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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
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Cancer Council NSW: Scott Walsberger, Phil Hull, Jon O’Brien
•
University of Wollongong: Pete Kelly
•
London: John Strang, Ann McNeill
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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
Single et al, 2000
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Annual drug-related deaths in the US
Centre for Disease Control, 2008, 2004, 2007
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Tobacco-related deaths within Australia
compared with other causes
Smoking
Breast Cancer
Infectious and parasitic diseases
Suicide
Drug dependence
Falls
Road traffic accidents
Alcohol dependence (inc cirrhosis)
Poisoning
Homicide and violence
Drowning
AIDS
Begg et al, 2007
Begg et al., 2007
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15511
2995
2416
2279
1705
1668
1662
1084
661
278
213
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Drug related deaths in Australia (2004/05)
Collins DJ, Lapsley HM. DoHA; 2008.
Begg et al., 2007
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Smoking rates in D&A treatment
populations
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Myth No 2:
“Tobacco smoking is a necessary selfmedication”
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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
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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
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
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N = 103 OTP clients in two clinics in Australia
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84% current smokers
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56% previous quit attempt
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38% thinking of quitting ‘next 6 months’
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Would like help with quitting – 36% said Yes and 31% were Unsure
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80% were heavy nicotine dependence
Bowman et al 2011
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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
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):11441156, December 2004.
Significant two-fold increase in the likelihood of smoking abstinence among
intervention versus control participants
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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):11441156, 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.
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How is smoking currently treated within
the drug and alcohol sector?
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
Walsh et al, 2006
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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
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Follow-up discussion
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Walsh et al, 2006
Bonevski et al., 2012, under review
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Barriers to the provision of smoking
cessation care in D&A setting
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•
•
•
•
•
•
•
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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
1
Zeidonis, Guydish, 2006; 2 Walsh, Bowman et al 2005; 3 Baca et al, 2008
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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
53
Increasing restrictions on smoking and greater provision of
smoking 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
64
Clients of this agency usually have enough other problems without worrying
about smoking
58
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
Heavily addicted!! Best to throw everything at them!
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How to integrate this into usual care
provision in drug and alcohol services?
What is a systems based strategy?
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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
(Fiore et al, Zeidonis et al)
How technology can be used
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• 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
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
Guydish, 2010, 2012; Zeidonis 2007
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Trial of system change intervention in drug
and alcohol setting (NHMRC:2013-16)
30 Drug & Alcohol
Treatment Centres in
QLD, NSW & Vic
randomised to:
15 Drug & Alcohol
centres in control
group:
usual care
15 Drug & Alcohol centres
in intervention group:
• Touchscreen survey and
print out
• Staff training
• Organisational policies
• NRT
• Follow-up
Outcomes at 6 months:
•
•
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Cessation
Quit attempts
Smoking care provision
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THANK YOU
Funding:
•Cancer Council NSW
•Cancer Institute NSW
•NHMRC
•University of Newcastle
•HMRI
Contact me on:
[email protected]
or ph: 02 40335710
CRICOS Provider 00109J | www.newcastle.edu.au
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