1. The University of Georgia Smoking Cessation Programs in Addiction Treatment Centers: An Organizational Analysis Hannah K. Knudsen, Ph.D. Lori J. Ducharme, Ph.D. Paul M. Roman, Ph.D.

2. The University of Georgia Nicotine Dependence: A Co-Occurring Condition in Substance Abuse Treatment Rates of cigarette smoking among individuals seeking substance abuse treatment far exceed the general population –General public = 22.5% –Treatment-seeking > 70% Treatment-seekers who smoke are at greater risk of negative health consequences due to greater cigarette consumption per day Tobacco-related illnesses are a major factor in the increased likelihood of premature death among individuals treated for substance use disorders

3. The University of Georgia Smoking Cessation Programs in Substance Abuse Treatment Traditionally, smoking cessation has been viewed as outside the purview of treatment providers –Fears of increased risk of treatment dropout & relapse Recent research indicates such fears may be unfounded –Smoking cessation does not worsen SUD treatment outcomes –It may improve outcomes & reduce the risk of relapse Clinical practice guideline issued by the Public Health Service advocates the delivery of smoking cessation services during treatment

4. The University of Georgia Availability of Smoking Cessation Programs The assumption remains that specialty SUD treatment programs do not offer smoking cessation This claim is difficult to test because of absence of national data –SAMHSA’s N-SSATS survey of treatment providers does not collect this information Even less is known about whether centers that offer smoking cessation are relying on psycho-social techniques or have integrated medications into these programs

5. The University of Georgia Research Questions To what extent have community-based addiction treatment programs adopted smoking cessation (SC) programs? What organizational characteristics are associated with the presence of SC programs? To what extent do SC programs include the use of SC medications?

6. The University of Georgia Methods Data from the National Treatment Center Study –Community-based addiction treatment centers –Must offer a minimum of outpatient care (as defined by ASAM) Two nationally representative samples –Publicly funded centers (n = 363): > 50% of revenues from government block grants/contracts  Response rate = 80% –Privately funded centers (n = 401): <50% of revenues from government block grants/contracts  Response rate = 88% Data collected via face-to-face interviews with administrators and/or clinical directors Complete data from n = 704

7. The University of Georgia Measures: Smoking Cessation Programming Availability of SC Programs –1 = yes, 0 = no Adoption of SC Medications by SC Programs –Nicotine replacement therapy (patch, gum) –Bupropion-SR (i.e. Zyban®)

8. The University of Georgia Measures: Organizational Characteristics Center type: –Government-owned –Publicly funded non-profit –For-profit –Privately funded non-profit (reference category) Organizational affiliation: –Hospital-based –Community mental health center –Freestanding (reference category) Size: natural log-transformed number of employees Age: natural log-transformed years Accreditation: center is accredited by JCAHO or CARF

9. The University of Georgia Measures: Staffing & Services Physician Services: –Physicians on staff –Physicians on contract –No access to physicians (reference category) Levels of care: –Inpatient/Residential-only –Outpatient-only (reference category) –Mixed levels of care 12-Step Treatment Model: 1 = yes, 0 = no Use of the ASAM PPC: 1 = yes, 0 = no Use of the Addiction Severity Index (ASI): 1 = yes, 0 = no

10. The University of Georgia Availability of Smoking Cessation Programs

11. The University of Georgia Results: Availability of SC Programs The majority of addiction treatment centers do not have SC programs About 32.2% have SC programs

12. The University of Georgia SC Programs by Center Type There was significant variation in availability of SC programs by center type (  2 = 8.82, p<.05) Government-owned centers significantly more likely to offer smoking cessation programs than: –Publicly funded non-profit centers (O.R. =.58, p<.05) –For-profit centers (O.R. =.42, p<.01)

13. The University of Georgia Logistic Regression of Availability of Smoking Cessation Programs Logistic regression used to estimate the likelihood of SC programs by: –Center type –Organizational characteristics –Staffing and services Center type differences persist after controlling for other organization-level measures –SC programs less likely in publicly funded non-profits (vs. government-owned, O.R. =.59, p<.05) –SC programs less likely in for-profits (vs. government- owned, O.R. =.48, p<.05)

14. The University of Georgia The Use of Standardized Criteria and Smoking Cessation Programs Centers that have adopted the ASAM-PPC were significantly more likely to offer smoking cessation, net of the other variables –O.R.= 1.69, p<.01 Centers that use the Addiction Severity Index (ASI) were more likely to offer smoking cessation –O.R. = 1.58, p<.05

15. The University of Georgia Other Predictors of Smoking Cessation Programming Organizational affiliation was associated with the availability of SC programs –Compared to freestanding programs, centers affiliated with community mental health centers were less likely to offer SC programs (O.R. =.38, p<.05) –No difference between freestanding and hospital- based centers There was a trend (p<.10) for larger centers being more likely to offer smoking cessation programs

16. The University of Georgia Organization-Level Measures NOT Associated with SC Program Availability Center age Access to physicians Center accreditation by JCAHO or CARF Levels of care 12-Step treatment philosophy

17. The University of Georgia Adoption of Medications in Smoking Cessation Programs

18. The University of Georgia Medications in Smoking Cessation Programs Among centers with smoking cessation programs, there may be variability in the adoption of medications –Nicotine replacement therapies have the advantage of being OTC –Bupropion-SR (Zyban®) by prescription Little is known about whether these programs have integrated medications into their smoking cessation treatment protocols

19. The University of Georgia Adoption of SC Medications (n = 222 centers offering smoking cessation programs)

20. The University of Georgia Medications by Center Type Compared to privately funded non-profits: –Government-owned SC programs are less likely to have adopted bupropion & nicotine gum –Publicly funded non-profits SC programs were less likely to have adopted all three medications –For-profit SC programs were less likely to have adopted nicotine gum

21. The University of Georgia Adoption of Any Medications by Center Type The only significant difference is between privately funded non-profits and publicly funded non-profits

22. The University of Georgia Multivariate Model of Medication Adoption Same set of independent variables as model of SC programs Logistic regression of “any adoption” The difference between public and private non-profits is no longer significant once other variables are controlled Other significant variables: –Access to physicians on staff (O.R. = 2.89, p<.05) or physicians on contract (O.R. = 2.52, p<.05) –Inpatient/residential-only SC programs were more likely to have adopted medications than outpatient-only programs (O.R. = 4.44, p<.01)

23. The University of Georgia Summary About one-third of substance abuse treatment centers offer smoking cessation programs Of these centers with SC programs, the majority (65.5%) have adopted some type of SC-related medications –There is variation in adoption rates of specific SC-related medications, with nicotine patch adoption being the most widely adopted

24. The University of Georgia Summary (continued) Smoking cessation programs were more common in centers that: –Use the ASAM-PPC –Use the ASI Although levels of care were not associated with the probability of SC program availability, inpatient/residential-only centers were more likely to use medications within their SC programs than outpatient-only centers Physician resources were not associated the SC program availability, but were associated with medication adoption within those programs

25. The University of Georgia Future Research Directions Additional data collection on the implementation of the PHS clinical practice guideline for smoking cessation –Assessment of smoking status at intake –Brief interventions –Counseling approaches to smoking cessation –Use of pharmacotherapies Data collected at the center-level and from individual counselors

26. The University of Georgia The authors gratefully acknowledge the support of research funding from the National Institute on Drug Abuse (R01- DA-14482 and R01-DA-13110). This presentation and other reports from the National Treatment Center Study are available at http://www.uga.edu/ntcs