Changing organisational systems to address tobacco dependence in drug

and alcohol treatment centres

Billie Bonevski

Cancer Institute NSW

Research Fellow

University of Newcastle, Australia

The team• University of Newcastle: Amanda Wilson, Flora Tzelepis, Chris Paul, Jamie

Bryant, Andrew Searle

• Hunter New England Health: Adrian Dunlop

• National Drug and Alcohol Research Centre (NDARC): Anthony Shakeshaft, Michael Farrell, Richard Mattick

• Cancer Council NSW: Scott Walsberger, Phil Hull, Jon O’Brien

• University of Wollongong: Pete Kelly

• London: John Strang, Ann McNeill

• US: Judith Prochaska

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Overview

Part 1 – Myth Busting

Part 2 – What is current practice

Part 3 – What can we do

Part 4 – How do we do it

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Why address smoking amongst drug and alcohol (D&A) treatment clients?

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Myth No 1:

“Tobacco is not a health priority for this population. Other drugs are more important/deadly/more harmful”

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Hospital admissions in Canada 6

Single et al, 2000

Annual drug-related deaths in the US 7

Centre for Disease Control, 2008, 2004, 2007

Tobacco-related deaths within Australia compared with other causes

Begg et al., 2007

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Begg et al, 2007

Drug related deaths in Australia (2004/05)

Begg et al., 2007

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Collins DJ, Lapsley HM. DoHA; 2008.

Smoking rates in D&A treatment populations

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Myth No 2:

“Tobacco smoking is a necessary self-medication”

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Tobacco is part of the problem not the solution

• Perpetuated by the tobacco industry

• Mental illness

• Stress, coping, stabilise mood etc

• Nicotine reward system

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Nicotine dependence

Physiological addiction Behavioural habit

Triggers the release of dopamine Frequency and immediacy of reinforcement firmly cements a behavioural cluster

Positive affect – brain reward system

1 pack/day = 200/day hand to mouth rituals

De-activation leads to withdrawal (cravings)

Social acceptability increases range and number of triggers

Limited effect on lifestyle

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Myth No 3:

“Addicts are not interested in quitting smoking”

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Australian D&A clients are interested to quit

• N = 228 smokers in residential D&A treatment

• 75% had tried quitting in the past

• 67% were ‘seriously thinking about quitting’

Kelly et al, 2012

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Methadone maintained clients interest in quitting • N = 103 OTP clients in two clinics in Australia

• 84% current smokers

• 56% previous quit attempt

• 38% thinking of quitting ‘next 6 months’

• Would like help with quitting – 36% said Yes and 31% were Unsure

• 80% were heavy nicotine dependence

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Bowman et al 2011

Myth No 4:

“Drug and alcohol clients are unable to quit smoking”

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Smoking cessation offered during D&A treatment is effective

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A Meta-Analysis of Smoking Cessation Interventions With Individuals in Substance Abuse Treatment or Recovery.Prochaska, Judith; Delucchi, Kevin; Hall, Sharon

Journal of Consulting & Clinical Psychology. 72(6):1144-1156, December 2004.

Significant two-fold increase in the likelihood of smoking abstinence among intervention versus control participants

Myth No 5:

“Addressing smoking compromises other treatment outcomes”

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Alcohol and illicit drug abstinence following smoking cessation intervention

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A Meta-Analysis of Smoking Cessation Interventions With Individuals in Substance Abuse Treatment or Recovery.Prochaska, Judith; Delucchi, Kevin; Hall, Sharon

Journal of Consulting & Clinical Psychology. 72(6):1144-1156, December 2004.

Significant increase of 25% in the likelihood of abstinence from drugs and alcohol among participants receiving a smoking cessation intervention relative to participants in the control condition.

How is smoking currently treated within the drug and alcohol sector?

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Clinically recommended

• Tobacco dependence is:

‘a chronic disease with remission and relapse’

“Nicotine dependence warrants medical treatment as does any drug dependence disorder or chronic disease”

Fiore et al, U.S. Dept of Health and Human Services, June 2000

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Is smoking cessation care provided to D&A treatment clients?

• National survey of D&A agencies (n =260 agencies: 213 managers and/or 204 other staff)

– 23-25% said they had a written smoke-free policy

– 80-83% indicated delivery of smoking support was left to the discretion of individual staff - ie, not routinely and systematically provided

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Walsh et al, 2006

D&A treatment centres smoking cessation care practices

Statement % of clients receiving

Smoking status recorded 65

Recommendation to quit 36

Counselling on behavioural methods 26

Attempt to negotiate quit date 17

Recommendation to use NRT 20

Referral to stop smoking group 16

Follow-up discussion 27

Bonevski et al., 2012, under review

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Walsh et al, 2006

Barriers to the provision of smoking cessation care in D&A setting• Staff smoking status1

• Lack of training1,2,3

• Resistance to smoke-free policies1,3

• Limited resources, eg, cost of NRT1

• Lack of coordinated staff approach (no system!)2

• Lack of staff time2

• Lack of confidence2,3

• Pessimism regarding effectiveness of smoking cessation interventions2

• Misperceptions – eg, “tobacco is not a real drug”, “its too difficult to address tobacco and other dependencies”, “clients don’t want to quit”1,2,3

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1 Zeidonis, Guydish, 2006; 2 Walsh, Bowman et al 2005; 3 Baca et al, 2008

Attitudes of managers and staff toward smoking interventions (strongly agree/agree) Walsh et al 2006

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%

Provision of smoking cessation interventions should be an integral function of this agency

65

Smoking clients of this agency should receive smoking cessation interventions tailored to their readiness to quit

86

Smoking cessation counselling is as important as counselling about other drugs for clients of this agency

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Increasing restrictions on smoking and greater provision ofsmoking interventions would have very little impact on client attendance at this agency

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Most drug and alcohol clients who smoke are not interested in doing anything about their smoking

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Clients of this agency usually have enough other problems without worrying about smoking

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Occasionally it is useful for staff to smoke with a client in an effort to build rapport/trust

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What can we do - Menu of support

Brief Advice 5As (ASK, ADVISE, ASSESS, ASSIST, ARRANGE)

Motivational Interviewing

Behavioural Counselling

Pharmacotherapy (NRT gum, patches, inhaler, lozenges), buproprion

Quitline

Follow-up

Referral to other stop smoking services

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Heavily addicted!! Best to throw everything at them!

How to integrate this into usual care provision in drug and alcohol services?

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What is a systems based strategy?

Six Core Components

1.Implement a system of identifying and recording smoking status

2.Equip staff with education, resources and feedback

3.Dedicate staff to tobacco dependence treatment

4.Organisational policies

5.Provide tobacco dependence treatments as part of service (pharmaco and behavioural)

6.Defined duties of care

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(Fiore et al, Zeidonis et al)

How technology can be used

• Touchscreen computers– Highly acceptable to clients– Accurate

– Assesses smoking status, nicotine

dependence, quit attempts– Print-out for client files– Education for staff and clients– Ongoing monitoring and improvement

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Shakeshaft et al, 1999, Bonevski et al, 2010, Bryant et al 2012

Advantages of a systems based strategy

• Integration of smoking cessation support provision in routine care

• Aim to build capacity of the organisation to address smoking

• De-normalisation of smoking within the setting• Based on systems - sustainable model in the

long term

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Is it effective at reducing smoking?

• Pilot studies have found

– Improves staff attitudes score regarding smoking

– Increases distribution of NRT

– Increases provision of behavioural cessation support

• The potential is evident

• Well designed trials needed

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Guydish, 2010, 2012; Zeidonis 2007

Trial of system change intervention in drug and alcohol setting (NHMRC:2013-16)

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30 Drug & Alcohol Treatment Centres in

QLD, NSW & Vic randomised to:

15 Drug & Alcohol centres in intervention group:•Touchscreen survey and print out•Staff training•Organisational policies•NRT•Follow-up

15 Drug & Alcohol centres in control group: usual care

Outcomes at 6 months:•Cessation•Quit attempts•Smoking care provision

CRICOS Provider 00109J | www.newcastle.edu.au

THANK YOU

Funding:•Cancer Council NSW•Cancer Institute NSW•NHMRC•University of Newcastle•HMRI

Contact me on:Billie.bonevski@newcastle.edu.auor ph: 02 40335710

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