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

2. 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

3. Outline 3

4. Benefit of stopping smoking: smokers in general 4

5. Benefits of stopping smoking 5 Doll et al 2004 BMJ

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

7. Quitting: smokers in general 7

8. 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

9. Quitting: A/SUD smokers StudyFinding Bobo 1988 Add Beh 12 209 People with more severe AUD appear to be less likely to be successful at stopping smoking when they try Covey 1993 Am J Psychiatry 150 1546 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 65 190 Recovering alcoholics appear to have equal success at stopping smoking as other smokers 9

10. Quitting: A/SUD smokers StudyFinding Marks 1997 J Subs Ab Treat 14 521 Nicotine dependence is greater in smokers with AUD Hays 1999 Ann Beh Med 21 244 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 59 235 People with AUD are less likely than those without to stop smoking 10

11. Quitting: A/SUD smokers StudyFinding Kalman 2001 J Subs Abuse Treat 20 233 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 30 1247 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 24 79 Long-term smoking abstinence rates may be reasonable after motivational interviewing and pharmacological treatment for smoking cessation in SUD patients 11

12. Quitting: A/SUD smokers StudyFinding Agosti 2009 Soc Psychiat Psychiat Epid 44 120 Remission from A/SUD is associated with higher rate of smoking cessation MacKillop 2009 Drug & Alc Dep 104 197 Delayed reward discounting predicts worse smoking cessation treatment outcome in heavy drinking smokers Kahler 2010 N&TR 12 781 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

13. Quitting: A/SUD smokers StudyFinding Sonne 2010 Am J Add 19 111 In treatment seeking substance users, baseline depression is associated with lower smoking abstinence rates following smoking cessation treatment Hays 2011 J Subs Abuse Treatment 40 102 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 20 45 SUD treatment clients may succeed in stopping at rates similar to general population of smokers if given intensive tobacco dependence treatment 13

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

15. Brief physician advice 15

16. 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: 52-210%) Offering prescription increased quit attempts by 68% (95%CI: 48-89%)

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

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

19. Interest in stopping smoking in A/SUD StudyFinding Ellingstad 1999 Drug Alc Dep 54 259 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 10 159 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

20. Interest in stopping smoking in A/SUD StudyFinding Joseph 2003 J Add Dis 22 87 There is considerable interest in smoking cessation in alcohol dependent treatment populations Joseph 2004 Am J Addict 13 405 Patients being treated for AUD with a history of depressive disorder or depressive symptoms are less interested in stopping smoking Flach 2004 Addict Beh 29 791 In people undergoing treatment for AUD who smoke there may be lower interest in stopping smoking than in alcohol abstinence 20

21. Interest in stopping smoking in A/SUD StudyFinding Nahvi 2006 Addict Beh 2 127 There is at least a moderate interest in quitting among injecting drug users in methadone maintenance programmes Ramo 2010 Drug & Alc Dep 106 48 Young people undergoing treatment for SUD typically show at least moderate interest in stopping smoking Bowman 2012 Drug Alc Review 31 507 Only 15% of clients on methadone maintenance had tried to stop in the past year and only 10% of ever- smokers had stopped 21

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

23. 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

24. Effectiveness of support: smokers in general 24

25. Medication options 25

26. 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

27. Specialist behavioural support 27

28. 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

29. 52-week abstinence rates for selected methods of stopping smoking 29 West and Owen 2012 www.smokinginengland.info Based on treatment as directed in guidelines

30. Effectiveness of support: A/SUD smokers StudyFinding MMWR 1997 Morb Mort Wkly Rep 46 1114 Brief counselling without medication does not appear to be effective in helping smokers with AUD to stop Prochaska 2004 J Cons Clin Psy 72 1144 (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 65 681 In patients treated for AUD, concurrent smoking cessation treatment is not more effective than delayed treatment Bankole 2005 Arch Int Med 165 1600 Topiramate may be effective in aiding smoking cessation in AUD smokers at least up to 12 weeks 30

31. Effectiveness of support: A/SUD smokers StudyFinding Hurt 2005 J Stud Alc 66 506 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 30 213 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 44 614 The acetylcholinesterase inhibitor, galantamine, reduced smoking in recently detoxified AUD patients enrolled regardless of willingness to stop smoking 31

32. Effectiveness of support: A/SUD smokers StudyFinding Grant 2007 Alcohol 41 381 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 11 859 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 38 191 (Review) Few studies evaluating smoking cessation treatment in methadone maintained patients; success rates are low and there is little evidence of effectiveness 32

33. Effectiveness of support: A/SUD smokers StudyFinding Kalman 2011 Drug Alc Dep 118 111 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 37 487 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

34. Effectiveness of support: A/SUD smokers StudyFinding Tuten 2012 Addiction 107 1868 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

35. Stopping smoking effects on A/SUD StudyFinding Bobo 1988 Add Beh 12 209 Stopping smoking in recovering alcoholics appears not to jeopardise sobriety Covey 1993 Am J Psychiatry 150 1546 Stopping smoking in recovering alcoholics does not appear to precipitate relapse to alcohol Martin 1997 J Cons Cl Psy 65 190 Stopping smoking does not appear to precipitate relapse in recovering alcoholics 35

36. Stopping smoking effects on A/SUD StudyFinding McIlvaine 1998 Am Fam Physician 15 1869 (Review) Treatment to aid smoking cessation may promote alcohol abstinence in patients with AUD Bobo 2002 Addiction 93 877 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 65 681 In patients treated for AUD, concurrent smoking cessation treatment may lead to worse alcohol outcomes than delayed treatment 36

37. Stopping smoking effects on A/SUD StudyFinding Myers 2006 Alc Res Hlth 29 221 (Review) What little research there is suggests that smoking cessation treatment may be beneficial for adolescents with A/SUD disorders Grant 2007 Alcohol 41 381 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 21 81 Participation in smoking cessation treatment programmes may help reduce substance use in adolescents 37

38. Stopping smoking effects on A/SUD StudyFinding Kalman 2010 Clin Psy Rev 30 12 (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 114 110 Stopping smoking within 1 year of treatment for A/SUD predicted alcohol and substance use outcomes up to 9 years later 38

39. 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

40. Provision of stop smoking treatment StudyFinding Bobo 1995 Psychiat Serv 46 945 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 22 73 (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 24 235 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

41. 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 39 423 (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 38 212 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

42. Provision of stop smoking treatment StudyFinding Wye 2010 Aus NZ J Publ Hlth 34 298 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 110 177 (Review) A/SUD treatment providers have an ethical duty to provide nicotine dependence treatment Knudsen 2011 Drug Alc Dep 118 244 NRT availability in SUD treatment centres in the US is low and decreasing 42

43. 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

44. Conclusions 44

45. Conclusions 45