Journal of Substance Abuse Treatment, Vol. 10, pp. 147-152, 1993 074t-5472/93 $6.00 + .OO Printed in the USA. All rights reserved. 1993 Pergamon Press Ltd.

IN THE SPOTLIGHT

Nicotine Treatment at the Drug Dependency Program of the Minneapolis VA Medical Center

A Researcher’s Perspective

MINNEAPOLIS, MINNESOTA

Abstract-Substance use disorder treatment professionals historically have been reluctant to ad- dress tobacco dependence in their patients, despite a high prevalence of smoking, unique health effects, and evidence of physical addiction to nicotine. We performed two prospective studies to examine (1) the feasibility of a smoke-free policy and nicotine treatment program in an inpatient drug and alcohol treatment program, and (2) the impact of this intervention on long-term treat- ment outcomes. In both studies we used self-reported data from two groups of patients; one hospi- talized after the implementation of the intervention and a historical control. The first set of data indicated that patients were more interested in quitting smoking and were more likely to abstain from smoking after the policy was implemented than before. They did not feel quitting smoking would threaten abstinence, and the policy did not increase early discharges. The second study failed to show that the change in policy was associated with an adverse effect on drug and alcohol treat- ment outcomes. A small but significant positive effect was demonstrated for smoking cessation. These studies also showed that many patients regard smoking as different from the primary drug that brought them to treatment, Randomized clinical trials testing a variety of smoking interven- tion techniques are desperately needed in this population to scientifically determine effective meth- ods to decrease smoking.

Keywords-nicotine dependency; inpatient nicotine treatment; smoking cessation; smoking policy.

INTRODUCTION many substance use disorder patients’ addiction to nic-

THE SUBSTANCE USE DISORDER TREATMENT FIELD has tra- ditionally regarded tobacco use as less important and less dangerous than use of alcohol and other drugs. This attitude has developed from fear that challeng- ing nicotine addiction would jeopardize other treat- ment outcomes, and appreciation of the severity of

otine. In the past treatment professionals objected to treating alcohol and heroin or cocaine simultaneously, for reasons similar to those we now hear about the need to defer nicotine treatment. Because harmful conse- quences of other addictive disorders are often more im- mediately apparent than tobacco, smoking is frequently ignored or put on the back burner in the treatment pro- cess. It has finally become impossible, however, to ig-

Requests for reprints should be addressed to Anne M. Joseph, MD, nore smoking in populations hospitalized for treatment

MPH, Section of General Internal Medicine (11 l-O), Veterans Af- of substance use disorders because of the high preva- fairs Medical Center, One Veterans Drive, Minneapolis, MN 55417. lence of nicotine addiction among alcoholics and other

147

148 A.M. Joseph

drug users, recognition of the physically addictive na- ture of smoking, and progressive restrictions placed on smoking in hospital settings.

There is a consistent association between cigarette and alcohol consumption in representative samples of the general population, including men and women of all races (Klatsky, 1977). Over 90% of alcoholic male and female outpatients are cigarette smokers, far more than in the general population (Ashley, 1981; Dreher & Fraser, 1967). Heavy drinkers are less likely to at- tempt to quit smoking (Zimmerman et al., 1990). This is reflected in the fact that alcoholics have not shared in the decline in the prevalence of smoking that has been observed in the general population in the last four decades (Hatziandreu et al., 1990; Koslowski, Jelinek, & Pope, 1986).

Recent research on smoking cessation has empha- sized the importance of physical dependence on nico- tine. The establishment by the American Psychiatric Association of diagnostic categories of nicotine addic- tion and withdrawal (American Psychiatric Associa- tion, 1987), publication of the Surgeon General’s report on Nicotine Addiction (USDHHS, 1988), and investigation of the role of nicotine replacement ther- apy in smoking cessation interventions (Benowitz, 1988; Tonnesen et al., 1991) reflect this emphasis. Re- search has also further described the risks associated with environmental tobacco smoke (USDHHS, 1986). This has contributed to legislative and policy develop- ments that have progressively restricted smoking in public buildings, including hospitals (Knapp & Kottke, 1991). In 1992 the Joint Commission on Accreditation of Healthcare Organizations issued a new accredita- tion standard requiring all hospitals to become com- pletely smoke-free.

These events have put pressure on the substance use treatment field to consider two questions. First, should institutional smoke-free policies be applied to inpa- tient chemical dependency treatment wards? Potential concerns about this practice include potential patient noncompliance, need to manage nicotine withdrawal symptoms, and declining rates of admission for treat- ment because of smoking policies. The second ques- tion is more complex. Should inpatient treatment for substance abuse include treatment for nicotine depen- dence? The answer depends on whether including nico- tine treatment helps or harms other treatment outcomes, and on whether interventions that are effective for other substances are effective for nicotine dependence.

In June 1988, a 725bed urban VA, including 60 in- patient acute psychiatry care beds and 30 drug depen- dency treatment program beds, implemented a new smoking policy totally banning smoking inside the building. Hospital grounds are not included in the pol- icy. Tobacco products are not sold in the hospital. The drug dependency treatment program elected to use this policy turning point to embark on treatment of

nicotine dependence during inpatient drug and alcohol treatment (Pletcher, 1993). Prior to the new policy there was ample concern about establishing a smoke- free inpatient treatment program, but little scientific data on which to base expectations or plans.

In anticipation of the implementation date we de- signed prospective studies to examine two questions: (1) the feasibility of a smoke-free policy, and (2) its effect on long-term drug and alcohol treatment out- comes. In both studies a patient group hospitalized be- fore policy implementation was compared to a control population hospitalized after the policy.

METHODS AND RESULTS

Setting

The drug dependency treatment program is a 21-day residential program treating drug and alcohol depen- dence simultaneously. Permanent abstinence from all mood-altering substances is the goal of treatment, which is based on the Minnesota Model, or 12 steps of Alcoholics Anonymous. Most patients are alco- hol dependent and approximately 65 070 have some ex- perience with other drugs. All counselors, but not all staff, are themselves recovering from substance use disorders.

In 1988, prior to the implementation of the smok- ing policy, patients were not given specific informa- tion about smoking. Ward smoking was only permitted in two designated rooms and not during group ses- sions. After implementation of the policy patients were required upon admission to the hospital to acknowl- edge the smoke-free policy and agree to nicotine ab- stinence during treatment. This was confirmed in a written contract. They were then subjected to a two- pronged intervention: the hospital policy as well as a smoking cessation program specifically designed for use with substance use disorder patients. This program included didactic lectures on the pharmacology of nic- otine, films, and discussion groups. Clonidine patches were available during hospitalization, but were not studied in a systematic fashion.

Study I. Interest in Quitting and Feasibility

We studied 912 consecutive patients admitted for in- patient drug dependency treatment. The sample con- sisted of 407 patients admitted before May 1988, and 299 patients admitted after July 1988. Patients admit- ted over the 2-month period spanning the move were excluded to avoid patients who were hospitalized un- der both policies. Seventy-seven percent of patients were current cigarette smokers, and 80% smoked more than one pack per day. We compared responses to brief (1 page) standardized questionnaires about smok- ing habits and attitudes toward smoking cessation be-

Inpatient Nicotine Dependency Treatment 149

TABLE 1 Study I. Interest in Quitting and Feasibility

Pre- n (%)

Post- n (%) P

Admission Questionnaire Cigarette Smokers Want to Quit Interest in Quit

in Hospital Discharge Questionnaire

Cigarette Smokers Abstain from Smoking

>l Week Cut Down in Hospital Not Smoking Regularly Feel Quit Threatens

Sobriety

407 312 (77) 112 (36)

175 (24) 336 252 (75)

23 (9) 116 (46)

48 (19)

71 (28)

299

226 (76) 140 (62)

138 (61) 252

97 (78)

41 (41) 90 (93) 56 (58)

31 (32)

.91 <.OOl

<.OOl

.99

<.OOl <.OOl <.OOl

.22 No Plan to Change

Habits 30 (12) 6 (6) <.OOl

fore and after the policy was implemented. The questionnaires were self-administered; the first ques- tionnaire on admission to the hospital and the second during the third week of hospitalization.

Thirty-six percent of patients in the prepolicy group said they wanted to quit smoking, compared to 62% in the postpolicy group (p < .OOl). Twenty-four per- cent said they were interested in quitting during hos- pitalization before the policy, compared to 61 Vo after the policy (p < .OOl). Rates of early termination of treatment did not change in the two study periods. Forty-one percent of patients hospitalized in the post- policy group abstained from smoking for more than 1 week during hospitalization, compared to 9% in the prepolicy group (see Table 1). We concluded that con- current intervention for nicotine addiction during in- patient treatment is feasible, and associated with a temporary reduction in smoking and increased moti- vation to quit smoking (Joseph et al., 1990).

Study II. Effect on Treatment Outcomes

We conducted structured telephone interviews with 319 patients about smoking, alcohol, and drug use behav- ior approximately 1 year after completion of inpatient treatment. If patients could not be reached by phone after four attempts, a survey was mailed. Prepolicy patients (n = 156) were interviewed a mean of 16.2 months after discharge from the hospital, and post- policy patients (n = 163) were interviewed a mean of 10.7 months after discharge.

Demographic data from both groups were similar. Alcohol was the drug of choice for 72%, cocaine the drug of choice for 15%; and 70% used more than one substance. Seventy-nine percent of patients were cig- arette smokers at the time of admission.

Improvement in chemical dependency was defined as less or no use of the substance of choice (excluding nicotine). Ninety-seven percent of the prepolicy pa- tients reported improvement, compared to 89% of postpolicy patients (difference not statistically signif- icant). We considered it likely that nonrespondents had significantly different smoking behaviors and at- titudes toward smoking policy, and made a conserva- tive assumption that all nonrespondents were chemical dependency and smoking treatment failures. This as- sumption did not result in significant differences in treatment outcomes pre- and postpolicy.

At the time of follow-up, 21% of prepolicy patients smoked less than on admission, compared to 19% of postpolicy patient (difference not statistically signifi- cant). Thirteen postpolicy patients quit smoking, com- pared to 5 prepolicy patients (p < .05) (see Table 2).

Spontaneous comments during the interview process, though difficult to analyze, made a strong impression on interviewers. They indicated that in general post- policy patients found the hospital smoking ban accept- able but many resented the mandatory nature of the nicotine treatment program. Many patients said they did not consider nicotine equivalent to drugs or alco- hol. The following statements reflect some frequently expressed sentiments; “I agree with the no-smoking policy but don’t think it should be mandatory”, “It’s a good idea but too difficult”, “. . . should deal with one addiction at a time”, and “Smoking is not the main problem I have.” Many patients noted difficulty at- tending aftercare meetings outside the hospital setting, such as in Alcoholics Anonymous. They reported that smoking in such settings was ubiquitous and there was limited support for smoking cessation.

We concluded that a smoke-free inpatient drug treatment program was associated with a slightly higher rate of smoking cessation but did not compro- mise drug and alcohol treatment outcomes. There was a nonsignificant trend in this direction, however (Jo- seph & Nichol, 1990).

TABLE 2 Study II. Long-Term Effects of Smoking Intervention

on Treatment Outcomes

Pre- n (%)

Post- n (%) P

Patients 156 163 Respondents 101 (65) 96 (59) Time to Interview

(months) 16.7 10.7 Improvement Chemical

Dependency 151 (97) 145 (89) .15 Smoke Less than on

Admission 33 (21) 18 (19) .49 Patients Quitting Smoking 5 (3) 13 (8) <.05

I50 A.M. Joseph

DISCUSSION

These data indicate that there is considerable unex- pected interest in smoking cessation in this population, but that patients frequently consider nicotine depen- dence in a different manner than drugs or alcohol. Long-term treatment outcomes are not obviously af- fected by including nicotine treatment interventions. The interventions were associated with a small posi- tive effect on self-reported smoking behaviors.

There are several potential biases in these studies. The use of historic controls allows the possibility that changes in the treatment program over time such as moving to a new building site or staff changes other than the smoking policy were responsible for the find- ings. Also, in the treatment outcome study, there was an overall nonresponse rate of 38%. We addressed this by making conservative and critical assumptions about patients’ views, practices, and treatment outcomes. These assumptions did not alter our conclusions. It is also possible the postpolicy treatment group’s out- comes will worsen with time, and it was not followed as long as the prepolicy group. Finally, the study de- signs do not allow assessment of treatment refusal rates because of the smoking policy: a critical issue but methodologically difficult because such patients who refuse treatment may never present for admission.

Work from other investigators also suggests that al- coholic patients are more interested in stopping smok- ing than anticipated by treatment professionals. Koslowski et al. found a majority of clients interested in drug or alcohol treatment “moderately” or “very much” wanted to give up smoking (Koslowski et al., 1989). Some patients are interested in quitting at the same time as their other treatment while others want to wait until their other problems have stabilized (Sobell et al., 1990; Koslowski et al., 1989). Most pa- tients report that it would be more difficult to quit cigarettes than the substance they are seeking treatment for (Koslowski, Wilkinson et al., 1989).

There is little information available on the effect of treatment for nicotine addiction on other treatment outcomes. Bobo and Gilchrist reported that 19% of 73 recovering alcoholics had quit smoking, a mean of 36 months following treatment, those who successfully quit smoking had less severe substance abuse histories (Bobo et al., 1987). Miller found that smoking cessa- tion by pretreatment smokers was associated with suc- cessful control of drinking, raising the possibility that smoking cessation might improve alcohol treatment outcomes (Miller, Hedrick, & Taylor, 1983).

There are several hypotheses to support this. As noted, methods used during inpatient drug and alco- hol treatment are often similar to those used in nico- tine dependency treatment, such as teaching skills to manage craving, stress reduction, and development of alternative behavior patterns. It may be more effective

to apply these principles consistently than selectively. Also, addictive behaviors have been demonstrated to be powerful cues for one another, and continued smoking may provide a stimulus for continued drug or alcohol use. Drinkers smoke more heavily when consuming alcohol and cigarettes are puffed more in- tensively when used in combination with alcohol (Hen- ningfield, Chait, & Griffiths, 1984; Nil, Buzzi, & Battig, 1984). In the general population, individuals who enjoyed smoking with alcohol were more likely to attempt and be successful at quitting smoking when they quit drinking than those who did not enjoy smok- ing and drinking concurrently (Zimmerman et al., 1990).

The recovery process for alcohol, drugs, and nico- tine is similar in many ways. In each case, quitting is most commonly self-directed and accomplished with- out structured treatment. Abstinence rather than re- duced consumption is the usual goal of treatment. Relapse rates are similar for alcohol, tobacco, and opi- ates (Hunt, Barnett, & Branch, 1971). Similar factors contribute to abstinence and relapse (structural sup- port, partner support, stress, conflict, social pressure) and similar intervention techniques are effective (mul- tiple intervention modalities, frequency of client con- tact, length of contact) (Havassy, Hall, 8z Wasserman 1991; Kottke et al., 1988).

Important differences between nicotine, alcohol, and other drugs should be acknowledged. Nicotine reaches the brain more rapidly than alcohol, affects behavior more quickly, has a shorter half-life, and is dosed more frequently. Over 90% of smokers are physically dependent on cigarettes, but the majority of drinkers are only occasional users (USDHHS, 1988; Pomerleau, 1990).

Drug and alcohol treatment professionals’ doubt about tackling smoking issues may be based in part of staff smoking habits. Many treatment staff are them- selves recovering but approximately 50% continue to smoke cigarettes. Smoking staff have been shown to be significantly less likely to urge cessation (Bobo & Gilchrist, 1983). Treatment staff continue to place a priority on recovery from drugs or alcohol, as distin- guished from tobacco (Bobo & Davis, 1993).

Patients and staff continue to struggle with the rel- ative severity of consequences of substance use. Nic- otine enjoys a privileged and protected status in our society, made possible by the tobacco industry. Smok- ing is acceptable although it kills more people than any other drug. Society is more likely to tolerate an addiction if the consequences only hurt the drug user; smoking hurts others as well, however. This occurs di- rectly through environmental tobacco smoke, and in- directly by costing billions of dollars in health care. The legal and social problems associated with overuse of alcohol and drugs are more obvious than nicotine, but as society changes attitudes toward smoking and

Inpatient Nicotine Dependency Treatment 151

recognizes the health risks of exposure to environmental tobacco smoke smokers are likely to experience impor- tant problems, in addition to health effects from smok- ing. These include employability, social acceptability, insurance costs, and other financial consequences. These factors are important in motivating smoking cessation.

Our experience with introduction of a new treat- ment for nicotine dependence in this population raised many controversial issues. Staff conflicts over appro- priate consequences for smoking during treatment oc- curred almost immediately. The model for management of slip-ups during treatment (using drugs and alcohol) was not easily applicable to nicotine use. Punishment for smoking inhibited discussion of nicotine with- drawal and management, which is important to suc- cessful smoking cessation programs, and only served to hide the issue. It was therefore necessary to develop a process whereby patients could safely discuss nico- tine use. The program’s approach is in evolution and the current treatment philosophy is considerably more flexible than the original one.

Also, the Minnesota Model stresses abstinence as the only goal of treatment. Therefore, we did not con- sider nicotine replacement therapy for this patient pop- ulation. However, alcoholic smokers might be expected to benefit from nicotine replacement therapy for sev- eral reasons: they are heavy nicotine users and exhibit high level of physical dependence on nicotine. Nico- tine withdrawal symptoms include anxiety, difficulty concentrating, and sleep disturbance, and typically peak during hospitalization. .Substance use disorder treatment interventions might be more effective if these symptoms were controlled by nicotine replacement therapy. A double-blind randomized controlled trial could easily be designed to evaluate the effect of nic- otine replacement therapy in this population.

The program philosophy that each patient must re- ceive equal treatment, however, presented an obsta- cle to use of a randomized controlled trial. Although many treatment professionals advocate other methods of choosing treatment modalities (such as by availabil- ity, clinical judgment, or algorithm) for research pur- poses random assignment is the only method that is not subject to bias. If study subjects are not randomly assigned selective choice of treatment groups can bias results. If there is no concurrent control group period effects can confound results. Drug intervention trials should be double-blind so patients and staff cannot an- ticipate treatment effects. In drug and alcohol treat- ment patient populations, geographic sites, programs, practices, and philosophies are sufficiently different that randomized controlled trials are likely to be best performed within programs rather than between them, thereby controlling for case mix, program content, and other demographic variables. It is ethical to give pa- tients different treatments if we do not know that one

treatment offers an advantage over another. Clinical trials would be appropriate to examine the effect of factors such as institutional policies, timing of smok- ing cessation interventions (concurrent or delayed), or clonidine therapy, in addition to nicotine replacement therapy.

Most patients who undergo structured inpatient treatment for substance use disorders are young and have not developed irreversible consequences of smok- ing. Alcohol and tobacco act synergistically to increase ._- the risk for motor vehicle accidents, esophageal can- cer, and cancer of the oral cavity and pharynx. Pre- vention of these and other smoking related diseases such as heart disease, chronic obstructive pulmonary disease, lung cancer, and peptic ulcer disease through cessation would significantly improve the future health of this population. If we can determine specific effec- tive measures to reduce smoking among substance abuse treatment patients fewer will ultimately die from another addiction.

Anne Marie Joseph, MD, MPH

University of Minnesota

Minneapolis, Minnesota

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