Survey of clinician attitudes toward smoking cessation for psychiatric and substance abusing clients

Physician Reluctance to Intervene in Addiction: A Systematic Review

Importance

The overdose epidemic continues in the US, with 107 941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low.

Objective

To describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions.

Data Sources

A literature search of PubMed, Embase, Scopus, medRxiv, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021.

Study Selection

Publications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included.

Data Extraction and Synthesis

Two reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons.

Main Outcomes and Measures

The primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria.

Results

A total of 183 of 9308 returned studies reporting data collected from 66 732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug.

Conclusions and Relevance

In this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.

Staff attitudes to completely smoke-free policies and smoking cessation practices in a mental health setting

BACKGROUND

Mental health trusts in England were expected to become completely smoke-free and embed smoking cessation practices by 2018. Such policies are fraught with concerns and have received mixed support from mental health staff. Understanding staff attitudes to these practices prior to enforcement of the policy could help design an effective implementation strategy.

METHODS

A cross-sectional survey was conducted with clinical and non-clinical staff in a Mental Health Trust to understand smoking cessation practices and attitudes to the implementation of a completely smoke-free policy.

RESULTS

There were 631 responses. Most participants disagreed with the policy on wards (59.6%) and throughout all mental health settings (57.4%). Clinicians expressed significantly lower organizational policy support (P = 0.001) than non-clinicians (P = 0.001). Psychiatrists were more supportive of the organizational items than nurses and allied health professionals. Clinicians' attitudes towards smoking cessation practices were less positive for those who were current smokers (P < 0.001), but more positive for clinicians who had received or were interested in attending smoking cessation training (P < 0.001).

CONCLUSIONS

Partial and completely smoke-free policies remain unsupported by staff in mental health settings. Smoking cessation training appears to reinforce rather than alter attitudes towards smoking cessation.

Becoming tobacco-free: Changes in staff and patient attitudes and incident reports in a large academic mental health and addictions hospital

BACKGROUND AND OBJECTIVE

Complete tobacco bans in mental health facilities are thought to have the potential for adverse consequences. We evaluated staff and patient attitudes and adverse events associated with implementing Canada's largest, multi-site academic psychiatric hospital tobacco ban.

METHODS

A total of 1,173 staff and 422 patients completed an anonymous attitudes survey at prior to implementation (baseline), and 4-6 months and 10-12 months post-implementation. The tobacco-free initiative was implemented in a phased approach, allowing the prospective measurement of changes in attitudes and adverse outcomes such as agitation over a 1-year period.

RESULTS

We observed positive changes in staff and patient attitudes toward the tobacco-free policy for both staff and patients. Moreover, there was also a statistically significant decrease in patient agitation F (2, 99) = 3.25, p = .04, but no change F (2, 21) = 1.09, p = .35 in fire-related incidents.

DISCUSSION AND CONCLUSIONS

We observed positive changes in staff and patients attitudes and significant decrease in patient agitation during the first year of this tobacco-free hospital initiative.

SCIENTIFIC SIGNIFICANCE

During the first year of this tobacco-free psychiatric hospital policy, implementation of a tobacco-free environment in a large mental health and addictions setting was feasible and perceived as desirable by the majority of staff and patients surveyed and a decrease in incidents related to patient agitation was also observed. Further well-controlled studies with longer study durations are warranted. (Am J Addict 2017;26:183-191).

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Understanding counselors' implementation of tobacco cessation services with patients

This study aimed to understand substance use disorder counselors' implementation of evidence-based tobacco cessation services (TCS) with their patients who smoke. Drawing from an established adoption of innovations framework, we investigated the association between counselors' perceptions of the availability of TCS (both pharmacotherapies and behavioral treatments) in their treatment program and the implementation of TCS (both pharmacotherapies and behavioral treatments) with their patients who smoke and whether this association is moderated by the strength of an organization's climate for implementation and the fit of the innovation with users' values. Data were collected in 2010 from 682 counselors working in 239 treatment programs across the U.S. that offer evidence-based TCS. Mixed-effect models showed that perceived availability of TCS was related with greater TCS implementation. This relationship was moderated by several indicators of climate for implementation but not by the fit of the innovation with users' values.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of smoking cessation on schizophrenia and major depression

OBJECTIVE

This review sought to determine whether quitting smoking behaviour places people with a history of schizophrenia or major depression at risk of worsening symptoms or relapse.

METHOD

Literature searches of Embase, MEDLINE, the Cochrane Library and PsycINFO.

RESULTS

Six studies involving 735 people diagnosed with schizophrenia, schizoaffective disorder or psychotic disorder did not find significant change in mental health status after quitting smoking. Five out of six studies involving 1,293 people with a history of major depression did not find an increased risk of depression with abstinence from smoking, while one study did. Two of these studies found an improvement in depressive symptoms among quitters.

CONCLUSIONS

There is no published evidence to support the hypothesis that quitting smoking is harmful to the mental health of people with schizophrenia. Smoking cessation does not appear to place smokers with a history of major depression at increased risk of worsening symptoms nor relapse, and may even improve their mood. Psychiatrists and other mental health professionals should provide their patients with the same level of support to quit smoking that is given to the rest of the population.

Smoking and opioid detoxification: behavioral changes and response to treatment

INTRODUCTION

The relevance of tobacco use in opioid addiction (OA) has generated a demand for available and more effective interventions. Thus, further analysis of less explored nicotine-opioid clinical interactions is warranted.

METHODS

A post-hoc analysis of OA participants in a double-blind, randomized very low dose naltrexone (VLNTX) inpatient detoxification trial evaluated measures of opioid withdrawal and tobacco use. Intreatment smokers were compared with nonsmokers, or smokers who were not allowed to smoke.

RESULTS

A total of 141 (81%) of 174 OA participants were smokers, all nicotine-dependent. Inpatient smoking was a predictor of opioid withdrawal discomfort. Intreatment smokers (n = 96) showed significantly higher opioid craving (F = 3.7, p < .001) and lower detoxification completion rate (χ(2) = 7.9, p < .02) compared with smokers who were not allowed to smoke (n = 45) or nonsmokers (n = 33). Smoking during treatment was associated with more elevated cigarette craving during detoxification (F = 4.1, p < .001) and a higher number of cigarettes smoked at follow-up (F = 3.6, p < .02). Among intreatment smokers, VLNTX addition to methadone taper was effective in easing opioid withdrawal and craving more than other treatments, whereas the combination VLNTX-clonidine was associated with significantly reduced cigarette craving and smoking during detoxification.

CONCLUSIONS

Failure to address tobacco use may negatively affect pharmacologically managed opioid discontinuation. Opioid detoxification may offer a window of opportunity to expand smoking cessation treatment, hence improving OA outcomes. The observed effects support testing of VLNTX-clonidine in smoking cessation trials among individuals with or without substance abuse.

The implementation of smoking cessation counseling in substance abuse treatment

Research on the implementation of smoking cessation counseling within substance abuse treatment organizations is limited. This study examines associations among counselors' implementation of therapy sessions dedicated to smoking cessation, organizational factors, and counselor-level variables. A two-level hierarchical linear model including organization- and counselor-level variables was estimated using survey data collected from 1,794 counselors working in 359 treatment organizations. Overall implementation of smoking cessation counseling was low. In the final model, implementation was positively associated with counselors' knowledge of the Public Health Service's clinical practice guideline, perceived managerial support, and belief that smoking cessation had a positive impact on recovery. Private versus public funding and presence of a formal smoking cessation program were organization-level variables which interacted with these counselor-level effects. These results highlight the importance of organizational contexts as well as counselors' knowledge and attitudes for effective implementation of smoking cessation counseling in substance abuse treatment organizations.

Do smoking cessation websites meet the needs of smokers with severe mental illnesses?

Many people learn about smoking cessation through information on the Internet. Whether people with severe mental illnesses, who have very high rates of smoking, are able to use currently available websites about smoking cessation is unknown. The study reported here assessed whether four smoking cessation websites met usability guidelines and whether they were usable by smokers with severe mental illnesses. Four websites that appeared first on a Google search and represented an array of sponsors were selected. First, five experts rated the websites on adequacy of content in six areas and usability in 20 areas. Second, 16 smokers with severe mental illnesses performed two search tasks on the websites with researchers observing their searches and interviewing them regarding usability. One of the websites was rated by experts as acceptable for content and usability, but most of the participants were unable to navigate this website. The only website that was navigable received poor content ratings by experts. Four easily accessible websites did not meet the needs of smokers with severe mental illnesses. Although the Internet is a promising strategy to provide education about treatments, website developers must attend to the needs and capacities of multiple user groups.

Differences in cigarette smoking behaviors among heroin inhalers versus heroin injectors

INTRODUCTION

The high prevalence of cigarette smoking among heroin users has triggered many studies to explore possible interactions between cigarette smoking and heroin addiction; however, little is known about the relationship between cigarette smoking behaviors and routes of heroin administration. The present study provided the first examination of cigarette smoking status, motivation, and cigarette smoking cue reactivity among injecting or inhaling heroin users.

METHODS

Forty-six heroin-dependent patients were recruited in the present study. A battery of self-report questionnaires was used to assess cigarette smoking status and the reasons for smoking. In the clinical laboratory study, participants completed a cue-reactivity procedure that involved collecting psychophysical and motivational data in response to cigarette smoking slides.

RESULTS

The average number of cigarette per day among heroin inhalers was higher than that among heroin injectors. Most heroin inhalers reported that the primary reason for smoking was "maintaining drug pleasure," whereas heroin injectors reported that the primary smoking reason was "nicotine pleasure." Compared with heroin injectors, heroin inhalers provided increased ratings of heroin craving and desire to heroin use when exposed to cigarette smoking cues. Number of cigarettes per day was significantly correlated with cue-induced overall mean motivation in heroin inhalers but not in heroin injectors.

CONCLUSIONS

Cigarette smoking behaviors were different among heroin inhalers from among heroin injectors. These results emphasize the stronger association between cigarette smoking and heroin inhaling.

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.

Tobacco, cocaine, and heroin: Craving and use during daily life

BACKGROUND

Relationships among tobacco smoking, tobacco craving, and other drug use and craving may have treatment implications in polydrug-dependent individuals.

METHODS

We conducted the first ecological momentary assessment (EMA) study to investigate how smoking is related to other drug use and craving during daily life. For up to 20 weeks, 106 methadone-maintained outpatients carried PalmPilots (PDAs). They reported their craving, mood, behaviors, environment, and cigarette-smoking status in 2 to 5 random-prompt entries/day and initiated PDA entries when they used cocaine or heroin or had a discrete episode of craving for cocaine or heroin.

RESULTS

Smoking frequency increased linearly with random-prompt ratings of tobacco craving, cocaine craving, and craving for both cocaine and heroin. Smoking frequency was greater during discrete episodes of cocaine use and craving than during random-prompt reports of low craving for cocaine. This pattern was also significant for dual cocaine and heroin use and craving. Smoking and tobacco craving were each considerably reduced during periods of urine-verified abstinence from cocaine, and there was a (nonsignificant) tendency for morning smoking to be especially reduced during those periods.

CONCLUSIONS

This EMA study confirms that smoking and tobacco craving are strongly associated with the use of and craving for cocaine and heroin. Together with prior findings, our data suggest that tobacco and cocaine may each increase craving for (and likelihood of continued use of) themselves and each other. Treatment for tobacco dependence should probably be offered concurrently with (rather than only after) initiation of treatment for other substance-use disorders.

The impact of cigarette smoking on stimulant addiction

OBJECTIVES

Stimulant users smoke cigarettes at high rates; however, little is known about the relationship between tobacco and stimulants.

METHODS

Our goal in this article is to synthesize a growing literature on the role of cigarette smoking in stimulant addiction.

RESULTS

Early nicotine exposure may influence the development of stimulant addiction. Preclinical and clinical studies suggest a facilitatory role of nicotinic agonists for stimulant addiction. Smoking appears to be associated with more severe stimulant use and poorer treatment outcomes.

CONCLUSIONS

It is important to assess smoking and smoking-related variables within stimulant research studies to more fully understand the comorbidity. Integrating smoking cessation into stimulant treatment may improve nicotine and stimulant treatment outcomes.