Tobacco Cessation Pharmacotherapy Research Articles

Development and Demonstration of Tobacco Treatment Measures for Cancer Registries: Novel Metrics for Quality Improvement.

Individuals undergoing cancer treatment have better outcomes when they discontinue tobacco use. Few cancer centers systematically provide evidence-based cessation services. As part of a national quality improvement initiative [Cancer Center Cessation Initiative (C3i)], we collaborated with our cancer registry to develop and implement two tobacco treatment metrics for tracking the provision of behavioral support and pharmacotherapy. Post-development, the tobacco treatment metrics were integrated into the registry for all future patients. We used means and frequencies to summarize tobacco treatment for cases treated between 2017 and 2019, coinciding with the timeframe of C3i participation. Of 17,735 cancer cases reviewed, both measures were captured on 17,654 (99.5%) of patients, with 3,091 (17.4%) identified as users of tobacco. Across the 3 years, 557 (18%) of individuals who used tobacco received either tobacco cessation pharmacotherapy or behavioral support; with 478 (15.5%) receiving behavioral counseling, 352 (11.4%) receiving pharmacotherapy, and 273 (8.8%) receiving both-considered gold standard care. Tobacco treatment varied substantially across cancer types. The odds of receiving gold standard care were 2.37 times greater in 2019 compared with 2017. (OR, 2.37; 95% confidence interval, 1.63-3.46; P < 0.0001). The new metrics demonstrated high completion rates and their potential to track quality improvement efforts over time. They identified suboptimal treatment reach, but a potential increase in treatment over time and greater treatment among tobacco-related versus nontobacco-related cancers. Continued tobacco use worsens cancer care outcomes. Integrating measures into cancer registries is a viable option for tracking tobacco treatment and cessation in the context of cancer care.

Determining the impact of cannabis use and severity on tobacco cessation outcomes: study protocol for a prospective tobacco treatment trial

BackgroundSeveral evidence-based tobacco cessation treatment strategies exist, though significant barriers to cessation remain which must be addressed to improve abstinence rates for sub-populations of those smoking cigarettes. Cannabis co-use among those who use tobacco is common and appears to be increasing among adults in the United States (US). The literature evaluating the impact of cannabis use on tobacco cessation has been mixed and has several important limitations, which precludes development of treatment recommendations specific to individuals who use tobacco and co-use cannabis. To date, no prospective studies have evaluated the impact of cannabis use and severity on tobacco cessation or quantified cannabis use changes during tobacco treatment to assess for concurrent reductions, abstinence, or compensatory (i.e., increased) cannabis use. This study’s aims are to: (1) evaluate tobacco cessation outcomes among participants who co-use cannabis compared to participants only using tobacco, (2) using daily diaries and biochemical verification, assess changes in cannabis use during tobacco treatment, and (3) assess for a dose-dependent impact of cannabis use on tobacco cessation.MethodA multi-site, prospective, quasi-experimental 12-week tobacco treatment trial enrolling treatment-seeking adults (ages 18–40; N = 208) from three sites across South Carolina (US) who use tobacco daily and oversampling (2:1) those who co-use cannabis. Participants receive tobacco cessation pharmacotherapy (varenicline) paired with behavioral support, while cannabis use is not addressed as part of treatment. The primary outcome is 7-day point prevalence tobacco abstinence at the week 12 end of treatment visit, measured via biochemical verification and self-report. Secondary outcome measures include changes in cannabis use (via biochemical verification and self-report) during tobacco cessation treatment.DiscussionResults from this trial have the potential to inform tobacco treatment among those co-using cannabis, which may require a tailored approach to address the role of cannabis in quitting tobacco.Trial registrationThe trial is registered with ClinicalTrials.gov: NCT04228965. January 14th, 2020.

Comparative clinical effectiveness and safety of tobacco cessation pharmacotherapies and electronic cigarettes: a systematic review and network meta-analysis of randomized controlled trials.

AimTo determine how varenicline, bupropion, nicotine replacement therapy (NRT) and electronic cigarettes compare with respect to their clinical effectiveness and safety.MethodSystematic reviews and Bayesian network meta‐analyses of randomized controlled trials, in any setting, of varenicline, bupropion, NRT and e‐cigarettes (in high, standard and low doses, alone or in combination) in adult smokers and smokeless tobacco users with follow‐up duration of 24 weeks or greater (effectiveness) or any duration (safety). Nine databases were searched until 19 February 2019. Primary outcomes were sustained tobacco abstinence and serious adverse events (SAEs). We estimated odds ratios (ORs) and treatment rankings and conducted meta‐regression to explore covariates.ResultsWe identified 363 trials for effectiveness and 355 for safety. Most monotherapies and combination therapies were more effective than placebo at helping participants to achieve sustained abstinence; the most effective of these, estimated with some imprecision, were varenicline standard [OR = 2.83, 95% credible interval (CrI) = 2.34–3.39] and varenicline standard + NRT standard (OR = 5.75, 95% CrI = 2.27–14.88). Estimates were higher in smokers receiving counselling than in those without and in studies with higher baseline nicotine dependence scores than in those with lower scores. Varenicline standard + NRT standard showed a high probability of being ranked best or second‐best. For safety, only bupropion at standard dose increased the odds of experiencing SAEs compared with placebo (OR = 1.27, 95% CrI = 1.04–1.58), and we found no evidence of effect modification.ConclusionsMost tobacco cessation monotherapies and combination therapies are more effective than placebo at helping participants to achieve sustained abstinence, with varenicline appearing to be most effective based on current evidence. There does not appear to be strong evidence of associations between most tobacco cessation pharmacotherapies and adverse events; however, the data are limited and there is a need for improved reporting of safety data.

Provider and clinical setting characteristics associated with tobacco pharmacotherapy dispensed in the Veterans Health Administration.

INTRODUCTIONWhile initiation rates of tobacco cessation pharmacotherapy have improved both inside and outside the Department of Veteran Affairs (VA), prescribing rates remain low. The objective of this study was to examine correlation of the characteristics of providers, clinics, and facilities with initiation of tobacco cessation pharmacotherapy.METHODSThis retrospective, observational study used VA outpatient electronic medical record data from federal fiscal year 2011. Logistic regression models estimated the adjusted odds ratio associated with provider characteristics for pharmacotherapy initiation.RESULTSFor the 639507 veterans who used tobacco, there were 30388 providers caring for them. Younger (p<0.001) and female (p<0.001) providers were more likely to initiate tobacco cessation pharmacotherapy. Compared to physicians, pharmacists were 74% more likely to initiate pharmacotherapy, while all groups of nurses were 5–8% and physicians’ assistants were 12% less likely (p<0.001). Compared to those seen in primary care clinics, patients assessed in substance use treatment clinics were 16% more likely to have pharmacotherapy initiated (p<0.001), while those in psychiatry were 10% less likely (p<0.001), and those in outpatient surgery were 39% less likely to initiate pharmacotherapy (p<0.001). Compared to almost all other classes of VA facilities, patients seen in primary care community-based outpatient clinics (CBOCs) were 7–28% more likely to initiate pharmacotherapy (p<0.0001).CONCLUSIONSWhile the VA is at the leading edge of providing tobacco cessation pharmacotherapy, targeting quality improvement efforts towards providers, clinics, and facilities with low prescribing rates will be essential to continue the declining rates of tobacco use among VA patients.

Multidisciplinary barriers to addressing tobacco cessation during an inpatient psychiatric hospitalization

Tobacco use and resultant health complications disproportionately impact individuals with psychiatric disorders. Inpatient psychiatric hospitalizations provide an opportunity to initiate tobacco treatment. In this study, electronic medical record review identified demographic and clinical information, smoking status, and tobacco cessation treatment offered for adults hospitalized on two acute, non-smoking psychiatric units in Massachusetts from January 2016 to March 2018. We additionally conducted semi-structured interviews with 15 inpatient nursing, psychiatry, psychology and social work providers regarding their tobacco cessation treatment practices and perceived facilitators and barriers to addressing tobacco use on psychiatric inpatient units. Chart review identified 1099 of 3140 (35%) people admitted reporting daily tobacco smoking. On discharge, 5 (0.005%) of inpatient smokers received a prescription for varenicline, 43 (0.04%) for dual-nicotine replacement therapy, 211 (19.2%) for nicotine patch, and 5 (0.005%) for bupropion. Barriers to inpatient smoking cessation treatment initiation identified in qualitative interviews included: 1) smoking cessation as low priority, 2) smoking cessation as the responsibility of outpatient providers, 3) lack of education about tobacco treatment, and 4) treatment discussions framed as preventing withdrawal. Given the potential to impact a large percentage of psychiatric tobacco users, future interventions should investigate provision of tobacco cessation counseling and pharmacotherapy in inpatient settings, with interventions that take into account the barriers and opportunities presented in this study.

Interventions to reduce tobacco use in people experiencing homelessness.

Interventions to reduce tobacco use in people experiencing homelessness.

Smoking and Nicotine Effects on Surgery: Is Nicotine Replacement Therapy (NRT) a Safe Option?

Smoking and Nicotine Effects on Surgery: Is Nicotine Replacement Therapy (NRT) a Safe Option?

Cost-effectiveness of real-world administration of tobacco pharmacotherapy in the United States Veterans Health Administration.

Cost-effectiveness studies in randomized clinical trials have shown that tobacco cessation pharmacotherapy is among the most cost-effective of health-care interventions. Clinical trial eligibility criteria and treatment protocols may not be followed in actual practice. This study aimed to determine whether tobacco cessation pharmacotherapy is cost-effective in real-world settings. A retrospective analysis of costs and outcomes. Hospitals and clinics of the US Veterans Health Administration, USA. A total of 589 862 US veterans who screened positive for tobacco use in 2011. Tobacco users who initiated smoking cessation pharmacotherapy in the 6months after screening were compared with those who did not use pharmacotherapy in this period. Pharmacotherapy included nicotine replacement therapy, bupropion (if prescribed at 300mg per day or specifically for tobacco cessation) or varenicline. Effectiveness was determined from responses to a subsequent tobacco screening conducted between 7 and 18months after the treatment observation period. Cost of medications and prescribing health-care encounters was determined for the period between initial and follow-up tobacco use screening. Multivariate fixed-effects regression was used to assess the effect of initial treatment status on cost and outcome while controlling for differences in case-mix with propensity weighting to adjust for confounding by indication. Thirteen per cent of participants received tobacco cessation pharmacotherapy within 6months of initial screening. After an average of an additional 218.1days' follow-up, those who initially received pharmacotherapy incurred $143.79 in additional treatment cost and had a 3.1% absolute increase in tobacco quit rates compared with those who were not initially treated. This represents an incremental cost-effectiveness ratio of $4705 per quit. The upper limit of the 99.9% confidence region was $5600 per quit. Without propensity adjustment, the cost-effectiveness ratio was $7144 per quit, with the upper limit of the 99.9% confidence region $9500/quit. Tobacco cessation pharmacotherapy provided by the US Veterans Health Administration in 2011/12 was cost-effective in this real-world setting, with an incremental cost-effectiveness ratio of $4705 per quit.

Evaluating the Impact of Eliminating Copayments for Tobacco Cessation Pharmacotherapy.

We examined the impact of the Affordable Care Act-mandated elimination of tobacco cessation pharmacotherapy (TCP) copayments on patient use of TCP, overall and by income. Electronic health record data captured any and combination (eg, nicotine gum plus patch) TCP use among adult smokers newly enrolled in Kaiser Permanente Northern California (KPNC). KPNC eliminated TCP copayments in 2015. We included current smokers newly enrolled in the first 6 months of 2014 (before copayment elimination, N=16,199) or 2015 (after elimination, N=16,469). Multivariable models estimated 1-year changes in rates of any TCP fill, and of combination TCP fill, and tested for differences by income (<$50k, $50≥75k, ≥$75k). Through telephone surveys in 2016 with a subset of smokers newly enrolled in 2014 (n=306), we assessed barriers to TCP use, with results stratified by income. Smokers enrolled in KPNC in 2015 versus 2014 were more likely to have a TCP fill (9.1% vs. 8.2%; relative risk, 1.19; 95% confidence interval, 1.11-1.27), and combination TCP fill, among those with any fill (42.3% vs. 37.9%; relative risk, 1.12; 95% confidence interval, 1.02-1.23); findings were stronger for low-income smokers. Low-income patients (<$50k) were less likely to report that clinicians discussed smoking treatments with them (58%) compared with higher income smokers ($50≥75k, 67%; ≥$75k, 83%), and were less aware that TCP was free (40% vs. 53% and 69%, respectively, P-values<0.05). The Affordable Care Act's copayment elimination was associated with a modest increase in TCP use and a greater effect among low-income smokers. Uptake may have been enhanced if promoted to patients directly and via providers.

Effectiveness of tobacco cessation pharmacotherapy in the Veterans Health Administration

IntroductionIn 2003, the Veterans Health Administration (VHA) implemented a directive that cessation pharmacotherapy be made available to all who use tobacco and are interested in quitting. Despite the efficacy of...

Tobacco Use in Adults With Mental Illness: An Overview of One State-Wide Tobacco Cessation Program

Even though one of the public health's top achievements of the 20th century involves tobacco cessation, a disproportionate burden of tobacco-related comorbidity still affects those with mental illness (Centers for Disease Control and Prevention, 2017; Cook et al., 2014). There is evidence suggesting that psychiatric disorders are associated with an increased prevalence in cigarette smoking (Tsoi, Porwa, &amp; Webster, 2013). One explanation for this is the potentiating effect of nicotine on dopamine receptors (Mao, Gallagher, &amp; McGehee, 2011). Other explanations include poverty, educational advancement and industry bias in tobacco marketing (MMWR Vital Signs: Current Cigarette, 2016; CDC Morbidity and Mortality, 2013). We know that adults with mental illness smoke at rates twice that of the general population, and are nicotine-dependent at rates up to three times higher than the general population (Cook et al., 2014; Grant, Hasin, Chou, Stinson, &amp; Dawson, 2004). Adults with mental illness comprise about 19% of the population, but smoke approximately one-third of all the cigarettes smoked (MMWR Vital Signs: Current Cigarette, 2016). In the United States, the national tobacco use prevalence is estimated at 19%; however, prevalence among those with bipolar disorder is 51%–70% and 36%–80% among those with major depressive disorder (Grant et al., 2004; King, Dube, &amp; Tynan, 2012; Lasser et al., 2000). Despite these high rates, recent studies suggest that smokers with mental illness are highly motivated to quit (Cook et al., 2014). However, it remains rare for mental and behavioural health professionals to offer tobacco cessation pharmacotherapy and counselling to clients with psychiatric disorders.

Tobacco cessation pharmacotherapy use among racial/ethnic minorities in the United States: Considerations for primary care

Pharmacotherapies for tobacco cessation are efficacious and recommended during quit attempts. Racial/ethnic minorities in the United States are less likely to use medication-based aids for tobacco cessation, despite greater difficulty achieving long-term abstinence. The reasons for this include, among others, provider- and patient-level considerations. Primary care clinicians play an important role in encouraging racial/ethnic minority tobacco users to use cessation pharmacotherapy. To better understand pharmacotherapy use, we conducted a narrative review of patient-level factors that may determine uptake and adherence. This review indicates that social and cultural factors impact pharmacotherapy use, including health care experiences, beliefs, perceptions, and norms. The proportion of individuals using pharmacotherapy during quit attempts and adhering to the full course of treatment may be enhanced with greater attention to the ethnocultural concerns of these groups. Culturally appropriate assessment and brief advice delivered by primary care providers could yield significant benefits in population health. Recommendations for treating racial/ethnic tobacco users with pharmacotherapy for cessation are offered.

A Mixed Method Review of Tobacco Cessation for the Cardiopulmonary Rehabilitation Clinician.

To systematically survey the literature, describe the current tobacco science, and perform a mixed method review of randomized control trials of tobacco research in the cardiopulmonary population. Mixed method review was conducted on major resource databases. Inclusion criteria were English language with a minimum follow-up of 6 months, published between January 1, 2007, and June 30, 2016; adult smokers ≥18 years of age with cardiovascular and/or pulmonary disease; initiation of subject recruitment from hospital or community; tobacco cessation (TC) as the main aim of the study; biometric validation of smoking status; first-line TC medications; and nonpharmacological treatments. The pooling of the 10 studies through forest plot analysis revealed the effect of tobacco continuous abstinence rates significant at 3, 6, and 12 months (total OR = 3.73; 95% CI, 2.58-5.38). Also, tobacco point prevalence rates of TC treatments demonstrated overall effects that were significant at the different end points (total OR = 2.63; 95% CI, 1.90-3.64). In both cases, the higher ORs were found in the 3 months end point. Most successful interventions consisted of a combination of pharmacological and nonpharmacological therapy (predominantly counseling). The evidence continues to support the recommended first-line TC pharmacotherapy and nonpharmacological practices published in the 2008 national guidelines. Implications for cardiopulmonary rehabilitation clinicians are discussed.

Availability of tobacco cessation services in substance use disorder treatment programs: Impact of state tobacco control policy

ObjectiveGiven the high prevalence of smoking among substance use disorder (SUD) patients, the specialty SUD treatment system is an important target for adoption and implementation of tobacco cessation (TC) services. While research has addressed the impact of tobacco control on individual tobacco consumption, largely overlooked in the literature is the potential impact of state tobacco control policies on availability of services for tobacco cessation. This paper examines the association between state tobacco control policy and availability of TC services in SUD treatment programs in the United States. MethodsState tobacco control and state demographic data (n=51) were merged with treatment program data from the 2012 National Survey of Substance Abuse Treatment Services (n=10.413) to examine availability of TC screening, counseling and pharmacotherapy services in SUD treatment programs using multivariate logistic regression models clustered at the state-level. ResultsApproximately 60% of SUD treatment programs offered TC screening services, 41% offered TC counseling services and 26% offered TC pharmacotherapy services. Results of multivariate logistic regression showed the odds of offering TC services were greater for SUD treatment programs located in states with higher cigarette excise taxes and greater spending on tobacco prevention and control. ConclusionsFindings indicate cigarette excise taxes and recommended funding levels may be effective policy tools for increasing access to TC services in SUD treatment programs. Coupled with changes to insurance coverage for TC under the Affordable Care Act, state tobacco control policy tools may further reduce tobacco use in the United States.

Interventions for tobacco use cessation in people in treatment for or recovery from substance use disorders.

Smoking rates in people with alcohol and other drug dependencies are two to four times those of the general population. Concurrent treatment of tobacco dependence has been limited due to concern that these interventions are not successful in this population or that recovery from other addictions could be compromised if tobacco cessation was combined with other drug dependency treatment. To evaluate whether interventions for tobacco cessation are associated with tobacco abstinence for people in concurrent treatment for or in recovery from alcohol and other drug dependence. We searched the Cochrane Tobacco Addiction Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and clinicaltrials.gov databases, with the most recent search completed in August 2016. A grey literature search of conference abstracts from the Society on Nicotine Research and Treatment and the ProQuest database of digital dissertations yielded one additional study, which was excluded. We included randomised controlled trials assessing tobacco cessation interventions among people in concurrent treatment for alcohol or other drug dependence or in outpatient recovery programmes. Two review authors independently assessed study risk of bias and extracted data. We resolved disagreements by consensus. The primary outcome was abstinence from tobacco use at the longest period of follow-up, and the secondary outcome was abstinence from alcohol or other drugs, or both. We reported the strictest definition of abstinence. We summarised effects as risk ratios and 95% confidence intervals (CI). Two clustered studies did not provide intraclass correlation coefficients, and were excluded from the sensitivity analysis. We used the I2 statistic to assess heterogeneity. Thirty-five randomised controlled trials, one ongoing, involving 5796 participants met the criteria for inclusion in this review. Included studies assessed the efficacy of tobacco cessation interventions, including counselling, and pharmacotherapy consisting of nicotine replacement therapy (NRT) or non-NRT, or the two combined, in both inpatient and outpatient settings for participants in treatment and in recovery. Most studies did not report information to assess the risk of allocation, selection, and attrition bias, and were classified as unclear.Analyses considered the nature of the intervention, whether participants were in treatment or recovery and the type of dependency. Of the 34 studies included in the meta-analysis, 11 assessed counselling, 11 assessed pharmacotherapy, and 12 assessed counselling in combination with pharmacotherapy, compared to usual care or no intervention. Tobacco cessation interventions were significantly associated with tobacco abstinence for two types of interventions. Pharmacotherapy appeared to increase tobacco abstinence (RR 1.60, 95% CI 1.22 to 2.12, 11 studies, 1808 participants, low quality evidence), as did combined counselling and pharmacotherapy (RR 1.74, 95% CI 1.39 to 2.18, 12 studies, 2229 participants, low quality evidence) at the period of longest follow-up, which ranged from six weeks to 18 months. There was moderate evidence of heterogeneity (I2 = 56% with pharmacotherapy and 43% with counselling plus pharmacotherapy). Counselling interventions did not significantly increase tobacco abstinence (RR 1.33, 95% CI 0.90 to 1.95).Interventions were significantly associated with tobacco abstinence for both people in treatment (RR 1.99, 95% CI 1.59 to 2.50) and people in recovery (RR 1.33, 95% CI 1.06 to 1.67), and for people with alcohol dependence (RR 1.47, 95% CI 1.20 to 1.81) and people with other drug dependencies (RR 1.85, 95% CI 1.43 to 2.40).Offering tobacco cessation therapy to people in treatment or recovery for other drug dependence was not associated with a difference in abstinence rates from alcohol and other drugs (RR 0.97, 95% CI 0.91 to 1.03, 11 studies, 2231 participants, moderate evidence of heterogeneity (I2 = 66%)).Data on adverse effect of the interventions were limited. The studies included in this review suggest that providing tobacco cessation interventions targeted to smokers in treatment and recovery for alcohol and other drug dependencies increases tobacco abstinence. There was no evidence that providing interventions for tobacco cessation affected abstinence from alcohol and other drugs. The association between tobacco cessation interventions and tobacco abstinence was consistent for both pharmacotherapy and combined counselling and pharmacotherapy, for participants both in treatment and in recovery, and for people with alcohol dependency or other drug dependency. The evidence for the interventions was low quality due primarily to incomplete reporting of the risks of bias and clinical heterogeneity in the nature of treatment. Certain results were sensitive to the length of follow-up or the type of pharmacotherapy, suggesting that further research is warranted regarding whether tobacco cessation interventions are associated with tobacco abstinence for people in recovery, and the outcomes associated with NRT versus non-NRT or combined pharmacotherapy. Overall, the results suggest that tobacco cessation interventions incorporating pharmacotherapy should be incorporated into clinical practice to reduce tobacco addiction among people in treatment for or recovery from alcohol and other drug dependence.

High-Risk Smoking Behaviors and Barriers to Smoking Cessation Among Homeless Individuals.

Although tobacco practices and the effects of tobacco use among the general American population are well described, minimal data exist regarding tobacco use and barriers to smoking cessation among homeless individuals. Anonymous, voluntary surveys based on a previously implemented instrument were completed by 100 smoking individuals residing at a homeless shelter. These surveys assessed high-risk smoking behaviors and respondents' perceived barriers to long-term smoking cessation. Ninety percent of study participants reported engaging in at least one of the high-risk tobacco practices. Nicotine replacement therapy was perceived by respondents to be the most desired form of smoking cessation aid. Excessive stress with use of tobacco smoking to alleviate stress and anxiety was the most significant self-perceived barrier to smoking cessation. High-risk tobacco practices are remarkably common among smoking homeless individuals. Despite literature consistently showing that non-nicotine tobacco cessation pharmacotherapies (varenicline, buproprion) have higher smoking cessation rates, nicotine replacement monotherapy was perceived as more valuable by survey respondents. Although lack of financial resources was expected to be the biggest barrier to successful cessation, social stressors and the use of smoking to cope with homelessness were perceived as a greater obstacle in this cohort. Given the paucity of data on the long-term effects of the high-risk tobacco behaviors reported by these homeless smokers, this study highlights the need for further investigations regarding tobacco use and tobacco cessation in this vulnerable population.

The Contribution of Tobacco Use to High Health Care Utilization and Medical Costs in Peripheral Artery Disease: A State-Based Cohort Analysis

BackgroundTobacco use is an important preventable cause of peripheral artery disease (PAD) and a major determinant of adverse clinical outcomes. ObjectivesThis study hypothesized that tobacco use by PAD patients would be associated with higher health care utilization and associated costs. MethodsWe conducted a retrospective, cross-sectional study using 2011 claims data from the largest Minnesota health plan. The total cohort included individuals with 12 months of continuous enrollment and ≥1 PAD-related claim. Tobacco cessation pharmacotherapy billing codes were queried in a subgroup with pharmacy benefits. Outcomes were total costs, annual proportion of members hospitalized, and primary discharge diagnoses. ResultsA PAD cohort of 22,203 was identified, comprising 1,995 (9.0%) tobacco users. A subgroup of 9,027 with pharmacy benefits included 1,158 (12.8%) tobacco users. The total cohort experienced 22,220 admissions. The pharmacy benefits subgroup experienced 8,152 admissions. Within 1 year, nearly one-half the PAD tobacco users were hospitalized, 35% higher than nonusers in the total cohort (p < 0.001) and 30% higher in the subgroup (p < 0.001). In both cohorts, users were more frequently admitted for peripheral or visceral atherosclerosis (p < 0.001), acute myocardial infarction (p < 0.001), and coronary heart disease (p < 0.05). Observed costs in the total cohort were $64,041 for tobacco users versus $45,918 for nonusers. Costs for tobacco users also were consistently higher for professional and facility-based care, persisting after adjustment for age, sex, comorbidities, and insurance type. ConclusionsTobacco use in PAD is associated with substantial increases in PAD-related hospitalizations, coronary heart disease and PAD procedures, and significantly greater costs. The results suggest that immediate provision of tobacco cessation programs may be especially cost effective.

Substance Use Disorder Counselors' Reports of Tobacco Cessation Services Availability, Implementation, and Tobacco-related Knowledge

PurposeAdolescence is a prime developmental stage for early tobacco cessation (TC) intervention. This study examined substance use disorder counselors' reports of the availability and implementation of TC services (behavioral treatments and pharmacotherapies) in their treatment programs and the relationship between their tobacco-related knowledge and implementation of TC services. MethodsSurvey data were collected in 2012 from 63 counselors working in 22 adolescent-only treatment programs. Measures included 15 TC behavioral treatments, nine TC pharmacotherapies, and three tobacco-related knowledge scales (morbidity/mortality, modalities and effectiveness, pharmacology). ResultsFirst, nine of the 15 behavioral treatments are reported as being available by more than half of counselors; four of the 15 behavioral treatments are used by counselors with more than half of adolescents. Of the nine pharmacotherapies, availability of the nicotine patch is reported by almost 40%, buproprion by nearly 30%, and clonidine by about 21% of counselors. Pharmacotherapies are used by counselors with very few adolescents. Second, counselors' tobacco-related knowledge varies based on the knowledge scale examined. Third, we only find a significant positive relationship between counselors' implementation of TC behavioral treatments and TC modalities and effectiveness knowledge. DiscussionFindings suggest that more behavioral treatments should be made available in substance use disorder treatment programs considering that they are the main treatment recommendation for adolescents. Counselors should be encouraged to routinely use a wide range of available behavioral treatments. Finally, counselors should be encouraged to expand their knowledge of TC modalities and effectiveness because of the relationship with behavioral treatments implementation.

Defining and predicting short-term alcohol use changes during a smoking cessation attempt

IntroductionAlcohol and nicotine are commonly used substances in the U.S., with significant impacts on health. Using both substances concurrently impacts quit attempts. While studies have sought to examine changes in alcohol use co-occurring with tobacco cessation, results have not been consistent. Understanding these changes has clinical implications. The objective of this study is to identify changes in alcohol consumption that occur following tobacco cessation, as well as predictors of alcohol use patterns following a smoking cessation attempt. MethodsA secondary analysis of a randomized, placebo-controlled trial evaluating the efficacy of five tobacco cessation pharmacotherapies. Participants (N=1301) reported their smoking and alcohol consumption daily for two weeks prior to, and two weeks after, the target quit date (TQD). ResultsGenerally, alcohol use decreased post-TQD. Smokers who reported less pre-quit alcohol use, as well as smokers who were female, non-white, and had a history of alcohol dependence tended to use less alcohol post-quit. Pre- and post-quit alcohol use were more strongly related among men and among those without a history of alcohol dependence. ConclusionsFor most smokers alcohol use decreased following smoking cessation. These results suggest that the expectation should be of decreased alcohol use post cessation. However, attention may be warranted for those who drink higher amounts of alcohol pre-cessation because they may be more likely to drink more in the post-quit period which may influence smoking cessation success.

Relationship between Low-Income Patient Census and Substance Use Disorder Treatment Programs' Availability of Tobacco Cessation Services.

Low income adults with substance use disorders (SUDs) have a high prevalence of tobacco use and often limited access to tobacco cessation treatment. This study examines the relationship between low-income SUD patient census (i.e., percentage of patients whose treatment costs are covered by Medicaid and Federal block grants) and SUD programs' availability of three evidence-based tobacco cessation services: behavioral treatments, system-level support, and pharmacotherapy. Data were collected from a random sample of 1,006 program administrators in 2010. Mixed-effects models results show that the percentage of low-income patients is significantly positively associated with the availability of behavioral treatments and system-level support but not pharmacotherapy. Thus, low-income patients may have similar access to tobacco cessation pharmacotherapy but greater access to behavioral treatments and system-level support. However, the availability of tobacco cessation services is not widespread overall, which may hamper access to extensive services to address low-income SUD patients' high smoking rates.