Substance Use Disorders

 Why is smoking cessation important for substance abusers?

• Cigarette smoking is an addictive behavior with significant long and short term health effects
• Smoking rates among treatment-seeking and community-dwelling individuals with SUDs remains elevated.²
• Poly-drug (alcohol and other drugs) users undergoing treatment have smoking rates close to 100%, which also explains why more than half of these individual die from smoking-related diseases.³
• Cognitive recovery is slower for patients who smoke compared to nonsmokers.²
• Continued smoking increases the risk of relapse after discharge from substance abuse treatment programs.⁴

Efficacious Interventions for smoking with Substance Abusers^2,5

1. Brief motivational interviewing
2. Nicotine replacement therapy (NRT)
3. Transdermal nicotine therapy
4. Cognitive-behavioral therapy
5. Individual and/or group counseling
6. 5 A’s

Find out more about these interventions here.

Barriers and complications to integrating smoking cessation with substance abuse treatment

• Treatment providers fear that the addition of another treatment goal or focus could:
  
  • Impede the success rate of the primary problem behavior.^6,7
  • Decrease client enrollment
  • Promote early withdrawal from treatment programs
  • Increase the likelihood of relapse back to substance use.^4,6,7
     
• Tobacco cessation is viewed as a low priority.⁸
  
  • Counselors who feel overwhelmed with other demands of clients (such as co-occurring mental illness, transportation, child care, etc.) tend to prioritize these demands

• Many clinicians smoke, and do not promote and/or implement smoking cessation interventions as much as clinicians who do not smoke. ^4,8
  
  • Smoking staff may resist the implementation of smoke-free policies. ⁷

• Clients in substance abuse programs may be ambivalent about taking on smoking cessation as a goal, and staff may perceive the task to be too hard to accomplish in addition to achieving substance abuse recovery.⁷

• Many treatment centers do not have smoke-free policies, which may  inadvertently increase smoking in clients or create a hindrance for clients trying to quit smoking.⁷

• Clinicians willing to promote tobacco cessation are faced with other additional barriers which include:
  
  • Insufficient financial reimbrusement to properly administer tobacco cessation interventions to their clients.⁸
  • Lack of access to smoking cessation services as well as insufficient training and educational tools for staff members to address tobacco dependence among patients.^4,6,7

Recommendations

Substance Abuse Treatment Settings

• Studies have shown that when smoking cessation is integrated into substance abuse treatment:
  
  • Client enrollment increases and dropout rates do not change.⁷
  • Treatment outcomes are improved,
  • Likelihood of relapse decreases before and after implementations of smoke-free policies.^4,7,9
     
• Treatment settings should provide concurrent smoking cessation treatment programs to all clients entering a substance abuse program. ^2,9
   
• A smoke-free policy should be implemented on all grounds of the treatment facilities.⁷
  
  • Helps to reinforce healthy behaviors among clients
  • Promotes a drug-free environment for both patients in treatment and patients out of treatment
     
• Smoke-free policies can be successfully established by:
  
  • Providing tobacco education to all staff members.⁷
  • Thoughtfully and carefully implementing the smoke-free regulations
     
• Policy regulation, provision of NRT and training for treatment providers can help integrate smoking cessation programs into residential substance abuse treatment centers.⁷

• Barriers associated with financial issues faced while trying to administer proper smoking cessation interventions can be circumvented by opting for less expensive interventions such as:
  
  • Quitlines
  • Handouts with information on smoking cessation,
  • Referrals to nonprofit organizations that provide free services and/or
  • Websites that provide additional information and self-help guidelines to quit smoking, etc.
    • American Legacy Foundation's Become An Ex Program
    • Smoking Stops Here

Substance Abuse Treatment Providers

• Tobacco cessation can be made priority for clinicians by:
  
  • Increasing awareness of the current TTUD guidelines.^8,10
  • Learning how to administer brief Tobacco Cessation Guidelines (TCG’s) to all their clients.^2,8

• Clinicians and staff should receive adequate training to address the concerns and problems faced by clients attempting to quit smoking concurrently with other treatment programs.⁷

• Clinicians must consider offering their clients a multi-faceted intervention program
  
  • Combining treatments such as counseling and medications can be far more effective in helping clients quit smoking.¹⁰

• Staff members should be encouraged to reduce and/or quit smoking.⁷
  
  • Providing smoking cessation resources not only helps them quit but also provides them with essentials tools necessary to help substance abuse clients quit smoking.⁷

• Staff should be trained on how to provide brief motivational interventions to patients in substance abuse treatment centers.²

Helpful Resources

Fact Sheets about Smoking and Substance Abuse:

• Tobacco Free for Recovery
• NY OASAS Smoking and Substance Abuse Fact Sheet

Other:

• SAMHSA Advisory - Tobacco Use Cessation During Substance Absuse Treatment Counseling
• Tobacco Treatment for Persons with Substance Use Disorders - Treament Provider Toolkit

1. United States Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Office of Applied Studies. National Survey on Drug Use and Health, 2009 [Computer file]. ICPSR29621-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2012-02-10. doi:10.3886/ICPSR29621.v2
2. 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
3. White, T. (2011). Effectiveness of a Brief Behavioral Smoking Cessation Intervention in a residential substance abuse treatment center. Dissertation Abstracts International, 71.
4. 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
5. 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
6. 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
7. 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 
8. 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
9. 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 
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.