1 Smoking cessation treatment for people with alcohol and substance use disorder University College London June 2013 Robert West

The big question Should people attending drug and alcohol treatment services routinely be offered support for quitting smoking? No because : The gains of stopping are too small There’s not enough demand It won’t work It will worsen their other problems It’s not practicable Yes because : The benefits are significant Many clients would take it up Many will stop smoking as a result It may mitigate their other problems It can be made to work 2

Outline 3

Benefit of stopping smoking: smokers in general 4

Benefits of stopping smoking 5 Doll et al 2004 BMJ

Benefits of stopping smoking: A/SUD 1 smokers 6 1 Alcohol or substance use disorder

Quitting: smokers in general 7

Rapid review: search strategy Pubmed Web of Science Google Scholar Sources Alcohol or substance Use disorder Smoking cessation Search terms Prevalence Efficacy and implementation Effects Selection 8

Quitting: A/SUD smokers StudyFinding Bobo 1988 Add Beh People with more severe AUD appear to be less likely to be successful at stopping smoking when they try Covey 1993 Am J Psychiatry Recovering alcoholics appear to have equal success at stopping smoking as other smokers but AUD with depression appears to be associated with lower success rates Martin 1997 J Cons Cl Psy Recovering alcoholics appear to have equal success at stopping smoking as other smokers 9

Quitting: A/SUD smokers StudyFinding Marks 1997 J Subs Ab Treat Nicotine dependence is greater in smokers with AUD Hays 1999 Ann Beh Med Past and current AUD appears to be associated with lower chances of short-term success at stopping in smokers treated with NRT Dawson 2000 Drug Alc Dep People with AUD are less likely than those without to stop smoking 10

Quitting: A/SUD smokers StudyFinding Kalman 2001 J Subs Abuse Treat Success rates appear very low in smokers undergoing inpatient treatment for AUD treated with limited behavioural support and NRT, whether treatment is started immediately or delayed Karam-Hage 2005 Addict Beh Stopping smoking unaided following treatment for AUD is not uncommon and is more likely in those who were abstinent from alcohol at the end of treatment Richter 2005 J Addict Dis Long-term smoking abstinence rates may be reasonable after motivational interviewing and pharmacological treatment for smoking cessation in SUD patients 11

Quitting: A/SUD smokers StudyFinding Agosti 2009 Soc Psychiat Psychiat Epid Remission from A/SUD is associated with higher rate of smoking cessation MacKillop 2009 Drug & Alc Dep Delayed reward discounting predicts worse smoking cessation treatment outcome in heavy drinking smokers Kahler 2010 N&TR Among heavy drinkers in cessation treatment, even moderate alcohol use is associated with increased risk of smoking, with heavy drinking further increasing the risk 12

Quitting: A/SUD smokers StudyFinding Sonne 2010 Am J Add In treatment seeking substance users, baseline depression is associated with lower smoking abstinence rates following smoking cessation treatment Hays 2011 J Subs Abuse Treatment Long-term smoking abstinence rates in recovering alcoholics given behavioural support plus varenicline may be similar to other patient groups Khara 2011 Am J Addict SUD treatment clients may succeed in stopping at rates similar to general population of smokers if given intensive tobacco dependence treatment 13

Interest in taking up offer of help: smokers in general 14

Brief physician advice 15

Brief advice: efficacy 16 Stead et al 2008, Cochrane Very brief advice: N=13,724 More extensive advice: N=1,254 95% confidence intervals from meta-analyses Aveyard et al 2012, Addiction Advice only increased quit attempts by 24% (95% CI: 16-33%) Offering behavioural support increased quit attempts by 117% (95% CI: %) Offering prescription increased quit attempts by 68% (95%CI: 48-89%)

Response to brief GP offer by social grade 17 Source: Smoking Toolkit Study N=3,311

Response to brief GP offer by age 18 Source: Smoking Toolkit Study N=3,311, p=0.02 for difference

Interest in stopping smoking in A/SUD StudyFinding Ellingstad 1999 Drug Alc Dep A majority of smokers in treatment for AUD would probably be interested in help with stopping either during or after AUD treatment Clarke 2001 Am J Addict There is at least a moderate level of interest in stopping smoking in injecting drug users, more so in those who are older, engaged in methadone maintenance programmes and without AUD Stotts 2003 Drug Alc Dep 24 1 Smokers in treatment for AUD appear to be more motivated to abstain from alcohol than to stop smoking and those who are motivated to do both may be more likely to drop out of treatment 19

Interest in stopping smoking in A/SUD StudyFinding Joseph 2003 J Add Dis There is considerable interest in smoking cessation in alcohol dependent treatment populations Joseph 2004 Am J Addict Patients being treated for AUD with a history of depressive disorder or depressive symptoms are less interested in stopping smoking Flach 2004 Addict Beh In people undergoing treatment for AUD who smoke there may be lower interest in stopping smoking than in alcohol abstinence 20

Interest in stopping smoking in A/SUD StudyFinding Nahvi 2006 Addict Beh There is at least a moderate interest in quitting among injecting drug users in methadone maintenance programmes Ramo 2010 Drug & Alc Dep Young people undergoing treatment for SUD typically show at least moderate interest in stopping smoking Bowman 2012 Drug Alc Review Only 15% of clients on methadone maintenance had tried to stop in the past year and only 10% of ever- smokers had stopped 21

Behaviour change framework for aiding smoking cessation 22 Michie et al 2011 Implementation Sci

Behaviour change framework for aiding smoking cessation 23 Build capacity for self-regulation Help understand benefits of cessation Inform about best ways of quitting Build capacity for self-regulation Help understand benefits of cessation Inform about best ways of quitting Persuade that quitting is worthwhile Foster desire to quit Tackle urges to smoke Persuade that quitting is worthwhile Foster desire to quit Tackle urges to smoke Provide easy access to support Minimise exposure to smoking cues Develop norms around quitting Provide easy access to support Minimise exposure to smoking cues Develop norms around quitting

Effectiveness of support: smokers in general 24

Medication options 25

Medications: efficacy 26 Stead et al 2008, Cahill et al 2012, Cochrane Varenicline: N=6,166 Single NRT: N=51,265 Dual NRT: 4,664 NRT for ‘reduce to quit’: N=3,429 95% confidence intervals from meta-analyses

Specialist behavioural support 27

Behavioural support: efficacy 28 Stead et al 2012, Cochrane 1 Individual vs brief advice: N=7,855 Group vs self-help: N=4,375 Internet vs nothing: N=2,960 Text messaging versus control messages: N=9,110 Written materials: N=15,117 95% confidence intervals from meta-analyses 1 Updates about to be published See caveats on previous slide Available as evaluated through the NHS

52-week abstinence rates for selected methods of stopping smoking 29 West and Owen Based on treatment as directed in guidelines

Effectiveness of support: A/SUD smokers StudyFinding MMWR 1997 Morb Mort Wkly Rep Brief counselling without medication does not appear to be effective in helping smokers with AUD to stop Prochaska 2004 J Cons Clin Psy (Review) Smoking cessation treatment appears to have short- term effects in people during or following A/SUD treatment but effects may not be sustained longer term Joseph 2004 J Stud Alc In patients treated for AUD, concurrent smoking cessation treatment is not more effective than delayed treatment Bankole 2005 Arch Int Med Topiramate may be effective in aiding smoking cessation in AUD smokers at least up to 12 weeks 30

Effectiveness of support: A/SUD smokers StudyFinding Hurt 2005 J Stud Alc Attempting high level nicotine replacement through nicotine patches was followed by at least moderate short-term smoking abstinence in stable recovering AUD patients but success was not associated with degree of nicotine replacement achieved Kalman 2005 J Subst Abuse Tr High dose nicotine patch was not more effective than standard dose in promoting smoking cessation in recovering AUD patients Diehl 2006 Int J Clin Pharm Ther The acetylcholinesterase inhibitor, galantamine, reduced smoking in recently detoxified AUD patients enrolled regardless of willingness to stop smoking 31

Effectiveness of support: A/SUD smokers StudyFinding Grant 2007 Alcohol Adding bupropion to NRT did not improve smoking cessation rates in smokers with AUD but success rates overall were similar to what is found in general population Hays 2009 Nic & Tob Res In recovering alcoholic smokers, providing bupropion up to 52 following 8 weeks of treatment with nicotine patches did not improve abstinence rates Okoli 2010 J Subs Abuse Treat (Review) Few studies evaluating smoking cessation treatment in methadone maintained patients; success rates are low and there is little evidence of effectiveness 32

Effectiveness of support: A/SUD smokers StudyFinding Kalman 2011 Drug Alc Dep Adding bupropion to NRT appears to be no more effective than NRT alone in promoting smoking cessation in patients who have received treatment for AUD. Karam-Hage 2011 Am J Drug Alc Abuse Bupropion may help smoking cessation in AUD patients (very small pilot RCT) Bernstein 2012 J Subst Abuse Tr epub Behavioural support plus medication increased long-term smoking abstinence in A/SUD patients attending an emergency department 33

Effectiveness of support: A/SUD smokers StudyFinding Tuten 2012 Addiction Incentives for reduced breath CO may reduce cigarette consumption in methadone maintained pregnant smokers Carmody 2012 Drug Alc Dep High intensity behavioural support plus dual form NRT for 26 weeks in AUD smokers led to short-term but not long-term smoking abstinence; there was no difference in alcohol outcomes 34

Stopping smoking effects on A/SUD StudyFinding Bobo 1988 Add Beh Stopping smoking in recovering alcoholics appears not to jeopardise sobriety Covey 1993 Am J Psychiatry Stopping smoking in recovering alcoholics does not appear to precipitate relapse to alcohol Martin 1997 J Cons Cl Psy Stopping smoking does not appear to precipitate relapse in recovering alcoholics 35

Stopping smoking effects on A/SUD StudyFinding McIlvaine 1998 Am Fam Physician (Review) Treatment to aid smoking cessation may promote alcohol abstinence in patients with AUD Bobo 2002 Addiction Low intensity tobacco cessation support in people following AUD treatment resulted in improves AUD outcomes but not improved smoking cessation outcomes Joseph 2004 J Stud Alc In patients treated for AUD, concurrent smoking cessation treatment may lead to worse alcohol outcomes than delayed treatment 36

Stopping smoking effects on A/SUD StudyFinding Myers 2006 Alc Res Hlth (Review) What little research there is suggests that smoking cessation treatment may be beneficial for adolescents with A/SUD disorders Grant 2007 Alcohol Stopping smoking in a trial of smoking cessation treatment in AUD patients was associated with improved alcohol outcomes Hall 2007 Am J Prev Med 33 S406 (Review) What little research there is suggests that smoking cessation treatment could be beneficial and not adversely effect A/SUD outcomes Myers 2008 Subst Abuse Participation in smoking cessation treatment programmes may help reduce substance use in adolescents 37

Stopping smoking effects on A/SUD StudyFinding Kalman 2010 Clin Psy Rev (Review) Treatment for tobacco dependence does not jeopardise alcohol abstinence in those undergoing treatment for AUD Nieva 2011 Eur Add Res 17 1 Participation in a smoking cessation programme does not impair alcohol outcomes, at least during the first 6 months Tsoh 2011 Drug Alc Dep Stopping smoking within 1 year of treatment for A/SUD predicted alcohol and substance use outcomes up to 9 years later 38

How can stop-smoking support be made routine? Factors likely to be associated with provision of tobacco cessation support –Staff motivation and skills –Management support –Systems and access to treatment options 39 Michie 2011 Implementation Sci

Provision of stop smoking treatment StudyFinding Bobo 1995 Psychiat Serv Counsellors in AUD treatment services are more likely to offer smoking cessation support if they are non-smokers, know more about nicotine addiction and have services that they can refer to Bowman 2003 Drug Alc Rev (Review) There is a need for research into improved systems to offer smoking cessation support to patients with A/SUD Walsh 2005 Drug Alc Rev Only a quarter of Australian A/SUD treatment services questioned had smoking cessation intervention policies and one third had adequate treatment programmes. Concerns over negative effects and lack of client interest were reported as significant barriers 40

Provision of stop smoking treatment StudyFinding Richter 2006 Subst Abuse Tr Prev Pol 14 1 (Review) Stop-Smoking treatment should be embedded in A/SUD treatment programmes and involve behavioural support and medication Guydish 2007 J Psychoactive Drugs (Review) Staff smoking prevalence in A/SUD treatment centres is variable and not necessarily high. The main barriers to providing smoking cessation support appear to be staff smoking, lack of knowledge and skills, concern about effect on A/SUD outcomes Knudsen 2010 J Subs Ab Treat Substance abuse counsellors are less likely to provide brief tobacco interventions if they smoke, had less knowledge of guidance, and perceived less management support 41

Provision of stop smoking treatment StudyFinding Wye 2010 Aus NZ J Publ Hlth Recording of smoking status may be very low in psychiatric hospitals but higher for patients with A/SUD than those without Prochaska 2010 Drug Alc Dep (Review) A/SUD treatment providers have an ethical duty to provide nicotine dependence treatment Knudsen 2011 Drug Alc Dep NRT availability in SUD treatment centres in the US is low and decreasing 42

Provision of stop smoking treatment StudyFinding Huntt 2012 J Subst Abuse Treat 42 4 A study of treatment provision found that provision was rare and systems were non-existent Knudsen 2012 Nic Tob Res In Press A high proportion of smoking cessation programmes in SUD treatment centres fail to be sustained. Management attitudes, low staff skills and competing demands were associated with discontinuation 43

Conclusions 44

Conclusions 45