish the effect of smoke on health outcomes. To implement the smoking cessation services in Vietnam, we examined the stages of change to quit and determined associated factors among MMT patients.

Methods

We conducted a cross-sectional survey with 1016 MMT patients in five clinics in Hanoi and Nam Dinh province, of those, 932 (91.7 %) were ever-smokers. Patients were classified into four groups: “pre-contemplation,” “contemplation,” “preparation,” and “action and maintenance” by using the transtheoretical model. Multivariate logistic regression was applied to determine the associated factor for intention and action to quit smoking.

Results

Overall, 96 % were not actively trying to quit or maintain abstinence. Age older than 45, HIV-positive status, and residence in Hanoi were negatively associated with intention to quit. Meanwhile, higher levels of nicotine dependence and number of years of smoking negatively associated with quitting and abstinence.

Conclusions

The study indicated the high rate of MMT smokers being in pre-contemplation stage but low proportion of quitting and maintaining abstinence. It emphasizes the importance of availability and accessibility of information about smoking cessation therapies and services. Integrating cessation programs into health-care services should be considered to provide tailored interventions for different patient groups.