Smoking Cessation Programs in Addiction Treatment Centers: An Organizational Analysis

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Smoking Cessation Programs in Addiction
Treatment CentersAn Organizational Analysis

• Hannah K. Knudsen, Ph.D.
• Lori J. Ducharme, Ph.D.
• Paul M. Roman, Ph.D.

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Nicotine DependenceA Co-Occurring Condition in
Substance Abuse Treatment

• Rates of cigarette smoking among individuals
  seeking substance abuse treatment far exceed the
  general population
• General public 22.5
• Treatment-seeking gt 70
• Treatment-seekers who smoke are at greater risk
  of negative health consequences due to greater
  cigarette consumption per day
• Tobacco-related illnesses are a major factor in
  the increased likelihood of premature death among
  individuals treated for substance use disorders

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Smoking Cessation Programs in Substance Abuse
Treatment

• Traditionally, smoking cessation has been viewed
  as outside the purview of treatment providers
• Fears of increased risk of treatment dropout
  relapse
• Recent research indicates such fears may be
  unfounded
• Smoking cessation does not worsen SUD treatment
  outcomes
• It may improve outcomes reduce the risk of
  relapse
• Clinical practice guideline issued by the Public
  Health Service advocates the delivery of smoking
  cessation services during treatment

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Availability of Smoking Cessation Programs

• The assumption remains that specialty SUD
  treatment programs do not offer smoking cessation
• This claim is difficult to test because of
  absence of national data
• SAMHSAs N-SSATS survey of treatment providers
  does not collect this information
• Even less is known about whether centers that
  offer smoking cessation are relying on
  psycho-social techniques or have integrated
  medications into these programs

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Research Questions

• To what extent have community-based addiction
  treatment programs adopted smoking cessation (SC)
  programs?
• What organizational characteristics are
  associated with the presence of SC programs?
• To what extent do SC programs include the use of
  SC medications?

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Methods

• Data from the National Treatment Center Study
• Community-based addiction treatment centers
• Must offer a minimum of outpatient care (as
  defined by ASAM)
• Two nationally representative samples
• Publicly funded centers (n 363) gt 50 of
  revenues from government block grants/contracts
• Response rate 80
• Privately funded centers (n 401) lt50 of
  revenues from government block grants/contracts
• Response rate 88
• Data collected via face-to-face interviews with
  administrators and/or clinical directors
• Complete data from n 704

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Measures Smoking Cessation Programming

• Availability of SC Programs
• 1 yes, 0 no
• Adoption of SC Medications by SC Programs
• Nicotine replacement therapy (patch, gum)
• Bupropion-SR (i.e. Zyban)

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Measures Organizational Characteristics

• Center type
• Government-owned
• Publicly funded non-profit
• For-profit
• Privately funded non-profit (reference category)
• Organizational affiliation
• Hospital-based
• Community mental health center
• Freestanding (reference category)
• Size natural log-transformed number of employees
• Age natural log-transformed years
• Accreditation center is accredited by JCAHO or
  CARF

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Measures Staffing Services

• Physician Services
• Physicians on staff
• Physicians on contract
• No access to physicians (reference category)
• Levels of care
• Inpatient/Residential-only
• Outpatient-only (reference category)
• Mixed levels of care
• 12-Step Treatment Model 1 yes, 0 no
• Use of the ASAM PPC 1 yes, 0 no
• Use of the Addiction Severity Index (ASI) 1
  yes, 0 no

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Availability of Smoking Cessation Programs
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Results Availability of SC Programs

• The majority of addiction treatment centers do
  not have SC programs
• About 32.2 have SC programs

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SC Programs by Center Type

• There was significant variation in availability
  of SC programs by center type (c2 8.82, plt.05)
• Government-owned centers significantly more
  likely to offer smoking cessation programs than
• Publicly funded non-profit centers (O.R. .58,
  plt.05)
• For-profit centers (O.R. .42, plt.01)

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Logistic Regression of Availability of Smoking
Cessation Programs

• Logistic regression used to estimate the
  likelihood of SC programs by
• Center type
• Organizational characteristics
• Staffing and services
• Center type differences persist after controlling
  for other organization-level measures
• SC programs less likely in publicly funded
  non-profits (vs. government-owned, O.R. .59,
  plt.05)
• SC programs less likely in for-profits (vs.
  government-owned, O.R. .48, plt.05)

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The Use of Standardized Criteria and Smoking
Cessation Programs

• Centers that have adopted the ASAM-PPC were
  significantly more likely to offer smoking
  cessation, net of the other variables
• O.R. 1.69, plt.01
• Centers that use the Addiction Severity Index
  (ASI) were more likely to offer smoking cessation
• O.R. 1.58, plt.05

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Other Predictors of Smoking Cessation
Programming

• Organizational affiliation was associated with
  the availability of SC programs
• Compared to freestanding programs, centers
  affiliated with community mental health centers
  were less likely to offer SC programs (O.R.
  .38, plt.05)
• No difference between freestanding and
  hospital-based centers
• There was a trend (plt.10) for larger centers
  being more likely to offer smoking cessation
  programs

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Organization-Level Measures NOT Associated with
SC Program Availability

• Center age
• Access to physicians
• Center accreditation by JCAHO or CARF
• Levels of care
• 12-Step treatment philosophy

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Adoption of Medications in Smoking Cessation
Programs
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Medications in Smoking Cessation Programs

• Among centers with smoking cessation programs,
  there may be variability in the adoption of
  medications
• Nicotine replacement therapies have the advantage
  of being OTC
• Bupropion-SR (Zyban) by prescription
• Little is known about whether these programs have
  integrated medications into their smoking
  cessation treatment protocols

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Adoption of SC Medications (n 222 centers
offering smoking cessation programs)
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Medications by Center Type

• Compared to privately funded non-profits
• Government-owned SC programs are less likely to
  have adopted bupropion nicotine gum
• Publicly funded non-profits SC programs were less
  likely to have adopted all three medications
• For-profit SC programs were less likely to have
  adopted nicotine gum

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Adoption of Any Medicationsby Center Type

• The only significant difference is between
  privately funded non-profits and publicly funded
  non-profits

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Multivariate Model of Medication Adoption

• Same set of independent variables as model of SC
  programs
• Logistic regression of any adoption
• The difference between public and private
  non-profits is no longer significant once other
  variables are controlled
• Other significant variables
• Access to physicians on staff (O.R. 2.89,
  plt.05) or physicians on contract (O.R. 2.52,
  plt.05)
• Inpatient/residential-only SC programs were more
  likely to have adopted medications than
  outpatient-only programs (O.R. 4.44, plt.01)

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Summary

• About one-third of substance abuse treatment
  centers offer smoking cessation programs
• Of these centers with SC programs, the majority
  (65.5) have adopted some type of SC-related
  medications
• There is variation in adoption rates of specific
  SC-related medications, with nicotine patch
  adoption being the most widely adopted

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Summary (continued)

• Smoking cessation programs were more common in
  centers that
• Use the ASAM-PPC
• Use the ASI
• Although levels of care were not associated with
  the probability of SC program availability,
  inpatient/residential-only centers were more
  likely to use medications within their SC
  programs than outpatient-only centers
• Physician resources were not associated the SC
  program availability, but were associated with
  medication adoption within those programs

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Future Research Directions

• Additional data collection on the implementation
  of the PHS clinical practice guideline for
  smoking cessation
• Assessment of smoking status at intake
• Brief interventions
• Counseling approaches to smoking cessation
• Use of pharmacotherapies
• Data collected at the center-level and from
  individual counselors

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• The authors gratefully acknowledge the support of
  research funding from the National Institute on
  Drug Abuse (R01-DA-14482 and R01-DA-13110).
• This presentation and other reports from the
  National Treatment Center Study are available at
  http//www.uga.edu/ntcs