A cluster-randomized trial of a brief multi-component intervention to improve tobacco outcomes in substance use treatment

BACKGROUND

Smoking prevalence is high among people in substance use disorder (SUD) treatment, and program interventions to address smoking are often complex and lengthy. This cluster-randomized trial tested whether a brief multi-component intervention impacted tobacco outcomes among staff and clients.

METHODS

Seven SUD treatment programs were randomly assigned to the multi-component intervention or to waitlist control. The 6-month intervention included a leadership motivation assessment, program incentives, 4 staff training sessions and a leadership learning community session. Survey data were collected from staff and clients at pre- and post-intervention. Outcomes were first compared across condition (intervention vs waitlist control), and then examined pre- to post-intervention with condition collapsed.

RESULTS

Staff in the intervention (n = 48) and control conditions (n = 26) did not differ at post-intervention on smoking prevalence, self-efficacy to help clients quit, or practices used to help clients quit smoking. Intervention clients (n = 113) did not differ from controls (n = 61) in smoking prevalence or receipt of tobacco services. Pre-post comparisons collapsed across condition showed a decrease in client and staff smoking prevalence, which could not be attributed to the intervention, and a decrease in client receipt of cessation medication.

CONCLUSION

The brief multi-component intervention did not support changes in smoking prevalence or in tobacco-related services received by clients. Other intervention features are needed to reduce smoking among SUD clients.

TRIAL REGISTRATION

Randomization occurred at the program level and outcomes measured are program-level measures. Accordingly, the trial is not registered.

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.

Culture change in addictions treatment: a targeted training and technical assistance initiative affects tobacco-related attitudes and beliefs in addiction treatment settings

Targeted training and technical assistance can have a major impact on the attitudes and beliefs of addiction service providers with respect to the treatment of tobacco dependency. Major gains have been made with the general public since the mid-1960s with respect to the reduction of tobacco use behavior and tobacco-related diseases. Tobacco use continues to be a major public health problem, and tobacco control initiatives are significantly affecting public attitudes and norms regarding tobacco use. There is, however, a specific population that has not benefited from these gains and, in fact, has been encouraged to continue smoking rather than make an attempt to quit. Individuals with a substance use disorder and/or mental health disorder have a much higher percentage of tobacco use than the general population, resulting in major health disparities. The addiction treatment and recovery community has lagged behind the general public in addressing tobacco use. New York State's project, "Integrating Tobacco Use Interventions Into Chemical Dependence Services," is a model that demonstrates how innovative regulations, and training and technical assistance developed specifically for addiction service providers, can initiate culture change with respect to tobacco use within addiction treatment settings, resulting in improved treatment outcomes and longer term stable recovery.

The New York policy on smoking in addiction treatment: findings after 1 year

OBJECTIVES

We assessed changes in smoking prevalence and other measures associated with the July 2008 New York Office of Alcoholism and Substance Abuse Services tobacco policy, which required that all publicly funded addiction treatment programs implement smoke-free grounds, have "no evidence" of smoking among staff, and make tobacco dependence treatment available for all clients.

METHODS

In a random sample of 10 programs, staff and clients were surveyed before the policy and 1 year later. Measures included tobacco-related knowledge, attitudes, and practices used by counselors and received by clients.

RESULTS

Client smoking decreased from 69.4% to 62.8% (P = .044). However, response to the policy differed by program type. Outpatient programs showed no significant changes on any of the staff and client survey measures. In methadone programs, staff use of tobacco-related practices increased (P < .01), client attitudes toward tobacco treatment grew more positive (P < .05), and clients received more tobacco-related services (P < .05). Residential clients were more likely to report having quit smoking after policy implementation (odds ratio = 4.7; 95% confidence interval = 1.53, 14.19), but they reported less favorable attitudes toward tobacco treatment (P < .001) and received fewer tobacco-related services from their program (P < .001) or their counselor (P < .001).

CONCLUSIONS

If supported by additional research, the New York policy may offer a model that addiction treatment systems can use to address smoking in a population where it has been prevalent and intractable. Additional intervention or policy supports may be needed in residential programs, which face greater challenges to implementing tobacco-free grounds.

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.

Does the Presence of a Smoking Cessation Clinical Trial Affect Staff Practices Related to Smoking?

This study investigated whether organizational changes occurred when nicotine treatments were tested in specialty care clinics. Two intervention clinics (one drug treatment and one HIV-care) participated in clinical trials for nicotine treatment. Three clinics (two drug and one HIV-care) were control clinics. Staff in the intervention clinics (n=57) and in the control clinics (n=62) were surveyed at baseline and 18 months later. Staff surveys concerned nicotine-related knowledge, beliefs about treating smoking, self-efficacy in delivering such treatment, nicotine related practices, and barriers to providing nicotine treatment. Mean scale scores at 18 months were no different in clinics participating in the clinical trials from the control group for any of the five scales (knowledge, practices, barriers, efficacy, and beliefs). The presence of a smoking cessation clinical trial did not influence staff knowledge, attitudes, or practices related to smoking in these clinics. More specific organizational intervention may influence staff practices related to addressing smoking among clients in drug treatment and HIV-care clinics.

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.

Effects of a Tobacco Ban on Long-term Psychiatric Patients

A total ban on all tobacco products was implemented in a diverse psychiatric institution. A post hoc evaluation examined the effect of the ban on long-term patients by comparing their characteristics the year before the ban to the year after. Several variables measuring physical health, psychiatric symptomatology, feelings of well-being, and interpersonal conflict were coded with very high reliability from health records. For the majority of patients who were in the maximum security forensic division, the tobacco ban was associated with almost no detectable ill effects with some clear benefits. Among the remainder of the long-term patients, the ban might have been associated with a temporary increase in physical aggression towards staff members. It was concluded that successful implementation, and the avoidance of ill effects, depended entirely on the success staff members had in actually preventing patient access to tobacco.

Integrated treatment of co-occurring mental illness and addiction: clinical intervention, program, and system perspectives

Individuals with mental illness and addiction comprise at least half of the patients in most mental health treatment systems. This combination results in increased risk for frequent psychiatric relapses, poor medication compliance, violence, suicide, legal problems, and high utilization of the emergency room or inpatient services. Traditional mental health and addiction treatments have not adequately addressed these co-occurring disorders due to clinical interventions, programs, and system flaws that have not addressed the individual's needs. Integrated treatment requires both an understanding of mental illness and addiction and the means to integrate and modify the traditional treatment approaches in both the mental health and addiction treatment fields. There is strong evidence to support the efficacy and effectiveness of integrated treatment in this population. All mental health clinicians should become experienced and skilled in the core psychotherapy approaches to treating substance use disorders, including motivational enhancement therapy, relapse prevention (cognitive-behavioral therapy), and 12-step facilitation. In addition, integrated treatment includes integrating medications for both addiction and mental illness with the behavioral therapies and other psychosocial interventions. This article reviews the clinical intervention, program, and system components of integrated treatment and specific clinical interventions for this population.

Serious mental illness and tobacco addiction: a model program to address this common but neglected issue

Tobacco addiction among persons with serious mental illness (SMI) has been largely ignored. About 75 to 85% of persons with schizophrenia, bipolar disorder, and other SMI use tobacco; most will either die and/or have reduced quality of life because of tobacco-caused medical diseases. Tobacco addiction is the most common co-occurring disorder for the SMI population. A dramatic reduction in tobacco use in the general population has occurred during the past 40 years; however, there has been almost no reduction for smokers with SMI. The University of Medicine and Dentistry of New Jersey program targets smokers with SMI and provides outreach services, clinical treatment and research, and consultation to other community-based mental health treatment agencies in New Jersey. Clinical and research evidence supports motivation-based treatment, blending mental health and addiction treatment approaches, and integrating tobacco dependence treatment within mental health settings. The unique barriers and clinical issues for this population are described.