Substance Abuse Providers

 

Why address smoking in substance abuse treatment clinics?

      Tobacco-related diseases are the leading cause of morbidity and mortality among substance abusers in treatment programs.1, 2 Numerous studies have shown a strong positive correlation between the rates of smoking and substance abuse, such that the prevalence of smoking is two to three times higher among substance abusers compared to the general population.2, 3 However, smoking cessation is not always included as a part of the treatment program in substance abuse treatment clinics.4 Addressing smoking can help improve the overall well-being of the patients and reduce their risk for relapse to other substances.2

Commonly reported barriers to integrating smoking cessation into substance abuse treatment clinics and recommendations to overcome those barriers

  1. Treatment providers tend to cite common arguments against the integration of smoking cessation programs with other substance abuse treatments such as decreased client enrollment, early withdrawal from treatment programs and/or the increased likelihood of relapse.2, 5, 6

a.  Williams et al. (2005) showed that client enrollment and dropout rates do not change significantly before and after implementations of smoke-free policies. Instead, the rates of client enrollment increase which leads to better treatment outcomes including decreased likelihood for relapse.2, 3, 6, 7

b.   Recommendation: Provide concurrent smoking cessation treatment programs to all clients entering a substance abuse program.3, 8

i.  Clients have an increased motivation to stop quit smoking when the cessation program is offered concurrently with other treatment programs

  1. Providers who smoke do not promote and/or implement smoking cessation interventions as much as those who do not smoke and some providers use smoking as a means to form a therapeutic alliance.1, 2, 9

 a.   Recommendations:

i.   Treatment providers should be up-to-date with the current the Treating Tobacco Use and Dependence (TTUD) guidelines outlined by the Public Health Service (PHS).2, 9

1.   Raising treatment provider’s awareness of the current TTUD guidelines can help provider’s better address tobacco use with their clients.

2.   In particular, the TTUD guidelines recommend that providers:7, 10

a.   Screen every client for their tobacco use status

b.   Encourage clients to quit smoking

c.   Provide brief interventions

d.   Individual, group or telephone counseling

e.   Provide pharmacological interventions

f.  Provide combined treatment options such as both counseling and medications

g.   Telephone quitline counseling

h.   Provide motivational interventions &

i.    Provide coverage for the treatments

ii.   Providing counselors and staff who smoke with smoking cessation programs can help them quit smoking, raise their awareness to the dangers of smoking and provide them with useful skills to administer smoking cessation guidelines to their clients based on their personal experience.7

  1. Treatment centers without smoke-free policies can serve as a stimulus, which could either increase smoking in clients or create a hindrance for clients trying to quit smoking.6

a.   Smoking on grounds increase the rates of smoking in treatment clinics because some patients tend to use smoking as a compensatory relief for their withdrawal from other substances they have recently discontinued as part of their treatment.1

b.   Recommendations:

i.   Implementing a smoke-free policy on all grounds of the treatment facility can promote healthy behavior,  help reduce smoking in clients and promotes a drug-free environment for both patients in treatment and patients out of treatment.6

ii. The PHS also recommends increased implementation of smoking cessation interventions in substance abuse treatments because studies have shown that individuals in substance use treatments tend to be heavily dependent on smoking and also face greater difficulties in quitting smoking.9

  1. Providers willing to promote tobacco cessation are faced with other additional barriers which include:

a.   Lack of financial assistance to properly administer tobacco cessation interventions to their clients.9

i.   Recommendation:

1.   Providers faced with financial and re-compensation barriers associated with administration of proper smoking cessation interventions could circumvent this issue by opting for less expensive interventions such as:

a.   Quitlines

b.   Handouts with information on smoking cessation,

c.   Referrals to nonprofit organizations that provide free services

d.   Websites that provide additional information and self-help guidelines to quit smoking, etc.

b.   Lack of access to smoking cessation services as well as insufficient training and educational tools for staff members to address tobacco dependence among patients.2, 5, 6

i.   Studies have shown that insufficiently trained staff members may influence the way in which tobacco dependence treatment is provided. For instance, staff members may lack the adequate skills and knowledge required to provide tobacco cessation interventions.1

ii.   Staff attitudes towards client smoking habits may also dictate whether or not they address smoking in their clients. For instance, Knudsen et al. (2010) showed that staff who perceived smoking to be less important to the overall treatment of substance abuse or those who perceived less time available for administer of smoking cessation interventions along with other substance abuse treatments were less likely to adopt treatment plans that included smoking cessation as part of the service.

1.   Recommendation (s):

 a.   Counselors must learn how to administer small and brief Tobacco Cessation Guidelines (TCGs) to all their patients according to the PHS recommendations.9

i.   The TCG guidelines recommend that providers implement:9

1.   The 5 A’s

2.  Use problem-solving and skill building techniques to assist their clients quit smoking

3. Develop a quit plan and provide self-help materials/quitline numbers

4.  Help clients recognize triggers and teach them coping skills to reduce risk of use

5.    Provide motivation with positive feedbacks

ii.   Tools to help with the administration of the TCGs can be located on the following pages/links:

1.   The brief interventions and 5 A’s page

2.   Toolkit for Substance Abuse Treatment Providers

      In summary, there is evidence to suggest it is critical to integrate smoking cessation programs into current substance abuse treatment.  Policy regulations such as implementation of smoke free grounds, provision of nicotine replacement therapy (NRT) and training for treatment providers can help integrate smoking cessation programs into residential substance abuse treatment centers and address tobacco dependence in clients suffering from substance use disorders.6

Types of Interventions

1.   Brief motivational interviewing 7

a.   Can be used to treat patients who express uncertainty when it comes to quitting.

b.   Can help to promote intrinsic motivation and strengthen commitment.

Refer to the brief interventions page for more details

2.   Nicotine replacement therapy (NRT) 7

a.  There are various types of NRT including gum, patch, nasal spray, inhaler and lozenge.

b.   They are available over the counter and studies show that they are associated with long term smoking abstinence rates.

Refer to the NRT page for more details

3.   Pharmacotherapy 7

a.   Pharmacological interventions such as bupropion and varenicline assist clients to quit smoking .

Refer to the medication/pharmacotherapy page for more details

4.   Individual and/or group counseling

a.   Individuals/ group counseling helps to educate patients on the dangers of smoking and the benefits of quitting.

b.   Counseling provides patients with tools and skills to aid in their quit attempts and provides support and motivation to those who feel ambivalent about pursuing quitting.

c.   A group setting environment also helps to increase social support for tobacco cessation.11

5.   5 A’s

a.   Ask

b.   Advise

c.   Assess

d.   Assist

e.   Arrange

Refer to the 5 A's page for more details

Helpful Links:-

http://www.ncbi.nlm.nih.gov/books/NBK63948/#A28270

http://drugabuse.gov/treatingtobacco.html

http://smokingcessationleadership.ucsf.edu/Downloads/Steppsudtoolkit.pdf

 

Last updated: May 06, 2013
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References
  1. Ziedonis, D., Guydish, J., Williams, J., Steinberg, M., & Foulds, J. (2006). Barriers and solutions to addressing tobacco dependence in addiction treatment programs. Alcohol Research & Health, 29(3), 228-235. 
  2. Knudsen, H. K., & Studts, J. L. (2010). The implementation of tobacco-related brief interventions in substance abuse treatment: A national study of counselors. Journal of Substance Abuse Treatment, 38(3), 212-219. doi:10.1016/j.jsat.2009.12.002
  3. Hahn, E.J., Warnick, T.A., & Plemmons, S. (1999). Smoking cessation in drug treatment programs. J. Addict. Dis.18, 89-101.1063196610.1300/J069v18n04. 10.1300/J069v18n04 
  4. Prochaska, J. J., Delucchi, K., & Hall, S. M. (2004). A Meta-Analysis of Smoking Cessation Interventions With Individuals in Substance Abuse Treatment or Recovery. Journal Of Consulting And Clinical Psychology, 72(6), 1144-1156. doi:10.1037/0022-006X.72.6.1144
  5. Knudsen, H. K., Studts, J. L., Boyd, S., & Roman, P. M. (2010). Structural and cultural barriers to the adoption of smoking cessation services in addiction treatment organizations. Journal of Addictive Diseases, 29, 294-305.2010-14813-00510.1080/10550887.2010.489446. 10.1080/10550887.2010.489446
  6. Williams, J.M., Foulds, J., Dwyer, M., Order-Connors, B., Springer, M., Gadde, P., &   Ziedonis, D.M. (2005). The integration of tobacco dependence treatment and tobacco-free standards into residential addictions treatment in New Jersey. J. Subst. Abuse Treat.28, 331-340.1592526710.1016/j.jsat.2005.02.0102005-07458-005. 10.1016/j.jsat.2005.02.010 
  7. Baca, C. T., & Yahne, C. E. (2009). Smoking cessation during substance abuse treatment: What you need to know. Journal of Substance Abuse Treatment, 56, 205-219
  8. Kalman, D., Kim, S., DiGirolamo, G., Smelson, D., & Ziedonis, D. (2010). 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. Clinical Psychology Review, 30(1), 12-24. doi:10.1016/j.cpr.2009.08.009
  9. Rothrauff, T. C., & Eby, L. T. (2011). Substance abuse counselors' implementation of tobacco cessation guidelines. Journal of Psychoactive Drugs, 43(1), 6-13. doi:10.1080/02791072.2011.566491
  10. Fiore MC, Jaen CR, Baker TB, Bailey WC, Benowitz N, et al. 2008. Treating Tobacco Use and Dependency: 2008 Update Practice Guideline. Rockville, MD: US Dep. Health Hum. Serv. Public Health Serv. 179 pp.
  11. U.S. Department of Health and Human Services, Public Health Service. (2008). Treating Tobacco Use and Dependence: 2008 Update- Clinical Practice Guideline. Retrieved May 23, 2008, from http://www.surgeongeneral.gov/tobacco/default.htm.