Tobacco Cessation Services

In Brief
  • In 2011, 5,737 substance abuse treatment facilities—less than half (42 percent) of all such facilities nationwide—offered tobacco cessation services
  • Over half of facilities located in the Northeast (58 percent) offered tobacco cessation services compared with 40 percent of facilities in the West, 38 percent of facilities in the South, and 34 percent of facilities in the Midwest
  • A larger percentage of substance abuse treatment facilities (44 percent) that offered tobacco cessation services prohibited smoking anywhere compared with facilities that did not offer these services (27 percent)
  • Nearly three fourths (72 percent) of substance abuse treatment facilities that offered any type of tobacco cessation service provided screening for tobacco use, compared to 34 percent of facilities that did not offer tobacco cessation services

Tobacco is a highly addictive substance with well-documented health risks. Although great progress has been made in reducing and preventing tobacco use in the United States,1 the rates of cigarette use and dependence remain high in certain subpopulations, including those with substance use disorders. For example, 2011 data show that an estimated 22 percent of U.S. adults are current cigarette smokers,2 whereas smoking prevalence rates for those in substance abuse treatment exceeded 70 percent between 2005 and 2009.3 The negative health effects of tobacco use among alcohol- and drug-dependent individuals can be substantial. Individuals in substance abuse treatment smoke more heavily than the general population, and consequently are more likely to suffer from tobacco-related morbidity, including cardiopulmonary problems, emphysema, and cancer, than are smokers in the general population.4 One study of substance abuse treatment clients found that tobacco use caused more deaths than the alcohol or drug use that brought them to treatment; specifically, the rate of death among tobacco users was nearly 1.5 times the rate of death from other addiction-related causes.5

A growing body of studies has dispelled the common notions that (1) tobacco cessation efforts compromise the treatment and sobriety of persons who are working on recovery from alcohol or drug abuse, and (2) clients in treatment are not interested in quitting tobacco use.6,7 Tobacco cessation services have been found, for example, to be associated with a 25 percent increase in maintaining long-term abstinence from alcohol and illicit drugs.7 Moreover, surveys of treatment populations show that 44 to 80 percent are interested in tobacco cessation.7 Thus, the substance abuse treatment setting offers a good opportunity to introduce tobacco cessation services to clients because these services complement drug and alcohol treatment and benefit overall health.8 The goal of this report is to identify how many facilities offer tobacco cessation services as a part of substance abuse treatment, determine how they are distributed geographically, and highlight other important characteristics of these programs. Comparisons will be made with those facilities that did not offer any tobacco cessation services.

The National Survey of Substance Abuse Treatment Services (N-SSATS), an annual survey of all known substance abuse treatment facilities, both public and private, provides information on the numbers of facilities that provide tobacco cessation services. Facilities offering "any" tobacco cessation service provided any one or a combination of the following services in 2011: tobacco cessation counseling, nicotine replacement medication, and/or non-nicotine tobacco cessation medication.

Note that N-SSATS is a census of all treatment facilities in the United States. Because N-SSATS involves actual counts rather than estimates, statistical significance and confidence intervals are not applicable. The differences mentioned in the text of this report have Cohen's h effect size ≥ 0.20, indicating that they are considered to be meaningful.


Overview

In 2011, 5,737 substance abuse treatment facilities—less than half (42 percent) of all such facilities nationwide—offered tobacco cessation services (Figure 1). Specifically, 34 percent of all facilities offered tobacco cessation counseling, 21 percent offered nicotine replacement medication, and 16 percent offered non-nicotine tobacco cessation medication.

Figure 1. Substance Abuse Treatment Facilities Offering Tobacco Cessation Services: 2011
This is a bar graph comparing substance abuse treatment facilities offering tobacco cessation services: 2011. Accessible table located below this figure.

Figure 1 Table. Substance Abuse Treatment Facilities Offering Tobacco Cessation Services: 2011
Cessation Services Percent
Any Tobacco Cessation Service 42%
Specific Tobacco Cessation Service(s)
Smoking Cessation Counseling 34%
Nicotine Replacement Pharmacotherapy 21%
Non-nicotine Tobacco Cessation Pharmacotherapy 16%
Source: SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS), 2011.


Geographic Differences

The proportions of substance abuse treatment facilities offering tobacco cessation services differed by Census region, and there were several notable differences at the State level as well (Figure 2). Over half of facilities located in the Northeast (58 percent) offered tobacco cessation services compared with 40 percent of facilities in the West, 38 percent of facilities in the South, and 34 percent of facilities in the Midwest. The higher percentage of facilities offering tobacco cessation services in the Northeast were primarily driven by two States. Specifically, 83 percent of facilities in New York offered tobacco cessation services, and 73 percent of those in Massachusetts did. Arkansas and Wyoming also had high percentages of treatment facilities offering tobacco cessation services; the proportions in these States were about double that of their respective regional averages (80 percent in Arkansas vs. 38 percent in the South, and 72 percent in Wyoming vs. 40 percent in the West).

Figure 2. Substance Abuse Treatment Facilities Offering Any Tobacco Cessation Services, by Census Region and by State: 2011
This is a map comparing substance abuse treatment facilities offering any tobacco cessation services, by census region and by state: 2011. Accessible table located below this figure.

Figure 2 Table. Substance Abuse Treatment Facilities Offering Any Tobacco Cessation Services, by Census Region and by State: 2011
Census Region Percent
MIDWEST REGION 34%
Illinois 29%
Indiana 44%
Iowa 31%
Kansas 29%
Michigan 32%
Minnesota 32%
Missouri 35%
Nebraska 33%
North Dakota 34%
Ohio 36%
South Dakota 41%
Wisconsin 44%
NORTHEAST REGION 58%
Connecticut 48%
Maine 36%
Massachusetts 73%
New Hampshire 41%
New Jersey 42%
New York 83%
Pennsylvania 35%
Rhode Island 42%
Vermont 67%
SOUTH REGION 38%
Alabama 23%
Arkansas 80%
Delaware 51%
District of Columbia 31%
Florida 39%
Georgia 33%
Kentucky 28%
Louisiana 39%
Maryland 38%
Mississippi 32%
North Carolina 40%
Oklahoma 47%
South Carolina 49%
Tennessee 34%
Texas 44%
Virginia 38%
West Virginia 27%
WEST REGION 40%
Alaska 49%
Arizona 34%
California 36%
Colorado 34%
Hawaii 57%
Idaho 32%
Montana 32%
Nevada 34%
New Mexico 40%
Oregon 55%
Utah 59%
Washington 46%
Wyoming 72%
Source: SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS), 2011.


Facility Operation

A larger proportion of substance abuse treatment facilities operated by Federal Government agencies offered tobacco cessation services than that of all other facilities. Specifically, 80 percent of facilities operated by the Federal Government offered tobacco cessation services, compared with just over half (51 percent) of those operated by State governments and more than one third (34 percent) of those operated by private for-profit organizations (Figure 3).

Figure 3. Substance Abuse Treatment Facilities Offering Tobacco Cessation Services, by Facility Operation: 2011
This is a bar graph comparing substance abuse treatment facilities offering tobacco cessation services, by facility operation: 2011. Accessible table located below this figure.

Figure 3 Table. Substance Abuse Treatment Facilities Offering Tobacco Cessation Services, by Facility Operation: 2011
Facility Operation Percent
Federal Government 80%
State Government 51%
Local Government 45%
Private Non-profit 44%
Tribal Government 41%
Private For Profit 34%
Source: SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS), 2011.


Primary Therapeutic Focus

The majority (81 percent) of substance abuse treatment facilities with a primary general health care focus (usually facilities located within hospitals) offered tobacco cessation services (Figure 4). These facilities offered tobacco cessation services at a higher rate than those with a primary focus on both substance abuse and mental health services (46 percent), mental health services only (42 percent), or substance abuse services only (39 percent).

Figure 4. Substance Abuse Treatment Facilities Offering Tobacco Cessation Services, by Primary Therapeutic Focus: 2011
This is a bar graph comparing substance abuse treatment facilities offering tobacco cessation services, by primary therapeutic focus: 2011. Accessible table located below this figure.

Figure 4 Table. Substance Abuse Treatment Facilities Offering Tobacco Cessation Services, by Primary Therapeutic Focus: 2011
Primary Therapeutic Focus Percent
General Health Care 81%
Mix of Substance Abuse & Mental Health Services 46%
Mental Health Services 42%
Substance Abuse Services 39%
Other 37%
Source: SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS), 2011.


Smoking Policy

The 2011 N-SSATS survey included questions about a facility's smoking policy. About one third (34 percent) of substance abuse treatment facilities reported that they prohibited smoking on site (i.e., did not allow smoking anywhere), 54 percent reported that they permitted smoking outside only, and 10 percent reported they permitted smoking outside and in designated areas only. The remainder reported some other policy or had an invalid or missing response to this question.

A larger percentage of substance abuse treatment facilities (44 percent) that offered tobacco cessation services prohibited smoking anywhere compared with facilities that did not offer these services (27 percent) (Figure 5). Less than half of facilities that offered tobacco cessation services (45 percent) permitted smoking outdoors but not indoors—this was a lower percentage than for facilities that did not offer tobacco cessation services (62 percent).

Figure 5. Substance Abuse Treatment Facility Smoking Policies, by Tobacco Cessation Services: 2011
This is a bar graph comparing substance abuse treatment facility smoking policies, by tobacco cessation services: 2011. Accessible table located below this figure.

Figure 5 Table. Substance Abuse Treatment Facility Smoking Policies, by Tobacco Cessation Services: 2011
Smoking Policies Any Tobacco
Cessation Service
No Tobacco
Cessation Service
Not Permitted Anywhere 44% 27%
Permitted Outdoors Only 45% 62%
Permitted Outdoors and Designated Indoor Areas 10% 11%
Source: SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS), 2011.


Screening for Tobacco Use

The 2011 N-SSATS asked about screening for tobacco use during assessment and/or as a pretreatment service. Half (50 percent) of substance abuse treatment facilities reported that they screened for tobacco use (Figure 6), more than one third (38 percent) reported that they did not screen, and the remainder (12 percent) had either an invalid or missing response to this question. Nearly three fourths (72 percent) of substance abuse treatment facilities that offered any type of tobacco cessation service provided screening for tobacco use, compared to 34 percent of facilities that did not offer tobacco cessation services.

Figure 6. Substance Abuse Treatment Facilities Providing Screening for Tobacco Use, by Tobacco Cessation Services: 2011
This is a bar graph comparing substance abuse treatment facilities providing screening for tobacco use, by tobacco cessation services: 2011. Accessible table located below this figure.

Figure 6 Table. Substance Abuse Treatment Facilities Providing Screening for Tobacco Use, by Tobacco Cessation Services: 2011
Tobacco Cessation Services Percent
All Facilities 50%
Any Tobacco Cessation Service 72%
No Tobacco Cessation Service 34%
Source: SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS), 2011.


Discussion

Tobacco cessation services provide important benefits that can improve the short- and long-term health of clients in substance abuse treatment and can enhance drug and alcohol treatment outcomes.6,7 Yet this report shows that less than half of treatment facilities nationwide provide tobacco cessation services. Notably, the Census regions with the heaviest rates of smoking and tobacco-related mortality and morbidity—the Midwest and South—are the regions in which facilities are least likely to offer tobacco cessation services.1 Compared with other regions, the Northeast has more treatment facilities that offer tobacco cessation services, are operated by the Federal Government, or have a primary general health care focus (Table 1). Many of these findings are expected given the policies that typically prohibit tobacco use in hospitals, other health care facilities, and Federal and some State government facilities. New York, for example, prohibits smoking in State-owned substance abuse treatment facilities and requires that all treatment centers help their patients to quit smoking.9

Table 1. Summary of Differences Found between Substance Abuse Treatment Facilities That Do Offer and Those That Do Not Offer Tobacco Cessation Services: 2011*
Substance abuse treatment facilities offering tobacco cessation services were MORE likely than facilities that did not offer services to be or to report:
  • Located in the Northeast
  • Operated by the Federal government
  • A primary general health care focus
  • Prohibit on-site smoking
  • Use of tobacco screens during assessment and/or as a pretreatment service
Substance abuse treatment facilities offering tobacco cessation services were LESS likely than facilities that did not offer services to be or to report:
  • Allow smoking in outdoor areas but not indoors
* The differences shown in this table have Cohen's h effect size > 0.20, indicating that they are considered to be meaningful.
Source: SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS), 2011.

Treatment programs that do not screen for tobacco use or offer tobacco cessation services should be encouraged to implement these services as an important, complementary adjunct to substance abuse treatment and to meet an important public health need. To that end, the Substance Abuse and Mental Health Services Administration (SAMHSA) has developed resources for implementing tobacco use cessation during substance abuse treatment.

Please see the following documents that are available on the SAMHSA website:

The U.S. Preventive Services Task Force has also developed general counseling recommendations to prevent tobacco use and tobacco-caused disease for adults and pregnant women (see http://www.uspreventiveservicestaskforce.org/uspstf09/tobacco/tobaccors2.htm). Clinicians who work in treatment programs without formal tobacco cessation programs or services may refer interested clients to 1-800-QUIT-NOW or http://www.smokefree.gov.



End Notes
1 Centers for Disease Control and Prevention. (2011, September 9). Vital Signs: Current cigarette smoking among adults aged ≥ 18 years—United States, 2005-2010. Morbidity and Mortality Weekly Report, 60(35), 1207-1212. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6035a5.htm?s_cid=%20mm6035a5.htm_w
2 Center for Behavioral Health Statistics and Quality. (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of national findings (HHS Publication No. SMA 12-4713, NSDUH Series H-44). Rockville, MD: Substance Abuse and Mental Health Services Administration.
3 Center for Behavioral Health Statistics and Quality. (2011, June 23). The NSDUH Report: Nicotine dependence among persons who received substance use treatment. Rockville, MD: Substance Abuse and Mental Health Services Administration.
4 Burling, T. A., Ramsey, T. G., Seidner, A. L., & Kondo, C. S. (1997). Issues related to smoking cessation among substance abusers. Journal of Substance Abuse, 9, 27-40.
5 Hurt, R. D., Offord, K. P., Croghan, I. T., Gomez-Dahl, L., Kottke, T. E., Morse, R. M., & Melton, L. J. (1996). Mortality following inpatient addictions treatment: Role of tobacco use in a community-based cohort. JAMA, 275(14), 1097-1103.
6 Baca, C. T., & Yahne, C. E. (2009). Smoking cessation during substance abuse treatment: What you need to know. Journal of Substance Abuse Treatment, 36(2), 205-219.
7 Prochaska, J. J., Delucchi, K., & Hall, S. M. (2004). A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of Consulting and Clinical Psychology, 72(6), 1144-1156.
8 Centers for Disease Control and Prevention. (2004). The health consequences of smoking: A report of the Surgeon General. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
9 New York State Office of Alcoholism & Substance Abuse Services (NYS OASAS). (2008, July 24). Regulations for tobacco-free services, Title 14, NYCRR Part 856. Retrieved from http://www.oasas.ny.gov/tobacco/providers/documents/Part856reg.pdf


Suggested Citation
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (September 19, 2013). The N-SSATS Report: Tobacco Cessation Services. Rockville, MD.

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.

The National Survey of Substance Abuse Treatment Services (N-SSATS) is an annual survey designed to collect information from all facilities in the United States, both public and private, that provide substance abuse treatment. N-SSATS provides the mechanism for quantifying the dynamic character and composition of the United States substance abuse treatment delivery system. The objectives of N-SSATS are to collect multipurpose data that can be used to assist SAMHSA and State and local governments in assessing the nature and extent of services provided and in forecasting treatment resource requirements, to update SAMHSA's Inventory of Behavioral Health Services (I-BHS), to analyze general treatment services trends, and to generate the Substance Abuse Treatment Facility Locator [http://findtreatment.samhsa.gov/].

N-SSATS is one component of the Behavioral Health Services Information System (BHSIS), maintained by the Center for Behavioral Health Statistics and Quality (CBHSQ), SAMHSA. N-SSATS collects three types of information from facilities: (1) characteristics of individual facilities such as services offered and types of treatment provided, primary focus of the facility, and payment options; (2) client count information such as counts of clients served by service type and number of beds designated for treatment; and (3) general information such as licensure, certification, or accreditation and facility website availability. In 2011, N-SSATS collected information from 13,720 facilities from all 50 States, the District of Columbia, Puerto Rico, the Federated States of Micronesia, Guam, Palau, and the Virgin Islands. Information and data for this report are based on data reported to N-SSATS for the survey reference date March 31, 2011.

The N-SSATS Report is prepared by the Center for Behavioral Health Statistics and Quality, SAMHSA; Synectics for Management Decisions, Inc., Arlington, VA; and RTI International, Research Triangle Park, NC.

Latest N-SSATS reports:
http://www.samhsa.gov/data/DASIS.aspx#N-SSATS

Latest N-SSATS public use files and variable definitions:
http://datafiles.samhsa.gov

Other substance abuse reports:
http://www.samhsa.gov/data