Nicotine dependence and intentions to quit smoking in three samples of male and female recovering alcoholics and problem drinkers

Initial leadership concerns and availability of tobacco cessation services moderate changes in employee-reported concerns about tobacco-free workplace policy implementation over time

Tobacco-free workplace policies (TFWPs) are underused evidence-based interventions that reduce the elevated use of tobacco among substance use treatment center (SUTC) employees and patients. SUTC employees' anticipated concerns about stakeholder pushback are barriers to TFWP adoption. Examination of discrepancies between anticipated and actualized employee-reported TFWP concerns arising from coworkers, patients, and community members in the context of leadership concerns and tobacco cessation care availability for employees may inform strategies to increase TFWP uptake. This study analyzed changes in employee-reported TFWP concerns from before to after a comprehensive tobacco-free workplace intervention that included TFWP implementation, using Chi-square/Fisher's exact tests. Preimplementation leadership policy concerns and tobacco cessation care availability were examined as moderators in generalized linear mixed models. Overall, 452 employees and 13 leaders provided data from 13 SUTCs collectively serving >82 000 patients annually. Results revealed significant decreases over time in employee-reported concerns about TFWP resistance from coworkers. Moderation analyses indicated that employee-anticipated concerns from coworkers and patients, respectively, were less likely to be actualized in SUTCs where leadership endorsed preimplementation TFWP concerns, whereas employee-reported patient concerns rose over time in SUTCs where leadership had no initial implementation concerns. Additionally, employee-anticipated concerns from coworkers were overestimated in SUTCs that did not offer tobacco cessation care to employees. Results supporting the nonactualization of anticipated employee concerns following TFWP implementation can be used to engage other SUTCs for TFWP adoption. Furthermore, moderation effects may suggest that center characteristics translate to greater attention to rollout, ultimately enhancing TFWP stakeholder acceptance.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Female smokers have the highest alcohol craving in a residential alcoholism treatment cohort

BACKGROUND

Cigarette smoking among female and male alcoholics has not been extensively studied as a factor related to intensity of alcohol craving during residential treatment and corresponding sobriety length.

METHODS

This retrospective cohort study assessed self-reported sobriety outcomes in patients with alcohol dependence at 3-month intervals over 12 months after completion of a 30-day residential treatment program. Demographic and clinical variables were collected including smoking status, alcohol craving utilizing the Penn Alcohol Craving Scale (PACS), and alcohol relapse. Statistical analyses included Chi-square, ANOVA, Tukey's test, Kaplan-Meier plots and Cox proportional hazards models as appropriate.

RESULTS

Of the 761 alcohol-dependent study subjects, 355 (47%) were current smokers. Alcohol craving intensity was higher in smoking females compared to nonsmoking females (p=0.0096), smoking males (p<0.0001), and nonsmoking males (p<0.0001). Smoking status-by-sex interaction was not associated with post-treatment relapse. After controlling for other variables, higher PACS scores at admission were associated with higher probability of relapse (p=0.0003).

CONCLUSIONS

In this study, female alcoholic smokers experienced the highest level of alcohol craving in an alcohol treatment setting. Interestingly, this did not translate into higher rates of post-treatment relapse. Further research is warranted to explore the neurobiological basis for sex differences in this highly prevalent comorbidity.

Nicotine interventions with comorbid populations

This article reviews and comments on studies of treatment and prevention of cigarette smoking in individuals with comorbid psychiatric and non-nicotine substance abuse disorders. Despite a high prevalence of cigarette smoking in these populations and interest in quitting, treatment interventions and studies of these interventions are sparse. Multiple barriers to implementation of interventions exist. Existing data suggest that provision of cigarette-smoking interventions in substance abuse treatment patients is efficacious and does not appear to interfere with abstinence from alcohol or illicit drugs, but more research is needed. There are few studies in populations with psychiatric disorders, with the exception of studies of individuals with a history of major depressive disorder. The available data suggest at least moderate efficacy and little evidence of exacerbation of these disorders. Integration of interventions into existing treatment clinics appears desirable. Despite the identification of subgroups that are especially likely to adopt cigarette smoking, there have been no targeted prevention efforts. Further research is recommended in both the treatment and prevention of cigarette smoking in individuals with psychiatric and substance abuse disorders. It is reasonable to offer existing treatments to these subgroups of smokers, since there is some evidence of efficacy and little evidence of harm.

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

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

Smoking cessation efforts among substance abusers with and without psychiatric comorbidity

Little is known about the natural course of smoking behaviors following substance use treatment, particularly among individuals with comorbid substance use and psychiatric disorders. This study examined smoking cessation efforts among 120 substance abusers with and without psychiatric comorbidity. Participants completed assessments of smoking prior to and 6 months following treatment for substance abuse. Comorbidity predicted quit attempts such that a larger proportion of psychiatrically comorbid individuals made quit attempts (54%) relative to those with substance use disorders (SUDs) only (35%). The presence of a psychiatric disorder, in conjunction with a substance use disorder, does not appear to deter smoking cessation efforts in early recovery.

Acceptance of an intended smoking ban in an alcohol dependence clinic

Alcohol treatment professionals are often reluctant to address tobacco dependence in their patients or to implement smoke-free policies in inpatient treatment programs, fearing, among others, non-adherence to alcohol treatment. The aim of the present study was to evaluate the acceptance of an intended smoking ban in a specialized hospital for alcohol withdrawal. Fifteen of 54 patients reported that they would not begin or quit alcohol treatment if smoking were banned in the clinic, but only five would not begin or quit if nicotine replacement were available. The present study indicates that a non-smoking policy would be feasible in a Swiss alcohol clinic, without jeopardizing alcohol treatment adherence.

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.

Predictors of tobacco quit attempts among recovering alcoholics

Reported here are findings from a randomized community intervention trial that followed 90 recovering alcoholic smokers for 6 months. Because the brief (10-min) study intervention had no effect on tobacco use, intervention and control participants were pooled to identify predictors of attempts to quit smoking that may inform clinical practice. During the first 6 months after discharge from residential alcohol treatment, 31% of all participants reported having quit smoking for 48 hrs or longer. Demographic and drug use history variables did not predict quit attempts, but two baseline tobacco use variables did, specifically the Fagerstrom Test for Nicotine Dependence and stage of readiness to quit smoking, p < .01. Participants with high or very high nicotine dependence scores were significantly less likely than those with moderate or low scores to attempt smoking cessation. Compared to those in precontemplation at baseline, those in the preparation stage of readiness to change were about 12 times more likely to make a serious quit attempt.