Tobacco Related Practice & Policy in Women’s Drug Abuse Treatment & Recovery Services Marty Jessup RN, PhD, CNS

1. Tobacco Related Practice & Policy in Women’s Drug Abuse Treatment & Recovery ServicesMarty Jessup RN, PhD, CNSYeonsu Song, RN, MS UCLA Substance Abuse Research Consortium September 18, 2007

2. Acknowledgements • UCSF School of Nursing, Office of the Dean • Institute for Health & Aging, UCSF • Yeonsu Song, RN • Sue Dibble RN, DNSc. • Mickey Eliason, PhD

3. Study Aims To describe • tobacco-related treatment policies & practices and personnel policies on smoking in perinatal residential programs • knowledge & attitudes re: smoking among directors of residential perinatal programs in California

4. Rates of Cigarette Smoking Adults Males Females U.S.1 20.9 23.9 18.1 CA.2 13.3 17.5 9.1 Utah3 11.2 (1CDC 2006; 2CA DHS 2007; 3UDH 2006)

5. Women and Smoking • Cigarette smoking kills an estimated 178,000 women in the U.S. every year (CDC 2006) • Among U.S. women, lung cancer deaths have increased by 600 % since 1950 (CDC 2001) • 99% of perinatal women in AOD treatment are smokers (Svikis et al. 1999)

6. Smoking: Perinatal Effects • Conception delay & infertility • Increases risk for: miscarriage intrauterine growth restriction LBW and VLBW placental previa and abruption Sudden Infant Death Syndrome (SIDS) (USDHHS 1990; Schoendorf 1992)

7. Environmental Tobacco Smoke • 150 - 300,000 lower respiratory infections/yr. • increase in # and severity of asthma episodes • pneumonia • coronary artery disease • ear infections • colds and flu • worsening of allergies • increased # of hospitalizations • SIDS (Moskowitz et al. 1999)

8. Smoking: Pediatric Effects • Delayed development • Attention Deficit Hyperactivity Disorder • Conduct disorders in male offspring • Teen smokers more likely to be depressed (Wakschlag et al. 1997; Fergusson et al. 1998; Millberger et al. 1996; Brown et al.1996)

9. Effects of Smoking on Substance Abuse Clients • In-recovery persons with alcohol dependency were more likely to die from smoking-related causes than from alcohol-related causes. (Hurt 1998)

10. Treatment of Nicotine Dependency in Recovering Persons • Quitting smoking is associated with recovery from alcohol dependence; there are longer periods of drug/alcohol abstinence with smoking cessation. (Sullivan & Covey 2002; Bobo et al. 1986)

11. Smoking Among Perinatal In-treatment AOD Clients • Majority of MMT women were smokers;1/3 reduced smoking while pregnant; motivational readiness to quit decreased as pregnancy progressed. (Haug, Stitzer & Svikis 2001) • Smoking stage of change associated with treatment stay (Haller, Miles & Cropsey 2004)

12. Why no nicotine treatment? • Other drugs viewed as more harmful • Tobacco is legal • Staff smoking and institutional resistance • No internal/external pressure to change • Inadequate technology transfer (Gill et al 2000; Bobo & Davis 1994; Hurt et al 1995)

13. Why no nicotine treatment? • Recovery vs. health orientation • Harm reduction infusion • Collaborative agency resistance

14. Professional Attitudes: Addiction Treatment Staff • Among drug abuse treatment staff, attitudes and perceptions are influenced by smoking status (Gill et al 2000; Bobo & Davis 1994; Hurt et al 1995)

15. Professional Attitudes: Addiction Treatment Staff • More likely to positively view smoking cessation tx if their setting • operated a nicotine dependence tx program; • admitted veterans, women, and pregnant women; • did not offer residential detox services; • if they valued evidence-based practices. (Fuller et al. 2007)

16. Professional Attitudes: Addiction Treatment Staff • If a current smoker: minimized the impact of smoking on recovery • Education = therapeutic optimism about smoking cessation and recovery (Gill & Bennett 2000)

17. Study Aims To describe • tobacco-related treatment policies & practices and personnel policies on smoking in perinatal residential programs • knowledge & attitudes re: smoking among directors of residential perinatal programs in California

18. Methods • CHR approved consent procedures • Data collection: April - August 2006 • Mailed survey: 83 directors of res.perinatal programs • $30 food gift card mailed after survey returned • 22 returned 1st mailing; 9 returned 2nd mailing • 10 refusal postcards returned • 12 dropped (9 wrong address; 3 program closure ) N = 31 40% response rate

19. Perinatal Directors Survey • 104 closed-response items • Self-report: 40 minutes to complete • Comments option on select questions • Adapted from prior surveys (Guydish 2004; Sharp et al. 2003; Hurt et al, 1995; Bobo & Gilchrist 1983)

20. Results: Perinatal Program Director Demographics (n=31) • GenderN% Female 28 (90.3) Male 3 ( 9.7) • Ethnicity White 18 (58.1) Afr Am 9 (29.0) Latina 3 ( 9.7) • Smoker? Yes 2 ( 6.5) No 29 (93.5)

21. Staff Smokers • In Smoking Director settings, 73% (SD=.09) of staff were also smokers as compared to Non-Smoking Director settings where 34% (SD=.17) of staff were smokers (p=.005)

22. Director Demographics • Recovery Status Yes = 17 (54.8) No = 12 (38.7) Not reported = 2 ( 6.5) • Years in drug abuse treatment = 13.9 • Years at current agency = 8.6 • Years in current position = 5.8

23. Director Backgrounds n% Program Administration 12 (38.7) Addictions Counseling 10 (32.3) Social Work 5 (16.1) Psychology 3 ( 9.7) Nursing 1 ( 3. 2)

24. Program Demographics mean (SD) • # female admits/yr 99.7 (104.7) (range: 5 - 533) • # children admits/yr 35.8 (28.56) (range: 0-100) • program age 21.5 yrs (11.7) (range: 4 – 47 yrs.)

25. Knowledge • The hazards of smoking have been clearly demonstrated.True: 100% (31) False: 0% ( 0) • Smoking light cigarettes is safer than smoking regular cigarettes. True: 93.5% (29) False: 6.5% ( 2) • Smoking is a personal decision that does not concern the clinician. True: 38.7% (12) False: 61.3% (19)

26. Knowledge: Perinatal Effects • The dangers of smoking during pregnancy are well documented.True: 80.6% (25) False: 19.4% (6) • Smoking during pregnancy is less damaging than using other drugs during pregnancy. True: 80.6% (25) False: 19.4% ( 6)

27. Knowledge: Pediatric Effects • A mother’s smoking increases the risk of Sudden Infant Death Syndrome (SIDS). True: 67.7% (21) False: 32.3% (10) • A mother’s smoking increases the risk of low birth weight. True: 93.5% (29) False: 6.5% ( 2) • A mother’s smoking increases the risk of ear infections in her infant. True: 64.5% (20) False: 35.5% (11)

28. Knowledge: Recovery Effects • If a person has smoked a pack of cigarettes a day for >20 yrs. there is little health benefit to quitting. True: 90.3% (28) False: 9.7% ( 3) • If a client has been in recovery for < six months, quitting smoking would threaten their sobriety. True: 77.4% (24) False: 22.6% ( 7) • Counseling by a clinician helps motivate smokers quit smoking.True: 71% (22) False: 29% ( 9)

29. Knowledge of Smoking Effects • Smoking (2) v. Non-Smoking (29) No significant between-group differences in knowledge.

30. Program Policy Development • 51.6% reported having written policy on client tobacco-related treatment procedures; • 65% reported having written policy on staff smoking; • 84% reported client and staff “smoking at times in designated locations” in the program • 16% reported “smoke-free grounds”

31. Directors’ Exposure to Smoking Policy N % • CDC Guidelines NO 17 (54.8) YES 13 (41.9) • Policy Statement NO 20 (65.5) YES 10 (32.3) • Manualized Curriculum NO 22 (71) YES 8 (25.8)

32. Policy: County Requirements • Does your county AOD entity require you to provide tobacco related services to perinatal women? Yes 11 (35.5) No 15 (48.4) Missing data 5 • Does your county AOD entity have a written policy on treatment of tobacco dependence in persons with AOD problems? Yes 7 (22.6) No 11 (35.5) Don’t know 12 (38.7) Missing data 1

33. Program Practices • Does the program offer in-house tobacco-related treatment procedure? Yes 16 (51.6) implemented 8 years ago No 15 (48.4) • Do mothers wear “smoking jackets” while smoking? Yes 6 (19.6) No 25 (80.6) • Are children placed in the care of others while their moms are smoking? Yes 18 (58.1) No 13 (41.9)

34. Nicotine Dependence: Treatment Tools %N Educational classes 82.6 19 Written materials 78.3 18 Support Group 65.2 15 Counseling on Br feeding 56.5 13 AA principles applied 52.2 12 Smoking on tx plan 47.8 11 Smoking in chem use hx/chart 43.5 10 “cold turkey” 43.5 10

35. Nicotine Dependence: Treatment Tools %N NRT 34.8 8 Counseling group 34.8 8 Slowly cut down on cigs 30.4 7 Smoking in chem use hx/client story 30.4 7 Bupropion 8.7 2 Clonidine 8.7 2 Acupuncture 4.3 1 Aversion therapy 4.3 1 Change to low tar/nicotine 4.3 1 CO testing 4.3 1 Cotinine testing (saliva) 4.3 1

36. Directors: Staff Development • 100% indicated interest in offering AOD counseling staff smoking cessation skills.

37. Director Perspectives: When to Quit • Timing of smoking cessation Half respondents said “quit AOD first” Half endorsed “quit AOD and tobacco at the same time”

38. Directors: Quitting with Help • The half of respondents that endorsed “quit AOD & tobacco at the same time” had more in-house nicotine dependence treatment (x2=6.533, p=.027) than those respondents who endorsed “quit AOD first.”

39. Director: Recovery Status • In Recovery (17) v. Not in Recovery (14) No significant between-group differences in knowledge, attitudes or practices.

40. Summary of Findings • Gaps in knowledge on smoking effects • Limits on adoption of EBPs and tobacco-related policies • Smoking directors have greater number of staff who also smoke

41. Study Limitations • Closed-response items limit content • Sample bias • Recall bias • Small sample size limits analyses • Meaning and processes unknown

42. Implications • Education on perinatal effects of smoking; • Directors willing to arm staff with smoking cessation skills; • Evidence-based practices for smoking cessation not widely in use in this sample; • Knowledge does not necessarily = action.

43. Qualitative Research Questions • Perspectives on health status is recovery • Views on smoking in recovery • Is client smoking a “personal decision” ? • Meaning of why offer/not offer smoking cessation

44. New York Policy on Tobacco • Requires programs supported by state Office of Addiction and Substance Abuse Services to address tobacco addiction in all settings. • NRT • Training • Mentors for program staff www.oasas.state.ny.us/tobacco/index.cfm

45. NJ Smoke-Free Policies • In 1999, the state AOD agency of New Jersey in its licensure policies, placed tobacco on a par with alcohol and drugs in all residential drug treatment centers.

46. Tobacco use assessed Individual counseling Group counseling Discharge plans Treatment/referrals for cessation BeforeAfter 37% 90% 50% 97% 47% 90% 17% 67% 43% 80% Effects of Tobacco Policy Change

47. Recommendations • Wider-ranging survey of all modalities • Smoking cessation services: a part of trauma-responsive treatment • Explore barriers to adoption of EBP for smoking cessation and nicotine dep treatment • Dissemination of materials • Training and support for organizational change for adoption

48. Smokable Drugs “The whole process of using smokable drugs is so similar that failure to address all smokable drugs, including cigarette smoking, may predispose the client to relapse.” (Sees & Clark 1993)

49. Thank You