The University of Georgia

Smoking Cessation Programs in Addiction Treatment Centers:

An Organizational Analysis

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

The University of Georgia

Nicotine Dependence:A 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 > 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– SAMHSA’s 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): > 50% of revenues from government block grants/contracts

Response rate = 80%– Privately funded centers (n = 401): <50% 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

The University of Georgia

Results: Availability of SC Programs

67.8%

32.2%

0%

20%

40%

60%

80%

100%

NoProgram

Offers SCProgram

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

• About 32.2% have SC programs

The University of Georgia

SC Programs by Center Type

33.7%42.9%30.5% 23.8%

0%

20%

40%

60%

80%

100%

Gov-owned Public NP Private NP For-Profit

• There was significant variation in availability of SC programs by center type (2 = 8.82, p<.05)

• Government-owned centers significantly more likely to offer smoking cessation programs than:– Publicly funded non-profit centers (O.R. = .58, p<.05)– For-profit centers (O.R. = .42, p<.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, p<.05)– SC programs less likely in for-profits (vs.

government-owned, O.R. = .48, p<.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, p<.01

• Centers that use the Addiction Severity Index (ASI) were more likely to offer smoking cessation– O.R. = 1.58, p<.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, p<.05)

– No difference between freestanding and hospital-based centers

• There was a trend (p<.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)

56.1%

41.0%

31.8%

0%

10%

20%

30%

40%

50%

60%

70%

Nicotine Patch Nicotine Gum Bupropion-SR

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Medications by Center Type

56%

41%

54%

32%

15%

27% 27%

69%

48%

19%

58%54%

0%

20%

40%

60%

80%

100%

Bupropion Patch Gum

Gov-owned Public NP Private NP For-Profit

• 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

77.4%64.1% 61.4%

69.2%

0%

20%

40%

60%

80%

100%

Gov-owned Public NP Private NP For-Profit

• 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, p<.05) or

physicians on contract (O.R. = 2.52, p<.05)– Inpatient/residential-only SC programs were more

likely to have adopted medications than outpatient-only programs (O.R. = 4.44, p<.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