10/6/2015. Quotes from the Literature PATIENT, PROGRAM AND POLICY STRATEGIES TO REDUCE TOBACCO USE IN ADDICTION TREATMENT.

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1 PATIENT, PROGRAM AND POLICY STRATEGIES TO REDUCE TOBACCO USE IN ADDICTION TREATMENT Joseph Guydish, PhD University of California, San Francisco National Conference on Tackling Tobacco Use in Vulnerable Populations Bethesda, Oct. 5, 2015 Acknowledgement: This work was supported by NIDA P50 DA009253, NIDA/FDA R01 DA036066, and by the California Tobacco Related Disease Research Program 22XT Background Patient level intervention Program level intervention Policy level intervention Notes from the field Quotes from the Literature Cigarette smoking among alcohol abusers: a continuing and neglected problem (Kozlowski et al.) The time has come to face the burdensome costs of tobacco use and to address nicotine dependence in chemical dependents (Goldsmith & Knapp) In addition to the transformation of institutional culture which will be required, managers and staff need to know how to implement smoking intervention (Bowman & Walsh) Confronting a neglected epidemic: tobacco cessation for persons with mental illnesses and substance abuse problems. 20 (Schroeder & Morris) 1

2 Smoking Prevalence in 42 US Addiction Treatment Studies and the US 0% 90% 80% 70% 60% 50% 40% 30% 20% % 0% US Adult Population (NHIS data) US Drug Treatment Studies NSDUH Guydish J, Passalacqua E, Tajima B, Chan M, Chun J, Bostrom A. Smoking prevalence in addiction treatment: a review. Nicotine Tob Res. 2011;13(6): PMCID: PMC Smoking Prevalence % U.S. General Population 70% Patients in Addiction Treatment Clinics Treatment and National Smoking Prevalence

3 Percentage /6/2015 Smoking and mortality in substance abuse Hurt et al., JAMA patients receiving IP alcohol tx Tracked death certificates to 1994 For 214 deaths 50% tobacco-related, 34% alcohol-related deaths Hser et al., Prev. Med patients receiving narcotics tx Tracked death certificates to 1986 For 77 deaths Death rates for smokers 4x non-smokers Oregon death rates due to tobacco use Overall General population Mental health only Substance abuse only Dual diagnosis < > 80 Age Death rates due to tobacco use General population Substance abuse only 0 < > 80 3

4 Background Patient level intervention Program level intervention Policy level intervention Notes from the field IQ (I Quit) Study Aim: Test a readiness intervention for smokers Increase participation in tobacco dependence treatment Eligibility: Smoker Women in residential treatment Baseline and 30 day assessment S-KAS survey CO level IQ Study: Readiness Groups 3 week Readiness Group (ES activities) Group 1: ES report discussion PAC Activities selection Review Medication/ NRT facts Group 2: Prep for 24 hour quit (dealing with withdrawal/cravings) PAC Resources Medication/NRT instructions Group 3: 24 hour quit discussion Continuing change process after group ends Review PAC resources/1-800-no-butts Quitline 4

5 IQ Study Readiness Group (n=36) 75 Women Smokers Readiness Group + Incentives (n=39) IQ Study Baseline Expert System Computerized Assessment Readiness Group 1 Readiness Group 2 Readiness Group 3 30 day Followup Expert System Computerized Assessment Quit Attempt Initiate Smoking Cessation 0% 90% 80% 70% 60% 50% 40% 30% 20% % 0% 31% Incentive 44% Control Chi-square(1df, n=75) = 2.14, p=0.14 5

6 Predictors of Attending at Least One Smoking Cessation Group (N = 75)* Model 1 Model 2 Adjusted OR Wald p Wald (95% CI) Chi-square, Adjusted OR Chi-square, df (95% CI) df p Number of weeks in tx. program 1.08 ( ) 4.28, ( ) 13.40, 1 <0.001 Risk perception of lung cancer 1.03 ( ) 9.12, ( ) 31.25, 1 <0.001 Condition Control 1 Incentive 0.47 ( ) 0.71, ( ) 0.96, No. of readiness groups attended 2.23 ( ) 5.24, Successful practice quit attempt (PQA) 6.78 ( ).05, Multivariate logistic regression was built from all significant variables from univariate analysis (at p value 0.) including number of weeks in the program, perception of risk of lung cancer, and number of readiness groups attended or making a successful practice quit attempt. Models controlled for age, race, and education. Models also controlled for nesting participants within cohort. Number of Readiness Groups attended is inter-correlated with making a successful practice quit attempt. Model 1 includes Number of Readiness Groups attended, while Model 2 includes making a successful practice quit attempt. Background Patient level intervention Program level intervention Policy level intervention Notes from the field Organizational Change Intervention 6

7 Study Design Clinic 1 Pre X Post F.U. Clinic 2 Clinic 3 Pre Post F.U X Pre X Post F.U. ATTOC Client KAS Knowledge*(S) Attitudes*(S,T) 3.5 Pre Post 3 Pre Post Pre Services*(T, SxT) Post Site 3 Site 2 Site 1 (S) = significant site effect (T) = significant time effect (S x T) = significant site x time interaction Drug and Alcohol Dependence (2012), 121,

8 Background Patient level intervention Program level intervention Policy level intervention Notes from the field New York System Intervention to improve tobacco treatment (2008) (a) Tobacco-free grounds: prohibiting the use of all tobacco products in facilities, on grounds and in vehicles... (b) No evidence of staff smoking (c) All patients receive cessation intervention if wanted New York System Intervention: Study Methods Data Collection (2008, 2009, 2013) Survey staff (S-KAS) Survey clients convenience sample n=25-50 per program Interview program director 8

9 Percentage Cigarettes per day (CPD) /6/2015 Client and Staff smoking prevalence Clients Staff Client CPD All Programs Residential Methadone Background Patient level intervention Program level intervention Policy level intervention Notes from the field 9

10 METHODS Participants: 1,114 participants from 24 addiction treatment clinics nationwide. Measures: ipad based online survey containing smoking knowledge, attitudes and services (S-KAS) scales. Program Sites Native American Rehabilitation Association Portland, OR Opiate Treatment Outpatient Program Shelton, CT Bridgeport, CT Philadelphia, PA AIDS Care Group Chester, PA Hershey, PA Minneola Treatment Center Mineola, NY Chesterfield Community Columbus, Service Board & Substance OH Abuse Services Chesterfield, VA Tarzana, CA Lexington, NC Dorchester Alcohol and Drug Commission Summerville, SC Raleigh, NC Wilmington, NC Dallas, TX Jacksonville, FL Kaneohe, HI Clearwater, FL Orlando, FL The Village South Miami, FL

11 Mean S-KAS Score /6/2015 RESULTS 5.00 Mean of S-KAS Score between Clinic with Staff-Client Smoking Rate 50% and < 50% (p ) * * * * % <50% 1.00 Knowledge Attitude Service by Clinician S-KAS Scale * : Statistically significant when p<0.05 Service by Program RESULTS * : Statistically significant when p<0.05 Use of other tobacco products 50% Past 30 days 40% 30% 30.8% 20% 16.1% % 9.2% 9.9% 6.9% 0% Smokeless Cigarillos or Little Filtered Cigars Cigars Electronic cigarettes Hookah 11

12 Background Patient level intervention Program level intervention Policy level intervention Notes from the field Patient: Assess, treat, or refer MI, PQA, NRT, Quitline Medicaid/ACA Program Reduce staff smoking Leadership/investment Staff training Eliminate staff/client smoking together Policy Tobacco free grounds Access to tobacco medication Reimbursement for tobacco counseling State and National leadership (SAMHSA/CSAT, NIDA, CDC) 12