Commentary on Guydish et al. (2016): The continuing deadly threat of tobacco use in addiction treatment.

Abstract

Guydish and colleagues document the high prevalence of tobacco use among addiction treatment patients in many countries. Tobacco accounts for widespread premature mortality among individuals with addiction disorders, yet smoking cessation does not receive the attention it deserves in treatment settings. The bidirectional linkages between cigarette use and illicit substance use are well established. Tobacco misuse is a powerful marker for other substance use disorders in many populations, such as pregnant women 1. Tobacco use disorders are also pervasive comorbidities that accompany many other forms of substance use. Among US respondents in the 2013 National Survey of Drug Use and Health (NSDUH), 55% of those who reported illicit substance use in the past month also reported tobacco use during the same period. Smoking prevalence is higher among individuals who satisfy the criteria for alcohol and illicit drug disorders. The current systematic review by Guydish and colleagues underscores the importance of these linkages in a global context 2. These authors find a particularly high prevalence among patients receiving opiate addiction treatment, but find a high prevalence in almost all treatment populations for which data are systematically collected. Smoking cessation poses difficult challenges in addiction treatment, partly because smoking is so deeply embedded within these settings. Partly for that reason, tobacco use comprises a leading threat to life and health among individuals who experience a wide range of substance use disorders. Hurt and colleagues followed a cohort of in-patient addiction treatment patients. One hundred and nine of 214 attributable deaths occurred from tobacco-related causes 3 In similar fashion, Hser and colleagues performed a 24-year follow-up study of a patient cohort admitted to addiction treatment in 1964. The death rate among smokers was four times that found among non-smokers 4. Despite these findings, in many treatment organizations smoking cessation does not appear to be a high priority. High smoking prevalence among staff, passive staff attitudes regarding the intractability of smoking behaviors and limited access to smoking cessation treatments remain key obstacles to quitting within treatment populations 5. Cookson and colleagues’ survey of clients and staff associated with the South London and Maudsley NHS Foundation Trust underscores these difficulties. Eighty-eight per cent of clients and 45% of staff were current smokers. Fifty-six per cent of clients had never received assistance from clinicians with smoking cessation. Only 15% of clients received smoking cessation support during their current treatment stay, even though 79% expressed a desire to quit. Treatment staff rated smoking cessation as markedly less important than addressing clients’ use of other substances alongside their primary addiction 6 This pattern persists, despite evidence that smoking cessation interventions can be effective with this population within treatment settings without compromising other treatment goals 7. Analyzing 2004–05 US data, Friedmann and colleagues reported that only 41% of US out-patient treatment facilities offered smoking cessation counseling or pharmacotherapy 8; 38% offered individual/group counseling, and only 17% provided pharmacotherapy. Analyzing 2012 data, Shi and colleagues found similar results. Only 47% of the organizations surveyed offered behavioral counseling or pharmacotherapy for smoking cessation 9. Public policies can influence these practices. Shi and colleagues find that treatment facilities in US states that adopted strong tobacco control measures were more likely to offer smoking cessation services. Clinical guidelines and accreditation bodies can also play a helpful role 7. Policy findings in many other national settings are more sparse. Regulatory policies requiring addiction treatment providers to pay greater attention to smoking cessation deserve high priority in both services research and tobacco control policy. Guydish and collaborators perform an important service by drawing attention to this issue. The treatment community must improve its efforts to address this deadly and pervasive comorbidity. Millions of patients with addiction disorders seek help from the treatment system; whatever their treatment course and whatever their primary diagnosis, most have serious tobacco issues that are typically unaddressed. As a result, many will die prematurely of tobacco-related causes. We as a field can do much better. None.