Barriers and solutions to addressing tobacco dependence in addiction treatment programs

Alcohol Research & Health, Fall, 2006 by Douglas M. Ziedonis, Joseph Guydish, Jill Williams, Marc Steinberg, Jonathan Foulds

Despite the high prevalence of tobacco use among people with substance use disorders, tobacco dependence is often overlooked in addiction treatment programs. Several studies and a meta-analytic review have concluded that patients who receive tobacco dependence treatment during addiction treatment have better overall substance abuse treatment outcomes compared with those who do not. Barriers that contribute to the lack of attention given to this important problem include staff attitudes about and use of tobacco, lack of adequate staff training to address tobacco use, unfounded fears among treatment staff and administration regarding tobacco policies, and limited tobacco dependence treatment resources. Specific clinical-, program-, and system-level changes are recommended to fully address the problem of tobacco use among alcohol and other drug abuse patients. KEY WORDS: Alcohol and tobacco; alcohol, tobacco, and other drug (ATOD) use, abuse, dependence; addiction care; tobacco dependence; smoking; secondhand smoke; nicotine; nicotine replacement; tobacco dependence screening; tobacco dependence treatment; treatment facility-based prevention; co-treatment; treatment issues; treatment barriers; treatment provider characteristics; treatment staff; staff training; AODD counselor; client counselor interaction; smoking cessation; Tobacco Dependence Program at the University of Medicine and Dentistry of New Jersey

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Tobacco dependence is one of the most common substance use disorders and a leading cause of morbidity and mortality in addiction treatment programs (American Psychiatric Association [APA] 2006; Ziedonis and Williams 2003). Not surprisingly, people who successfully maintain abstinence from alcohol and other drugs often will prematurely die from tobacco-caused diseases such as coronary artery disease, chronic obstructive pulmonary disease, lung cancer, etc. (Hurt et al. 1996). Multiple biological, psychological, and social factors account for the high co-occurrence of alcohol and tobacco dependence, including genetic evidence showing that people with genetic vulnerability to one disorder also are vulnerable to the other. The common genetic vulnerability may be located on chromosome 2 (Bierut et al. 2004; True et al. 1999; See also the article by Grucza and Bierut in this issue).

Despite the existence of effective, evidence-based nicotine dependence treatments, tobacco dependence is commonly ignored in addiction treatment programs. Why has tobacco dependence treatment not been routinely integrated into addiction treatment programs? What are the barriers? Interestingly, 100 years ago the treatment of alcohol, opiates, and cocaine problems included treating tobacco dependence (Hoffman and Slade 1993). Addiction was perceived as a unitary problem, and the use of either the primary substance or any other substance use was considered a potential trigger for the primary addiction. What led to the decision to defer to primary care for the treatment of tobacco dependence? This paper will attempt to answer these questions and to make recommendations for addressing tobacco use in addiction treatment programs.

INTEGRATING TOBACCO DEPENDENCE TREATMENT AT THE CLINICAL, PROGRAM, AND SYSTEM LEVELS

Addiction treatment professionals eventually recognized that co-occurring mental illness and addiction needed to be addressed in the context of addiction treatment programs. Likewise, members of this field are beginning to recognize that there also is a need to integrate tobacco dependence treatment across the continuum of substance abuse treatment and prevention services. Improved health services interventions for tobacco dependence are needed at the clinical, program, and system levels (Stuyt et al. 2003). Clinical-level change requires better screening and assessment of nicotine dependence and the inclusion of tobacco dependence in the treatment plan. Staff training is necessary and an important first step to address attitudes, skills, and knowledge. Staff who traditionally treated "alcohol dependence only" have adapted their skills and knowledge to treat other co-occurring substance use disorders such as marijuana or cocaine addiction. A similar transformation could occur for co-occurring alcohol and tobacco dependence. In addition to staff training, other program-level interventions include developing models that integrate the treatment of alcohol and tobacco dependence, staff training on assessing and treating tobacco dependence, and continuous quality improvement on this topic. Broader system-level interventions include increasing collaboration between health and behavioral health providers, developing policy changes to promote addressing tobacco, and providing financial support for tobacco dependence treatment.

This article reviews commonly perceived barriers to addressing tobacco and health services interventions that can help addiction treatment programs better recognize and treat tobacco dependence.

BARRIERS

In addition to program culture and financial barriers to treating tobacco dependence, staff attitudes, skills, and knowledge all influence the lack of attention given to tobacco in addiction treatment programs. Staff attitudes set the tone as to whether tobacco dependence will be addressed; tobacco-dependent staff often are the most resistant to change (Bobo and Davis 1993; Asher et al. 2003; Williams et al. 2005; Hurt et al. 1995). Treatment wisdom discourages major life changes during early recovery for fear of relapse, and the treatment culture has accepted that "quitting tobacco" would be a major life change--although quitting other substances simultaneously is not (Sussman 2002; Joseph et al. 2002).