Lack of effectiveness of traditional smoking cessation approaches is not an acceptable reason to postpone smoking cessation treatment for individuals who are newly abstinent from alcohol and other drugs. In fact, many of these individuals are well-positioned to attempt quitting because they are in a controlled environment where smoking is either restricted or banned. They are also likely to have regularly scheduled contact with providers who can support their efforts to quit. Research also shows that rates of participation in a smoking cessation program are higher when treatment is offered concurrently with addiction treatment as opposed to being delayed until a period of sobriety is attained.11
Although some of the benefits of and barriers to quitting smoking may be different for substance abusers than for smokers without other addictions, the process of quitting remains the same. Interventions found to be effective for the general population of smokers should therefore be offered to smokers with substance use disorders. All smokers should be given at least a brief intervention consistent with the “5 A’s” approach described in the Clinical Practice Guideline (ie, Ask, Advise, Assess, Assist, and Arrange).14 For individuals who are ready to quit, combined pharmacological and behavioral interventions are considered to be the gold standard of treatment.
An FDA-approved medication to aid cessation (ie, nicotine replacement therapy, bupropion SR, and varenicline) should be used in combination with individual or group behavioral treatment that offers skill training and support for quitting.14 The Updated Clinical Practice Guideline suggests that combination nicotine replacement therapy (ie, a nicotine patch for 14 weeks plus a nico-tine spray or gum) is more effective than a patch alone (odds ratio, 1.9; 95% confidence interval, 1.3 - 2.7).14
For individuals who are not ready to quit smoking, a brief motivational intervention should be provided. Providers should consistently convey optimism that smoking cessation is both achievable and essential to the drug-free, healthy lifestyle that they are working toward as part of their treatment for substance abuse.
The role of organizational practices
“I went outside with the smokers because I needed some fresh air, and the smell of smoke got to me. I just figured, I might as well smoke and enjoy myself. I don’t know what I’m going to do. I try to stay away from the smokers as much as possible, but it’s hard when everyone here smokes.”
Challenges to successful smoking cessation in substance abuse treatment occur at multiple levels, including individual treatment providers as well as organizations. For example, the treatment environment may reinforce rather than discourage smoking. Group “smoke breaks” and mutual support group meetings where smoking is normative present a powerful environmental trigger to smoke and contribute to relapse. Staff smoking is also problematic in that it has been shown to decrease the probability of encouraging patients to quit smoking almost 6-fold.16
Creating an organizational culture that supports smoking cessation is an important task worthy of the time and effort to develop and implement a plan for change. Such a plan might include free smoking cessation medications and counseling for staff; offering staff training in the assessment and treatment of tobacco use disorders as well as alcohol and other substance use disorders; providing information about and access to support meetings that are smoke-free; and restructuring break times so that they do not reinforce social rewards of smoking or the use of nicotine to “self-medicate” negative affect (eg, encouraging smoke breaks to calm down after a difficult session). Ziedonis and colleagues17 provide additional suggestions on programmatic changes that can be made to facilitate smoking cessation.
Conclusions
Many individuals in substance abuse treatment are quite willing and able to quit smoking with the assistance of pharmacological and behavioral support. Although absolute quit rates tend to be lower for smokers who are in treatment than for those in recovery from alcohol and other substance use disorders, smoking cessation interventions are effective for both groups and do not appear to increase the risk of relapse to alcohol and other drug use.
Some individual and organizational barriers need to be overcome to improve smoking cessation outcomes among those in substance abuse treatment. However, the available research as well as our own experience suggest that quitting smoking during substance abuse treatment is indeed achievable—in other words, a mission possible.
