1. Changing organisational systems to address tobacco dependence in drug and alcohol treatment centres Billie Bonevski Cancer Institute NSW Research Fellow University of Newcastle, Australia

2. The team University of Newcastle: Amanda Wilson, Flora Tzelepis, Chris Paul, Jamie Bryant, Andrew Searle Hunter New England Health: Adrian Dunlop National Drug and Alcohol Research Centre (NDARC): Anthony Shakeshaft, Michael Farrell, Richard Mattick Cancer Council NSW: Scott Walsberger, Phil Hull, Jon O’Brien University of Wollongong: Pete Kelly London: John Strang, Ann McNeill US: Judith Prochaska 2

3. Overview Part 1 – Myth Busting Part 2 – What is current practice Part 3 – What can we do Part 4 – How do we do it 3

4. Why address smoking amongst drug and alcohol (D&A) treatment clients? 4

5. Myth No 1: “Tobacco is not a health priority for this population. Other drugs are more important/deadly/more harmful” 5

6. Hospital admissions in Canada 6 Single et al, 2000

7. Annual drug-related deaths in the US 7 Centre for Disease Control, 2008, 2004, 2007

8. Tobacco-related deaths within Australia compared with other causes Begg et al., 2007 8 Begg et al, 2007

9. Drug related deaths in Australia (2004/05) Begg et al., 2007 9 Collins DJ, Lapsley HM. DoHA; 2008.

10. Smoking rates in D&A treatment populations 10

11. Myth No 2: “Tobacco smoking is a necessary self- medication” 11

12. Tobacco is part of the problem not the solution Perpetuated by the tobacco industry Mental illness Stress, coping, stabilise mood etc Nicotine reward system 12

13. Nicotine dependence Physiological addictionBehavioural habit Triggers the release of dopamineFrequency and immediacy of reinforcement firmly cements a behavioural cluster Positive affect – brain reward system 1 pack/day = 200/day hand to mouth rituals De-activation leads to withdrawal (cravings) Social acceptability increases range and number of triggers Limited effect on lifestyle 13

14. Myth No 3: “Addicts are not interested in quitting smoking” 14

15. Australian D&A clients are interested to quit N = 228 smokers in residential D&A treatment 75% had tried quitting in the past 67% were ‘seriously thinking about quitting’ Kelly et al, 2012 15

16. Methadone maintained clients interest in quitting N = 103 OTP clients in two clinics in Australia 84% current smokers 56% previous quit attempt 38% thinking of quitting ‘next 6 months’ Would like help with quitting – 36% said Yes and 31% were Unsure 80% were heavy nicotine dependence 16 Bowman et al 2011

17. Myth No 4: “Drug and alcohol clients are unable to quit smoking” 17

18. Smoking cessation offered during D&A treatment is effective 18 A Meta-Analysis of Smoking Cessation Interventions With Individuals in Substance Abuse Treatment or Recovery. Prochaska, Judith; Delucchi, Kevin; Hall, Sharon Journal of Consulting & Clinical Psychology. 72(6):1144- 1156, December 2004. Significant two-fold increase in the likelihood of smoking abstinence among intervention versus control participants

19. Myth No 5: “Addressing smoking compromises other treatment outcomes” 19

20. Alcohol and illicit drug abstinence following smoking cessation intervention 20 A Meta-Analysis of Smoking Cessation Interventions With Individuals in Substance Abuse Treatment or Recovery. Prochaska, Judith; Delucchi, Kevin; Hall, Sharon Journal of Consulting & Clinical Psychology. 72(6):1144- 1156, December 2004. Significant increase of 25% in the likelihood of abstinence from drugs and alcohol among participants receiving a smoking cessation intervention relative to participants in the control condition.

21. How is smoking currently treated within the drug and alcohol sector? 21

22. Clinically recommended Tobacco dependence is: ‘a chronic disease with remission and relapse’ “Nicotine dependence warrants medical treatment as does any drug dependence disorder or chronic disease” Fiore et al, U.S. Dept of Health and Human Services, June 2000 22

23. 23

24. Is smoking cessation care provided to D&A treatment clients? National survey of D&A agencies (n =260 agencies: 213 managers and/or 204 other staff) –23-25% said they had a written smoke-free policy –80-83% indicated delivery of smoking support was left to the discretion of individual staff - ie, not routinely and systematically provided 24 Walsh et al, 2006

25. D&A treatment centres smoking cessation care practices Statement% of clients receiving Smoking status recorded65 Recommendation to quit36 Counselling on behavioural methods26 Attempt to negotiate quit date17 Recommendation to use NRT20 Referral to stop smoking group16 Follow-up discussion27 Bonevski et al., 2012, under review 25 Walsh et al, 2006

26. Barriers to the provision of smoking cessation care in D&A setting Staff smoking status 1 Lack of training 1,2,3 Resistance to smoke-free policies 1,3 Limited resources, eg, cost of NRT 1 Lack of coordinated staff approach (no system!) 2 Lack of staff time 2 Lack of confidence 2,3 Pessimism regarding effectiveness of smoking cessation interventions 2 Misperceptions – eg, “tobacco is not a real drug”, “its too difficult to address tobacco and other dependencies”, “clients don’t want to quit” 1,2,3 26 1 Zeidonis, Guydish, 2006; 2 Walsh, Bowman et al 2005; 3 Baca et al, 2008

27. Attitudes of managers and staff toward smoking interventions (strongly agree/agree) Walsh et al 2006 27 % Provision of smoking cessation interventions should be an integral function of this agency 65 Smoking clients of this agency should receive smoking cessation interventions tailored to their readiness to quit 86 Smoking cessation counselling is as important as counselling about other drugs for clients of this agency 53 Increasing restrictions on smoking and greater provision of smoking interventions would have very little impact on client attendance at this agency 47 Most drug and alcohol clients who smoke are not interested in doing anything about their smoking 64 Clients of this agency usually have enough other problems without worrying about smoking 58 Occasionally it is useful for staff to smoke with a client in an effort to build rapport/trust 15

28. What can we do - Menu of support Brief Advice 5As (ASK, ADVISE, ASSESS, ASSIST, ARRANGE) Motivational Interviewing Behavioural Counselling Pharmacotherapy (NRT gum, patches, inhaler, lozenges), buproprion Quitline Follow-up Referral to other stop smoking services 28 Heavily addicted!! Best to throw everything at them!

29. How to integrate this into usual care provision in drug and alcohol services? 29

30. What is a systems based strategy? Six Core Components 1.Implement a system of identifying and recording smoking status 2.Equip staff with education, resources and feedback 3.Dedicate staff to tobacco dependence treatment 4.Organisational policies 5.Provide tobacco dependence treatments as part of service (pharmaco and behavioural) 6.Defined duties of care 30 (Fiore et al, Zeidonis et al)

31. How technology can be used Touchscreen computers –Highly acceptable to clients –Accurate –Assesses smoking status, nicotine dependence, quit attempts –Print-out for client files –Education for staff and clients –Ongoing monitoring and improvement 31 Shakeshaft et al, 1999, Bonevski et al, 2010, Bryant et al 2012

32. Advantages of a systems based strategy Integration of smoking cessation support provision in routine care Aim to build capacity of the organisation to address smoking De-normalisation of smoking within the setting Based on systems - sustainable model in the long term 32

33. Is it effective at reducing smoking? Pilot studies have found –Improves staff attitudes score regarding smoking –Increases distribution of NRT –Increases provision of behavioural cessation support The potential is evident Well designed trials needed 33 Guydish, 2010, 2012; Zeidonis 2007

34. Trial of system change intervention in drug and alcohol setting (NHMRC:2013-16) 34 30 Drug & Alcohol Treatment Centres in QLD, NSW & Vic randomised to: 15 Drug & Alcohol centres in intervention group: Touchscreen survey and print out Staff training Organisational policies NRT Follow-up 15 Drug & Alcohol centres in control group: usual care Outcomes at 6 months: Cessation Quit attempts Smoking care provision

35. CRICOS Provider 00109J | www.newcastle.edu.au THANK YOU Funding: Cancer Council NSW Cancer Institute NSW NHMRC University of Newcastle HMRI Contact me on: Billie.bonevski@newcastle.edu.au or ph: 02 40335710 35