Smoking prevalence in the past month among adolescents in residential drug abuse treatment was 66%. This is lower than the 85% past month prevalence reported in a prior study of adolescents in residential treatment facilities, which may be the most recent comparable study (Myers & Brown 1994
). Part of this difference may be due to decreasing smoking rates nationally in the past decade; however, the smoking prevalence observed in this sample was nearly three times higher than the 23% observed for U.S. high school students (Eaton et al. 2006
All sites prohibited indoor smoking for both clients and staff. About 75% of the sites had tobacco-free grounds policies for adolescents and 67% had tobacco-free grounds for staff. In this study, only one third had tobacco-free grounds for both clients and staff. Program-level policies were related to client-level smoking.
A recent meta analysis of 58 studies on controlled trials of adolescent cigarette smoking cessation intervention found that cognitive-behavioral interventions, motivational enhancement interventions, and social influence interventions were effective (Sussman, Sun & Dent 2006
). A systematic review of 15 controlled trials (Grimshaw & Stanton 2007
) considered psychosocial interventions (such as motivational interviewing) to be promising, although this approach had not demonstrated effectiveness. Myers and Kelly (2006)
commented that peer influences, motivation, and nicotine dependence should be focused on smoking cessation intervention for adolescents with substance abuse problems. They also suggested that Project EX (a school-based tobacco cessation programs derived from a motivation-coping skills-personal commitment model of teen cessation, specifically designed for high school students) (Sussman, Dent & Lichtman 2001
) assesses these developmental issues and may be helpful for smoking intervention in this population. In the current study, 42% of treatment programs provided individual or group counseling on smoking cessation and 33% provided reading materials on tobacco. Despite the high smoking prevalence among youth in residential drug abuse treatment, smoking interventions are still limited in these settings. In future research, those suggested interventions may be applied and tested in adolescent drug abuse treatment samples (e.g., Project EX).
Pharmacotherapy is another prevalent form of smoking intervention. This intervention alleviates the symptoms of physical withdrawal during the quitting process by the use of NRT, including nicotine gum, patch, and lozenge, as well as other prescription medications including a nicotine inhaler, nicotine nasal spray, and bupropion. NRT has been shown to be safe and effective with adults, yet there is no evidence to date on whether NRT plays a major role in smoking cessation for adolescents (Grimshaw & Stanton 2007
; Adelman 2004
). NRT has not been approved by the Federal Drug Administration for use with individuals younger than 18 years of age. According to the guidelines for youth smoking cessation by Fiore and colleagues (2000)
, NRT may be considered when adolescents are tobacco dependent and have the intention to quit. Although there is a debate on NRT use among adolescents, in this study it was found that NRT is used in some adolescent treatment settings (42%).
Only two sites included a tobacco policy in their mission statement, goals, and objectives. Although most of the sites did not have written policies forbidding tobacco use, they did restrict indoor smoking for both adolescents and staff. However, 25% of programs permitted adolescent smoking on the outdoor campus or off campus, including across the street, in the facilities at 12-Step meetings or in schools. Moreover, they provided smoke breaks for adolescents.
This study did not examine whether the agencies merely complied with existing state law concerning smoking, or whether they developed additional policies in addition to legal requirements. However, three of the seven sites that participated in this study were in states that have a smoke-free workplace law (www.smokefree.net
). We are aware of only one state, New Jersey, that eliminated smoking in all residential treatment programs (Williams et al. 2005
Tobacco-free policies were related to adolescent smoking. Adolescents in nontobacco-free grounds smoked more than those in tobacco-free grounds in the past two days. These results were also aligned with those from a study by McDonald and colleagues (2000)
, which considered the tobacco-free policy as extremely helpful to quitting smoking. There are concerns that tobacco-free policies may result in lower admission rates or shorter treatment retention in adolescent programs (Kempf & Stanley 1996
). Therefore, the relationship between tobacco-free policy and treatment retention needs to be examined among adolescents in a future study.
Compared to McDonald’s study (2000)
in an adolescent residential drug treatment facility, smoking prevalence among staff was lower in this study (22% vs. 14%). This is also a positive result compared to the rate of smoking among staff in community-based adult drug abuse treatment settings (Olsen et al. 2005
; Bobo & Davis 1993a
; Bobo & Gilchrist 1983
). Walsh and colleagues (2005)
asked one director and one staff member from multiple programs to estimate staff smoking prevalence. Compared to prevalence estimates made by staff key informants, those made by director key informants were lower. This suggests the possibility that program directors may underestimate smoking prevalence among staff in their program. If directors underestimated staff smoking prevalence in the current study, staff smoking prevalence may be higher than that reported (14%). Moreover, 67% of sites allowed staff smoking on campus, so that adolescents were exposed to adult modeling of smoking behavior and were exposed to smoking-related cues such as cigarette packs, lighters, and the smell of cigarette smoke on staff clothing. Adolescents in facilities that allowed staff smoking on campus were more likely to report recent (past two days) smoking than were those in facilities with restrictions on staff smoking.
This study included a policy analysis of adolescent treatment programs where only 12 programs (71 %) agreed to participate and secondary data analysis of interview data for adolescents entering seven residential treatment programs. This collection of programs represents a sample of programs selected for participation in a larger CSAT study of residential treatment and, further, measures of client-level smoking behavior were limited to a few items. For these reasons, the sample may be regarded as a convenience sample, and the findings may be regarded as preliminary and of limited generalizability. We interviewed only one key informant who was either the program director or another program leader. Interviewing program directors has been used in similar studies of smoking in drug abuse treatment facilities (i.e., Walsh et al. 2005
; Richter et al. 2004
; Knapp et al. 1993
). At the same time, and to our knowledge, data reported here represent the broadest view available of smoking among adolescents enrolled in residential drug abuse treatment, and of smoking related policies in such programs. Although the findings reported here warrant further research and confirmation or correction, some practical recommendations may emerge from these data. First, smoking among adolescents in drug abuse treatment is prevalent, and should be assessed and treated in these programs. Second, consistent smoking policies for adolescents and staff within the same program appear desirable, not only because staff smoking represents adult modeling of a health risk behavior for adolescents, but also because smoking-related cues may make it harder for adolescents to adhere to a higher level of smoking restriction than staff in the same program. Third, tobacco-free ground policies, which are broader and more encompassing than elimination of indoor smoking, appear to be related to lower levels of recent smoking among youth entering such programs. Based on these observations we recommend that adolescent residential treatment programs formulate and implement tobacco-free ground policies applicable to both clients and staff, and that programs assess and address nicotine use among youth, including NRT in the presence of nicotine dependence.