Understanding the prevalence and quality of tobacco treatment services for drug treatment patients should be a public health priority. People with mental illness or substance abuse problems consume nearly half (44%) of all cigarettes smoked in the U.S. . Drug treatment patients are interested in quitting smoking, and quitting smoking does not adversely affect short-term drug use outcomes [2–15]. Indeed, quitting smoking in the first year of drug treatment predicts better long-term substance abuse outcomes .
U.S. Public Health Service (PHS) tobacco treatment guidelines recommend that high quality, evidence-based care include the following: a) all smokers be offered treatment, b) patients unwilling to quit be provided with brief intervention to build motivation, and c) patients willing to quit be offered evidence-based treatment . The highest abstinence rates are achieved when pharmacotherapy is combined with intensive counseling . Office-based intervention should follow five major steps (The “5 A’s”): Ask, Advise, Assess, Assist and Arrange follow-up. The guidelines also recommend that office-based systems identify, track, and follow-up with smokers at every visit and remind providers to intervene with every smoker. Finally, substance abuse treatment facilities should adhere to treatment guidelines for the general population and should incorporate new interventions, that are effective for those in drug treatment, as new treatments become available.
To date, the prevalence and quality of tobacco treatment in drug treatment has been poorly described. In 1998 the Substance Abuse and Mental Health Service Administration’s (SAMHSA’s) Uniform Facility Data Set survey found that only 20% of U.S. substance abuse treatment facilities offered any smoking cessation services . A more recent (2001) survey of Canadian drug abuse treatment facilities found that 54% “offered clients help quitting smoking,” but only 10% had any formal group or individual therapy dedicated to smoking cessation and fewer than 1% of facilities offered quit smoking medications . Friedmann et al. found that somewhat more U.S. facilities provide formal counseling (38%) and pharmacotherapy (17%) . Walsh and colleagues (2005) estimated that Australian substance abuse treatment programs provide brief advice to quit to 36% of clients who smoke; education about the risks of smoking to 39%, counseling to quit to 26%, and quit smoking medications to 15% . Knudsen and colleagues surveyed U.S. counselors about the frequency with which they provide five brief behavioral interventions for tobacco use (0 = never, 5 = always); the interventions included assessing current tobacco use, assessing past tobacco use, advising tobacco users to quit, assessing willingness to quit, and using brief intervention to increase motivation to quit . They found that counselors on average provided interventions infrequently, with a mean scale score of 2.69.
Three recent studies examined the effects of a 2008 New York State (NYS) policy change that required all publicly funded drug treatment facilities to offer tobacco dependence treatment to clients. In a survey of staff and clients from a random sample of 10 programs conducted before and one year after policy implementation, Guydish and colleagues found that client smoking prevalence diminished significantly (69.4% to 62.4%) but that implementation of tobacco treatment services differed by facility type . Clients in outpatient facilities reported no pre-policy to post-policy change in the amount of tobacco treatment services they received. Those in residential treatment received less services after the change took effect. Clients in methadone treatment reported receiving more services post-implementation. Eby and colleagues surveyed 147 clinicians associated with 13 facilities immediately before and one year after the NYS policy went into effect . They found that the manner in which the new policies were implemented in each facility predicted staff perceptions of how fairly the change occurred. Perceived fairness was in turn predictive of staff provision of tobacco treatment, psychological strain, and behavioral strain. Last, Brown and colleagues summarized state records and surveyed a randomly selected sample of directors of 285 facilities 3 years before and 9–12 months after policy implementation . Compared to before the policy, at post-assessment a greater proportion of administrators reported they “always or formally” screened clients for tobacco use; also, they reported a greater number of tobacco services were available for clients. State discharge data on medications administered during treatment found a significant increase in the percentage of clients receiving nicotine replacement therapy, from 3.0% before implementation to 6.3% after implementation.
These studies suggest that treatment practices vary greatly, are far from routine, and are of poor quality. For example, although quit smoking medications are known to double quit rates, few clinics offer or recommend them. Moreover, no comprehensive measures of tobacco treatment quality exist – none of the studies measured all PHS guideline recommended elements of evidence-based care. Only one study assessed whether facilities provided motivational interventions to unmotivated smokers  and several failed to assess whether cessation medications were recommended or provided [19, 23]. Moreover, the NYS studies suggest that policy change can increase implementation of treatment services but may increase strain on staff if implemented poorly.
Despite the low provision of tobacco treatment in drug treatment facilities, societal trends are creating new incentives for treating tobacco dependence in drug treatment. Staff attitudes toward nicotine dependence treatment appear to be changing; surveys conducted in 1999 and 2000 find more staff support for helping patients to quit smoking compared to surveys conducted in the 1980s and early to mid 1990s . In the 1990s, changes in hospital tobacco policy, state laws, and local ordinances forced drug abuse treatment facilities to restrict indoor smoking and consider treating tobacco use . Major organizations now recommend incorporating tobacco treatment into addictions treatment [30, 31], and two states—New Jersey and New York—have launched major initiatives to incorporate tobacco treatment into drug treatment.
Research on tobacco treatment in drug treatment is in its infancy – the types of services offered have not been well described, no conceptual models for quality of care have been developed, and measures of services and patient outcomes are lacking. Although few programs offer formal services, many more will likely begin to treat nicotine dependence as external forces and patient demand for services increases. In the absence of clear criteria and measures of quality of care, programs may adopt services based on cost and convenience rather than efficacy . It is important to develop a set of measures that capture how tobacco services are delivered, evaluate these practices, and ultimately disseminate effective practices throughout the treatment community.
The purpose of this paper is twofold: 1) to describe tobacco treatment provision across a representative sample of U.S. outpatient substance abuse treatment facilities, and 2) to develop and describe a brief index of tobacco treatment quality that assesses the extent to which facilities provide guideline-based treatment for tobacco dependence.