Three of the most frequently reported barriers to the provision of smoking cessation intervention in drug abuse treatment settings are lack of staff knowledge or training related to smoking, the belief that smoking cessation concurrent with other drug or alcohol treatment may create a risk to sobriety, and that many staff are themselves smokers (Guydish et al., 2007
). Studies examining organizational factors found that the availability of smoking cessation services in drug treatment programs was related to staff training on nicotine dependence (Richter et al., 2004
), more positive attitudes toward treating smoking (Fuller et al., 2007
), and greater emphasis on physical health and hospital affiliation (Friedmann et al., 2008
). In addition to being medical settings with hospital affiliation, Veterans Affairs systems have a history developing strategies to better address smoking among all patients they serve (Hamlett-Berry, 2004
). Following these findings, we assessed whether key demographic characteristics of substance abuse treatment staff, and staff knowledge, attitudes, and practices related to smoking, may be different across three types of treatment settings (VAMC, hospital-based, community-based). We hypothesized that staff in VAMC and hospital-based settings would be similar on key demographics, including education level and smoking status, but that staff in community-based settings would differ on demographic characteristics, and this was generally supported. Staff in VAMC and hospital-based settings were similar on all measures except the proportion of staff who were of Hispanic ethnicity and mean number of years in the field. However, compared to both other settings, staff in community-based clinics were more often current smokers, more often in recovery, had fewer years working in their field, and fewer had medical training.
These findings are of interest for two reasons. First, they suggest that high prevalence of smoking among substance abuse treatment staff may not be a problem in all types of settings, but is more likely a problem in community-based clinic settings. Second, among the differences observed between community-based and other types of clinics, addressing staff smoking may be the best target for intervention. Developed and effective smoking cessation interventions are available (Fiore et al., 2008
). Use of strategies to increase staff readiness to quit (Prochaska et al., 2005
) and making cessation intervention more accessible to staff in community-based substance abuse treatment settings would mitigate this frequently reported barrier to addressing smoking among clients in these settings.
We also expected that VAMC and hospital-based settings would perform better compared to community-based settings on measures of smoking related constructs (i.e., knowledge, beliefs, barriers, self-efficacy, and practice). This hypothesis was not confirmed. We found instead that staff in VAMC settings outperformed those in hospital-based and community-based settings on all five measures. This points to a discrepancy in findings, such that hospital-based settings were more similar to VAMC settings in terms of staff demographic characteristics including smoking status, education, and medical training, but hospital-based clinics were more similar to community-based clinics in terms of measures of smoking related constructs.
Controlling for other factors in regression analyses, higher education and medical training were associated with greater knowledge about the risks of smoking. Higher education and being certified or licensed were also associated with more positive beliefs about treating smoking, while being a clinician and being a current or former smoker were associated with less favorable beliefs about treating smoking. Among these the only unexpected finding may be that clinicians had less favorable beliefs about treating smoking, as compared to non-clinicians, and this may be because clinicians face the daily press of multiple clinical needs, where smoking is only one of several clinical issues that could be addressed. More unexpected was the finding that staff in recovery from addiction, compared to those not in recovery, saw fewer barriers to addressing smoking in their setting, and this may warrant verification in other samples or in future studies. However, the most consistent finding from the regression analyses was that staff in VAMC settings outperformed staff in other clinic settings on all of the S-KAP smoking construct scales.
Well-developed procedures to support VAMC clinicians in addressing smoking (Sherman & Farmer, 2004
) may account for these findings. The VAMC system has established Clinical Practice Guidelines for several conditions and disorders, including tobacco use (Veterans Administration, Department of Defense, 2004
). Performance measures for the tobacco cessation guideline include, for example, that all patients are screened annually about tobacco use. Clinicians are reminded about this screening through electronic records and—when tobacco use is reported—advice to quit, brief counseling, referral, and medication are offered to assist with cessation. National targets are set for each intervention, program performance is measured against these targets, and compliance is encouraged through performance monitoring reports, meetings, and program director incentives. If this system underlies the stronger performance of VAMC settings on smoking attitudes and practices, then that argues for increased smoking-related policy development, implementation, and counselor support in community-based drug abuse treatment systems. A few examples of such policy development are available in publicly-funded drug abuse treatment systems, notably smoke-free grounds policies implemented in New Jersey residential treatment settings (Williams et al., 2005
) and a New York policy requiring assessment and treatment of smoking for all persons entering publicly-funded drug abuse treatment (Tobacco-Free Services, 2008
Limitations to this study include generalizability, limited sample size, participation of HIV care clinics as well as substance abuse treatment clinics, and the use of new measurement scales to assess smoking related constructs. Participating clinics comprised a convenience sample of clinics involved in other research protocols and were not selected to be representative of county, state, or national treatment systems. A total of 11 clinics were divided into three categories, with 3-5 clinics representing each type of treatment setting. For these reasons the findings are not generalizable and may warrant testing with larger and more representative samples of treatment programs. The sample included HIV care clinics as well as drug abuse treatment clinics and, moreover, HIV care clinics appeared only in the hospital-based setting group. This offers potential confounding of differences in type of setting (VAMC, hospital-based, community-based) and what the clinics were treating (substance abuse or HIV). At the same time, the inclusion of staff from two HIV care clinics enabled increased sample size, the use of the hospital-based comparison group, and distinction between VAMC settings and non-VAMC hospital settings (both of which are hospital affiliated and whicg emphasize physical health).
The staff survey measures were based on prior similar surveys, and scales were developed based on factor analyses (Delucchi et al., in press
). Because these scales are new to the literature, there is no prior published research to demonstrate their usefulness in discriminating differences between types of clinic settings. Notwithstanding these limitations, this paper compared smoking related constructs across three types of clinical settings, and found differences that generally conform to the use of developed smoking related policies and procedures in VAMC settings, and to lower smoking related knowledge, beliefs, counselor self-efficacy, and practices in community-based settings where staff smoking rates are elevated.
In this study, staff in community-based treatment programs tended to have lower educational achievement and shorter time in their position and in their field, compared to those other settings. They also were often in recovery from their own addiction, and smoked at a rate approximately twice that of the U.S. adult population. Addressing staff smoking in these programs through policy development and smoking cessation intervention for staff may be the most direct route to increasing counselor use of smoking cessation practices with clients. Indeed, it is challenging to consider how smoking cessation intervention can be delivered to clients in settings where 40% of staff currently smokes. At the same time, findings for hospital-based programs suggest that much lower staff smoking rates, by themselves, are not sufficient to produce higher levels of smoking cessation intervention with clients. We found that it was in the VA system clinics that staff reported the most delivery of smoking cessation intervention to their clients, and this may be due to the use of smoking cessation guidelines implemented in a strong policy and performance monitoring framework. This suggests that both reductions in staff smoking and development and implementation of smoking policy, are needed to support staff in better addressing nicotine dependence in community-based drug abuse treatment settings.