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Billie Bonevski Cancer Institute NSW Research Fellow University of Newcastle, Australia

Changing organisational systems to address tobacco dependence in drug and alcohol treatment centres. Billie Bonevski Cancer Institute NSW Research Fellow University of Newcastle, Australia. The team.

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Billie Bonevski Cancer Institute NSW Research Fellow University of Newcastle, Australia

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  1. Changing organisational systems to address tobacco dependence in drug and alcohol treatment centres Billie Bonevski Cancer Institute NSW Research Fellow University of Newcastle, Australia

  2. The team • University of Newcastle: Amanda Wilson, Flora Tzelepis, Chris Paul, Jamie Bryant, Andrew Searle • Hunter New England Health: Adrian Dunlop • National Drug and Alcohol Research Centre (NDARC): Anthony Shakeshaft, Michael Farrell, Richard Mattick • Cancer Council NSW: Scott Walsberger, Phil Hull, Jon O’Brien • University of Wollongong: Pete Kelly • London: John Strang, Ann McNeill • US: Judith Prochaska

  3. Overview Part 1 – Myth Busting Part 2 – What is current practice Part 3 – What can we do Part 4 – How do we do it

  4. Why address smoking amongst drug and alcohol (D&A) treatment clients?

  5. Myth No 1: “Tobacco is not a health priority for this population. Other drugs are more important/deadly/more harmful”

  6. Hospital admissions in Canada Single et al, 2000

  7. Annual drug-related deaths in the US Centre for Disease Control, 2008, 2004, 2007

  8. Tobacco-related deaths within Australia compared with other causes Begg et al, 2007 Begg et al., 2007

  9. Drug related deaths in Australia (2004/05) Collins DJ, Lapsley HM. DoHA; 2008. Begg et al., 2007

  10. Smoking rates in D&A treatment populations

  11. Myth No 2: “Tobacco smoking is a necessary self-medication”

  12. Tobacco is part of the problem not the solution • Perpetuated by the tobacco industry • Mental illness • Stress, coping, stabilise mood etc • Nicotine reward system

  13. Nicotine dependence

  14. Myth No 3: “Addicts are not interested in quitting smoking”

  15. Australian D&A clients are interested to quit • N = 228 smokers in residential D&A treatment • 75% had tried quitting in the past • 67% were ‘seriously thinking about quitting’ Kelly et al, 2012

  16. Methadone maintained clients interest in quitting • N = 103 OTP clients in two clinics in Australia • 84% current smokers • 56% previous quit attempt • 38% thinking of quitting ‘next 6 months’ • Would like help with quitting – 36% said Yes and 31% were Unsure • 80% were heavy nicotine dependence Bowman et al 2011

  17. Myth No 4: “Drug and alcohol clients are unable to quit smoking”

  18. Smoking cessation offered during D&A treatment is effective A Meta-Analysis of Smoking Cessation Interventions With Individuals in Substance Abuse Treatment or Recovery. Prochaska, Judith; Delucchi, Kevin; Hall, Sharon Journal of Consulting & Clinical Psychology. 72(6):1144-1156, December 2004. Significant two-fold increase in the likelihood of smoking abstinence among intervention versus control participants

  19. Myth No 5: “Addressing smoking compromises other treatment outcomes”

  20. Alcohol and illicit drug abstinence following smoking cessation intervention A Meta-Analysis of Smoking Cessation Interventions With Individuals in Substance Abuse Treatment or Recovery. Prochaska, Judith; Delucchi, Kevin; Hall, Sharon Journal of Consulting & Clinical Psychology. 72(6):1144-1156, December 2004. Significant increase of 25% in the likelihood of abstinence from drugs and alcohol among participants receiving a smoking cessation intervention relative to participants in the control condition.

  21. How is smoking currently treated within the drug and alcohol sector?

  22. Clinically recommended • Tobacco dependence is:‘a chronic disease with remission and relapse’“Nicotine dependence warrants medical treatment as does any drug dependence disorder or chronic disease” Fiore et al, U.S. Dept of Health and Human Services, June 2000

  23. Is smoking cessation care provided to D&A treatment clients? • National survey of D&A agencies (n =260 agencies: 213 managers and/or 204 other staff) • 23-25% said they had a written smoke-free policy • 80-83% indicated delivery of smoking support was left to the discretion of individual staff - ie, not routinely and systematically provided Walsh et al, 2006

  24. D&A treatment centres smoking cessation care practices Walsh et al, 2006 Bonevski et al., 2012, under review

  25. Barriers to the provision of smoking cessation care in D&A setting • Staff smoking status1 • Lack of training1,2,3 • Resistance to smoke-free policies1,3 • Limited resources, eg, cost of NRT1 • Lack of coordinated staff approach (no system!)2 • Lack of staff time2 • Lack of confidence2,3 • Pessimism regarding effectiveness of smoking cessation interventions2 • Misperceptions – eg, “tobacco is not a real drug”, “its too difficult to address tobacco and other dependencies”, “clients don’t want to quit”1,2,3 1 Zeidonis, Guydish, 2006; 2 Walsh, Bowman et al 2005; 3 Baca et al, 2008

  26. Attitudes of managers and staff toward smoking interventions (strongly agree/agree) Walsh et al 2006

  27. What can we do - Menu of support Heavily addicted!! Best to throw everything at them!

  28. How to integrate this into usual care provision in drug and alcohol services?

  29. What is a systems based strategy? Six Core Components Implement a system of identifying and recording smoking status Equip staff with education, resources and feedback Dedicate staff to tobacco dependence treatment Organisational policies Provide tobacco dependence treatments as part of service (pharmaco and behavioural) Defined duties of care (Fiore et al, Zeidonis et al)

  30. How technology can be used • Touchscreen computers • Highly acceptable to clients • Accurate • Assesses smoking status, nicotine dependence, quit attempts • Print-out for client files • Education for staff and clients • Ongoing monitoring and improvement Shakeshaft et al, 1999, Bonevski et al, 2010, Bryant et al 2012

  31. Advantages of a systems based strategy • Integration of smoking cessation support provision in routine care • Aim to build capacity of the organisation to address smoking • De-normalisation of smoking within the setting • Based on systems - sustainable model in the long term

  32. Is it effective at reducing smoking? • Pilot studies have found • Improves staff attitudes score regarding smoking • Increases distribution of NRT • Increases provision of behavioural cessation support • The potential is evident • Well designed trials needed Guydish, 2010, 2012; Zeidonis 2007

  33. Trial of system change intervention in drug and alcohol setting (NHMRC:2013-16) 30 Drug & Alcohol Treatment Centres in QLD, NSW & Vic randomised to: 15 Drug & Alcohol centres in control group: usual care • 15 Drug & Alcohol centres in intervention group: • Touchscreen survey and print out • Staff training • Organisational policies • NRT • Follow-up • Outcomes at 6 months: • Cessation • Quit attempts • Smoking care provision

  34. THANK YOU • Funding: • Cancer Council NSW • Cancer Institute NSW • NHMRC • University of Newcastle • HMRI • Contact me on: • Billie.bonevski@newcastle.edu.au • or ph: 02 40335710 CRICOS Provider 00109J | www.newcastle.edu.au

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