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Mandatory Smoking Abstinence Improves Substance Treatment Outcomes !!TOP!!

Conclusions: This study demonstrates that tobacco use is correlated with relapse and addressing tobacco in treatment as seriously as and in the same fashion as other drugs, improves outcomes.

Mandatory Smoking Abstinence Improves Substance Treatment Outcomes

Tobacco-free campus policies and integration of tobacco cessation interventions in behavioral health treatment facilities could decrease tobacco-related disease and death and could improve behavioral health outcomes among persons with mental and substance use disorders.

Opportunities exist to enhance both smoke-free environments and tobacco cessation treatment in mental health and substance abuse treatment settings. In 2016, fewer than half of such facilities in the United States (including Puerto Rico) offered evidence-based tobacco cessation treatments, and substantial proportions of facilities with smoke-free campus policies did not report offering tobacco cessation counseling or medications. Given that tobacco cessation in behavioral health treatment could improve both physical and behavioral health outcomes, and continued smoking worsens those outcomes, behavioral health treatment facilities are an important setting for evidence-based tobacco cessation interventions (3,4).

Progress has been achieved in recent years in addressing tobacco use in behavioral health treatment settings. For example, New York adopted regulations requiring tobacco-free campus policies in state-funded or state-certified substance abuse treatment programs and expanded Medicaid cessation benefits to allow unlimited quit attempts per year. Oklahoma improved access to treatment by eliminating copayments and prior authorization for tobacco cessation treatment for Medicaid enrollees. In addition, Oklahoma required that all substance abuse treatment facilities and state-contracted mental health treatment facilities implement tobacco-free campus policies, conduct evidence-based clinical cessation interventions, and document tobacco quitline referrals. In 2016, the Smoking Cessation Leadership Center and the American Cancer Society convened health experts, organizations, and federal agencies, including CDC and SAMHSA, to create a national action plan to reduce smoking among persons with behavioral health issues from 34% in 2015 to 30% by the year 2020.

The association between cigarette smoking and both substance abuse onset and relapse reinforces the importance of tobacco prevention and cessation efforts across the lifespan. Preventing tobacco use initiation might be viewed as a primary substance abuse prevention strategy because of the association between adolescent cigarette smoking and subsequent drug dependence (6). Animal models suggest that adolescent exposure to nicotine increases susceptibility to addiction to other substances (6), including alcohol, cocaine, methamphetamine (6), and opioids (7). In the current context of rising demand for opioid addiction treatment,** it is noteworthy that nicotine and opioid addictions are mutually reinforcing, whereas smoking cessation is associated with long-term abstinence after opioid treatment (8,9). In addition, cigarette smoking and chronic pain might interact in ways that might make smokers with chronic pain especially susceptible to opioid misuse (8). Therefore, efforts to increase tobacco cessation and prevent youth tobacco initiation, including during substance abuse treatment, are important components of a comprehensive strategy to prevent and reduce substance abuse.

The figure above is a map of the United States, including Puerto Rico, showing the percentage of substance abuse treatment facilities that prohibited smoking in all indoor and outdoor locations during 2016, based on data from the National Survey of Substance Abuse Treatment Services.

Introduction: The aim was to evaluate the effectiveness of smoking cessation interventions for patients with substance use disorders. The secondary aim was to evaluate impact on substance use treatment outcomes.

Methods: Randomized controlled trials involving adult smokers, recently or currently receiving inpatient or outpatient treatment for substance use disorders were reviewed. Databases, grey literature, reference lists, and journals were searched for relevant studies between 1990 and August 2014. Two authors extracted data and assessed quality. The primary outcome was biochemically verified continuous abstinence from smoking at 6 or 12 months, secondary outcomes were biochemically verified 7-day point prevalence smoking abstinence (PPA) at 6 or 12 months and substance use outcomes. Heterogeneity between studies precluded pooled analyses of the data.

Results: Seventeen of 847 publications were included. Five studies reported significant effects on smoking cessation: (1) nicotine patches improved continuous abstinence at 6 months; (2) nicotine gum improved continuous abstinence at 12 months; (3) counseling, contingency management and relapse prevention improved continuous abstinence at 6 and 12 months; (4) cognitive behavioral therapy, plus nicotine replacement therapy (NRT), improved PPA at 6 months; and (5) a combination of bupropion, NRT, counseling and contingency management improved PPA at 6 months. Two studies showed some evidence of improved substance use outcomes with the remaining eight studies measuring substance use outcomes showing no difference.

Conclusions: NRT, behavioral support, and combination approaches appear to increase smoking abstinence in those treated for substance use disorders. Higher quality studies are required to strengthen the evidence base.

SAMHSA's mission is to lead public health and service delivery efforts that promote mental health, prevent substance misuse, and provide treatments and supports to foster recovery while ensuring equitable access and better outcomes.

The stresses of deployments and the unique culture of the military offer both risks and protective factors related to substance use among active duty personnel.1 Deployment is associated with smoking initiation, unhealthy drinking, drug use and risky behaviors.1 Zero-tolerance policies, lack of confidentiality and mandatory random drug testing that might deter drug use can also add to stigma, and could discourage many who need treatment from seeking it. For example, half of military personnel have reported that they believe seeking help for mental health issues would negatively affect their military career.1 However, overall, illicit drug use among active duty personnel is relatively low2 and cigarette smoking and misuse of prescription drugs have decreased in recent years.2 In contrast, rates of binge drinking are high compared to the general population.2

U.S. military veterans are estimated to be a large portion (around 11 percent) of homeless adults.17 According to a 2014 study, around 70 percent of homeless veterans also have a substance use disorder.16 In 2011, about one fifth of veterans in substance use treatment were homeless.16 These homeless veterans experience unique challenges and barriers to substance use disorder treatment. Targeting homeless veterans in need of treatment so that they can receive support through outreach services, case management, and housing assistance can improve their chances of entering substance use treatment and experiencing positive outcomes.16

The purpose of this Funding Opportunity Announcement (FOA) is to provide support for research designed to optimize smoking cessation treatment among people living with HIV (PLWH) in the United States (U.S.). Responsive applications must propose research that will be conducted with PLWH and will inform efforts to reduce the incidence of tobacco-related disease and death among PLWH. Research may address the behavioral and sociocultural factors and conditions that are associated with cigarette smoking among PLWH and may also address smoking-related health disparities among PLWH, considering the heterogeneity across the various subgroups of PLWH. This FOA aims to support research to systematically test existing evidence-based smoking cessation interventions (e.g., combination of behavioral and pharmacological) and/or to develop and test adaptations of evidence-based smoking cessation interventions among PLWH. The principal focus of this initiative is on cigarette smoking cessation; however, studies that address dual/poly tobacco product use as part of a cigarette smoking cessation intervention are acceptable. Proposed projects must include prospective, comparative evaluation(s) of the intervention(s) in terms of the rates of cigarette smoking cessation, including sustained abstinence, among current cigarette smokers.

The goal of this Funding Opportunity Announcement (FOA) is to improve cigarette smoking cessation treatment among people living with HIV (PLWH) in the United States (U.S.), with an emphasis on methodologically rigorous studies that propose to systematically test existing evidence-based smoking cessation interventions (e.g., combination of behavioral and pharmacological) and/or to develop and test adaptations of evidence-based smoking cessation interventions for application to this target population. The long-term goal is to reduce cigarette smoking rates among PLWH, and thus tobacco-related health disparities in this population. Responsive applications should address the highest HIV/AIDS research priorities as identified by NIH (see NOT-OD-15-137) which include research to reduce health disparities in the treatment outcomes of those living with HIV/AIDS.

The literature points to numerous risk factors associated with cigarette smoking among PLWH, including but not limited to substance use or co-dependence on other substances, alcohol use, marijuana use, mental illness, depression, lack of social support, not achieving HIV viral suppression, and other HIV-related symptoms. Some of these risk factors, particularly chronic stressors (e.g., poverty, racism/discrimination, stigmatization, lack of access to HIV treatment, emotional distress, pain, comorbid substance use), may serve as barriers to cessation. Additionally, given the increased number of tobacco products available to consumers, and the increasingly complex patterns of tobacco product use observed in the general population, it is likely that dual and poly tobacco product use has also increased among PLWH, which may pose another barrier to successful smoking cessation. The diversity of PLWH and risk factors posed by these sub-groups present unique challenges for smoking cessation. Understanding the complex interplay between sociodemographic and behavioral risk factors associated with cigarette smoking among PLWH will contribute to the development of effective smoking cessation interventions, as well as inform and guide the adaptation of existing evidence-based interventions for this population. 350c69d7ab

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