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Abstract: Introduction: Cigarette smoking rates among pregnant women with opioid use disorder (OUD), are significantly higher than those found in the general population. Methods: We conducted a secondary analysis of baseline data from a multisite, randomized clinical trial comparing two different buprenorphine formulations on outcomes during pregnancy. Cigarette use and smoking cessation goals were evaluated with the Fagerström Test for Nicotine Dependence and the Thoughts About Abstinence (TAA) questionnaire respectively. Factors associated with differences in cigarette use and smoking cessation goals were compared. Results: Among 156 participants, 85 (54.5 %) reported that they currently smoked cigarettes. Most participants had a desire to quit smoking (TAA score = 6), but they had low expectations of success (TAA score = 4) and a relatively high perceived difficulty (TAA score = 6.5) of quitting during pregnancy. Among participants who smoked, less than half (45.5 %) had a smoking cessation goal. Participants who had a smoking cessation goal were significantly more likely to have a stronger desire to quit and higher expectations of success in quitting than participants who did not have a goal. Conclusions: Many pregnant women with OUD would like to quit or reduce smoking during pregnancy. A combination of pharmacologic and non-pharmacologic interventions to reduce or eliminate cigarette use should be incorporated into obstetric and substance use treatment clinical settings. Smoking cessation interventions should be aligned with patients’ goals and preferences. Related protocols: CTN-0080

Abstract:

Smoking prevalence in individuals with opioid use disorder (OUD) is over 80%. Research suggests that opioid use significantly increases smoking, which could account for the strikingly low smoking-cessation rates observed in both methadone- and buprenorphine-maintained patients, even with the use of first-line smoking-cessation interventions. If opioids present a barrier to smoking-cessation, then better smoking outcomes should be observed in OUD patients treated with extended-release naltrexone (XR-NTX, an opioid antagonist) compared to those receiving buprenorphine (BUP-NX, a partial opioid agonist).

The current study is a secondary analysis of a 24-week, multi-site, open-label, randomized clinical trial conducted within the National Drug Abuse Treatment Clinical Trials Network comparing the effectiveness of XR-NTX vs. BUP-NX for adults with OUD (CTN-0051; X:BOT). Longitudinal mixed effects models were used to determine if there was a significant reduction in cigarette use among daily smokers successfully inducted to treatment (n = 373) and a subset of those who completed treatment (n = 169).

Results found that among daily smokers inducted onto OUD medication, those in the XR-NTX group smoked fewer cigarettes per day (M = 11.36, SE = 0.62) relative to smokers in the BUP-NX group (M = 13.33, SE = 0.58) across all study visits, (b (SE) = -1.97 (0.55), p < .01). Results were similar for the treatment completers.

Conclusions: OUD patients treated with XR-NTX reduced cigarette use more than those treated with BUP-NX, suggesting that XR-NTX in combination with other smoking cessation interventions might be a better choice for OUD smokers interested in reducing their tobacco use.

Related protocols: CTN-0051

Abstract:

Specialty addiction programs treat people who are addicted to alcohol, opioids, stimulants, and other drugs. This study identified the proportion of addiction program clients who received tobacco-related services and factors associated with receipt of such services.

In 2015 and 2016, clients (N=2119) in 24 programs affiliated with the NIDA Clinical Trials Network were surveyed for receipt of services aligning with three of the five As of tobacco cessation: ask, advise, assist. Multi-variate analyses examined factors associated with receipt of each service.

Most clients (76%) were asked about smoking. Among smokers (N=1630), 53% were advised to quit, 41% received counseling, 26% received cessation medication, and 17% received counseling and medication. Clients were more likely to receive tobacco-related services if they wanted help quitting smoking or were enrolled in programs with tobacco-free grounds.

Conclusions: These correlational findings suggest that increasing client motivation to quit and implementing tobacco-free policies on the grounds of treatment centers may increase tobacco-related services in addiction treatment.

Abstract:

This study examined rates of use, health risk perceptions, and reasons for use of combustible and non-combustible tobacco products among clients enrolled in addictions treatment across the United States. The study was conducted in 24 addiction treatment programs affiliated with the NIDA Clinical Trials Network (CTN). Participants (N=1153) completed tobacco use surveys and rated health risk perception of all products. Users of non-cigarette products reported their main reason for use of each product. Logistic regression analyses examined associations between health risk perceptions and product use, including combustible cigarette use, and between reasons for use and non-cigarette product use.

Cigarette smoking was reported by 77.5%, followed by use of e-cigarettes (26.6%), little filtered cigars (LFCs)/cigarillos (15.4%), smokeless tobacco (11.4%), and cigars (8.4%). Lower perceived health risk of cigarettes was associated with smoking cigarettes. Lower perceived health risk of e-cigarettes was associated with e-cigarette use. Users of cigars and users of LFCs/cigarillos (versus other product use) were more likely to report their main reason for use as “enjoying flavor/taste,” and smokeless tobacco users were more likely to report “at times when can’t smoke” as their main reason for use compared to other reasons. E-cigarette users were more likely to report to “reduce/quit cigarettes” as their main reason for use as compared to all other reasons except “reduce health risk.”

Conclusions: This study provides important information about rates of use, reasons for use, and perceived health risks of a range of tobacco products in a sample of individuals in addictions treatment from a vulnerable, high smoking population. Treating smoking in addictions treatment should assess all tobacco product use, accuracy of health risk perceptions, and use of e-cigarettes to reduce/quit smoking, in order to promote cessation of combustible tobacco.

Abstract:

It is common for cannabis users to also use tobacco. While data suggest that tobacco users have more difficulty achieving cannabis cessation, secondary analyses of clinical trial data sets may provide insight into the moderating variables contributing to this relationship, as well as changes in tobacco use during cannabis treatment. Those were the aims of this secondary analysis.

The parent study, CTN-0053, was a multi-site trial of N-acetylcysteine (NAC) for cannabis dependence conducted within the National Drug Abuse Treatment Clinical Trials Network. Participants were treatment-seeking adults (ages 18–50) who met criteria for cannabis dependence (N=302). For cigarette smokers (n=117), tobacco use was assessed via timeline follow-back and nicotine dependence was assessed via the Fagerström Test for Nicotine Dependence (FTND). Outcome measures included: 1) changes in tobacco use based on treatment assignment, nicotine dependence, and concurrent cannabis reduction/abstinence, and 2) independent associations between nicotine dependence and cannabis abstinence.

Analysis found that cigarette smokers accounted for 39% of the sample (117/302), with a median FTND score of 3.0 (10-point scale). Among those with lower baseline nicotine dependence scores, cigarette smoking was reduced in the active treatment group compared to placebo. Those with moderate/high levels of nicotine dependence showed slight increases in smoking following active treatment. Nicotine dependence did not affect cannabis cessation.

Conclusions: Cigarette smoking during cannabis treatment was affected, but depended on baseline nicotine dependence severity, though dependence levels did not impact cannabis abstinence. Interventions that address both tobacco and cannabis are needed, especially due to an increasing prevalence of cannabis use.

Related protocols: CTN-0053

Abstract:

Differences in tobacco use behaviors have been identified between Latinos and non-Latino whites in the general US population. Little is known about cigarette smoking and quitting behaviors of Latinos in treatment for substance use disorders (SUDs), who represent two major tobacco-vulnerable groups. This study aimed to compare, in a national sample of persons enrolled in SUD treatment, demographic, drug use, and smoking and quitting prevalence and behaviors between Latinos and non-Latino whites. Researchers surveyed 777 SUD treatment clients, sampled from 24 clinics selected at random from the NIDA Clinical Trials Network (Latino client n=141; 40% female). Univariate and multivariate analyses were then conducted to identify correlates of smoking behaviors by Latino/non-Latino white ethnicity.

Latinos’ smoking prevalence resembled that of non-Latino whites (78.7% vs. 77.4%). In regression analyses, Latino smokers (n=111) tended to smoke fewer cigarettes per day (CPD) than non-Latino white smokers (n=492), were more often nondaily smokers and menthol smokers, more often reported a smoking quit attempt in the last year, and tended to report higher numbers of past-year quit attempts. Among Latino smokers, those with less education and those reporting opioids as their primary drug of use reported higher CPD.

Conclusions: Latinos in SUD treatment are at equally high risk of being current heavy smokers as compared to non-Latino whites in SUD treatment. At the same time, Latinos in SUD treatment exhibit ethnic-specific smoking and quitting behaviors that should be considered when designing smoking interventions for this group. Ethnic minorities and persons with SUDs are treated within health policy and scientific literature as distinct groups with specific risk factors for tobacco use and related disease, but in everyday life individuals occupy more than one social category. Thus, tobacco cessation efforts must confront multiple sources of risk and inequality to reach intersectional populations such as Latinos with SUDs. The findings presented here not only attest to the complexity of such efforts, but also signal their necessity.

Abstract:

A double blind, placebo-controlled randomized trial evaluation osmotic-release oral system methylphenidate (OROS-MPH) for smoking cessation revealed a significant interaction effect in which participants with higher baseline ADHD severity had better abstinence outcomes with OROS-MPH while participants with lower baseline ADHD severity had worse outcomes (CTN-0029). This study examined secondary outcomes that might bear on the mechanism for this differential effect treatment effect. Longitudinal analyses were conducted to evaluate the effect of OROS-MPH on three secondary outcomes (ADHD symptom severity, nicotine craving, and withdrawal) in the total sample (N=255, 56% male) and in the high (N=134) and low (N=121) baseline ADHD severity groups.

Results found that OROS-MPH significantly improved ADHD symptoms and nicotine withdrawal symptoms in the total sample, and exploratory analyses showed that in both higher and lower baseline severity groups, OROS-MPH statistically significantly improved these two outcomes. No effect on craving overall was detected, though exploratory analyses showed statistically significantly decreased craving in the high ADHD severity participants on OROS-MPH. No treatment by ADHD baseline severity interaction was detected for the outcomes.

Conclusions: Methylphenidate improved secondary outcomes during smoking cessation independent of baseline ADHD severity, with no evident treatment-baseline severity interaction. Results suggest divergent responses to smoking cessation treatment in the higher and lower severity groups cannot be explained by concordant divergence in craving, withdrawal, and ADHD symptoms severity, and alternative hypotheses may need to be identified.

Related protocols: CTN-0029

Abstract:

This study assessed changes in smoking-related outcomes in two cross-sectional samples of clients enrolled in addiction treatment and whether tobacco-free grounds policies were associated with smoking-related outcomes. Clients in 25 NIDA Clinical Trials Network-affiliated treatment programs were surveyed in 2015 (N=1,176) and 2016 (N=1,055). The samples were compared on smoking prevalence, cigarettes per day (CPD), thinking of quitting, past year quit attempts, staff and clients smoking together, attitudes towards quitting, and tobacco-related services. Second, programs with (n=6) and without (n=17) tobacco-free grounds at both time points were compared on smoking-related outcomes. Last, we examined changes in these measures for two programs that adopted tobacco-free grounds between 2015 and 2016.

Results found one difference across such years, such that the mean score for the tobacco Program Service scale increased from 2.37 to 2.48 (p=0.043, effect size=0.02). In programs with tobacco-free grounds policies, compared to those without, both CPD and the rate of staff and clients smoking together were significantly lower. In the two programs where tobacco-free grounds were implemented during study years, client smoking prevalence decreased (92.5% v. 67.6%, p=.005), the rate of staff and clients smoking together decreased (35.6% v. 4.2%, p=.031), mean CPD decreased (10.62 v. 8.24, p<.001) and mean tobacco services received by clients increased (2.08 v. 3.05, p<.001).

Conclusions: Findings indicate first, little change over time in smoking prevalence or other smoking-related measures in this population, and second, support the use of tobacco-free grounds policies as a strategy to address smoking in these settings. The authors recommend that the Center for Substance Abuse Treatment require tobacco-free grounds policies as a condition for block grant and capacity expansion funding to addiction treatment programs, that state agencies concerned with regulation and licensing of addiction treatment programs require adoption of tobacco-free grounds and that, even in the absence of a future mandate, addiction treatment programs implement tobacco-free grounds as a way to reduce health risks for both program staff and clients.

Abstract:

Although individuals in substance use disorders (SUD) treatment continue to smoke at high rates, regulatory policy and programming changes promoting tobacco cessation are being implemented, and some patients quit successfully. This study examined associations of smoking patterns, tobacco advertising receptivity, anti-tobacco message awareness, health risk perception, attitudes toward addressing smoking and availability of smoking cessation services with quitting smoking during SUD treatment. Surveys were completed by 1127 patients in 24 programs chosen randomly, stratified by program type (residential, methadone maintenance, outpatient), from among publicly funded, adult treatment programs within the NIDA Clinical Trials Network. Among respondents who had been in SUD treatment for at least one month, there were 631 current smokers and 52 former smokers who reported quitting smoking during treatment for at least one month prior to survey completion; these respondents comprised our sample (N=683). Results showed that participants who reported health concerns as a reason for quitting were 1.27 times more likely to have quit during treatment than those reporting health concerns affected quitting a little or not at all. Additionally, participants who reported that smoking cessation was part of their personal treatment plan during SUD treatment were 1.08 times more likely to have quit during treatment. Participants in methadone treatment were 49% less likely to report successfully quitting during treatment than those in outpatient treatment.

Conclusions: Results indicated that some smokers in SUD treatment successfully quit smoking during treatment, although their numbers were low. Participants’ reports of health concerns as a reason for quitting and including smoking cessation in personal, SUD treatment plans may hold promise for inclusion in smoking cessation interventions. The challenge of developing cost-effective, easy to implement, and individualized smoking cessation interventions to increase quit rates among smokers in SUD treatment continues.

Abstract:

Smoking is endemic in drug abuse treatment populations, and smoking prevalence in this population appears unresponsive to existing tobacco control strategies. Clinical and policy guidelines encourage programs to address smoking among clients, and research has identified key barriers to doing so. This report explores the practice of staff and clients smoking together in drug treatment programs, and how this practice is associated with other tobacco-related measures. Clients (N=1113) were surveyed and program directors were interviewed in a national sample of 24 drug abuse treatment programs affiliated with the NIDA Clinical Trials Network. Clients were asked whether they observed staff and clients smoking together in their program and, using program as the unit of analysis, this measure was tested for its association with client-level and program-level tobacco-related outcomes. Higher rates of staff and client smoking together were associated with higher staff smoking prevalence (p=0.006), lower rates of client thoughts about quitting in the next 30 days (p=0.027), more negative client attitudes toward quitting smoking (p=0.004), and with clients receiving fewer tobacco-related services (p=0.024).

Conclusions: These findings illuminate an actionable, low-cost policy intervention to address smoking in drug abuse treatment: prohibiting the practice of staff smoking together with clients. There may be challenges to face in changing a practice that is culturally accepted in some program (for example, some believe that smoking together builds rapport/trust). Despite these challenges, however, there is no reason to continue the practice of staff and clients smoking together. In the interest of the health of clients whom they serve, counselors, program directors, state regulatory agencies, and federal funding agencies should act to end this practice.

Abstract:

Decreasing smoking during pregnancy is a priority in both research and clinical practice. In contrast, despite the high prevalence of smoking in pregnant substance users (upward of 90%), smoking-cessation treatment has received relatively little attention in substance use disorder treatment. Several barriers to integrating smoking cessation treatment interventions into SUD treatment have been delineated, including the belief that smoking is unrelated to substance use and that substance using smokers don’t want to quit smoking. Research has demonstrated these beliefs may not be accurate, but less is known about all these factors in pregnant women.

The goal of this secondary analysis was to test hypotheses that in pregnant substance users: (1) cigarette smoking would be associated with greater alcohol and drug use; (2) approximately 50% of smokers would be interested in quitting smoking; and (3) greater self-efficacy and lower perceived difficulty of smoking would be associated with interest in quitting smoking.

Data from a randomized, multisite trial (CTN-0013) with 200 pregnant substance users, 145 (72.5%) of whom smoked at baseline, was analyzed. As predicted: (1) smokers had significantly greater substance use; (2) approximately half of smokers wanted to quit; and (3) smokers with a quit goal had significantly greater self-efficacy and lower perceived difficulty of quitting.

Conclusions: Smoking may be associated with more severe substance use in pregnant substance-using patients, half of whom may be interested in smoking-cessation interventions. These findings highlight the importance of addressing smoking in pregnant substance users. While some work is being done to identify effective smoking-cessation interventions for this population, this remains a significant clinical and research need.

Related protocols: CTN-0013