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.

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.

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).

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).

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).

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).

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.

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

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:

• SAMHSA: Tobacco Use Cessation Policies in Substance Abuse Treatment: Administrative Issues: http://store.samhsa.gov/shin/content//SMA11-4636ADMIN/SMA11-4636ADMIN.pdf
• SAMHSA: Tobacco Use Cessation During Substance Abuse Treatment Counseling: http://store.samhsa.gov/shin/content//SMA11-4636CLIN/SMA11-4636CLIN.pdf

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.