Predictors of Tobacco Use Among New York State Addiction Treatment Patients

Factors associated with dual and polytobacco use among people in residential substance use disorder treatment

BACKGROUND AND OBJECTIVES

Little is known about whether people in substance use disorder (SUD) treatment are at risk for multiple-tobacco use. We examined the factors associated with dual- and polytobacco use among clients in SUD treatment.

METHODS

A cross-sectional survey was conducted in 2019 among 562 clients (M_age  = 39, 74% male) in 20 residential SUD treatment programs in California, USA. The outcomes included single-, dual- (use of two products), and polytobacco use (use of three of more products). Independent variables were nicotine dependence, quitting-related factors, blunt/spliff use, and health-related factors. A multinomial model examined associations between the independent variables and the outcome, controlling for demographics, and time in treatment.

RESULTS

Overall, 32.6%, 18.9%, and 14.0% of the sample were single-, dual-, and polytobacco users, respectively. Factors associated with increased odds of polytobacco use included greater nicotine dependence (adjusted odds ratio [AOR] = 1.60; 95% CI = 1.19, 2.16), ever using e-cigarettes for quitting (AOR = 4.56; 95% CI = 2.23, 9.34), and past 30-day use of blunt/spliff (AOR = 2.96; 95% CI = 1.48, 5.89). Factors associated with increased odds of dual use were ever using e-cigarettes for quitting (AOR = 3.19; 95% CI = 1.79, 5.66) and reporting more mentally unhealthy days (AOR = 1.05; 95% CI = 1.02, 1.07).

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

This study extends the literature on tobacco use among people in SUD treatment by revealing the high prevalence of dual- and polytobacco use and the unique characteristics of users. The findings have implications for interventions reducing all types of tobacco use in this understudied population.

A Comparison of Daily Versus Weekly Electronic Cigarette Users in Treatment for Substance Abuse

Objective

This research examined electronic cigarette (e-cigarette) use by individuals in treatment for substance abuse, a population with a high prevalence of tobacco use and poor smoking cessation outcomes.

Methods

We surveyed 1127 individuals from 24 substance abuse treatment centers across the United States. Bivariate analyses and logistic regression were used to examine factors associated with daily (N = 87) versus weekly (N = 81) e-cigarette use.

Results

Among the full sample, 59.8% reported any lifetime use of e-cigarettes, with 23.6% reporting past 30-day use. Daily e-cigarette users were more likely to have used second-generation, tank-type e-cigarettes, χ2(1,N = 165) = 11.54, p = .001, used more flavors overall, t(168) = 2.15, p = .03, and were more likely to report using their e-cigarette continuously throughout the day, χ2(4,N = 168) = 16.7, p = .002, compared to weekly e-cigarette users. Over half (57.7%) of the daily and weekly e-cigarette users reported having an e-cigarette device that broke. The logistic regression model adjusting for clinic type and days with poor mental health found that daily e-cigarette users were significantly more likely than weekly e-cigarette users to be from methadone clinics (adjusted odds ratio [AOR] = 2.40, p = .04), and former smokers (AOR = 6.37, p < .002).

Conclusions

Daily e-cigarette users in substance abuse treatment were more likely to be from methadone clinics and former cigarette smokers. However, the majority (73.6%) of daily e-cigarette users were current cigarette smokers. E-cigarette device type reliability (eg, breakage) may be an important factor to consider among drug treatment and other populations with lower socioeconomic status.

Implications

This study found several differences in the device type, flavors, and use characteristics of daily versus weekly e-cigarette users. While majority of e-cigarette users in substance abuse treatment were current cigarette smokers, daily e-cigarette users were more likely to be former cigarette smokers. Administrators of substance abuse treatment programs should evaluate potential benefits and harms of e-cigarettes when developing program policies.

Menthol cigarette smoking among individuals in treatment for substance use disorders

There are higher rates of menthol cigarette smoking within certain population subgroups. Limited research has examined menthol use among individuals in treatment for substance use disorders (SUD), a population with a high prevalence of cigarette smoking, poor smoking cessation outcomes, and high tobacco disease burden. Survey data were collected from 863 smokers sampled from 24 SUD treatment programs affiliated with the NIDA Clinical Trials Network (CTN) in the United States. Prevalence of menthol cigarette smoking was examined for the sample. Bivariate and multivariate analyses were used to examine demographic and tobacco use characteristics associated with menthol cigarette smoking. Overall, the prevalence of menthol smoking among individuals in SUD treatment was 53.3%. Smoking menthol versus non-menthol cigarettes was associated with being female (AOR=1.61, p=0.003), African American (AOR=7.89, p<0.001), Hispanic/Latino (AOR=3.39, p<0.001), and lower odds of having a college degree (AOR=0.49, p=0.015). Controlling for demographic factors, menthol smokers were more likely to report marijuana (AOR=3.33, p<0.007) as their primary drug compared to alcohol. Lastly, menthol smokers were more likely to report interest in getting help for quitting smoking (AOR=1.53, p=0.01), although they were not more likely to report making a past year quit attempt. In conclusion, use of menthol cigarettes was higher among smokers in SUD treatment than in general population smokers. Regulatory policies targeting the manufacture, marketing, or sale of menthol cigarettes may benefit vulnerable populations, including smokers in SUD treatment.

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.

Drug abuse staff and clients smoking together: A shared addiction

Smoking is endemic in drug abuse treatment populations, and smoking prevalence in this population appears unresponsive to existing tobacco control strategies. Clinical and policy guidelines encourage programs to address smoking among clients, and research has identified key barriers to doing so. This report explores the practice of staff and clients smoking together in drug treatment programs, and how this practice is associated with other tobacco-related measures. Clients (N=1113) were surveyed and program directors were interviewed in a national sample of 24 drug abuse treatment programs affiliated with the NIDA Clinical Trials Network. Clients were asked whether they observed staff and clients smoking together in their program and, using program as the unit of analysis, this measure was tested for its association with client-level and program-level tobacco-related outcomes. Higher rates of staff and client smoking together were associated with higher staff smoking prevalence (p=0.006), lower rates of client thoughts about quitting in the next 30days (p=0.027), more negative client attitudes toward quitting smoking (p=0.004), and with clients receiving fewer tobacco-related services (p=0.024). These findings illuminate an actionable, low cost policy intervention to address smoking in drug abuse treatment, which is to prohibit the practice of staff smoking together with clients. In the interest of the health of clients whom they serve, counselors, program directors, state regulatory agencies, and federal funding agencies should act to end this practice.

Electronic-cigarette use by individuals in treatment for substance abuse: A survey of 24 treatment centers in the United States

Prevalence and reasons for using electronic cigarettes (e-cigarettes) was examined among patients enrolled in 24 substance abuse treatment centers in the United States (N=1113). Prevalence of e-cigarette use was assessed for the full sample. Bivariate analyses and multivariate logistic regression were used to identify characteristics associated with e-cigarette use among current cigarette smokers (the majority of e-cigarette users). Overall 55.5% of the sample reported lifetime use of e-cigarettes, and 30.5% reported using e-cigarettes in the past 30days (current users). The main reasons for using e-cigarettes were (a) at times/places when smoking was prohibited (53.5%), and (b) as a way to quit/reduce cigarette smoking (50.3%). Daily vs non-daily e-cigarette users were more likely to use e-cigarettes both as a way to reduce health risks, and as a way to quit/reduce cigarette smoking. A majority of e-cigarette users (87.1%) reported dual use of e-cigarettes and tobacco cigarettes during the past month. Among current cigarette smokers, those that also used e-cigarettes smoked more cigarettes per day, were more likely to have made a past year cigarette quit attempt, and to have tried nicotine replacement therapy compared to cigarette only smokers. There was a high rate of dual e-cigarette and cigarette use by persons enrolled in addiction treatment. E-cigarette users may be heavier cigarette smokers trying to quit or reduce their cigarette smoking. However, e-cigarettes were also used at times when individuals could not smoke cigarettes. Substance abuse treatment centers developing tobacco policies need to consider these potentially conflicting reasons for using e-cigarettes.

Smoking among patients in substance use disorders treatment: associations with tobacco advertising, anti-tobacco messages, and perceived health risks

BACKGROUND

Although tobacco control efforts have contributed to an overall decline in smoking, individuals with substance use disorders (SUDs) continue to smoke at high rates and remain targets of advertising to vulnerable groups, including those with mental health disorders and SUDs.

OBJECTIVES

We examined associations of tobacco advertising exposure and receptivity, anti-tobacco message awareness, and health-risk perception with smoking status and cigarettes-per-day (CPD) in a national sample of SUD treatment patients.

METHODS

The patients (N = 1,113) in 24 programs chosen randomly, stratified by program type, from among publicly funded adult treatment programs within the National Drug Abuse Treatment Clinical Trials Network completed surveys of smoking, advertising exposure and receptivity, anti-tobacco message awareness, and perceived health risks.

RESULTS

Current smokers (77.9% of the sample) smoked a daily median of 10 cigarettes (IQR = 13). The participants reporting daily advertising exposure were 1.41 times more likely to be smokers (p = 0.019) than others. Those highly receptive to advertising were 2.34 times more likely to be smokers (p < 0.001) than those with low/moderate receptivity. Higher perceived health risk was associated with lower odds of smoking (OR = 0.99, 95% CI: 0.98-0.99, p < 0.001). CPD for smokers highly receptive to advertising was 11.1% (95% CI: 2.8%-20.0%) higher than for smokers with low/moderate advertising receptivity. Anti-tobacco message awareness was not associated with smoking status or CPD.

CONCLUSION

The high rate of smoking among SUD treatment patients is associated with daily exposure and high receptivity to tobacco advertisements and lower perception of health-related smoking risks. Tobacco control efforts should target this vulnerable population.

Use of multiple tobacco products in a national sample of persons enrolled in addiction treatment

OBJECTIVE

To explore use of tobacco products in relationship to marketing exposure among persons in addiction treatment.

METHOD

A random sample of treatment programs was drawn from the National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN). Participants in each program completed surveys concerning use of tobacco products (N=1113). Exposure to tobacco marketing and counter-marketing, advertising receptivity, and perceived health risks of smoking were tested for their association with use of multiple tobacco products.

RESULTS

Prevalence of combustible cigarette use was 77.9%. Weekly or greater use of other products was: e-cigarettes (17.7%), little filtered cigars (8.6%), smokeless tobacco (5.2%), and standard cigars (4.6%) with 24.4% using multiple tobacco products. Compared to single product users, multiple product users smoked more cigarettes per day (OR=1.03, 95% CI 1.01-1.05, p<0.001), were more likely to have tried to quit (OR=1.41, 95% CI 1.02-1.96, p=0.041), reported greater daily exposure to advertising for products other than combustible cigarettes (OR=1.93, CI 1.35-2.75, p<0.001), and greater daily exposure to tobacco counter-marketing (OR=1.70, 95% CI: 1.09-2.63, p=0.019).

CONCLUSION

Heavier smokers and those trying to quit may be more likely to use e-cigarettes, little filtered cigars, or smokeless tobacco and have greater susceptibility to their advertising. This highlights the importance of regulating advertising related to smoking cessation as their effectiveness for this purpose has not been demonstrated.

Implementation of smoking cessation treatment in substance use disorder treatment settings: a review

BACKGROUND

The high prevalence of smoking among individuals receiving treatment for substance use disorder (SUD) has led to repeated calls for integrating smoking cessation treatment into these settings.

OBJECTIVES

This review summarizes key findings from the research on the implementation of smoking cessation in SUD treatment.

METHODS

PubMed searches of articles published from 2000 to 2015 yielded 48 empirical studies that focused on the delivery of smoking cessation in the US specialty SUD treatment settings in which organizations and counselors were the unit of analysis. Most studies used observational designs to gather data from organizations and counselors. Organizational studies show that few SUD treatment programs offer cessation counseling or pharmacotherapy. Organizational barriers include limited training, inadequate resources, and cultural norms that do not recognize smoking cessation as part of the organization's mission. Smoking cessation services are more likely to be available in medically oriented treatment settings, larger treatment programs, those offering a broader array of comprehensive services, and those that are more reliant on fee-for-service reimbursement (e.g., insurance, Medicaid). Surveys of counselors also show very low implementation. Counselors' personal skills and attitudes, their perceptions of managerial and coworker support for smoking cessation, and the availability of resources and reimbursement to support these services are correlated with implementation. State policies requiring treatment programs to offer tobacco treatment increase both adoption and implementation, yet these services continue to reach only modest percentages of the patients.

CONCLUSIONS

Few studies have tested specific implementation strategies. Such research is needed to determine how to accelerate the diffusion of these evidence-based practices to the SUD treatment field.

An international systematic review of smoking prevalence in addiction treatment

AIMS

Smoking prevalence is higher among people enrolled in addiction treatment compared with the general population, and very high rates of smoking are associated with opiate drug use and receipt of opiate replacement therapy (ORT). We assessed whether these findings are observed internationally.

METHODS

PubMed, PsycINFO and the Alcohol and Alcohol Problems Science Database were searched for papers reporting smoking prevalence among addiction treatment samples, published in English, from 1987 to 2013. Search terms included tobacco use, cessation and substance use disorders using and/or Boolean connectors. For 4549 papers identified, abstracts were reviewed by multiple raters; 239 abstracts met inclusion criteria and these full papers were reviewed for exclusion. Fifty-four studies, collectively comprising 37,364 participants, were included. For each paper we extracted country, author, year, sample size and gender, treatment modality, primary drug treated and smoking prevalence.

RESULTS

The random-effect pooled estimate of smoking across people in addiction treatment was 84% [confidence interval (CI) = 79, 88%], while the pooled estimate of smoking prevalence across matched population samples was 31% (CI = 29, 33%). The difference in the pooled estimates was 52% (CI = 48%, 57%, P < .0001). Smoking rates were higher in programs treating opiate use compared with alcohol use [odds ratio (OR) = 2.52, CI = 2.00, 3.17], and higher in ORT compared to out-patient programs (OR = 1.42, CI = 1.19, 1.68).

CONCLUSIONS

Smoking rates among people in addiction treatment are more than double those of people with similar demographic characteristics. Smoking rates are also higher in people being treated for opiate dependence compared with people being treated for alcohol use disorder.

A Pilot Study of a Readiness Group to Increase Initiation of Smoking Cessation Services among Women in Residential Addiction Treatment

This study implemented a smoking cessation readiness group (RG) in two women-focused residential substance abuse treatment programs, with the aim of engaging women in smoking cessation services. The primary outcome was defined as attending at least one cessation group after the RG ended. The RG combined features of the Expert Systems (ES) approach with a practice quit attempt. ES is an interactive system which tailors intervention to the smokers' stage of change, while the practice quit attempt rehearses the process of quitting smoking. As a secondary aim we tested whether incentives, used to promote participation and engagement in the RG, would increase initiation of smoking cessation services. Participants (N=75) were women smokers enrolled in two residential programs, and intention to quit smoking was not required for participation. Twelve participant cohorts were randomly assigned to receive the RG with or without incentives. Following the RG intervention, 38.7% of participants (n=29) attended at least one smoking cessation session. Both the number of RG sessions attended and a successful practice quit attempt predicted the later use of cessation services, while incentives did not. From pre- to post-RG, participants reported decreased cigarettes per day (CPD: 11.8 vs. 7.6, p<.0001) and decreased nicotine dependence as measured by the Heaviness Smoking Index (HSI: 2.3 vs. 1.8, p<.001). The 3-session group-format RG intervention was associated with initiation of smoking cessation services and with changes in smoking behavior.