A national sample of drug abuse treatment units provided information on variables associated with the adoption of smoking cessation treatment and the factors associated with positive staff attitudes about integrating nicotine dependence interventions as a component of care. This study examines the provision of smoking cessation services in a wide range of programs, including drug-free residential, methadone maintenance, outpatient, inpatient, and detoxification facilities. Factors at both treatment unit and staff levels were associated with the presence or the absence of smoking cessation services within drug abuse clinics.
Smoking cessation treatment was more likely to be available in units that offered other ancillary services, including detoxification. Treatment units providing multiple medical and mental health services appear to be more likely to offer smoking cessation interventions. Stand-alone drug abuse treatment programs were less likely to offer smoking cessation interventions. Treatment programs that provided a more comprehensive level of service were more likely to have the resources to provide nicotine dependence treatment. It is unclear whether the smoking cessation treatment was provided through ancillary services such as primary medical care. This might imply that smoking cessation was generally more acceptable in other health care settings but not in independent drug abuse treatment settings.
The second model examined staff attitudes. Employees were more likely to have a positive view of smoking cessation treatment if the clinic operated a nicotine dependence program, admitted certain populations (veterans, women, and pregnant women), and did not offer residential detoxification services. Counselor attitudes about evidence-based practices and ASAM placement criteria contributed to a positive attitude toward smoking cessation treatment.
These results are a mix of intuitive and paradoxical findings. Clinics providing smoking cessation care were more likely to have staff members with a supportive attitude toward such services. This is consistent with previous findings (Hahn et al., 1999
; Hurt, Croghan, Offord, Eberman, & Morse, 1995
; Williams et al., 2005
). Staff members with a positive view toward smoking cessation may be more likely to refer patients to the program. This raises the question as to whether the presence of nicotine dependence treatment improves staff attitudes or whether having a supportive staff increases the likelihood that a clinic would offer smoking cessation interventions. The association between staff attitude and the provision of smoking cessation treatment is likely bidirectional.
The results demonstrate that staff members who worked in clinics with a high number of pregnant women were more likely to support the integration of smoking cessation into drug abuse treatment. This finding may reflect that individuals in clinics serving pregnant and perinatal women are more aware of the negative impacts of smoking on fetal development and are more ready to integrate smoking cessation services into their clinics. On the other hand, the proportion of youth admissions was a predictor neither for staff attitudes nor for the provision of smoking cessation services.
A curious finding is the negative relationship between staff attitudes toward smoking cessation treatment and residential detoxification services. Additional analyses confirmed that this effect was due to most detoxification facilities operating in large hospital settings or any other level-of-care effect. Although staff attitudes toward the integration of smoking cessation services were less positive in stand-alone detoxification facilities than in multiservice agencies (3.09 vs. 3.43), this difference was not significant. Staff attitudes toward smoking cessation interventions in these settings may be negative because the staff members are focused on patients on withdrawal and may believe that removing smoking during this period will only make the patient more uncomfortable. This may contribute to the ideation that patients are likely to leave detoxification facilities prematurely because of cigarette cravings. Concerns such as these may lead staff members to have more negative attitudes toward the use of smoking cessation treatment. With staff education and administrative commitment, these attitudes usually change (Williams et al., 2005
). There is no evidence that more patients actually leave treatment because of smoking restrictions.
Employees working in VA Medical Centers tended to have more positive attitudes toward smoking cessation than the rest of the workforce and reflected governmental regulations requiring a smoke-free environment in VA hospitals (as well as most other health care facilities). Although a small number of drug treatment clinics were a part of VA Medical Centers (n = 15), there was still a significant effect on the regression equation (confirmed by a significant univariate correlation).
Respondents who valued evidence-based practices and those who perceived themselves to be knowledgeable of the ASAM placement criteria were also more likely to favor the integration of smoking cessation into drug treatment units. These staff members may be more aware of both the importance and the current techniques of treating nicotine dependence.
4.1. Study limitations
As with any large-scale survey, missing data were a limitation. The use of data imputation in constructing these models is a technological tool that allows the best use of incomplete data. In this study, most of the incomplete data were single omissions of items rather than large spans of missing data. In this case, imputation was the best way to use these data to determine underlying relationships.
Because the focus of the survey instruments was not on the provision of smoking cessation treatment, no details regarding specific types of services were obtained. For some clinics, smoking cessation treatment could mean providing nicotine replacement while the patient is on detoxification. For others, a program might involve nicotine replacement therapy, social support groups, and psychoeducational counseling or medication. This variation was not assessed and, thus, it is unclear what the respondent meant when indicating the presence of smoking cessation treatment at the clinic.
Staff surveys indicate that lack of demonstrated efficacy and lack of client interest are big barriers for the implementation of smoking reduction interventions while on treatment (Walsh, Bowman, Tzelepis, & Lecathelinais, 2005
). A large proportion of the workforce who smoke cigarettes was less likely to suggest smoking cessation treatment to their clients (Bobo & Gilchrist, 1983
). Some staff members believe that it is therapeutic to occasionally smoke with their clients (Walsh et al., 2005
Research has indicated that nicotine dependence treatment does not jeopardize drug treatment and may actually help recovery (Burling, Marshall, & Seidner, 1991
; Hurt et al., 1994
; Martin et al., 1997
; Stuyt, 1997
; Toneatto, Sobell, Sobell, & Kozlowski, 1995
). Some research studies demonstrate that smoking cessation interventions improve long-term abstinence from alcohol or drugs, but not tobacco use (Bobo, McIlvain, Lando, Walker, & Leed-Kelly, 1998
; Prochaska, Delucchi, & Hall, 2004
). Although smoking interventions started early in residential treatment have been shown to affect abstinence rates, these effects are largely short term (Joseph, Willenbring, Ngent, & Nelson, 2004
). Studies examining the effectiveness of smoking cessation treatment in drug treatment show short-term (6-month) reductions in cigarette use, but do not show long-term (18-month) effects (Prochaska et al., 2004
). It is unclear to what extent treatment staff members are aware of these findings and how much this lack of evidence influences staff attitudes. In addition, inconclusive is how generalizable the current findings are when compared to treatment agencies not affiliated with the CTN. Although this is likely a good sample of treatment units, the CTN may have more multifaceted clinics than a random sample of agencies would contain.