Characteristics and clinical treatment of tobacco smokers enrolled in a VA substance use disorders clinic

Accepted Manuscript Characteristics and clinical treatment of tobacco smokers enrolled in a VA substance use disorders clinic

Julie C. Gass, David H. Morris, Jamie Winters, Joseph W. VanderVeen, Stephen Chermack PII: DOI: Reference:

S0740-5472(17)30165-4 doi:10.1016/j.jsat.2017.10.006 SAT 7651

To appear in: Received date: Revised date: Accepted date:

17 April 2017 12 October 2017 13 October 2017

Please cite this article as: Julie C. Gass, David H. Morris, Jamie Winters, Joseph W. VanderVeen, Stephen Chermack , Characteristics and clinical treatment of tobacco smokers enrolled in a VA substance use disorders clinic. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Sat(2017), doi:10.1016/j.jsat.2017.10.006

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Running head: SMOKERS IN SUBSTANCE USE DISORDER CLINIC

1

IP

T

Characteristics and Clinical Treatment of Tobacco Smokers Enrolled in a VA Substance Use Disorders Clinic

VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105 b Department of Psychiatry, University of Michigan, Ann Arbor, MI, 48109

M

CE

PT

ED

Address Correspondence to: Julie C. Gass, PhD Center for Integrated Healthcare VA Western NY Healthcare System 3495 Bailey Avenue Buffalo, NY 14215 716-834-9200 X5429 [email protected] [email protected]

AN

US

a

CR

Julie C. Gassa1, David H. Morrisa,b, Jamie Wintersa,b, Joseph W. VanderVeena,b, and Stephen Chermacka,b

AC

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no financial conflicts of interest to disclose. Writing of this manuscript was supported in part by the Department of Veterans Affairs Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, and the Department of Veterans Affairs Center for Integrated Healthcare, VA Western New York Healthcare System at Buffalo.

1

Julie C. Gass is now at the VA Center for Integrated Healthcare, Buffalo, NY and the University at Buffalo, The State University of New York, Buffalo, NY

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

2

CE

PT

ED

M

AN

US

CR

IP

T

Abstract Individuals with a substance use disorder (SUD) diagnosis are more than twice as likely to smoke cigarettes as the general population. Emerging research has suggested that treating a substance use disorder simultaneously with tobacco use leads to a higher rate of treatment success for both substances. Despite this, substance use treatment protocols tend not to focus on tobacco use; in fact, traditional substance use treatments often discourage patients from attempting to quit smoking. One rationale is that patients may not be motivated to quit smoking. In the current study, data from veterans enrolled in outpatient treatment for a SUD were examined to assess for general characteristics of smokers as compared to non-smokers as well as to examine motivation to quit smoking. Baseline (i.e., pre-treatment) data from 277 Veterans were used. Charts of smokers in the SUD clinic (SUDC) were reviewed to assess how smoking is handled by SUDC providers, and if smokers attempt cessation. Of 277, 163 (59%) SUDC patients reported that they currently smoke cigarettes (M = 16.3 cigarettes per day, SD = 11.1). Smokers in the clinic reported greater general impairment than nonsmokers on the Short Index of Problems, F(1,248)=8.9, p=.003, as well as greater specific impairment: Physical Problems, F(1,258)=13.5, p=.000; Interpersonal Problems, F(1,262)=5.6, p=.019; Intrapersonal Problems, F(1,260)=6.5, p=.011, and Social Responsibility, F(1,262)=14.7, p=.000. Smokers in the sample were marginally more anxious than their non-smoking counterparts as measured by the GAD-7, F(1,254)=4.6, p=.053, though they were not significantly more depressed (p=0.19). On a 1-10 scale, smokers reported moderate levels of importance (M=5.4, SD=3.1), readiness (M=5.6, SD=3.2), and confidence (M=5.0, SD=3.0) regarding quitting smoking. Review of smokers’ medical records reveal that while SUDC providers assess tobacco use at intake (90%) and offer treatment (86.5%), a substantially small portion of smokers attempt cessation (41.1%) while enrolled in SUDC. Moreover, no patients were enrolled in smoking-specific behavioral interventions while in SUDC, though 78 patients did obtain nicotine replacement or another smoking cessation medication (41% were prescribed by a SUDC provider). Contrary to the belief that treatment-seeking substance users are not motivated to quit smoking, these preliminary analyses demonstrate that Veterans were at least contemplating quitting smoking while they were enrolled in substance use treatment. Further, there is evidence that cigarette smokers have greater impairment caused by substance use, suggesting that this subgroup is of particular high need. Specific treatment recommendations are discussed, including how behavioral health providers in SUD clinics may be better able to capitalize on patients’ moderate motivation to quit at intake.

AC

Keywords: smoking, tobacco, cessation, quitting, substance use clinic, behavioral health Highlights.  Smokers in the clinic reported greater general impairment than nonsmokers, as well as greater specific impairment regarding physical interpersonal, functional, and psychiatric domains  Smokers in the SUD clinic thought it was moderately important to quit smoking, and were moderately ready and confident  While the SUDC staff consistently evaluated smoking status at intake and offered services, only 26.1% of patients attempted to quit/cut down and no patients received the SUD clinic’s empirically based, formal behavioral treatment for smoking from a SUDC behavioral provider

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

3

1. Introduction Up to 480,000 American deaths per year can be attributed to smoking cigarettes– furthermore, tobacco accounts for greater morbidity in the U.S. than alcohol and all other drugs combined (Centers for Disease Control and Prevention, 2016). Across the U.S. veteran

T

population, approximately one in five veterans report current cigarette smoking, which is

IP

commensurate to the general US population (Hoggatt, Lehavot, Krenek, Schweizer, & Simpson,

CR

2017; U.S. Department of Veterans Affairs, 2016), and smoking appears to disproportionately affect veterans with co-occurring substance use disorders (SUDs) (U.S. Department of Veterans

US

Affairs, 2016). Cigarette smoking has been demonstrated to exacerbate the negative health

AN

effects of other drugs/alcohol (e.g., alcoholic pancreatitis, Maisonnueve et al., 2005; liver and upper aero-digestive cancers, Pelucchi et al., 2006). Those with co-occurring SUD and tobacco

M

use disorder are at increased risk for multiple health conditions including esophageal cancer,

ED

heart disease, and oral cancer when compared to patients with SUD who are non-smokers (Talamini et al., 2002). Thus, though smoking may incur fewer direct psychosocial negative

PT

outcomes than other drugs of abuse, the cost of continuing to smoke is high and often becomes

CE

deadly. Therefore, smoking cessation among patients with co-occurring SUD and smoking should be considered a top priority by medical establishments seeking to reduce health risks

AC

among patients. In the current study, we aimed to describe a sample of veterans enrolled in SUD treatment at a VA clinic and to evaluate how smokers are treated in a VA hospital, thus providing the opportunity to describe a typically-presenting VA SUD patient and provide clinical recommendations to the field. Traditional treatments for SUD, including Narcotics Anonymous/Alcoholics Anonymous, have actively discouraged tobacco cessation while a person is concurrently

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

4

attempting to abstain from other drugs or alcohol (Richter, McCool, Okuyemi, Mayo, & Ahluwalia, 2002). Despite national guidelines specifying a need for the integration of smoking cessation in SUD settings (Fiore, 2008), there remains low adoption of these practices in routine clinical care (Muilenburg, Lschober, & Eby, 2014). Research has suggested that few SUD

T

treatment programs (17-41%) in the US and Canada offer smoking cessation treatments (Currie,

IP

Nesbitt, Wood, & Lawson, 2003; Friedmann, Jiang, & Richter, 2008; Fuller et al., 2007;

CR

Muilenburg et al., 2014; Knudsen, Studts, Boyd, & Roman, 2010). One possible deterrent for treatment of substance and tobacco co-use is that some patients fear that attempting to quit

US

smoking will compromise abstinence from other substances (e.g., Kalman, 1998; Fuller et al.,

AN

2007; Sussman, 2002). This concern extends beyond patients – research shows that a minority of SUD treatment providers also endorsed this apprehension; those who held that belief were less

M

likely to discuss smoking cessation with patients (Richter, 2009)

ED

Another reason that smoking may not be addressed in SUD treatment is the perception that patients are not interested in quitting smoking (Hall & Prochaska, 2009). By and large, this

PT

perception is unfounded. Numerous studies have demonstrated that patients in SUD clinics are

CE

moderately to strongly interested in tobacco cessation (e.g., McClure et al., 2014; Nahvi, Richter, Li, Modali, & Arnsten, 2006; Richter, Gibson, Ahluwalia, & Schmelzle, 2001) or are at least

AC

willing to discuss this option with providers (e.g., Ellingstand, Sobell, Sobell, Cleland, & Agrawal, 1999). Studies specifically examining veterans have also found that, among smokers, there is a moderately strong desire to quit smoking. For instance, Duffy and colleagues (2011) found that two thirds of their sample of veterans reported quitting smoking to be either very or extremely important to their health.

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

5

In addition to interest/motivation in quitting, confidence in one’s ability to quit has been examined and appears to predict cessation attempts and success (Hughes & Naud, 2016); thus, low confidence or low self-efficacy may also be considered a barrier for tobacco cessation (Gwaltney, Metrik, Kahler, & Shiffman, 2009). Psychological interventions tailored toward

T

increasing motivation and confidence (i.e., motivational interviewing, Miller & Rollnick, 1991)

IP

could be particularly useful for ambivalent smokers in SUD treatments. Smokers with co-

CR

occurring SUD may have additional person-level barriers to quitting smoking - smoking tends to co-occur with other mental illness (e.g., bipolar disorder, depression, anxiety, psychosis) (Talati,

US

Keyes, & Hasin, 2016) and lower socioeconomic status (Meijer, Gebhardt, & Dijkstra, 2015),

AN

both of which may present challenges to quitting smoking in addition to greater consequences from substance use (Action on Smoking and Health, 2016; Baggett et al., 2015).

M

Finally, barriers at the clinic-level may prevent smokers from attempting to quit during

ED

SUD treatment. Mental health providers, including psychiatrists, psychologists, and social workers, may be less inclined to focus on smoking, characterizing it as a health concern better

PT

addressed by primary care (Himelhoch, Riddle, & Goldman, 2014; Williams, Stroup, Brunette,

CE

& Raney, 2014). As stated above, some SUD providers hold erroneous beliefs about SUD treatment interference caused by tobacco cessation (Richter et al., 2002) as well as a false sense

AC

that smokers do not want to quit (Williams et al., 2014). Further, given the high psychiatric (Heltemes, Clouser, MacGregor, Norman, & Galarneau, 2014; Trivedi et al., 2015) and psychosocial (e.g., homelessness, SAMHSA, 2014) complexities of individuals often seen in SUD clinics, providers may feel that smoking is a low priority (Himelhoch et al., 2014). Considering that tobacco use disorder is classified by the American Psychiatric Association’s Diagnostic and Statistical Manual (American Psychiatric Association, 2013) as an addictive

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

6

disorder, one that is conceptually and behaviorally similar to other addictive disorders, an argument has been made that SUD-specializing mental health providers may be uniquely skilled at addressing tobacco cessation (e.g., Bobo et al., 1998; Fiore, 2008; Williams et al., 2014). Despite such barriers, there is a growing body of literature suggesting that quitting

T

smoking during substance use treatment can lead to abstinence not only from tobacco (Cooney et

IP

al., 2009; Heffner et al., 2007; Prochaska Delucchi, and Hall, 2004), but from other substances as

CR

well (Bobo, McIlvain, Lando, Walker, & Leed-Kelly, 1998; Prochaska et al., 2004; Tsoh, Chi, Mertens, & Weisner, 2011). Thurgood and colleagues (2016) recently reviewed the literature and

US

found mixed support for tobacco cessation during SUD treatment (i.e., 9 of 17 studies found

AN

significant rates of tobacco cessation, 2 of 17 found positive SUD outcomes in those also abstaining from tobacco) though of note they report that no trials in the review found smoking

M

cessation to be negative for SUD outcomes. Similarly, McKelvey and colleagues (2017)

ED

reviewed the literature and also found mixed support (i.e., 46% of studies reported positive findings for the impact of quitting smoking; 73% and 45% found improvements in alcohol and

PT

drug use outcomes, respectively) and similarly find that few negative effects of including

CE

tobacco use treatment in SUD clinics (only one study showed a negative effect). The authors note significant weaknesses in the literature, and suggest continued research in this domain.

AC

Apollonio and colleagues also synthesized the literature and found that pharmacotherapy plus counseling for tobacco can increase smoking cessation outcomes in the context of SUD, though this review found no differences in SUD outcomes either positive or negative (Apollonio, Philipps, & Bero, 2016). Earlier work recommended sequential approaches (i.e., achieve abstinence from primary substance before attempting tobacco cessation) (Joseph, Willenbring, Nugent, & Nelson, 2003) however, a major disadvantage of this approach identified by

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

7

Prochaska and colleagues (2004) is that smokers may leave treatment before a SUD provider is able to address smoking and Kalman et al. (2005) note that patients generally prefer concurrent cessation; furthermore, recent work has suggested no major disadvantages of a concurrent approach (McKlevey et al, 2017). Thus, it appears that discussing tobacco use early and often in

T

substance use treatment is warranted.

IP

As above, one in five U.S. veterans report current cigarette smoking (Hoggatt et al.,

CR

2017; U.S. Department of Veterans Affairs, 2016), though veterans are more likely to have smoking-related illness and morbidity theoretically due to historically higher levels of smoking

US

(Bondurant & Wedge, 2009). Veterans with a SUD diagnosis are more than three times as likely

AN

to smoke cigarettes as veterans without co-occurring SUD (U.S. Department of Veteran’s Affairs, 2016). Though somewhat scant, there has been some research examining tobacco

M

cessation within VA SUD clinics that have demonstrated mixed, though generally positive,

ED

effects on tobacco abstinence (Carmody et al., 2012, Cooney et al., 2017). In the present study, we sought to add to the literature by closely examining characteristics of all smokers in a VA

PT

SUD clinic (SUDC) as opposed to those enrolled in a tobacco cessation trial, which will extend

CE

the literature by describing a “typical” VA SUD patient. We expected that veterans with cooccurring SUD and smoking will be similar to civilian counterparts insofar as smoking veterans

AC

with SUD will evince greater dysfunction than non-smoking veterans with SUD, and would show moderate levels of smoking cessation motivation/readiness. However, as there is evidence that mental and behavioral health concerns have been found to be more frequent among veterans than civilians (e.g., Hogland & Schwarz, 2014; Logan, Bonhert, Spies, & Jannausch, 2016), it was possible that veterans would show different patterns on key features, such as motivation to quit smoking.

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

8

In addition, understanding the typical clinician practices around patient smoking can provide data on points of clinician intervention. We sought to examine typical (i.e., treatment-asusual) clinical care delivered to smokers in a VA SUDC to examine what, if any, smoking assessments or interventions were provided as part of usual care. Thus, the primary aims of this

T

study were to (1) evaluate characteristics of veteran smokers from a SUD treatment-seeking

IP

sample to examine any notable differences from civilian samples; and (2) to carefully evaluate

CR

how smoking is addressed by VA SUDC providers using the electronic medical record (EMR). These aims allowed us to provide commentary on typical features of smokers and typical clinical

US

treatment of smoking within a VA SUDC, and allowed us to provide clinical recommendations

AN

for intervention of SUD-treatment seeking individuals who smoke. This manuscript adds to the rich literature supporting tobacco cessation among SUD patients in the civilian sector by

M

specifically examining a veteran SUDC sample engaged in usual care; we are unaware of any

ED

study that examines treatment-as-usual tobacco intervention practices in a VA SUDC. 2. Material and Methods

PT

2.1 Participants

CE

Patients were 277 veterans enrolled in VA substance use treatment between 7/11/2013 and 7/8/2015 for usual care clinical practice. All unique veterans who enrolled in the SUDC

AC

during this timeframe were included in this study. Veterans were included in this study if they completed the intake procedure (see below for details). The sample was primarily comprised of middle-aged (Mage = 46.6, SD = 14.3), white (78%), male (94%) Veterans. The majority served during the Operation Enduring Freedom/Operation Iraqi Freedom era (2001-present) (N = 105), with 69 from Vietnam era (1961-1975), 57 from Post-Vietnam era (1975-1990), 40 from Persian Gulf War era (1990-2001), and 4 from other eras; 42.8% of the veterans in the sample saw

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

9

combat. For the purposes of this study, smokers (N=163) were defined as any patient who endorsed past-month smoking on their intake evaluation paperwork. paperwork. EMR data were missing for two participants for whom SUDC intake data could not be linked to an EMR. Thus, all EMR data reported are for 161 smokers rather than the 163 smokers utilized for comparative

T

statistics.

IP

2.2 Clinic Procedures 2

CR

All procedures were approved by the VA’s institutional review board. Data were collected from patients enrolled in the outpatient Substance Use Disorders Clinic (SUDC), which

US

is a specialty mental health clinic at a Midwestern VA hospital. To be a patient in SUDC, and to

AN

be included in this study, veterans had to attend all components of the SUDC intake procedure which included (1) completing a baseline paper-and-pencil intake packet, measures below; (2)

M

completing a psychosocial interview with a mental health provider (i.e., social worker,

ED

psychologist, or psychology intern); and (3) completing a medical evaluation with a mental health psychiatrist or psychiatric resident. Research assistants entered data from the intake packet

PT

into an electronic database. Two separate evaluation reports (one by the mental health provider

CE

and one by the psychiatrist) were documented in the VA’s EMR system (Computerized Patient Record System - CPRS) for each patient. Diagnoses based on the DSM-5 (American Psychiatric

AC

Association, 2013) were recorded into both evaluation reports in the event that a veteran met criteria for a psychiatric disorder. Providers could list multiple diagnoses, if appropriate, including multiple substance use disorder diagnoses. Of note, CPRS allows providers to enter a diagnosis onto the patient’s official diagnostic list (Problem List) which is the primary means of 2

Once enrolled in VA SUDC, patients may be referred to individual and/or group treatment with a social worker, psychologist, or psychology trainee as well as ongoing treatment with a psychiatrist. Depending on the primary presenting concern, behavioral treatments might include cognitive-behavioral, relapse prevention, and motivational treatment. Pharmacological interventions could include suboxone, pharmacological interventions for alcohol use, nicotine replacement therapy, and various psychotropic medications.

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

10

communication about diagnoses between providers. The treatment offered for smoking was an empirically validated four-session CBT intervention for smoking that may be used in conjunction with a pharmacological tobacco cessation intervention. All behavioral health providers (social workers, psychologists, psychology interns/fellows) were qualified to provide this treatment.

T

2.3 Measures

CR

smoke cigarettes and 2) if yes, the number of cigarettes per day.

IP

2.3.1 Smoking. Patients indicated on a two-item branching questionnaire 1) if they

2.3.2 Brief Addiction Monitor – Revised. The Brief Addiction Monitor – Revised

US

(BAM-R) is a 17-item self-assessment of multiple substance use domains used commonly in

AN

VHA SUD clinics. The BAM-R can be summed to provide a general index of substance use and can also be broken into specific subscales as follows: Substance Use Severity (made up of

M

individual items examining alcohol/drug use and heavy drinking), Risk Factors (made up of

ED

items examining cravings, physical health, sleep, mood, risky situations, and family/social problems), and Protective Factors (made up of items examining self-efficacy, self-help

PT

behaviors, religion/spirituality, work/school participation, income, and sober support). These

CE

factors have generally good reliability and clinical utility (Nelson, Young, & Chapman, 2014). 2.3.3 Short Index of Problems. The Short Index of Problems (SIP; Alterman, Cacciola,

AC

Ivey, Habing, & Lynch, 2009; Miller, Tonigan, & Longabaugh, 1995) is a 15-item measure assessing problems caused by substance use. The version used in SUDC included drug and/or alcohol use in the item. A total index score of problems caused by use can be calculated as well as the following subscales: Physical, Intra-Personal, Social Responsibility, and Interpersonal Problems. SIP subscales have been demonstrated to have adequate reliability (α’s ranging from .57-.66) and the entire SIP has good reliability (α=.81) (Miller et al., 1995).

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

11

2.3.4 Importance, Readiness, and Confidence Rulers. Importance, readiness, and confidence to change were assessed using modified items from the Readiness Ruler (Center on Alcoholism, Substance Abuse, and Addictions, 1995; Miller, 1999). Veterans were provided 10point visual analog scales and asked to rate how important it was for them to quit a substance,

T

how ready they felt, and how confident they felt in their ability to quit. For each substance they

IP

used, (alcohol, opiates/heroin, crack/crack-cocaine, tobacco, marijuana, and other), veterans

CR

marked on the visual analog scale their level of importance, readiness, and confidence. If a veteran did not use a substance, they were instructed to circle “Don’t Use.”

US

2.3.5 Patient Health Questionnaire. The Patient Health Questionnaire (PHQ-9) is a 9-

AN

item measure of depression severity based on DSM-IV criteria for depression (Kroenke, Spitzer, & Williams, 2001). Veterans rated (0 “Not at all” to 3 “Nearly every day”) how bothered they

M

were by each item over the past two weeks. The PHQ-9 has good construct validity and is a

ED

reliable measure of depression (Martin, Rief, Klaiberg, & Braehler, 2006). Higher scores indicate more severe depression; scores above 9 suggest clinical depression (Kroenke et al., 2001).

PT

2.3.6 Generalized Anxiety Disorder. The Generalized Anxiety Disorder 7 (GAD-7) is a

CE

brief scale that measures general anxiety symptoms based on the DSM-IV criteria for GAD (Kroenke et al., 2001). Veterans rated (0 “Not at all” to 3 “Nearly every day”) how bothered they

AC

were by each item over the past two weeks. The GAD-7 has good internal consistency and criterion validity (Löwe et al., 2008). Higher total scores reflect more severe levels of anxiety, with scores greater than 9 indicating clinically significant anxiety (Spitzer et al., 2006) 2.3.7 Primary Substance of Concern. Patients were asked to indicate, using an openended question, the substance that they considered to be the major problem for them right now. 2.4 Tobacco Use and Treatment

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

12

Smokers’ EMRs were examined and data extracted for variables including: (1) presence or absence of a tobacco use diagnosis included in the patient’s Problem List; (2) presence or absence of tobacco cessation medication (nicotine replacement, bupropion, and/or varenicline) prescribed during the time in SUDC and whether it was prescribed by a SUDC provider; (3)

T

evaluation of tobacco use in intake reports; (4) documentation of treatment for tobacco cessation

IP

offered; (5) whether patient makes a quit attempt and whether it is advised by SUDC providers;

CR

and (6) if a patient receives formal tobacco cessation counseling by a SUDC provider. After intake, Veterans who engage in treatment are placed into a specific empirically-based treatment.

US

Non-exhaustively, offerings include cognitive-behavioral therapy (CBT) for SUD, CBT for

cessation, and CBT for anxiety disorders.

M

2.5 Data Analysis

AN

dually-diagnosed SUD and depression, mindfulness-based relapse prevention, CBT for tobacco

ED

Central tendency (mean, median, and standard deviation) statistics were calculated from the numeric values of the importance, readiness, and confidence rulers. To compare

PT

characteristics of smokers to nonsmokers in the sample, one-way ANOVAs were performed with

CE

smoking status as the grouping variable. Outcome variables included total score on the PHQ-9 and GAD-7 and subscales of the BAM-R and SIP. Data from the EMR (e.g., number of smokers

AC

with a tobacco use diagnosis in their Problem List) of smokers were summated to provide descriptive statistics for the sample. 3. Results 3.1 Participant Characteristics When asked what their primary substance of concern was, 166 veterans reported alcohol, 32 reported heroin/opiates/opioids, 15 reported crack/cocaine/other stimulants, fourteen reported

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

13

marijuana/hash, four reported nicotine, three reported various other substances, 29 reported “none,” and thirteen left the item blank. The smokers in the sample reported smoking on average 16.2 cigarettes per day (SD=11.2, range <1 to 80). Among smokers, mean ratings for the importance (M=5.4, SD=3.1), readiness (M=5.6, SD=3.2), and confidence (M=5.0, SD=3.0) in

T

quitting smoking were moderate (Table 1).

IP

3.2 Comparison of Smokers to Nonsmokers

CR

See Table 2 for a pattern of means. General impairment caused by substance use measured by the SIP total was significantly higher for smokers than for nonsmokers, F(1,

US

248)=8.9, p=.003. This trend was mirrored by all of the SIP subscales: Physical Problems, F(1,

AN

258)=13.5, p=.000; Interpersonal Problems, F(1, 262)=5.6, p=.019; Intrapersonal Problems, F(1, 260)=6.5, p=.011, and Social Responsibility, F(1, 262)=14.7, p=.000. Smokers in the sample

M

were marginally more anxious than their non-smoking counterparts as measured by the GAD=7,

ED

F(1, 254)=4.6, p=.053, though they were not significantly more depressed as measured by the PHQ-9 (p=0.19). No BAM subscales were significant (ps ranged from 0.15 to 0.24).

PT

3.3 EMR Data on Clinical Practices Regarding Tobacco Use

CE

Of the 161 smokers who had an EMR, 112 (69.6%) had tobacco use documented in their EMR Problem List; 68 (42%) were documented to have been prescribed a tobacco cessation aid

AC

(58% nicotine patch; 25% nicotine gum; 39% nicotine lozenge; 32% bupropion, 22% varenicline3) while receiving services in SUDC (41% of whom were prescribed this by their SUDC medical provider); 147 (91%) were documented to have discussed smoking at their initial SUDC intake evaluation; 141(87.6%) were documented to have offered tobacco treatment services at their initial SUDC intake evaluation; 42 (26.1%) were documented to have attempted tobacco cessation or tobacco reduction while they were enrolled in the SUDC program; and 0 3

Note: Several smokers received more than one type of prescription.

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

14

(0%) were documented to have enrolled in a formal evidence-based treatment (EBT) for tobacco cessation from a SUDC behavioral health provider (BHP). 4. Discussion As anticipated, the proportion of cigarette smokers (59%) in this VA substance-use

T

treatment seeking sample of veterans was substantially higher than the general population of

IP

veterans (one in five veterans report smoking; U.S. Department of Veterans Affairs, 2016).

CR

Given the high incidence of tobacco use in those with co-occurring SUD that is observed both in the literature and in this study, we believe that focusing on tobacco prevention and treatment

US

within SUD treatment settings would improve veteran health outcomes substantially. There is

AN

evidence that patients with co-occurring SUD and tobacco use struggle to quit tobacco more than non-SUD patients (Ward, Kedia, Webb & Relyea, 2014), suggesting that traditionally delivered

M

minimal intervention services may be insufficient for this population; thus, targeted, higher-dose

ED

interventions may be warranted. Specialty healthcare services are optimally designed to provide a higher dose of tobacco treatment given the average treatment course (7.9 sessions/year; Hunt &

PT

Rosenheck, 2011) as compared to primary care (3.3-3.6 sessions/year; Maciejewski et al., 2007).

CE

As noted in the Introduction, while the results of several recent reviews (Apollino et al., 2016; McKelvey et al., 2017; Thurgood et al, 2016) have yielded mixed results as to the efficacy of

AC

current tobacco treatments within SUD clinics, nearly no studies suggest that it is harmful, and we see the mixed results as an opportunity for future research to increase the efficacy of tobacco cessation interventions in SUD clinics. Our results indicate that, broadly, veterans in this sample were similar to civilian SUD patients with regards to smoking prevalence – civilian samples have ranged from 40-80% of SUD samples being identified as smokers (Guydish et al., 2016; Kalman et al., 2005; Smith,

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

15

Mazure, & McKee, 2014) - as well as motivation to quit smoking (McClure et al., 2014; Nahvi et al., 2006; Richter et al., 2001). Smokers in our sample evinced greater levels of dysfunction than the nonsmokers, which is consistent with research suggesting that smoking tends to cluster with issues of behavioral health (e.g., Hughes, 2008). These findings, together, suggest that the

T

clinical recommendations we give in the discussion are likely applicable to clinicians working

IP

with both civilian and veterans.

CR

Not only were there a greater number of patients with co-occurring SUD and tobacco use than those without tobacco use, we found that those who smoke report a higher level of

US

dysfunction and symptomatology across a variety of measures. This suggests that even within a

AN

specialty mental healthcare context such as a SUD clinic, these smokers are a higher-need group of individuals that may require greater attention and resources. We had anticipated that we would

M

find smokers to have a higher number of health problems, as there is a rich body of evidence

ED

pointing to the various health ailments caused or exacerbated by tobacco use (Centers for Disease Control and Prevention, 2016). However, we also found that the smokers had greater

PT

disturbance in interpersonal functioning, intrapersonal functioning, and functioning in social

CE

roles. This finding converges with the literature on health multimorbidity (MM) which often finds tobacco use clustering with a variety of other psychiatric concerns, including substance use

AC

disorders (Fortin et al., 2014), affective disorders and anxiety disorders (Fluharty, Taylor, Grabski , & Munafò, 2017), psychotic disorders (Kotov, Guey, Bromet, & Schwartz, 2010), suicidal behavior (Hughes, 2008; Schneider et al., 2009) and somatoform disorders (Jane-Llopis et al., 2006) in addition to clustering with physical health concerns. We are not suggesting – nor would the literature support - that tobacco use causes other psychiatric issues; rather, that tobacco use may be a signal or marker of potential physical and psychosocial dysfunction. Thus,

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

16

we recommend that within SUD clinic settings, when a patient is identified as a smoker, special care be given to assess for domains of psychosocial dysfunction, including suicidal risk. Given the finding that cigarette smokers with a SUD diagnosis reported broad psychobiological dysfunction, it encouraging to find that smokers reported at least contemplating

T

quitting smoking. This finding is in agreement with the existing literature that suggests substance

IP

using smokers are about moderately motivated to quit smoking (McClure et al., 2014; Nahvi et

CR

al., 2006; Richter et al., 2001). In our sample, veterans reported somewhat higher importance/readiness for most other substances than tobacco, suggesting that motivational work

US

regarding tobacco use may be necessary as a first step to address smoking. Importance and

AN

readiness ratings indicative of contemplation are promising, as contemplation is a common step toward behavior change (DiClemente, Nidecker, & Belleck, 2008). Treatment strategies such as

M

motivational interviewing (MI), which are designed to increase importance/readiness, have been

ED

demonstrated to increase motivation from moderate to high levels in as little as one appointment (Heckman, Egleston, & Hofmann, 2010). While our sample were reporting moderate

PT

readiness/importance, it is plausible that with some focused intervention, their ratings could have

CE

increased. We thus recommend that clinicians in SUD settings who find that their patients are moderately ready to quit utilize motivational strategies to increase their readiness with the hope

AC

that doing so could increase likelihood of a quit attempt. Considering these two findings together, it is likely the case that some of the smokers in our sample, like those in other studies, felt moderately ready to quit smoking but had a number of competing psychosocial/physical issues that demand their time. Given that these data were collected from a VA SUD treatment-seeking population, among their primary concerns to be addressed in clinic were their substance use issues. We would argue that tobacco use, in this

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

17

population, should fall under the definition of substance use. While some may argue that tobacco may be best addressed in primary care as discussed above we believe that co-substance users would be best served by addressing any/all abused substances in a specialty care service given their specific needs. In particular, considering the high rate of co-use of alcohol and tobacco and

T

emergent evidence that suggests a mutually exacerbating relationship between the two (e.g.,

IP

Piasecki et al., 2011), it is inefficient to address the problems in different settings. As we noted in

CR

the introduction of this paper, addressing both alcohol and tobacco use together can improve cessation rates for both, and from other drugs of abuse (Bobo et al., 1998; Cooney et al., 2009;

US

Prochaska et al., 2004; Tsoh et al., 2011). Given that many patients and providers are not aware

AN

of the positive relationship between multi-cessation efforts (and that not knowing this may prevent a tobacco cessation attempt), we suggest that SUD clinic leadership work to educate

M

their clinicians on this fact in an effort to transmit this information to patients via use of

ED

didactics, team meetings, and even creating initiatives. Low confidence in one’s ability to successfully sustain abstinence from smoking may

PT

also be a barrier to making a quit attempt. In our sample, confidence in ability to quit smoking

CE

was rated a 5/10, which was lower than confidence for all other substances. Examinations of substance use self-efficacy suggest that confidence/efficacy can be increased through skill

AC

acquisition, education, counseling, and small successes (e.g., cutting down from 10 to 8 cigarettes) (Loprinzi, Wolfe, & Walker, 2015; Okuyemi et al., 2013). Thus, while low confidence may impede tobacco cessation, there are strategies that providers could use to increase confidence which may lead to greater rates of cessation. We recommend that SUD clinic providers identify patients with low confidence regarding tobacco cessation and work with them to improve confidence levels. Confidence can be improved through a number of

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

18

mechanisms, described above, though it may be particularly useful to increase confidence for coping with cues or social pressure by using simulations or role-play (e.g., Streck et al., 2017). Taking these findings together, it appears that BHPs in SUD clinics may be uniquely trained to address nonpharmacological components of tobacco cessation, such as motivation,

T

readiness, confidence, and increasing self-efficacy through counseling and skill acquisition. As

IP

we found in the clinical outcomes portion of the study, providers nearly always inquired about

CR

tobacco and offered services at the intake evaluation, and a substantial portion of patients received a pharmacological tobacco cessation aid (notably higher, in fact, than rates of tobacco

US

cessation medication use found in a review by Knudsen & Studts, 2012); however, rates of

AN

documented cessation/reduction attempts were low and not a single patient were documented to receive an empirically-based behavioral tobacco cessation treatment. Thus, BHPs in this clinic

M

(and other specialty SUD clinics) could improve patient health outcomes by spending more time

ED

discussing smoking cessation and attempting to increase motivation to quit; clinic leadership may need to invest in training of BHPs to address these needs depending on current staff skill

PT

level in MI or tobacco cessation techniques. Additionally, SUD clinic leadership may consider

cessation.

CE

implementing smoking-related policies for their staff to underscore the importance of tobacco

AC

It is important to note that, while no patients in this sample received an EBT specifically for smoking, the EBT offered in this particular SUD clinic is a 4-session CBT protocol for smoking cessation. It is possible that this might simply be too intensive a treatment for providers and/or patients to deem necessary, given the context of multiple competing demands that may be viewed as more important. As such, we would encourage clinicians and stakeholders to consider ways to more briefly address smoking as adjunctive to other treatments, rather than having

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

19

mutually exclusive treatments. Very brief (~2-3 minute) tobacco use interventions can be effective (Anderson, Jorenby, Scott, & Fiore, 2002) and would certainly be more effective than a patient receiving no intervention. Knudsen (2017) calls for an increase in implementation research, would could provide empirical information on optimal structure and timing of tobacco

T

interventions within SUD clinics.

IP

Bodie (2014) argues that psychologists in various treatment settings are uniquely poised

CR

to address tobacco use among individuals with mental health concerns and asserts that raising awareness among providers and access to empirically-based tobacco cessation interventions is

US

key. Examples of such treatments include motivational interviewing (Miller & Rollnick, 1991)

AN

and cognitive-behavioral therapy (CBT) for tobacco use (Schnoll et al., 2005). As above, MI interventions are shown to increase readiness to make health/behavior changes and improve

M

outcomes in patients evincing moderate levels of motivation to change, as was the case in our

ED

sample. BHPs, rather than medical providers, are more likely to have training in MI and CBT techniques and in our opinion it is more within the scope of practice of a BHP to provide a

PT

primarily behavioral intervention. We thus recommend that SUD clinics add brief motivational

CE

interventions to the BHPs’ standards of practice when they identify a patient as a smoker. We further recommend that SUD clinics assess their own clinical practices regarding smoking, as

AC

results would vary between clinics. Knudsen and colleagues (2013) demonstrated that smoking cessation programs within SUD can be sustained with institutional support, though of note this study did not include VA SUD clinics. 4.1 Limitations While we feel that this study had many strengths, it is important to note limitations. First, intake data were obtained from a clinical sample in a cross-sectional manner; thus, we were

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

20

unable to examine any substantive change over time in measures such as motivation, dysfunction, and mental health as a result of being enrolled in the VA SUD clinic. We would recommend that future research examine not only data at intake, but also relevant clinical outcome data. Second, because these were data collected initially for clinical and not research

T

purposes, we were unable to exert control over data collection processes (i.e., measures were

IP

administered by clinical staff who did not rigorously check for completion), resulting in some

CR

missing data points. Third, tobacco use among individuals with other mental health diagnoses (e.g., post-traumatic stress disorder, depression, psychotic disorders) is also high (Lê Cook et al.,

US

2014). The current paper did not address characteristics and clinical practices in non-SUD

AN

specialty mental health services at the VA, though there is evidence that similar provider concerns (e.g., time constraints, perception that patients are not motivated) exist in other clinics

M

(Malte et al., 2013; Sheals, Tombor, McNeill, & Shahab, 2016). Thus, while this paper did not

ED

address non-SUD provider behaviors, we hope that this paper may inspire similar examinations by researchers in other treatment settings. Fourth, this study categorized anyone with past month

PT

smoking as a smoker; leading to a heterogeneous group in terms of smoking intensity. In future

CE

research, it may be advisable to examine findings as a function of smoking level. Fifth, as with most VA-obtained data, our sample was primarily white, male, and middle aged, which may

AC

limit the generalizability of our findings to other non-VA clinical settings; however, as above our results largely converge with other SUD clinic samples, which may offset this limitation somewhat. Generalizability may also be limited by clinical features; while all of the BHPs in the SUD clinic described in this manuscript were trained to administer CBT for tobacco use, that is likely not true in all SUD clinics, even VA SUD clinics. Finally, regarding the data obtained from the EMR, as is the case with all EMR studies, we were limited by what was reported in the

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

21

record. It is possible that what is reported in the record is not fully commensurate with clinical practice that occurred in the clinic, though of note we have no reason to believe that reporting biased our results in any particular way. We do note, for example, that of the patients selfreporting tobacco use on their intake paperwork, only 70% had a tobacco-related diagnosis in

T

their EMR. Additionally, certain components of theoretical interest (e.g., how many individuals

5. Conclusions

CR

regimens) were unable to be determined using the EMR.

IP

actually successfully quit smoking, how many adhered to smoking cessation medication

US

Overall, the results of this treatment as usual clinical study indicate that smokers enrolled

AN

in a Midwestern VA SUD clinic are generally more impaired than their nonsmoking counterparts and are moderately motivated, ready, and confident to make a smoking cessation attempt. While

M

providers in this VA SUD clinic almost unanimously assessed smoking at intake, rates of

ED

tobacco cessation follow-through could be vastly improved, particularly for behavioral health care (i.e., there was evidence that psychiatrists in this VA SUD clinic were providing medical

PT

intervention for smoking cessation). The primary clinical recommendation of this research is

CE

increasing the extent to which BHPs discuss and provide intervention around tobacco cessation. Doing so could vastly improve the physical health of SUD patients in addition to potentially

AC

improving their substance use outcomes.

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

22

6. References Action on Smoking and Health. (2016). Smoking and mental health (ASH Fact Sheet). Retrieved from http://ash.org.uk/information-and-resources/reports-submissions/reports/the-stolenyears/

T

Alterman, A. I., Cacciola, J. S., Ivey, M. A., Habing, B., & Lynch, K. G. (2009). Reliability and

IP

validity of the alcohol short index of problems and a newly constructed drug short index

CR

of problems. Journal of Studies on Alcohol and Drugs, 70(2), 304-307. doi: 10.15288/jsad.2009.70.304

US

American Cancer Society. (2016). Tobacco: The true cost of smoking (ACS Infographic).

AN

Retrieved from https://www.cancer.org/research/infographics-gallery/tobaccorelated-healthcare-costs.html

M

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

ED

disorders: DSM-5. Washington, D.C: American Psychiatric Association. Anderson, J. E., Jorenby, D. E., Scott, W. J., & Fiore, M. C. (2002). Treating tobacco use and

PT

dependence: an evidence-based clinical practice guideline for tobacco

CE

cessation. Chest, 121(3), 932-941. doi: 10.1378/chest.121.3.932 Apollonio, D., Phillips, R., Bero, L. (2016). Interventions for tobacco use cessation in people in

AC

treatment for or recovery from substance use disorders. The Cochrane Library; Cochrane Tobacco Addiction Group. doi: 10.1002/14651858.CD010274.pub2 Baggett, T. P., Chang, Y., Singer, D. E., Porneala, B. C., Gaeta, J. M., O’Connell, J. J., & Rigotti, N. A. (2015). Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston. American Journal of Public Health, 105(6), 1189-1197. doi: 10.2105/AJPH.2014.302248

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

23

Bobo, J. K., Mcilvain, H. E., Lando, H. A., Walker, R. D., & Leed‐Kelly, A. (1998). Effect of smoking cessation counseling on recovery from alcoholism: findings from a randomized community intervention trial. Addiction, 93(6), 877-887. doi: 10.1046/j.13600443.1998.9368779.x

T

Bodie, L. P. (2014). To treat or not to treat: Should psychologists treat tobacco use disorder?

IP

Psychological Services, 11 (3), 317-323. doi: http://dx.doi.org/10.1037/a0036610

CR

Bondurant, S., & Wedge, R. (Eds.). (2009). Combating tobacco use in military and Veteran

US

populations. Institute of Medicine, National Academies of Sciences, Washington, D.C. Carmody, T. P., Delucchi, K., Simon, J. A., Duncan, C. L., Solkowitz, S. N., Huggins, J., ... &

AN

Hall, S. M. (2012). Expectancies regarding the interaction between smoking and substance use in alcohol-dependent smokers in early recovery. Psychology of Addictive

M

Behaviors, 26(2), 358-363. doi: 10.1037/a0024424

ED

Cooney, N. L., Cooney, J. L., Perry, B. L., Carbone, M., Cohen, E. H., Steinberg, H. R., ... & Litt, M. D. (2009). Smoking cessation during alcohol treatment: a randomized trial of

PT

combination nicotine patch plus nicotine gum. Addiction, 104(9), 1588-1596. doi:

CE

10.1111/j.1360-0443.2009.02624.x Cooney, J. L., Cooper, S., Grant, C., Sevarino, K., Krishnan-Sarin, S., Gutierrez, I. A., &

AC

Cooney, N. L. (2017). A randomized trial of contingency management for smoking cessation during intensive outpatient alcohol treatment. Journal Of Substance Abuse Treatment, 72, 89-96. doi: 10.1016/j.jsat.2016.07.002 Currie, S. R., Nesbitt, K., Wood, C., & Lawson, A. (2003). Survey of smoking cessation services in Canadian addiction programs. Journal of Substance Abuse Treatment, 24, 59-65. doi: 10.1016/S0740-5472(02)00344-6

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

24

Center for Disease Control and Prevention. (2016). Health effects of cigarette smoking. Retrieved from cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_ cig_smoking/ Center on Alcoholism, Substance Abuse, and Addictions (1995). Readiness ruler. Retrieved

T

from: https://casaa.unm.edu/inst/Readiness%20Ruler.pdf

IP

DiClemente, C. C., Nidecker, M., & Bellack, A. S. (2008). Motivation and the stages of change

CR

among individuals with severe mental illness and substance abuse disorders. Journal of

US

Substance Abuse Treatment, 34(1), 25-35. doi: 10.1016/j.jsat.2006.12.034 Duffy, S. A., Biotti, J. K., Karvonen‐Gutierrez, C. A., & Essenmacher, C. A. (2011). Medical

AN

comorbidities increase motivation to quit smoking among veterans being treated by a psychiatric facility. Perspectives in Psychiatric Care, 47(2), 74-83. doi: 10.1111/j.1744-

M

6163.2010.00271.x

ED

Ellingstad, T. P., Sobell, L. C., Sobell, M. B., Cleland, P. A., & Agrawal, S. (1999). Alcohol abusers who want to quit smoking: implications for clinical treatment. Drug and Alcohol

PT

Dependence, 54(3), 259-265. doi: 10.1016/S0376-8716(98)00180-X

CE

Fluharty, M., Taylor, A. E., Grabski, M., & Munafò, M. R. (2016). The association of cigarette smoking with depression and anxiety: a systematic review. Nicotine & Tobacco

AC

Research, 19(1), 3-13. doi: 10.1093/ntr/ntw140 Fortin, M., Haggerty, J., Almirall, J., Bouhali, T., Sasseville, M., & Lemieux, M. (2014). Lifestyle factors and multimorbidity: a cross sectional study. BMC Public Health, 14(1), 686. doi: 10.1186/1471-2458-14-686

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

25

Friedmann, P. D., Jiang, L., & Richter, K. P. (2008). Cigarette smoking cessation services in outpatient substance abuse treatment programs in the United States. Journal of Substance Abuse Treatment, 34(2), 165-172. doi: 10.1016/j.jsat.2007.02.006 Fuller, B. E., Guydish, J., Tsoh, J., Reid, M. S., Resnick, M., Zammarelli, L., ... & McCarty, D.

T

(2007). Attitudes toward the integration of smoking cessation treatment into drug abuse

IP

clinics. Journal of Substance Abuse Treatment, 32(1), 53-60. doi:

CR

10.1016/j.jsat.2006.06.011

Gwaltney, C. J., Metrik, J., Kahler, C. W., & Shiffman, S. (2009). Self-efficacy and smoking

US

cessation: A meta-analysis. Psychology of Addictive Behaviors, 23(9), 56-66. doi:

AN

http://dx.doi.org/10.1037/a0013529

Guydish, J., Passalacqua, E., Pagano, A., Martinez, C., Le, T., Chun, J., … & Delucchi, K.

M

(2016). An international systematic review of smoking prevalence in addiction treatment.

ED

Addiction, 111(2), 220-230. doi: https://doi.org/10.1111/add.13099 Hall, S. M., & Prochaska, J. J. (2009). Treatment of smokers with co-occurring disorders:

PT

emphasis on integration in mental health and addiction treatment settings. Annual Review

CE

of Clinical Psychology, 5, 409-431. doi: 10.1146/annurev.clinpsy.032408.153614 Heckman, C. J., Egleston, B. L., & Hofmann, M. T. (2010). Efficacy of motivational

AC

interviewing for smoking cessation: a systematic review and meta-analysis. Tobacco Control, 19(5), 410-416. doi: 10.1136/tc.2009.033175 Heffner, J. L., Blom, T. J., Camerota, E., … & Anthenelli, R. M. (2007). Interrelated effects of substance use diagnosis, race, and smoking severity on abstinence initiation in dually dependent male smokers: results of a retrospective chart review. Journal of Addiction Medicine, 1 (4), 191-197. doi: 10.1097/ADM.0b013e31814b8893

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

26

Heltemes, K. J., Clouser, M. C., MacGregor, A. J., Norman, S. B., & Galarneau, M. R. (2014). Co-occurring mental health and alcohol misuse: dual disorder symptoms in combat injured veterans. Addictive Behaviors, 39(2), 392-398. doi: 10.1016/j.addbeh.2013.06.001

T

Himelhoch, S., Riddle, J., & Goldman, H. H. (2014). Barriers to implementing evidence-based

CR

Services, 65(1), 75-80. doi: 10.1176/appi.ps.201200247

IP

smoking cessation practices in nine community mental health sites. Psychiatric

Hoggatt, K. J., Lehavot, K., Krenek, M., Schweizer, C. A., & Simpson, T. (2017). Prevalence of

US

substance misuse among US veterans in the general population. The American Journal on

AN

Addictions, 26(4), 357-365. doi: 10.1111/ajad.12534

Hoglund, M. W., & Schwartz, R. M. (2014). Mental health in deployed and nondeployed veteran

M

men and women in comparison with their civilian counterparts. Military Medicine, 179,

ED

1:19. doi: 10.7205/MILMED-D-13-00235 Hughes, J. R. (2008). Smoking and suicide: a brief overview. Drug and Alcohol Dependence,

PT

98(3), 169-178. doi: 10.1016/j.drugalcdep.2008.06.003

CE

Hughes, J. R., & Naud, S. (2016). Abstinence expectancies and quit attempts. Addictive Behaviors, 63, 93-96. doi: 10.1016/j.addbeh.2016.07.009

AC

Hunt, M. G., & Rosenheck, R. A. (2011). Psychotherapy in mental health clinics of the Department of Veterans Affairs. Journal of Clinical Psychology, 67(6), 561-573. doi: 10.1002/jclp.20788 Jane-Llopis, E. V. A., Jané-Llopis, E., Matytsina, I., Jané-Llopis, E., & Matytsina, I. (2006). Mental health and alcohol, drugs and tobacco: a review of the comorbidity between

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

27

mental disorders and the use of alcohol, tobacco and illicit drugs. Drug and Alcohol Review, 25(6), 515-536. doi: 10.1080/09595230600944461 Kalman, D. (1998). Smoking cessation treatment for substance misusers in early recovery: a review of the literature and recommendations for practice. Substance Use & Misuse,

T

33(10), 2021-2047. doi: 10.3109/10826089809069815

IP

Joseph A., Willenbring M., Nugent S., & Nelson D. (2003) Timing of alcohol and smoking

CR

cessation study. 9th Annual Meeting of the Society for Research on Nicotine & Tobacco, February 19–22, 2003, New Orleans, LA.

US

Kalman, D., Morissette, S. B., & George, T. P. (2005). Co-morbidity of smoking in patients with

AN

psychiatric and substance use disorders. American Journal on Addictions, 14(2), 106123. doi: 10.1080/10550490590924728

M

Knudsen, H. K. (2017). Implementation of smoking cessation treatment in substance use disorder

43(2), 215-225. doi:

ED

treatment settings: A review. The American Journal of Drug and Alcohol Abuse, Vol

PT

http://dx.doi.org.gate.lib.buffalo.edu/10.1080/00952990.2016.1183019

CE

Knudsen, H. K., Muilenburg, J., & Eby, L. T. (2012). Sustainment of smoking cessation programs in substance use disorder treatment organizations. Nicotine & Tobacco

AC

Research, 15(6), 1060-1068. doi: 10.1093/ntr/nts242 Knudsen, H. K., & Studts, J. L. (2012). Availability of nicotine replacement therapy in substance use disorder treatment: Longitudinal patterns of adoption, sustainability, and discontinuation. Drug and Alcohol Dependence, 118 (2-3), 244-250. doi: http://dx.doi.org.gate.lib.buffalo.edu/10.1016/j.drugalcdep.2011.03.028 Knudsen, H. K., Studts, J. L., Boyd, S., & Roman, P. M. (2010). Structural and cultural barriers

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

28

to the adoption of smoking cessation services in addiction treatment organizations. Journal Of Addictive Diseases, 29(3), 294-305. doi: 10.1080/10550887.2010.489446 Knudsen, H. K., Studts, C. R., & Studts, J. L. (2012). The implementation of smoking cessation

IP

Research, 39 (1), 28-41. doi: 10.1007/s11414-011-9246-y.

T

counseling in substance abuse treatment. The Journal of Behavioral Health Services

CR

Kotov, R., Guey, L. T., Bromet, E. J., & Schwartz, J. E. (2010). Smoking in schizophrenia:

36(1), 173-181. doi: 10.1093/schbul/sbn066

US

diagnostic specificity, symptom correlates, and illness severity. Schizophrenia Bulletin,

AN

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Measure, 16, 606-613. doi:

M

10.1046/j.1525-1497.2001.016009606.x

ED

Lê Cook, B., Wayne, G. F., Kafali, E. N., Liu, Z., Shu, C., & Flores, M. (2014). Trends in smoking among adults with mental illness and association between mental health

PT

treatment and smoking cessation. JAMA, 311(2), 172-182.

CE

Logan, J., Bonhert, A., Spies, E., & Jannausch, M. (2016). Suicidal ideation among young Afghanistan/Iraq War veterans and civilians: Individual, social, and environmental risk

AC

factors and perception of unmet mental healthcare needs, United States, 2013. Psychiatry Research, 245, 398-405. doi: https://doi.org/10.1016/j.psychres.2016.08.054 Loprinzi, P. D., Wolfe, C. D., & Walker, J. F. (2015). Exercise facilitates smoking cessation indirectly via improvements in smoking-specific self-efficacy: prospective cohort study among a national sample of young smokers. Preventive Medicine, 81, 63-66. doi: 10.1016/j.ypmed.2015.08.011

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

29

Löwe, B., Decker, O., Müller, S., Braähler, E., Schellber, D., Herzog, W., & Herzberg, P. Y. (2008). Validation and standardization of the generalized anxiety disorder screener (GAD-7) in the general population. Medical Care, 46, 266-274. doi: 10.1097/MLR.0b013e318160d093

T

Maciejewski, M. L., Perkins, M., Li, Y. F., Chapko, M., Fortney, J. C., & Liu, C. F. (2007).

IP

Utilization and expenditures of veterans obtaining primary care in community clinics and

CR

VA medical centers: an observational cohort study. BMC Health Services Research, 7(1), 56-64. doi: 0.1186/1472-6963-7-56

US

Maisonneuve, P., Lowenfels, A. B., Müllhaupt, B., Cavallini, G., Lankisch, P. G., Andersen, J.

AN

R., ... & Ammann, R. W. (2005). Cigarette smoking accelerates progression of alcoholic chronic pancreatitis. Gut, 54(4), 510-514. doi: 10.1136/gut.2004.039263

M

Malte, C. A., McFall, M., Chow, B., Beckham, J. C., Carmody, T. P., & Saxon, A. J. (2013).

ED

Survey of providers' attitudes toward integrating smoking cessation treatment into posttraumatic stress disorder care. Psychology of Addictive Behaviors, 27(1), 249-255.

PT

doi: http://dx.doi.org/10.1037/a0028484

CE

Martin, A., Rief, W., Klaiber, A., & Braehler, E. (2006). Validity of the brief patient health

AC

questionnaire mood scale (PHQ-9) in the general population. General Hospital Psychiatry, 28, 71-77. doi: 10.1016/j.genhosppsych.2005.07.003 McClure, E. A., Acquavita, S. P., Dunn, K. E., Stoller, K. B., & Stitzer, M. L. (2014). Characterizing smoking, cessation services, and quit interest across outpatient substance abuse treatment modalities. Journal of Substance Abuse Treatment, 46(2), 194-201. doi: 10.1016/j.jsat.2013.07.009 McKlelvey, K., Thrul, J., & Ramo, D. (2017). Impact of quitting smoking and smoking cessation

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

30

treatment on substance use outcomes: An updated and narrative review. Addictive Behaviors, 65, 161-170. doi: http://dx.doi.org/10.1016/j.addbeh.2016.10.012 Meijer, E., Gebhardt, W. A., Dijkstra, A., Willemsen, M. C., & Van Laar, C. (2015). Quitting smoking: The importance of non-smoker identity in predicting smoking behaviour and

T

responses to a smoking ban. Psychology & Health, 30(12), 1387-1409. doi:

IP

10.1080/08870446.2015.1049603

CR

Miller, W.R. (1999). Enhancing motivation to change in substance abuse treatment. Treatment Improvement Protocol Series, 35. Rockville, MD: US Department of Health and Human

US

Services.

AN

Miller, W. R., & Rollnick, S. (1991). Motivational Interviewing: Preparing people to change addictive behavior. New York, New York: Guilford Press.

M

Miller, W. R., Tonigan, J. S., & Longabaugh, R. (1995). The Drinker Inventory of Consequences

ED

(DrInC): An Instrument for assessing adverse consequences of alcohol abuse. Test Manual, 4, 319-322. doi: dx.doi.org/10.1037/e563232012-001

PT

Muilenburg, J. L., Laschober, T. C., & Eby, L. T. (2014). Climate for innovation, 12-step

CE

orientation, & tobacco cessation treatment. Journal fo Susbtance Use Treatment, 46(4), 447-455. doi: 1 0.1016/j.jsat.2013.10.016

AC

Nahvi, S., Richter, K., Li, X., Modali, L., & Arnsten, J. (2006). Cigarette smoking and interest in quitting in methadone maintenance patients. Addictive Behaviors, 31(11), 2127-2134. doi: 10.1016/j.addbeh.2006.01.006 Nelson, K. G., Young, K., & Chapman, H. (2014). Examining the performance of the brief addiction monitor. Journal of Substance Abuse Treatment, 46(4), 472-481. doi: 10.1016/j.jsat.2013.07.002

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

31

Okuyemi, K. S., Goldade, K., Whembolua, G. L., Thomas, J. L., Eischen, S., Sewali, B., ... & Resnicow, K. (2013). Motivational interviewing to enhance nicotine patch treatment for smoking cessation among homeless smokers: a randomized controlled trial. Addiction, 108(6), 1136-1144. doi: 10.1111/add.12140

T

Pelucchi, C., Gallus, S., Garavello, W., Bosetti, C., & La Vecchia, C. (2006). Cancer risk

CR

Alcohol Research & Health, 29(3), 193-199.

IP

associated with alcohol and tobacco use: focus on upper aero-digestive tract and liver.

Piasecki, T. M., Jahng, S., Wood, P. K., Robertson, B. M., Epler, A. J., Cronk, N. J., ... & Sher,

US

K. J. (2011). The subjective effects of alcohol–tobacco co-use: An ecological momentary

AN

assessment investigation. Journal of Abnormal Psychology, 120(3), 557 - 571. doi: 10.1037/a0023033

M

Prochaska, J. J., Delucchi, K., & Hall, S. M. (2004). A meta-analysis of smoking cessation

ED

interventions with individuals in substance abuse treatment. Journal of Consulting and Clinical Psychology, 72(6). 1144-1156. doi: doi.org/10.1037/0022-006X.72.6.1144 .

PT

Richter, K. P. (2006). Good and bad times for treating cigarette smoking in drug treatment.

CE

Journal of Psychoactive Drugs, 38(3), 311-315. doi: 10.1080/02791072.2006.10399857 Richter, K. P., McCool, R. M., Okuyemi, K. S., Mayo, M. S., & Ahluwalia, J. S. (2002). Patients'

AC

views on smoking cessation and tobacco harm reduction during drug treatment. Nicotine & Tobacco Research, 4(Suppl 2), S175-S182. doi: 10.1080/1462220021000032735 Richter, K. P., Gibson, C. A., Ahluwalia, J. S., & Schmelzle, K. H. (2001). Tobacco use and quit attempts among methadone maintenance clients. American Journal of Public Health, 91(2), 296. SAMHSA (Substance Abuse and Mental Health Services Administration: The TEDS (Treatment

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

32

Episode Data Set) Report. (2014). Twenty-one percent of Veterans in substance abuse treatment were homeless. Retrieved from: http://www.samhsa.gov/data/. Schneider, B., Wetterling, T., Georgi, K., Bartusch, B., Schnabel, A., & Blettner, M. (2009). Smoking differentially modifies suicide risk of affective disorders, substance use

T

disorders, and social factors. Journal of Affective Disorders, 112, 165-173.

IP

doi:10.1016/j.jad.2008.04.018

CR

Schnoll, R. A., Rothman, R. L., Wielt, D. B., Pedri, H., Wang, H., Babb, J., ... & Unger, M. (2005). A randomized pilot study of cognitive-behavioral therapy versus basic health

US

education for smoking cessation among cancer patients. Annals of Behavioral

AN

Medicine, 30(1), 1-11. doi: 10.1207/s15324796abm3001_1 Sheals, K., Tombor, I., McNeill, A., & Shahab, L. (2016). A mixed‐method systematic review

M

and meta‐analysis of mental health professionals' attitudes toward smoking and smoking

PT

10.1111/add.13387

ED

cessation among people with mental illnesses. Addiction, 111(9), 1536-1553. doi:

Smith, P. H., Mazure, C. M., & McKee, S. A. (2014). Smoking and mental illness in the US

CE

population. Tobacco Control, 23(e2), e147-e153.

AC

Streck, J. M., Regan, S., Chang, Y., Kelley, J. H., Singer, D. E., & Rigotti, N. A. (2017). Examining the effects of illicit drug use on tobacco cessation outcomes in the helping hand 2 randomized controlled trial. Drug and Alcohol Dependence. doi: 10.1016/j.drugalcdep.2017.06.005 Sussman, S. (2002). Smoking cessation among persons in recovery. Substance Use & Misuse, 37(8-10), 1275-1298. doi: 10.1081/JA-120004185 Talamini, R., Bosetti, C., La Vecchia, C., Dal Maso, L., Levi, F., Bidoli, E., ... & Franceschi, S.

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

33

(2002). Combined effect of tobacco and alcohol on laryngeal cancer risk: a case–control study. Cancer Causes and Control, 13(10), 957-964. Talati, A., Keyes, K. M., & Hasin, D. S. (2016). Changing relationships between smoking and psychiatric disorders across twentieth century birth cohorts: clinical and research

T

implications. Molecular psychiatry, 21, 464-471. doi: 10.1038/mp.2015.224

IP

Thurgood, S. L., McNeill, A., Clark-Carter, D., & Brose, L. S. (2016). A systematic review of

CR

smoking cessation interventions for adults in substance abuse treatment or recovery. Nicotine & Tobacco Research, 18(5), 993-1001. doi: 10.1093/ntr/ntv127

US

Tsoh, J. Y., Chi, F. W., Mertens, J. R., & Weisner, C. M. (2011). Stopping smoking during first

AN

year of substance use treatment predicted 9-year alcohol and drug treatment outcomes. Drug and Alcohol Dependence, 114(2), 110-118. doi: 10.1016/j.drugalcdep.2010.09.008

M

Trivedi, R. B., Post, E. P., Sun, H., Pomerantz, A., Saxon, A. J., Piette, J. D., ... & Nelson, K.

ED

(2015). Prevalence, comorbidity, and prognosis of mental health among US veterans. Syracuse University Institute for Veterans and Military Families. Retrieved from:

PT

https://ivmf.syracuse.edu/wp-content/uploads/2016/06/Trivedi-2015-IVMF-Research-

CE

Brief.pdf

U.S. Department of Veterans Affairs (2016). Tobacco use in VA. Retrieved from:

AC

https://www.publichealth.va.gov/smoking/professionals/tobacco-use.asp

Ward, K. D., Kedia, S., Webb, L., & Relyea, G. E. (2012). Nicotine dependence among clients receiving publicly funded substance abuse treatment. Drug and Alcohol Dependence, 125(1–2), 95–102. http://dx.doi.org/10.1016/j.drugalcdep.2012.03.022.

Williams, J. M., Stroup, T. S., Brunette, M. F., & Raney, L. E. (2014). Integrated care: tobacco

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

34

use and mental illness: a wake-up call for psychiatrists. Psychiatric Services, 65(12),

AC

CE

PT

ED

M

AN

US

CR

IP

T

1406-1408. doi: 10.1176/appi.ps.2014002

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

35

Table 1. Self-Report of Importance of Quitting, Readiness, and Confidence N

Mean (SD)

Median

AC

CE

PT

ED

M

AN

US

CR

IP

T

Importance Alcohol 221 7.6 (2.9) 9 Cocaine/Crack 31 7.2 (3.6) 10 Marijuana 77 4.4 (3.6) 3 Opiates/Opioids 54 6.1 (4.0) 7 Tobacco 152 5.4 (3.1) 6 Other 23 6.4 (3.8) 7 Readiness Alcohol 216 8.1 (2.5) 9 Cocaine/Crack 26 8.7 (2.5) 10 Marijuana 72 5.1 (3.7) 5 Opiates/Opioids 51 6.4 (3.8) 7 Tobacco 144 5.6 (3.2) 6 Other 20 6.9 (3.4) 8.5 Confidence Alcohol 220 7.8 (2.5) 8 Cocaine/Crack 29 7.9 (2.9) 10 Marijuana 74 5.7 (3.5) 5.5 Opiates/Opioids 50 6.3 (3.4) 7 Tobacco 143 5.0 (3.0) 5 Other 21 6.3 (3.3) 7 Note: Missing data on these scales varied 0.4% to 16% across variables due to missing/skipped items.

ACCEPTED MANUSCRIPT SMOKERS IN SUBSTANCE USE DISORDER CLINIC

36

Table 2. Substance Use Dysfunction and Psychiatric Functioning by Smoking Status. Smokers

Non-smokers

AC

CE

PT

ED

M

AN

US

CR

IP

T

p Variable M (SD) M (SD) Short Index of Problems Total Score 3.86 (3.03) 2.68 (2.57) .003 Physical 4.01 (3.15) 3.11 (3.15) .000 Interpersonal 5.25 (3.19) 4.27 (3.22) .019 Intrapersonal 1.12 (0.83) 0.89 (0.78) .011 Social Responsibility 4.49 (3.36) 2.94 (2.89) .000 PHQ-9 11.62 (6.90) 10.56 (7.15) .193 GAD-7 10.97 (6.68) 9.30 (7.03) .053 BAM-R Substance Use Severity 22.18 (21.25) 18.52 (21.11) .152 Risk Factors 46.43 (24.41) 42.38 (24.94) .201 Protective Factors 28.40 (19.34) 31.12 (20.01) .244 Note: The number of patients with missing data varied by variable from 5.1% to 16.0% due to skipping items or not completing measures as instructed (e.g., writing in description of frequency, such as “a lot,” rather than providing a quantity, such as 20 out of past 30 days).