Background

Smoking prevalence among persons in addiction treatment is 3–4 times higher than in the general population. However, treatment programs often report organizational barriers to providing tobacco-related services. This study assessed the effectiveness of a six month organizational change intervention, Addressing Tobacco Through Organizational Change (ATTOC), to improve how programs address tobacco dependence.

Methods

The ATTOC intervention, implemented in three residential treatment programs, included consultation, staff training, policy development, leadership support and access to nicotine replacement therapy (NRT) medication. Program staff and clients were surveyed at pre- and post-intervention, and at 6 month follow-up. The staff survey measured knowledge of the hazards of smoking, attitudes about and barriers to treating smoking, counselor self-efficacy in providing such services, and practices used to address tobacco. The client survey measured knowledge, attitudes, and tobacco-related services received. NRT use was tracked.

Results

From pre- to post-intervention, staff beliefs became more favorable toward treating tobacco dependence (F(1, 163) = 7.15, p = 0.008), NRT use increased, and tobacco-related practices increased in a non-significant trend (F(1, 123) = 3.66, p = 0.058). Client attitudes toward treating tobacco dependence became more favorable (F(1, 235) = 10.58, p = 0.0013) and clients received more tobacco-related services from their program (F(1, 235) = 92.86, p < 0.0001) and from their counselors (F(1, 235) = 61.59, p < 0.0001). Most changes remained at follow-up.

Conclusions

The ATTOC intervention can help shift the treatment system culture and increase tobacco services in addiction treatment programs.

This article examines the variables associated with the presence of smoking cessation interventions in drug abuse treatment units, as well as staff attitudes toward the integration of smoking cessation services as a component of care. Surveys were administered to 106 organizations, 348 treatment clinics, and 3,786 employees in agencies that participated in the National Drug Abuse Treatment Clinical Trials Network. Organizational factors, attributes of the treatment setting, and staff attitudes toward smoking cessation treatment were assessed. Use of smoking cessation interventions was associated with the number of additional services offered at clinics, residential detoxification services, and attitudes of the staff toward smoking cessation treatment. Staff attitudes toward integrating smoking cessation services in drug treatment were influenced by the number of pregnant women admitted, the number of ancillary services provided, the attitudes of staff toward evidence-based practices, and whether smoking cessation treatment was offered as a component of care.

This paper examines variables that predicted outpatient treatment entry within six months of residential detoxification. Patient data were collected from 632 injection drug users enrolled in a randomized trial conducted at 8 detoxification programs within the National Drug Abuse Treatment Clinical Trials Network (CTN) with follow-up assessments conducted at 2, 8, 16,and 24 weeks. Detoxification program characteristics were collected during this study and from a survey of CTN treatment organizations. Survival analysis found that estimated proportions of reported outpatient treatment entry varied across sites from .06 to .72. A model-building approach determined variables significantly associated with outpatient treatment entry. The best predictive model contained five program-level variables: accreditation, fewer beds, longer stays, shorter distance between detoxification and outpatient unit, and larger city population. Results suggest the importance of detoxification program characteristics in facilitating further treatment and the need for systems modifications to improve continuity of care.

Compared to the general population, persons entering addiction treatment are three to four times more likely to be tobacco dependent and even addiction treatment staff members are two to three times more likely to be tobacco dependent. In these settings, tobacco use continues to be the norm; however addiction treatment programs are increasingly aware of the need to assess for and treat tobacco dependence. The problem is a cultural issue that is so ingrained that assumptions about tobacco use and dependence in addiction treatment are rarely questioned. Denial, minimization, and rationalization are common barriers to recovery from other addictions; now is the time to recognize how tobacco use and dependence must be similarly approached. This article describes the Addressing Tobacco through Organizational Change (ATTOC) model which has successfully helped many addiction treatment programs to more effectively address tobacco use. The article will review the six core strategies used to implement the ATTOC intervention, the 12-Step approach guiding the model, and describe a case study where the intervention was implemented in one clinic setting. Other treatment programs may use the experience and lessons learned from using the ATTOC organizational change model to better address tobacco use in the context of drug abuse treatment.

A broad array of agencies, institutions, and individuals interact with community-based substance abuse treatment programs, providing resources or services and asserting demands and expectations in return. These relationships shape the environment in which treatment and community-based research take place, and themselves raise issues worthy of research attention. This article enumerates the stakeholders in one well-established program and describes the scope of the program’s efforts to accommodate these stakeholders, along with some of the complications and difficulties programs confront in their attempts to satisfy stakeholders, especially when their demands are unrealistic or their interests conflict. The article concludes by identifying research areas that could facilitate these relationships, enhancing their benefits for patients.