Incorporating nicotine dependence into addiction treatment

Violence in mental health settings: A systematic review

The introduction of smoke-free policies is increasingly common in mental health settings, to improve health. However, a barrier to implementing smoke-free polices is staff concern that violence will increase. We conducted a systematic review comparing the rates of violence before and after the introduction of smoke-free policies in mental health settings. Two authors searched major electronic databases. We included studies reporting the prevalence of violence (verbal and/or physical or combined) before and after the introduction of a smoke-free policy in a mental health, forensic, or addiction setting. We included 11 studies in the review. A narrative synthesis was used to describe the key results of each study. Six studies measured physical violence specifically; four reported a decrease or no change and two reported a short-term increase. Five of these six studies also measured verbal violence; two found an increase, with one of the studies reporting that this increase was temporary. Three reported a decrease in verbal violence. A further five studies evaluated the rate of combined verbal and physical violence; four reported a decrease or no change and the other an increase. We conclude that the introduction of smoke-free policies generally does not lead to an increase in violence. There is a need for more robust studies to support this finding. However, the conclusions from this review may be a step in reducing staff concerns.

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.

Gesundheitsförderung von Menschen mit intellektueller Behinderung

Zahlreiche Publikationen belegen, dass die Gesundheit von Menschen mit intellektueller Behinderung (IB) für Krankheiten und Störungen anfälliger ist als die der Allgemeinbevölkerung. Zudem sind bestimmte Risikoverhaltensweisen (z. B. schlechte Ernährung und wenig Bewegung) häufiger bei dieser Personengruppe zu finden. Trotz der sensibleren Gesundheitssituation steht die gesundheitspsychologische Forschung für Menschen mit IB noch am Anfang. Für diesen Überblicksartikel wurde Fachliteratur über Menschen mit IB nach gesundheitspsychologischen Konzeptionen durchsucht und bestehende Forschungsarbeiten analysiert. Des Weiteren wurden rezente Gesundheitsmodelle sowie Kontinuitäts- und Stadienmodelle für die Allgemeinbevölkerung und ihre einzelnen Bestandteile hinsichtlich ihrer Übertragbarkeit auf diese spezielle Population untersucht. Eine Generalisierung von Gesundheitsmodellen der Allgemeinbevölkerung auf die Gruppe von Menschen mit IB erscheint aus verschiedenen Gründen problematisch. So erweist sich z. B. die Erfassung einzelner Bestandteile durch ihre Abstraktheit als zu komplex für Menschen mit IB. Dieses und ähnliche Forschungshindernisse werden in diesem Artikel besprochen. Diese genaue Analyse hilft jedoch notwendige Kriterien für die Entwicklung eines theoretischen Gesundheitsmodells speziell für Menschen mit IB zu erstellen. Schlussendlich werden relevante Modellbausteine für Menschen mit IB, die auf den präsentierten Forschungsergebnissen aufbauen, vorgestellt und diskutiert. Schließlich werden zukünftige Forschungsfragen erörtert.

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.

Smoking prevalence in addiction treatment: a review

INTRODUCTION

This review explores whether smoking prevalence in addiction treatment samples exceeds that shown in epidemiological data for persons with alcohol or other drug use disorders and whether smoking may have decreased over time in the addiction treatment population as it has done in the general population.

METHODS

English language papers published between 1987 and 2009 were searched electronically. Forty papers reporting smoking prevalence for addiction treatment samples in the United States were identified, and key predictor variables were abstracted. Random logistic models were used to assess relationships between each individual predictor (year, treatment modality, primary drug treated, government status, and public/private funding status) and smoking prevalence.

RESULTS

The lowest smoking prevalence aggregated for studies reported in any single year was 65%, well above epidemiological estimates reported among those with alcohol use and drug use disorders. The odds of smoking were higher in methadone maintenance programs (odds ratio [OR] = 2.25, CI = 1.08, 4.68) as compared with outpatient programs. No other variables in the model were significant. Reanalysis omitting recent studies that may represent outliers or confounding with type of treatment showed a small but significant decrease in smoking over time (OR = 0.9891, CI = 0.9888, 0.9893).

CONCLUSIONS

The very high smoking rates reported in addiction treatment samples warrant significant, organized, and systemic response from addiction treatment systems, from agencies that fund and regulate those systems, and from agencies concerned with tobacco control.

Addressing tobacco use disorder in smokers in early remission from alcohol dependence: the case for integrating smoking cessation services in substance use disorder treatment programs

Despite the declining overall rate of cigarette smoking in the general population in the United States, the prevalence of smoking is estimated to be as high as 80% among treatment-seeking alcoholics. The serious adverse health effects of tobacco and heavy alcohol use are synergistic and recent evidence suggests that smoking slows the process of cognitive recovery following alcohol abstinence. In addition, substantial evidence shows that treatment for tobacco dependence does not jeopardize alcohol abstinence. In this paper, we focus on the impact and treatment implications of tobacco dependence among treatment-seeking alcoholics through a review of five areas of research. We begin with brief reviews of two areas of research: studies investigating the genetic and neurobiological vulnerability of comorbid tobacco and alcohol dependence and studies investigating the consequences of comorbid dependence on neurobiological and cognitive functioning. We then review literature on the effects of smoking cessation on drinking urges and alcohol use and the effectiveness of smoking cessation interventions with alcoholic smokers. Finally, we offer recommendations for research with an emphasis on clinical research for enhancing smoking cessation outcomes in this population.

Autonomy in relation to health among people with intellectual disability: a literature review

BACKGROUND

Since the 1990s, individualisation, participation, normalisation and inclusion have been the main principles of care for people with intellectual disability (ID). Autonomy has become an important issue for these people. This review of the literature tried to answer the question: how do people with ID exercise autonomy in relation to health?

METHOD

Searches in Cochrane, Medline and PsycINFO were based on the following aspects of autonomy: self-determination, independence, self-regulation and self-realisation.

RESULTS

Thirty-nine of 791 articles met our criteria, including 14 on self-determination, seven on independence, 15 on self-regulation and three on self-realisation.

CONCLUSIONS

In spite of decades of promoting autonomy, the exercise of autonomy in relation to health has so far rarely been an issue in the literature.

Tobacco-related practices and policies in residential perinatal drug treatment programs

Despite serious health consequences from high rates of smoking among perinatal women, smoking cessation and/or nicotine treatment practices have yet to be broadly adopted into perinatal substance abuse treatment settings. This correlational cross-sectional survey examined tobacco-related policies, practices, knowledge, and attitudes of 31 directors of perinatal residential substance abuse treatment programs in California. We found that the directors' programs had limited on-site adoption of evidence-based practices for smoking cessation, and that directors had gaps in their knowledge of perinatal tobacco effects. Implications for tobacco policy initiatives in perinatal substance abuse treatment are discussed.

Targeting nicotine addiction in a substance abuse program

The potential benefits of addressing nicotine addiction as part of substance dependency treatment may include improved response to interventions for other addictions and, over the long term, reduced tobacco-related morbidity and mortality. The authors recount the experiences of three inpatient programs that instituted nicotine addiction interventions and a tobacco-free policy for both facilities and patients. After making adjustments to counter temporary adverse effects of the policy, two of the programs are achieving higher overall treatment completion rates than prior to implementation. Outstanding research issues include quantifying the costs and benefits of the antinicotine interventions, determining the long-term impact of tobacco-free treatment, and tailoring treatment to various patient groups.

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.

Addressing tobacco use through organizational change: a case study of an addiction treatment organization

Compared to the general population, persons entering addiction treatment are three to four times more likely to be tobacco dependent and even addiction treatment staff members are two to three times more likely to be tobacco dependent. In these settings, tobacco use continues to be the norm; however addiction treatment programs are increasingly aware of the need to assess for and treat tobacco dependence. The problem is a cultural issue that is so ingrained that assumptions about tobacco use and dependence in addiction treatment are rarely questioned. Denial, minimization, and rationalization are common barriers to recovery from other addictions; now is the time to recognize how tobacco use and dependence must be similarly approached. This article describes the Addressing Tobacco through Organizational Change (ATTOC) model which has successfully helped many addiction treatment programs to more effectively address tobacco use. The article will review the six core strategies used to implement the ATTOC intervention, the 12-Step approach guiding the model, and describe a case study where the intervention was implemented in one clinic setting. Other treatment programs may use the experience and lessons learned from using the ATTOC organizational change model to better address tobacco use in the context of drug abuse treatment.

Organizational change in a perinatal treatment setting: integration of clinical practice and policies on tobacco and smoking cessation

Perinatal smoking presents serious health risks to the fetus, mother, and child. Despite extensive evidence of risk and high rates of smoking among in-treatment perinatal women substance abusers, tobacco-related practice and policy change has not been widely transferred for application in drug abuse treatment programs for pregnant and parenting women. This qualitative study investigated the process of change and the resultant adoption of clinical policy and treatment innovation in a residential drug abuse treatment program that converted from tobacco-tolerant to tobacco-free with provision of smoking cessation services. Informed by the Organizational Readiness for Change Model, staff interviews and data analysis were conducted to examine program characteristics affecting adoption. An organizational climate of openness to change and the program's clarity of mission, expressed in perinatal-specific motivators for change, influenced the adoption of tobacco-related clinical practice and policy. Re-allocation of time, previously occupied by smoking behaviors, allowed for added promotion of maternal-child interaction and positive role-modeling for children.

Smoking cessation treatment in community-based substance abuse rehabilitation programs

Nicotine dependence is highly prevalent among drug- and alcohol-dependent patients. A multisite clinical trial of smoking cessation (SC) treatment was performed at outpatient community-based substance abuse rehabilitation programs affiliated with the National Drug Abuse Treatment, Clinical Trials Network. Cigarette smokers (N=225) from five methadone maintenance programs and two drug and alcohol dependence treatment programs were randomly assigned in a 2:1 ratio to receive either (1) SC treatment as an adjunct to substance abuse treatment-as-usual (TAU) or (2) substance abuse TAU. Smoking cessation treatment consisted of 1 week of group counseling before the target quit date and 8 weeks of group counseling plus transdermal nicotine patch treatment (21 mg/day for Weeks 1-6 and 14 mg/day for Weeks 7 and 8) after the target quit date. Smoking abstinence rates in SC, 10%-11% during treatment and 5%-6% at the 13- and 26-week follow-up visits, were significantly better than those in TAU during treatment (p< .01). In addition, SC was associated with significantly greater reductions as compared with TAU in cigarettes smoked per day (75% reduction, p< .001), exhaled carbon monoxide levels (p< .001), cigarette craving (p< .05), and nicotine withdrawal (p< .05). Smoking cessation did not differ from TAU on rates of retention in substance abuse treatment, abstinence from primary substance of abuse, and craving for primary substance of abuse. Compliance with SC treatment, moderate at best, was positively associated with smoking abstinence rates. Smoking cessation treatment resulted in significant reductions in daily smoking and modest smoking abstinence rates without having an adverse impact on substance abuse rehabilitation when given concurrently with outpatient substance abuse treatment. Substance abuse treatment programs should not hesitate to implement SC for established patients.

Methadone and nicotine self-administration in humans: a behavioral economic analysis

RATIONALE

Prior research has revealed inconsistencies in the behavioral relations between nicotine and opiates among methadone-maintained patients.

OBJECTIVES

The current study examined whether the drug reinforcers cigarette puffs and methadone were economic complements or substitutes.

METHODS

Five methadone-maintained, nicotine-dependent participants were trained to self-administer methadone, cigarette puffs, or concurrently available methadone and puffs. Following training, the fixed ratio (FR) value ("price") was increased across sessions (FR 32, 64, 128, 256, and 512), first for methadone and then for puffs. Subsequently, methadone and puffs were concurrently available, and the price of each drug was increased independently, while the price of the alternative (puffs or methadone) remained constant at FR 32.

RESULTS

Demand for methadone and cigarette puffs decreased as a function of increases in methadone and cigarette puff prices, respectively. When methadone and puffs were concurrently available, an increase in methadone's price decreased puff consumption, and demand for methadone was less elastic than when puffs were not concurrently available. An increase in puff price decreased puff and methadone demand, but the elasticity of puff demand was unaffected. The concurrent presence of methadone had no effect on the elasticity of demand for cigarette puffs.

CONCLUSIONS

Methadone and cigarette puffs appear to be asymmetric economic complements.

Addressing tobacco among individuals with a mental illness or an addiction

Tobacco dependence among individuals with a mental illness or an addiction is a tremendous problem that goes largely ignored. Studies of genetics, neuroimaging, and nicotinic receptors support a neurobiological link between tobacco use and alcohol dependence, drug dependence, schizophrenia, depression, attention-deficit hyperactivity disorder (ADHD), and anxiety disorders. This paper summarizes the recent literature on this topic and discusses how treatment for tobacco can no longer be ignored in mental-health and addiction-treatment settings. More research is needed as well as a national organized effort to address tobacco in this large segment of smokers.

Timing of Alcohol and Smoking Cessation (TASC)

Tobacco dependence is prevalent among alcohol dependent patients, and causes increased morbidity and mortality. Concurrent treatment for these disorders may be advantageous, but there are concerns about adverse effects on alcohol treatment outcomes. The Timing of Alcohol and Smoking Cessation (TASC) Study is a randomized controlled clinical trial to compare the effectiveness of smoking cessation treatment offered concurrently or six months following intensive rehabilitation for alcohol dependence. This paper describes the study design and baseline characteristics of the study population. Participants were current smokers in intensive alcohol dependence treatment, with willingness to consider quitting smoking. Smoking intervention offered behavioral and pharmacological treatment. One thousand nine hundred forty-three patients were screened for enrollment; 499 were eligible and participated (26%). We describe demographic characteristics, smoking behavior and attitudes among participants and nonparticipants toward smoking cessation and drinking. We conclude that there is considerable interest in smoking cessation in alcohol dependent treatment populations, and recruitment to research studies is feasible.

Treatment of tobacco dependence in alcoholics

Because of the high morbidity and mortality that alcoholic smokers experience from tobacco-caused diseases, treatment for tobacco dependence among alcoholics is warranted. Much progress has been made during the last decade in addressing tobacco dependence in alcoholism treatment units. Treatment of tobacco dependence in alcoholic smokers does not seem to cause excessive relapse to drinking and, in fact, stopping smoking may enhance abstinence from drinking. Therefore, treatment for alcoholic smokers should take place whenever and wherever the patient comes in contact with the health care system. Because alcoholic smokers as a rule are more dependent on nicotine than their nonalcoholic counterparts, they may need more intensive pharmacotherapy and behavioral therapy. Because many of them have experienced 12-step approaches to recovery, that same technology can be used to initiate and maintain abstinence from tobacco use. Moreover, several pharmacologic options exist to treat tobacco dependence in alcoholic smokers. However, the efficacy of several pharmacologic therapies for alcoholic smokers needs to be tested. In addition, further research is needed on effective treatments for recovering alcoholics of various racial/ethnic backgrounds.

Survey of smoking cessation services in Canadian addiction programs

Many alcohol and drug treatment programs now offer smoking cessation (SC) services to their clients. Little is known about the prevalence of such services in Canadian addiction programs. A telephone survey was conducted of all Canadian adult substance abuse programs with outpatient, day program, and residential treatment to determine: (a) whether the program offered help in quitting smoking; (b) the type of SC services; (c) the overall priority placed on quitting smoking; and (d) for residential programs, what type of smoking ban (indoors, outdoors, or both), if any, is imposed. Over half (54%) of the 223 programs that responded to the survey reported providing help in quitting smoking. Twenty-three programs had formal SC services, most often in the form of group treatment. The majority of programs surveyed stated their program placed 'very little' emphasis on smoking. Smoking was relatively unrestricted in residential programs. The implications of these findings for substance abuse treatment are discussed.

Tobacco smoking: current concepts in etiology and treatment

Tobacco smoking is the most important preventable cause of death and disease. Despite an increased awareness of the addictive nature of smoking and availability of effective treatments, smoking continues to be widespread among individuals with psychiatric disorders. Moreover, mental health professionals remain reluctant to address smoking among their patients for a variety of reasons. Recent research has provided a wealth of data that have shaped the concept of tobacco smoking as a chronic addictive disorder and also demonstrated the efficacy of smoking cessation interventions. This paper reviews the important factors that contribute to smoking and the various pharmacological and psychosocial interventions for smoking cessation from a biopsychosocial perspective. It also makes recommendations for the rational use of these interventions to treat nicotine dependence in individuals with psychiatric disorders.

Tobacco and alcohol use and medical symptoms among cocaine dependent patients

Despite the widespread use of tobacco and alcohol by illicit drug users, the medical effects of smoking and alcohol use remain understudied among such individuals. We investigated the relationship between smoking and alcohol use, and medical symptoms among 125 cocaine dependent patients. Subjects were assessed for smoking, alcohol use, and medical problems using a standardized self-report instrument (MILCOM). Medical symptoms were compared among nonsmokers, moderate smokers (less than 10 cigarettes per day), and heavy smokers (10 or more cigarettes per day) using partial chi-square statistics. Similar comparisons of medical symptoms were made between alcohol users (more than 2 drinks per day) and nonusers. Contrary to our expectations, there were no significant differences between nonsmokers, moderate smokers, and heavy smokers across most of the 14 major medical systems. However, regardless of the level of cocaine use, nonsmokers reported the fewest symptoms on the general subscale (p < 0.05) while moderate smokers reported the most nose/throat and respiratory symptoms (p < 0.01) among the three groups. As expected, significant relationships were observed between medical symptoms and alcohol use. Alcohol users reported more respiratory (p < 0.05), cardiovascular (p < 0.01), digestive (p < 0.05), head/neck (p < 0.001), eye (p < 0.01), and general (p < 0.05) symptoms than nonusers. While the findings generally support the link between alcohol and medical problems, it seems that the relationship between medical symptoms and smoking among cocaine patients may be more complex than that observed in the general population.

Smoking cessation in drug treatment programs

Substance abusers are more likely to smoke cigarettes than the general population. Yet, in most drug treatment programs smoking cessation receives little attention. The purposes of this study were to: (1) examine substance abuse counselors' attitudes toward and practices related to nicotine addiction and smoking cessation treatment; and (2) describe barriers to smoking cessation treatment and smoking policies in substance abuse treatment facilities. A total of 254 substance abuse counselors in Kentucky completed mailed questionnaires (53% response rate). Almost one-fourth were current smokers. Smoking and nonsmoking counselors differed in their attitudes toward nicotine addiction, barriers to treatment, and satisfaction with smoking cessation training. Few counselors routinely followed the clinical preventive guidelines with nicotine-dependent clients. However, they were receptive to providing smoking cessation treatment. Over half of the drug treatment programs banned indoor smoking, but permitted smoking on facility grounds. Implications for policy change by national addiction certification and licensing organizations and state accreditation authorities are discussed.